Position statement - Sugar-sweetened beverages

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Position statement - Sugar-sweetened beverages

Key messages

  • The consumption of sugar-sweetened beverages is associated with increased energy intake and in turn, weight gain and obesity. It is well established that obesity is a leading risk factor for diabetes, cardiovascular disease and some cancers.
  • Young Australians are very high consumers of sugar-sweetened beverages, and sugar-sweetened soft drinks in particular. The highest consumers of sugar-sweetened beverages are young males (19 to 24 years of age) and male adolescents (12 to 18 years of age), and males are higher consumers than females across all age groups.
  • The prevalence of sugar-sweetened beverages’ consumption is higher among lower socio-economic groups, compared to higher socio-economic groups.
  • A range of factors influence the consumption of sugar-sweetened beverages, including taste, social settings, price and marketing.

"Sugar-sweetened beverages"

For the purpose of this position paper, “sugar-sweetened beverages” refer to all non-alcoholic water based beverages with added sugar, including sugar-sweetened soft drinks, energy drinks, fruit drink, sports drinks and cordial. This term does not include milk-based products, 100% fruit juice or non-sugar sweetened beverages (i.e. artificial, non-nutritive or intensely sweetened).

“Sugar-sweetened soft drinks” refer to all non-alcoholic carbonated drinks, excluding non-sugar sweetened varieties and energy drinks.

References to ‘fruit juice’ include 100% fruit juices and sugar added fruit juices unless otherwise stated.

These definitions have been developed from the literature on the influence of sugar-sweetened beverages and sugar-sweetened soft drinks on health and aim to reflect the data that exists in relation to consumption and sales in Australia[1][2][3][4][5][6][7].

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What are the health impacts of sugar-sweetened beverage consumption?

Systematic reviews of the evidence have consistently found a significant association between sugar-sweetened beverages consumption and increased energy intake[5][6][8]. While various studies have found different effects and effect sizes (due largely to differences in study methodologies, sample characteristics and definitions in variables), there is also evidence of at least a probable association between sugar-sweetened beverages consumption and weight gain, body mass index, overweight and obesity (among adults and children)[4][5][6][8]. With respect to sugar-sweetened soft drinks in particular, research indicates that people do not compensate for the additional energy they consume from these drinks by reducing consumption of other foods, leading to increased total energy intake[5][9][10]. There is evidence that the increase in energy intake is greater than what can be attributed to these drinks alone, indicating that drinking sugar-sweetened soft drinks may lead people to consume more energy from other sources[4][5][9][11]. This may be because sugar-sweetened soft drinks stimulate appetite or suppress satiety[4][5][9][11].

A systematic review recently undertaken in the United States estimated that sugar-sweetened beverages’ consumption had accounted for at least one-fifth of the weight gained between 1977 and 2007 in the US population (among persons two years of age and above)[8]. It has also been estimated that consuming one can of soft drink per day could lead to a 6.75 kg weight gain in one year if these calories are added to a typical US diet and not offset by reduction in other energy sources[12].

Leading international health organisations, including the World Health Organization (WHO) and World Cancer Research Fund (WCRF) consider sugar-sweetened beverages’ consumption to be a probable risk factor for weight gain and obesity[13][14]. WHO recommended that consumption of these beverages should be restricted and WCRF recommended that consumption should be avoided[13][14]. It is well established that obesity is a leading risk factor for a range of chronic diseases and cancers, including endometrial, oesophageal, renal, gallbladder, bowel and postmenopausal breast cancers[14].

Systematic reviews and meta-analyses have found a significant relationship between the amount and frequency of sugar-sweetened beverages consumed and the increased risk of type 2 diabetes[5][15]. For example, it has been estimated that the risk of type 2 diabetes is 26% greater among the highest consumers of sugar sweetened beverages (most often 1–2 servings/day), compared to those with the lowest levels of intake (none or <1 serving/month)[15].

The consumption of added sugar by adolescents, with the greatest source being sugar-sweetened soft drinks, has been associated with multiple factors related to the increased risk of cardiovascular disease, including increased dyslipidemia (lower HDL ‘good’ cholesterol levels and higher LDL ‘bad’ cholesterol levels) among adolescents regardless of body size and increased insulin resistance among those that are overweight or obese[16].

