Environmental interventions to reduce the consumption of sugar-sweetened beverages and their effects on health.

von Philipsborn P, Stratil JM, Burns J, Busert LK, Pfadenhauer LM, Polus S, Holzapfel C, Hauner H, Rehfuess E (2021)

Cochrane - DOI: 10.1002/14651858.CD012292.pub2.

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Evidence Categories

• Care setting: Commercial food environment
• Care setting: National, regional or local policy
• Population group: General Population
• Population group: General population
• Population group: Adults living with overweight and obesity
• Population group: Adults with poor diet
• Intervention: Policy/environmental: Labelling
• Intervention: Policy / environmental: Availability
• Intervention: Policy / environmental: Taxation & subsidies
• Intervention: Policy / environmental: Policy actions
• Intervention: Intra-/Inter-personal: Food provision
• Outcome: Healthy Eating: Sugar-sweetened drinks intake
• Outcome: Healthy Eating: sugar sweetened drinks purchases

Type of Evidence

Systematic Review

Aims

The authors state:

"To assess the effects of environmental interventions (excluding taxation) on the consumption of sugar-sweetened beverages and sugar sweetened milk, diet-related anthropometric measures and health outcomes, and on any reported unintended consequences or adverse outcomes."

Findings

The authors state:

• "We found 58 studies meeting our inclusion criteria, including 22 RCTs, 3 NRCTs, 14 CBA studies, and 19 ITS studies, with a total of 1,180,096 participants."
• "The studies included children, teenagers and adults, and were implemented in a variety of settings, including schools, retailing and food service establishments. We judged most studies to be at high or unclear risk of bias in at least one domain, and most studies used non-randomised designs."
• "Labelling interventions (8 studies): We found moderate-certainty evidence that traffic-light labelling is associated with decreasing sales of SSBs, and low-certainty evidence that nutritional rating score labelling is associated with decreasing sales of SSBs. For menu-board calorie labelling reported effects on SSB sales varied.Labelling interventions (8 studies): We found moderate-certainty evidence that traffic-light labelling is associated with decreasing sales of SSBs, and low-certainty evidence that nutritional rating score labelling is associated with decreasing sales of SSBs. For menu-board calorie labelling reported effects on SSB sales varied."
• "Nutrition standards in public institutions (16 studies): We found low-certainty evidence that reduced availability of SSBs in schools is associated with decreased SSB consumption. We found very low-certainty evidence that improved availability of drinking water in schools and school fruit programmes are associated with decreased SSB consumption. Reported associations between improved availability of drinking water in schools and student body weight varied."
• "Economic tools (7 studies): We found moderate-certainty evidence that price increases on SSBs are associated with decreasing SSB sales. For price discounts on low-calorie beverages reported effects on SSB sales varied."
• "Whole food supply interventions (3 studies): Reported associations between voluntary industry initiatives to improve the whole food supply and SSB sales varied."
• "Retail and food service interventions (7 studies): We found low-certainty evidence that healthier default beverages in children’s menus in chain  restaurants are associated with decreasing SSB sales, and moderate-certainty evidence that in-store promotion of healthier beverages in  supermarkets is associated with decreasing SSB sales. We found very low-certainty evidence that urban planning restrictions on new fast-food  restaurants and restrictions on the number of stores selling SSBs in remote communities are associated with decreasing SSB sales. Reported associations between promotion of healthier beverages in vending machines and SSB intake or sales varied." 
• "Intersectoral approaches (8 studies): We found moderate-certainty evidence that government food benefit programmes with restrictions on purchasing SSBs are associated with decreased SSB intake.  For unrestricted food benefit programmes reported effects varied. We found moderate-certainty evidence that multicomponent community campaigns focused on SSBs are associated with decreasing SSB sales. Reported associations between trade and investment liberalisation and SSB sales varied."
• "Home-based interventions (7 studies): We found moderate-certainty evidence that improved availability of low-calorie beverages in the home environment is associated with decreased SSB intake, and high-certainty evidence that it is associated with decreased body weight among adolescents with overweight or obesity and a high baseline consumption of SSBs."
• "Adverse outcomes reported by studies, which may occur in some circumstances, included negative effects on revenue, compensatory SSB consumption outside school when the availability of SSBs in schools is reduced, reduced milk intake, stakeholder discontent, and increased total energy content of grocery purchases with price discounts on low-calorie beverages, among others. The certainty of evidence on adverse outcomes was low to very low for most outcomes."

Conclusions

The authors state:

"The evidence included in this review indicates that effective, scalable interventions addressing SSB consumption at a population level exist. Implementation should be accompanied by high-quality evaluations using appropriate study designs, with a particular focus on the long-term effects of approaches suitable for large-scale implementation."