Effectiveness of behavioural interventions to reduce the intake of SSBs in children and adolescents: What’s the Evidence?
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Health Evidence™ hosted a 60 minute webinar examining the effectiveness of behavioural interventions to reduce the intake of sugar-sweetened beverages (SSBs) in children and adolescents. Follow this link to access to the audio recording for this webinar: https://youtu.be/GORsLYLUY0I Dr. Lamis Jomaa, Assistant Professor at the Department of Nutrition and Food Sciences, Faculty of Agricultural and Food Sciences at the American University of Beirut, presented an overview of findings from their latest systematic review and meta-analysis: Rahman A, Jomaa L, Kahale L, Adair P, & Pine C. (2018). Effectiveness of behavioral interventions to reduce the intake of sugar-sweetened beverages in children and adolescents: A systematic review and meta-analysis. Nutrition Reviews, 76(2), 88-107. Consumption of sugar-sweetened beverages (SSBs) among children has been associated with adverse health outcomes. Numerous behavioral interventions aimed at reducing the intake of SSBs among children have been reported, yet evidence of their effectiveness is lacking. This systematic review explored the effectiveness of educational and behavioral interventions to reduce SSB intake and to influence health outcomes among children aged 4 to 16 years. Of the 16 trials included, 12 were school based and 4 were community or home based. Only 3 trials provided data that could be pooled into a meta-analysis for evaluating change in SSB intake. Subgroup analyses showed a trend toward a significant reduction in SSB intake in participants in school-based interventions compared with control groups. Change in body mass index z scores was not statistically significant between groups. The quality of evidence from included trials was considered moderate, and the effectiveness of educational and behavioral interventions in reducing SSB intake was modest.
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Effectiveness of behavioural interventions to reduce the intake of SSBs in children and adolescents: What’s the Evidence?
- 1. Welcome! Effectiveness of behavioural interventions to reduce the intake of SSBs in children and adolescents: What's the evidence? You will be placed on hold until the webinar begins. The webinar will begin shortly, please remain on the line.
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- 4. What’s the evidence? Rahman A, Jomaa L, Kahale L, Adair P, & Pine C. (2018). Effectiveness of behavioral interventions to reduce the intake of sugar-sweetened beverages in children and adolescents: A systematic review and meta-analysis. Nutrition Reviews, 76(2), 88-107. https://healthevidence.org/view- article.aspx?a=effectiveness-behavioral- interventions-reduce-intake-sugar- sweetened-beverages-33200
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- 13. Poll Question #2 Have you heard of PICO(S) before? A. Yes B. No
- 14. Searchable Questions Think “PICOS” 1.Population (situation) 2.Intervention (exposure) 3.Comparison (other group) 4.Outcomes 5.Setting
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- 16. Co-authors Lamis Jomaa, MSc, PhD • Assistant Professor, Department of Nutrition and Food Sciences, American University of Beirut, Lebanon • Affiliate assistant professor, Pennsylvania State University
- 17. Abir Abdel Rahman, MSc, PhD Assistant Director Medical Laboratory Sciences Program, Faculty of Health Sciences, University of Balamand, Lebanon Co-authors
- 18. Co-authors Lara A Kahale, RN, MSc, PhD(candidate) AUB GRADE center coordinator, Clinical Research Institute, AUB Medical Center, Lebanon
- 19. Effectiveness of behavioral interventions to reduce the intake of sugar-sweetened beverages in children and adolescents: a systematic review and meta- analysis Abir Abdel Rahman, Lamis Jomaa*, Lara Kahale, Pauline Adair, Cynthia Pine. Nutrition Reviews 2017; 76(2): 88-107 https://doi.org/10.1093/nutrit/nux061 * Corresponding author: lj18@aub.edu.lb
- 20. Introduction • Systematic Review Registration: PROSPERO registration number CRD42014004432. • http://www.crd.york.ac.uk/prospero/Dis playPDF.php?ID=CRD42014004432
- 21. Introduction • SSBs defined as soft drinks, carbonated beverages, fruit juices, and sweetened milk. • Rich sources of energy with poor nutritional value • Primary source of added sugar among children & adolescents. Malik et al. Circulation 2010; Wang et al. Pediatrics 2008
- 22. Rosinger et al 2017
- 23. U.S. youth consumed an average 7.3% of their total daily calories from SSBs Rosinger et al 2017
- 24. Pathways Linking Sugar-Sweetened Beverage Intake with Health Source: copyright, D. Ludwig & W Willett, Harvard SPH, 2009