Dental health in Australian children has declined over the past 20 years[17][18]. Studies have demonstrated an association between dental erosion and the amount and frequency of soft drinks and fruit juice consumed[4][13]. The World Health Organization therefore recommends limiting soft drink and juice intake to minimise the occurrence of dental erosion[13].

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How much do Australians consume?

The Australian Dietary Guidelines recommend limiting the intake of foods and drinks containing added sugars and in particular, limiting sugar-sweetened drinks[4]. These recommendations have been based upon evidence of a probable association (Grade B evidence) between sugar-sweetened beverage consumption and an increased risk of weight gain in adults and children[4]. They are also based upon evidence of a suggestive association (Grade C evidence) between soft drink consumption and an increased risk of dental caries in children, as well as an increased risk (from cola drinks) of reduced bone strength[4].

There is evidence that sugar-sweetened beverages continue to be consumed by large numbers of adults and children in Australia[1][3][7]. While the sale of sugar-sweetened soft drinks may have decreased over the past decade, and the sale of other sugar-sweetened beverages has increased, sugar sweetened soft drinks continue to hold the largest volume share of ‘water based beverage' sales in Australia (this excludes milk based drinks, fruit juice, cordials and tap water)[2][19]. In 2006, Australia was among the top 10 countries for per capita consumption of soft drinks[20]. Young men (19–24 years of age) and male adolescents (12–18 years of age) are the highest consumers of sugar-sweetened beverages, including sugar-sweetened soft drinks, and across all age groups, males are higher consumers than females[1][3][7][21].

The 2007 Australian National Children’s Nutrition and Physical Activity Survey found 47% of children (aged two to 16 years) consumed sugar-sweetened beverages daily (including sugar-sweetened soft drinks, cordials, fruit drinks, sports drinks and energy drinks)[22]. Daily, sugar-sweetened soft drinks were consumed by 25% of children (aged two to 16 years), with a mean daily intake among these children of approximately 1.2 cans – between 436 mL and 448 mL per day (see Table 1 below)[2][3][22]. Among children, consumption of all sugar-sweetened beverages and sugar-sweetened soft drinks increase with age, with adolescent boys being the highest consumers[2][3][7][21][22]. Among children aged two to 16 years that consumed sugar-sweetened soft drinks, these drinks contributed 26% of their daily sugar intake, 13% of their total carbohydrate intake and 7% of their total energy intake[3].

Comparisons between the 2007 survey and 1995 National Nutrition Survey have suggested a significant decrease in the percentage of children consuming sugar-sweetened soft drinks (except 9–13 year olds, where the percentage remained the same) and sugar sweetened beverages (p<0.001)[2]. The most significant reduction was among children aged 8 years and under[2]. The mean quantity of sugar-sweetened soft drinks consumed per consumer remained similar for all children (except 9–13 year olds, where the mean quantity consumed decreased)[2]. The mean quantity of sugar-sweetened beverages consumed per consumer decreased across all age groups[2]. The 2007 survey did not include 17 or 18 year olds, which the 1995 survey found to be the highest consumers of sugar-sweetened soft drinks, with 50% reporting consuming soft drinks on the day of the survey (with a mean daily intake among consumers of 714 mL or approximately two cans)[7]. Other limitations in comparing these surveys include that they were conducted at different time intervals, using different sampling frames and with differing levels of awareness of unhealthy diets and obesity[2].

For sugar-sweetened beverages other than sugar-sweetened soft drinks, the 2007 survey found that 37% of children consumed fruit juice, 10% consumed fruit drink, 20% consumed cordial and 2% consumed sports drinks and/or other flavoured waters[3]. The mean daily intake among consumers was highest for sports drinks, followed by sugar-sweetened soft drinks and cordials[3]. The high mean daily intake of sports drinks was likely to be influenced by their standard bottle size (see Table 1 below)[3]. There is evidence that bottle sizes for all sugar-sweetened beverages have steadily increased over the last 50 years, and that increased bottle size increases the volume of beverage consumed, regardless of beverage type[7]. Food intake has been found not to decrease, increasing extra energy intake overall[7].

