6

The Role of Industry in Sugar-Sweetened Beverage Consumption

Moderator Barbara Devaney, senior fellow at Mathematica Policy Research, began by noting that the session would consider industry’s role in current consumption patterns in the United States and explore approaches industry could take to reduce sugar-sweetened beverage consumption through approaches such as marketing, partnerships, product reformulation, and other strategies. Jennifer Harris, director of marketing initiatives at the Rudd Center for Food Policy and Obesity, spoke first, offering her perspective on marketing sugar-sweetened beverages to young children and their parents. Next, Richard Black, a principal at Quadrant D Consulting, outlined voluntary and regulatory industry approaches regarding sugar-sweetened beverages. Anne Ferree, the Alliance for a Healthier Generation’s leader of engagement with the business sector, then described partnerships with industry to improve beverage choices for young children. A facilitated discussion with the audience, moderated by Devaney, followed the prepared remarks.

MARKETING SUGAR-SWEETENED BEVERAGES TO YOUNG CHILDREN AND THEIR PARENTS¹

Harris provided definitions for key terms she used throughout her presentation in order to provide a common foundation:

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¹ This section summarizes information presented by Jennifer Harris.

• Sugar-sweetened beverages was used to describe any beverage that contains added sugars (e.g., soda, fruit-flavored drinks),² including sweetened milks and supplements designed for very young children.
• Marketing was defined as “anything that influences people’s purchases, attitudes, [and] opinions.” Harris noted that marketing encompasses “product formulation, packaging, claims, promotions, licensed characters, shelf placement, point-of-sale displays,” and other avenues.
• Advertising was defined as persuasive messages disseminated through mass media, such as television, radio, the Internet, and print.
• Brand was defined as the collection of images and concepts that represent the customer experience.

Citing a 2006 Institute of Medicine report on food marketing to children and youth (IOM, 2006), Harris explained that marketing affects children’s “brand recall, preferences, requests to parents, and short-term consumption of advertised products.” Since the release of the report, evidence has emerged to suggest that food advertising increases children’s preference of a product category (e.g., advertising for a specific soda brand increases preference for soda in general), increases caloric consumption while viewing the advertisement, improves the perception of a product, normalizes a product, and makes the product appear appropriate and suited for children (Harris et al., 2009; Kelly et al., 2015).

Harris then discussed three broad topic areas: beverages marketed as intended for children, marketing and advertising beverages to children, and marketing beverages to parents.

Beverages Marketed as Intended for Children

Sugar-sweetened beverages that are marketed as intended for children are mostly fruit drinks and a few flavored waters (Harris et al., 2014). Harris showed that the nutrition profiles of such products remained relatively unchanged between 2011 and 2014 (see Table 6-1). She highlighted that approximately 40 percent of these products contain nonnutritive sweeteners, such as stevia or sucralose. Despite the proportion of products containing juice increasing between 2011 and 2014, the median juice content of such products remained the same—at 5 percent juice.

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² In her presentation, Harris defined the term sugary drinks. As noted in Chapter 1, for consistency of language, the term sugar-sweetened beverages is used throughout this proceedings.

TABLE 6-1 Nutrition Profile of Children’s Beverages, 2011 and 2014

SOURCE: As presented by Jennifer Harris, June 22, 2017.

Marketing and Advertising Beverages to Children

Studies suggest that children younger than approximately 8 years of age view advertising as information and are not able to grasp its persuasive intent (IOM, 2006; Wilcox et al., 2004). It has therefore been argued that marketing to young children is inherently misleading (Harris and Graff, 2012; Pomeranz, 2010). Harris explained that companies use various approaches to market to young children, including attractive packaging, online games, and brand and licensed characters.

Shifting her remarks toward advertising, Harris discussed the voluntary Children’s Food and Beverage Advertising Initiative (CFBAI). Implemented in 2007, CFBAI establishes nutrition standards for products whose advertising is directed primarily to children younger than 12 years of age. Most of the companies that participate in CFBAI also have a policy to refrain from directing advertising toward children younger than 6 years of age. Harris credited CFBAI for no full-sugar beverages being advertised on child-oriented television in 2016. She noted, however, that while advertising is not directly targeted at young children, children in this age range do encounter advertising when they watch programming that is viewed by a wide audience of children and adults. Furthermore, evidence suggests that black children are exposed to approximately 60 percent more food advertising than their white counterparts, partially due to watching more television.