- 25. Introduction • Public health interventions targeting SSB consumption & aim at curbing the rising rates of overweight & obesity – Educational and behavioral interventions – Environmental interventions • In 2014 -- No systematic reviews were published exploring the effectiveness of interventions in reducing SSB consumption – Avery et al 2015: explored impact of interventions on reducing SSBs intake and changes in BMI among children aged 2–18 years
- 26. Aim & objectives To explore the impact of educational and behavioral interventions on (1) Reduce the intake of SSBs (2) Change in body weight, and other health outcomes among children and adolescents across different settings (school and non-school settings)
- 27. Parameter Inclusion Criteria Participants Children and adolescents aged 4 to 16 years in any setting (e.g., school, home or community) Intervention Educational or behavioral interventions targeting the reduction of SSBs consumption Comparison with no intervention Outcomes Primary outcome: change in SSB consumption (soft drinks, sweetened juices, or any sweetened drink (g/d, servings, ml/d)) Secondary outcomes: reduction in obesity; changes in body composition measures (e.g., body mass index [BMI] z scores based on age- and gender-specific growth charts)( kg, percentage, kg/m2); reduction in risk of any chronic disease (e.g., type II diabetes mellitus, hypertension) Study design Randomized controlled trials Methodology: PICOS criteria
- 28. Methodology: Search strategy • A comprehensive literature search (June- September 2014; updated search and screening - September 2016) o Databases : • Applied Social Sciences Index and Abstracts (ASSIA) • Cumulative Index of Nursing and Allied Health Literature (EBSCO) • Cochrane Central Register of Controlled Trials • Embase • MEDLINE (OVID & PubMed) • PsycINFO o Other sources – Web of Science – Google Scholar – References from other systematic reviews & studies included in this review
- 29. Methodology: Data collection and analysis Screening titles & abstracts Full-text reviewing Screening articles for eligibility using Cochrane guidelines Data abstraction about PICO based on Cochrane guidelines Meta–analysis using Review Manager software (version 5.3.5) • Conducted by two authors (A.A.R. and L.J.) in duplicate and independently • Disagreements resolved through discussion or by consulting a third author • Conducted by L.A.K
- 30. Methodology Risk of Bias Cochrane tool Heterogeneity Forest plots I2 statistic Subgroup analyses Stratification (school vs non- school)
- 31. Data synthesis Measure of relative effect (Mean Difference and SD) for continuous outcomes Random effects model Conversion and standardization of outcome units • Nutritionist Pro software (version 7.1.0, First Data Bank, Axxya Systems, San Bruno, CA) • SSBs consumption : g/d, servings per day milliliters per day (mL/d)
- 32. RESULTS
- 34. 16 trials n=19,925 participants 12 school-based 8 educational 4 educational & environmental 4 non-school based 1 educational 3 educational & environmental Brief summary of characteristics Follow up period ranged from 4 months – 36 months
- 36. Meta-analysis of Change in SSB intake (Primary Outcome)
- 37. Reduction in SSB intake (Primary outcome)
- 38. Change in SSB (Primary Outcome)
- 39. Primary outcome: Reduction in SSB intake
- 40. Meta-analysis of Change in BMI (Secondary Outcome)
- 41. Secondary outcomes: Reduction in prevalence of overweight and obesity and reduction in BMI
- 42. Conclusion Behavioral school interventions shown to : • Reduce SSB intake with relatively modest evidence • Insufficient evidence to support a positive effect on reduction in the prevalence of overweight and obesity among children and adolescents or BMI z scores
- 43. Why School interventions can work? Reduced SSBs intake Activities promoting healthy behaviors Spending prolonged periods at school Use of behavioral theories Parental involvement Role modeling from teachers and peers Improve food selection through environmental changes
- 44. No positive impact Secondary outcome: Reduction in prevalence of overweight and obesity and reduction in BMI Focused on a single message The multifactorial nature and complexity of obesity Possibility of compensatory behaviors adopted by children Variations in study design, sample size, & duration High dropout rates, lack of follow-up, & potential selection bias
- 45. Supportive evidence • Recently 2 other systematic reviews were published exploring the effects of interventions – Vezina-Im et al 2017: school-based only interventions; 12-17 year olds – Vargas Gracias et al 2017: effect of interventions on both SSBs and water intake among children, adolescents, and adults • Support our results: – Moderate evidence in reducing SSB consumption among children and adolescents – Home environment interventions had greater effects than school based interventions.