Table 1. Daily consumption of sugar-sweetened beverages and 100% fruit juice among children, including mean daily intake across all children and among children that consume each beverage

Consumed by % of children Mean daily intake (across all children) Mean daily intake (among children that consume the specific beverage)
Fruit juice 37% 112 g/day (1/2 cup) 301 mL/day (1.2 standard glasses)
Sugar-sweetened soft drink 25% 107 g/day (1/3 can) 436 mL/day (1.2 cans/1.7 standard glasses)
Fruit drink 10% Not reported 1.2 standard glasses (mL/day not reported)
Cordial 20% Not reported 1.7 standard glasses (mL/day not reported)
Sports drinks and/or flavoured water 2% 12 g/day (0.2 standard glasses) 620 mL/day (2.5 standard glasses)

Compiled from 2007 Australian National Children’s Nutrition and Physical Activity Survey data, reported in Mortensen 2010[3]

A national survey of secondary students in 2009–10 (NaSSDA survey) reported similar results[23]. Thirty per cent reported consuming four or more cups (1 L or more) of soft drink, cordial or sports drink per week[23]. Males were again found to consume higher quantities than females, and the prevalence of consuming four or more cups (1 L or more) of these beverages increased during adolescence[23].

Of further note, a survey conducted by Food Standards Australia New Zealand in 2003 found 12 to 17 year olds to be the highest consumers of sugar-sweetened soft drinks, with 78% reporting consuming these drinks in the week prior to the survey (followed by 75% of 18 to 24 year olds as discussed below)[21].

In adults, consumption of all types of sugar-sweetened beverages decreases with age for both frequency and mean daily intake[1][7]. Young men aged 19 to 24 years are the highest adult consumers of sugar-sweetened soft drinks[1][7]. In 1995, the National Nutrition Survey found that 58% of this group of consumers drank an average of 800 mL (2.1 cans) per day[7]. The 2003 FSANZ survey reported that 75% of 18–24 year-olds had consumed sugar-sweetened carbonated soft drinks in the previous week[21].

People from socially disadvantaged groups (across all age groups) are significantly higher consumers of sugar-sweetened beverages than those from higher socio-economic groups[3][7]. For example, the National Children’s Nutrition and Physical Activity Survey in 2007 found that 30% of children in the lowest socio-economic status (SES) regions consumed sugar-sweetened soft drinks on the day of the survey, compared to 19% in the highest SES regions[3]. Among adults, the FSANZ survey reported an association between occupation and soft drinks consumption, with those unemployed or in unskilled occupations consuming more sugar-sweetened beverages (and sugar-sweetened soft drinks in isolation) than white collar workers and professionals/managers[21].

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What are the factors influencing sugar-sweetened beverage consumption?

Factors influencing sugar-sweetened beverages consumption across the population include taste, availability, role modelling by significant others, advertising and marketing, and price[7][24][25][26].

Among adults, social settings are key triggers for consumption, particularly where alcohol is consumed. The purchase of fast food and the availability of soft drinks in the home, workplace and other social settings are also leading factors[27]. Among children, the availability of sugar-sweetened beverages in the home and taste preferences are the main drivers of consumption[24][25][26]. The availability of sugar-sweetened beverages in schools is also a key driver[24].

Soft drinks are heavily promoted through media advertising, a wide variety of entertainment and sporting venues, children’s sports and events, targeting of schools, movie tie-ins and merchandise[7]. In Australia in 2009, Coca Cola brands spent $29.6 million on media advertising, PepsiCo spent $12.3 million and Schweppes $10 million[28]. The sponsorship of children’s sports and events is a key marketing technique, for example Coca Cola sponsors Little Athletics in NSW and the Moomba festival in Victoria.

There is evidence from several systematic reviews that food and beverage marketing influences the types of food and beverages children prefer, demand and consume, and is likely to contribute to poor diets, negative health outcomes, weight gain and obesity in children[29].