- 46. Strengths Rigorous methodology Single and multi- component interventions conducted in various settings Various characteristics of the studies and the behavioral change techniques
- 47. Limitations Variability in the setting, baseline characteristics of participants, or intervention strategies of different trials heterogeneity Variability in scales & units of measure used difficult to include in the meta- analysis Exclusion of non-English studies
- 48. Implications Practical Implications: • Behavioral interventions in schools can be effective , although evidence is still modest • Combining educational and environmental strategies to reduce SSB consumption and associated adverse health outcomes Research Implications: • Develop well-designed prospective cohort studies and RCTs that report on continuous outcomes • Utilize standardized evaluation schemes to assist researchers in improving study protocols and minimizing risks of bias • Explore what constructs from the TBC can be most effective to reduce SSB consumption • Examine the effectiveness of single-strategy interventions (educational strategies alone) vs combined-strategy interventions (with educational and environmental components)
- 49. References • Avery A, Bostock L, McCullough F. A systematic review investigating interventions that can help reduce consumption of sugar-sweetened beverages in children leading to changes in body fatness. J Hum Nutr Diet. 2015;28:52–64. • Hu FB. Resolved: there is sufficient scientific evidence that decreasing sugarsweetened beverage consumption will reduce the prevalence of obesity and obesity-related diseases. Obes Rev. 2013;14:606–619. 5. Ng SW, Mhurchu CN, Jebb SA, et al. Patterns and trends • Leung, C. W., Laraia, B. A., Needham, B. L., Rehkopf, D. H., Adler, N. E., Lin, J., ... & Epel, E. S. (2014). Soda and cell aging: associations between sugar-sweetened beverage consumption and leukocyte telomere length in healthy adults from the National Health and Nutrition Examination Surveys. American journal of public health, 104(12), 2425-2431. • Malik VS, Pan A, Willett WC, et al. Sugar-sweetened beverages and weight gain in children and adults: a systematic review and meta-analysis. Am J Clin Nutr. 2013;98:1084–1102. • Mattes RD, Shikany JM, Kaiser KA, et al. Nutritively sweetened beverage consumption and body weight: a systematic review and meta-analysis of randomized experiments. Obes Rev. 2011;12:346–365. • Rosinger, A., Herrick, K., Gahche, J., & Park, S. (2017). Sugar-Sweetened Beverage Consumption among US Youth, 2011-2014. NCHS Data Brief. Number 271. National Center for Health Statistics. • Singh, G. M., Micha, R., Khatibzadeh, S., Shi, P., Lim, S., Andrews, K. G., ... & Global Burden of Diseases Nutrition and Chronic Diseases Expert Group (NutriCoDE. (2015). Global, regional, and national consumption of sugar-sweetened beverages, fruit juices, and milk: a systematic assessment of beverage intake in 187 countries. PloS one, 10(8), e0124845. • Vargas‐Garcia, E. J., Evans, C. E. L., Prestwich, A., Sykes‐Muskett, B. J., Hooson, J., & Cade, J. E. (2017). Interventions to reduce consumption of sugar‐sweetened beverages or increase water intake: evidence from a systematic review and meta‐analysis. Obesity Reviews, 18(11), 1350-1363. • Vezina-Im L-A, Beaulieu D, Be´langer-Gravel A, et al. Efficacy of school-based interventions aimed at decreasing sugar-sweetened beverage consumption among adolescents: a systematic review. Public Health Nutr. 2017;20:2416–2431. • Wang YC, Bleich SN, Gortmaker SL. Increasing caloric contribution from sugarsweetened beverages and 100% fruit juices among US children and dolescents, 1988–2004. Pediatrics. 2008;121:e1604– 1614.
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- During 2011–2014, 62.9% of youth consumed at least one sugar-sweetened beverage on a given day (Figure 1).
- https://www.cdc.gov/nchs/data/databriefs/db271.pdf We see a significantly linear trend by age in terms of the % of total daily calories from SSB consumption with highest intake among 12-19 year olds. WHO guideline recommends adults and children reduce their daily intake of added sugars to less than 10% of their total energy intake (strong recommendation). Free sugars are defined by the World Health Organization and the UN Food and Agriculture Organization in multiple reports as "all monosaccharides and disaccharides added to foods by the manufacturer, cook, or consumer, plus sugars naturally present in honey, syrups, and fruit juices".
- Compelling evidence supports the strong association and causal relationship between SSB consumption and increased risk of obesity as well as several NCDs including diabetes, metabolic syndrome and dental caries. Results from well-powered prospective cohort studies and randomized controlled trials (RCTs) support the association between SSB consumption and weight gain in both the short term and the long term among children and adults. Several plausible biological mechanisms have been proposed to explain these strong associations, such as decreased satiety and failure to reduce energy intake at meals subsequent to the consumption of liquid calories such as SSBs, which can lead to a positive energy balance and weight gain. Other proposed mechanisms include increased blood glucose and insulin concentrations resulting from consumption of rapidly absorbed sugars in SSBs, leading to high dietary glycemic loads and a cascade of changes in appetite-regulating hormones and inflammatory biomarkers. These changes in turn can contribute to increased risk of type 2
- Given the serious implications of high SSB consumption for children’s diet and health and the importance of identifying which educational interventions best predict behavioral change, the aims of the present systematic review are as follows: (1) to explore the impact of educational and behavioral interventions to reduce the intake of SSBs among children and adolescents across different settings (school and nonschool settings); and (2) to assess the effect of these interventions on change in body weight and other health outcomes, taking into consideration which behavioral change techniques were included in these interventions.
- Study design was restricted to RCTs as it is considered the gold standard for establishing causal relationships and providing reliable evidence while minimizing risks of confounding factors that influence the results.
- Screening of titles and abstracts was done by AAR and myself and any article judged to be potentially eligible by at least 1 author was retrieved for full text review. The full text article was further screened independently by these two authors for eligibility and The data were related to 5 aspects of the review: Methods (study design, unit of randomization) Participants (e.g., characteristics, number, setting) Intervention (details on how the intervention was delivered, duration); Outcomes (reduction in SSBs consumption, obesity, and risk of any chronic disease) Other notes such as statistical methods used, sources of funding, and registration identifier for interventions and the RCTs
- Heterogeneity between trials was assessed by visually inspecting the forest plots and estimating the percentage of heterogeneity using the I2 statistics. Subgroup analysis was conducted based on setting (school vs home or community based setting). Publication bias Limited evidence (3 studies)
- Mean differences in the consumption of SSBs were pooled using a random effects model.
- Figure 1 shows the detailed steps of the literature search and screening process. A total of 16 trials were included in the systematic review, of which only 3 were included in the meta-analysis of the primary study outcome. Of the 16 trials included, 12 were school based, 8 of which included educational approaches alone (not combined with environmental interventions), whereby the reduction in SSB consumption of children and adolescents was one of the main targeted behaviors. The remaining 4 school-based trials included a combination of educational and environmental components. As for the 4 non–school-based trials, 1 included an educational intervention only, whereas 3 others included both educational and environmental interventions. Details about all included trials, including characteristics of study participants, type of intervention (school or community based), duration of intervention, and length of follow-up, are shown in Table 2.
- A total of 16 trials were included in the systematic review, of which only 3 were included in the meta-analysis of the primary study outcome.
- Moderate quality The majority of the studies scored “low risk” in the domains related to selection bias, attrition bias, reporting bias, and other bias Slightly less than half of the studies scored low in the domain related to performance bias The majority of the studies scored “unclear risk” in the domain of allocation concealment More than a quarter of the included studies scored “high risk” in the domain related to detection bias (blinding of outcome assessment); the remaining studies scoring between low and unclear risk refrain from using the term quality of the evidence as it is confusing and now the trend is to do certainty of the evidence through (GRADE).