Price also influences consumption of sugar-sweetened beverages[30][31]. A recent systematic review found that soft drinks and juice have high price elasticity of demand[30]. After food purchased away from home, soft drinks are the category of food or beverage products most responsive to price changes[30]. Experts estimate that a 10% increase in soft drink prices could reduce consumption by 8–10%[30]. It has also been estimated that a 20% tax on sugar sweetened beverages could reduce body weight by 0.7 to 1.2kg per capita per year[32]. The influence of price elasticity on demand among different socio-economic groups requires further research.

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The effectiveness of interventions to reduce sugar-sweetened beverage consumption

A comprehensive approach from Australian governments, schools, non-government organisations and others is required to improve diets and combat the problems of overweight and obesity[13][33]. Reducing the consumption of sugar-sweetened drinks in Australia will require bold regulatory reforms and a range of policies and programs aimed at the factors influencing consumption, such as marketing, availability and price[33].

Food and beverage advertising in Australia is currently regulated under a complex mix of statutory regulations and co- and self-regulatory codes[34]. However these regulations and codes are inadequate to protect children from the problems of sugar-sweetened beverages advertising to children as they do not restrict the volume of advertising that children are exposed to, nor do they adequately restrict the marketing techniques most commonly used to target children, such as the sponsorship of children’s sports, events and activities. There are also significant deficiencies in the administration and enforcement of the self-regulatory codes[34].

There is evidence that school based programs can have a moderate impact (at least in the short term) on reducing children’s consumption of sugar-sweetened beverages, particularly when education campaigns and strategies to modify the environment are combined, and the strategies take a whole of school approach and extend to parents and families[35]. However school based programs are undermined by a range of other factors, including the promotion and ready availability of sugar sweetened beverages outside of school grounds[35].

The “Guidelines for healthy food and drinks supplied in school canteens” (as part of the National Healthy School Canteens project) aim to provide nationally consistent guidelines, building on state and territory based school canteen initiatives[36]. Under these national guidelines, sugar-sweetened beverages are not recommended for sale in school canteens. State governments have introduced their own policies banning the sale of sugar-sweetened beverages and other unhealthy foods in school canteens, but these policies may be being undermined by poor implementation and monitoring[37]. An evaluation in Victoria in 2010 found that banned foods continued to appear on 37% of Victorian government school menus, and of these menus, 63% continued to display banned beverages[37].

In the US, some state governments have introduced small sales taxes on sugar-sweetened soft drinks, at a mean tax rate of 5.2%[38]. However, these taxes have been predominantly aimed at raising revenue and have been inadequate to decrease consumption to reduce excess weight in the population[32][39][40][41]. Researchers and health experts agree that a tax capable of producing changes in consumption and weight would need to be substantially higher than the small taxes in the US, with suggestions that retail prices would need to increase by about 20%[32][39][41].

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Cancer Council Australia’s recommendations

Cancer Council Australia recommends that adults and children should limit sugar-sweetened beverages and instead drink water or reduced-fat milk. Australian governments should support this call and encourage consumers to limit their sugar-sweetened beverage consumption in line with the new dietary guidelines.

Cancer Council Australia recommends comprehensive action by governments, schools, non-government organisations and others to inform the public about the health impacts of sugar-sweetened beverages and to influence the public to limit their consumption. A comprehensive approach should include:

  1. A social marketing campaign, supported by Australian governments, to highlight the health impacts of sugar-sweetened beverages consumption and encourage people to reduce their levels of consumption.
  2. An investigation by the federal Department of Treasury and Finance into tax options to increase the price of sugar-sweetened beverages or soft drinks, with the aim of changing purchasing habits and achieving healthier diets.
  3. Comprehensive restrictions by Australian governments to reduce children’s exposure to marketing of sugar-sweetened beverages, including through schools and children’s sports, events and activities.
  4. Comprehensive restrictions by state governments on the sale of sugar-sweetened beverages in all schools (primary and secondary), places frequented by children, such as activity centres and at children’s sports and events (with adequate resources to ensure effective implementation, monitoring and evaluation).
  5. An investigation by state and local governments into the steps that may be taken to reduce the availability of sugar-sweetened beverages in workplaces, government institutions, health care settings and other public places.

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