- START WITH INCLUDED STUDIES AND THESE MEANS AND SD. THE MEAN DIFFERENCE USING THE RANDOM EFFECTS MODEL – PLOTTED ON THIS DIAGRAM AND THEN RISK OF BIAS. The meta-analysis of these 3 trials (n=3004 participants) showed that behavioral and educational interventions are associated with a trend toward reduction in SSB intake compared with no intervention; however, this trend did not reach statistical significance [MD, 283.54; 95%CI, 642.65 to 75.57; P ¼ 0.12) (Figure 2). The I2 value indicated that the percentage of the variability in effect estimates, which is due to heterogeneity was very high (I2 = 99%). Subgroup analysis reduced heterogeneity (I2 =6%) while increasing the overall strength of the results to borderline significance (MD, 26.53; 95%CI, 53.72 to 0.66; P = 0.06). I2 = 99% then we split school from community-based. To confirm this observation the difference between the school and outside school is a real difference (p<0.00001).
- Muckelbauer: included educational and environmental components, whereby four 45-minute classroom lessons highlighting the water needs of the body and the water circuit in nature, among other nutrition messages, were provided to students by trained teachers. In addition, the intervention component included installing water fountains in intervention schools and providing students with plastic water bottles to be refilled during the school day. Sichieri: The intervention group received only an educational program, which consisted of ten 1-hour sessions supported by classroom activities, banners, and the distribution of plastic water bottles to all students. In the home-based study conducted by Albala et al.,20 milk was distributed to children at home, and parents were provided with educational instructions supporting the consumption of the delivered beverages and the removal of SSBs from the home environment.
- 6 of the remaining 10 studies conducted in the school-based setting showed similar trends to results presented in the meta-analysis.
- The meta-analysis of the 3 trials, which included 3474 participants, found that behavioral and educational interventions, compared with no intervention, had no significant effect on the reduction in adjusted BMI z scores (MD, 0.01; 95%CI, 0.05 to 0.03; P=0.71) (Figure 3). The percentage of the variability in effect estimates that could be attributed to statistical heterogeneity rather than to sampling error (chance) was moderate to high (I2=60%). In addition, the test for subgroup effect was not statistically significant for the subgroup analysis (in-school interventions vs out-of-school intervention), with a P value of 0.27. None of the other health-related secondary outcomes, as defined for the present review, were assessed by the trials included in this review.
- The lack of consistent evidence from the included studies for this outcome as well. Of the16 included trials evaluating change in SSB intake, only 3 provided statistical data that could be pooled into a meta-analysis. Two of these were conducted in a school-based setting15,39 and 1 in a home-based setting.20 The first school intervention, conducted by Muckelbauer et al.,39 included educational and environmental components, whereby four 45-minute classroom lessons highlighting the water needs of the body and the water circuit in nature, among other nutrition messages, were provided to students by trained teachers. In addition, the intervention component included installing water fountains in intervention schools and providing students with plastic water bottles to be refilled during the school day. The intervention group in the school trial conducted by Sichieri et al.15 received only an educational program, which consisted of ten 1-hour sessions supported by classroom activities, banners, and the distribution of plastic water bottles to all students. In the home-based study conducted by Albala et al.,20 milk was distributed to children at home, and parents were provided with educational instructions supporting the consumption of the delivered beverages and the removal of SSBs from the home environment.
- Overall, educational and behavioral interventions included in this review, when compared with no intervention, were found to be successful in reducing SSB intake as the primary outcome among children and adolescents The trend toward reduction in SSB consumption approached statistical significance in school-based settings (P=0.06) Insufficient evidence to support a positive effect of these interventions on secondary outcomes such as a reduction in the prevalence of overweight and obesity among children and adolescents or BMI z scores
- This meta-analysis did not support a positive effect of behavioral interventions targeting SSB intake on a reduction in the prevalence of overweight and obesity. These results are not surprising, given that the only 2 trials identified to measure the change in prevalence of overweight and obesity among children in this review, those by Sichieri et al.15 and James et al.,17 focused on a single message that included reducing soda consumption, which may have been insufficient to limit excessive weight gain. Obesity is a complex and multifactorial problem,63 and thus other dietary and lifestyle behaviors besides the consumption of SSBs may have contributed to excessive weight gain in children. Another explanation is that compensatory behaviors may be adopted by children when sodas are replaced by other sugar-loaded, energy-dense beverages, including sports drinks and flavored juices. The consumption of sugar rich beverages and low-nutrient, energy-dense foods as a replacement for soda consumption may offset the reduced caloric intake, which in turn can lead to excessive weight gain
- Vezina-Im et al 2017: Design: systematic review Aim: To verify the efficacy of school-based interventions aimed at reducing sugar-sweetened beverage (SSB) consumption among adolescents (12-17 years) Databases: The following databases were investigated: MEDLINE/PubMed, PsycINFO, CINAHL and EMBASE. Proquest Dissertations and Theses was also investigated for unpublished trials. Results: 36 different interventions included in the review :20 educational/behavioural , 10 legislative/environmental interventions,6 interventions targeted both individuals and their environment Over 70% of all interventions, regardless of whether they targeted individuals, their environment or both, were effective in decreasing SSB consumption. Legislative/environmental studies had the highest success rate (90·0%). Educational/behavioural interventions only and interventions that combined educational/ behavioural and legislative/environmental approaches were almost equally effective in reducing SSB consumption with success rates of 65·0 and 66·7%, respectively. Among the interventions that had an educational/behavioural component, 61·5% were theory-based. The behaviour change techniques most frequently used in interventions were providing information about the health consequences of performing the behaviour (72·2%), restructuring the physical environment (47·2%), behavioural goal setting (36·1%), self-monitoring of behaviour (33·3%), threat to health (30·6%) and providing general social support (30·6%). Conclusions: School-based interventions show promising results to reduce SSB consumption among adolescents. A number of recommendations are made to improve future studies. Vargas Gracias et al 2017: Design: systematic review and meta-analysis Aim: to evaluate the effects of interventions to reduce sugar-sweetened beverages (SSB) or increase water intakes and to examine the impact of behaviour change techniques (BCTs) in consumption patterns. Databases: Randomized and nonrandomized controlled trials published after January 1990 and until December 2016 reporting daily changes in intakes of SSB or water in volumetric measurements (mL d-1 ) were included. Methods: We calculated mean differences (MD) and synthesized data with random-effects models . Forty studies with 16 505 participants were meta-analysed. Results: Interventions significantly decreased consumption of SSB in children. Pooled estimates of water intakes were only possible for interventions in children, and results were indicative of increases in water intake. modelling/demonstrating the behaviour helped to reduce SSB intake and that interventions within the home environment had greater effects than school-based interventions. - Strengths: rigorous published protocol with a thorough search strategy and screening process allowing us to synthesize data on more studies than previous reviews and meta- analyses in this subject. Multi- and single- component programmes included from a diversity ofcountries and settings. Limiattions: findings are limited, by the overall quality of studies. a compensation in other sugary drinks or sugar-added products could also have occurred which have not been quantified nor reported. Efforts have been made to better categorize SSB, but a clearer definition is needed so as to incorporate and differentiate between those offering better nutritional values. Although we restricted our inclusion criteria to studies that used standard methods of assessment, measuring beverage intake is challenging and prone to error, particularly from biased or underestimated portion sizes. Heterogeneity was high across analyses in SSB and water outcomes and, while measures were taken a priori to explore this variation, subgroup analyses were only partially able to explain it which is suggestive of other differences between study outcomes not explained by the variables considered in our analyses. Conclusions: public health interventions - mainly via nutritional education/counselling - are moderately successful at reducing intakes of SSB and increasing water intakes in children. However, on average, only small reductions in SSBs have been achieved by interventions targeting adolescents and adults.
- Search strategy was comprehensiveness and was able to capture all possible interventions and different types – global view on this topic.
- Variability in the setting, baseline characteristics of participants, or intervention strategies of different trials THIS VARIATION ENRICHED THE QUALITATIVE SYNTHESIS BUT IT WAS A DRAWBACK IN THE QUANTIATIVE analysis.
- Examine the effectiveness of multiple- vs. single-component interventions
- This should be a check-box answer (i.e. select all that apply)