Marketing Beverages to Parents

In explaining the marketing of children’s beverages, Harris said:

One way in which children’s beverages are marketed to parents is through nutrition claims (e.g., “good source of vitamin E”). Harris noted that, on average, children’s beverages have 4.3 nutrition claims per package. Use of fruit images on packages and placement of a shelf-stable product next to orange juice in the refrigerated section in the grocery store are other examples Harris shared.

A survey of 1,100 parents provided insight into the opinions and behaviors of parents regarding various beverages. Results found that 92 percent with a child 2 to 5 years of age provided some form of sugar-sweetened beverage in the month prior to the survey (Munsell et al., 2016). On average, 2.4 different types of beverages were provided, with 80 percent serving fruit drinks, approximately one-third providing flavored waters and sports drinks, and 40 percent providing soda. Parents who provided sugar-sweetened beverages were more likely to view such products as very or somewhat healthy, as compared to parents who did not provide such beverages. Parents also tended to view particular brands as healthier than the product category.

Harris also shared unpublished data on child beverage sales, particularly single-serving bottles and aseptic juices. Of the child-targeted beverages, 71 percent contained added sugars, as compared to 46 percent of other products. Sales of child-targeted products with added sugars were also more responsive to price reductions than other products and child-targeted products with no sweeteners. Promotional displays had a similar effect, noted Harris.

To conclude her presentation, Harris drew attention to toddler drinks (also called toddler milks or toddler formulas), a fairly new product category with the intended consumer being young children who no longer consume infant formula. The marketing of such products largely focuses on benefits to children’s growth and development. Harris noted that all toddler drinks currently on the market have structure/function claims (a claim suggesting an ingredient will be beneficial to the child in some way), averaging 2.3 claims per package. Total advertising spending on toddler drinks has increased since 2011, whereas it has decreased for infant formulas (see Figure 6-1). Harris noted that toddler drinks are heavily advertised in Spanish-language media. Referring to these products as “sweetened milk,” Harris characterized toddler drinks as an emerging issue.

SUGAR-SWEETENED BEVERAGES: VOLUNTARY AND REGULATORY INDUSTRY APPROACHES³

Black’s presentation focused on four central topics: establishing trust, interpreting statistics, building on successes and acknowledging failures, and considering impediments and opportunities for forward progress.

Establishing Trust

“Simply because you work in one space or another does not mean you should not be trusted,” stated Black. Trust among stakeholders is essential to forward progress. Drawing on the definitions of Solomon and Flores (2001), Black presented trust as a spectrum. Blind trust, an unwavering type of trust that continues even in spite of betrayal, anchors one end of the spectrum. Simple trust follows and is a type of trust that lacks doubt, but may not be restored if betrayed. At the other end of the spectrum is a “façade of goodwill and congeniality that hides distrust” called cordial hypocrisy, a type of trust that impedes honest communication. Authentic trust exists in the middle of the spectrum. Underlying authentic trust is an awareness that disappointment and betrayal are possibilities, and as such, authentic trust is something that must be fostered. Black explained that the food and

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³ This section summarizes information presented by Richard Black.

beverage industries seek to establish and cultivate authentic trust through partnerships and highlighted features that make for successful partnerships (see Box 6-1). He emphasized that while biases need to be acknowledged and managed, “everyone brings something worthwhile to the table.”

Interpreting Statistics

Black demonstrated the need for careful interpretation of statistics by first using an example of advertising to children. He stated that television advertisement is considered child-directed if 30 percent or more of the program’s audience are children, irrespective of total viewership. A television show with a large audience could remain under the 30 percent threshold while drawing a greater absolute number of children as compared to children’s programming with a smaller total audience. Black pointed out that while children see advertisements, as it is currently determined, they are not targeted in general.

To further emphasize his point, Black presented a graph showing the prevalence of adult obesity increasing between 1999 and 2009, while the daily per capita calories from sugar-sweetened beverages were decreasing during the same period. Layering on the context of consumption patterns (see Figure 6-2), he indicated that the per capita data encompass a situation in which the top quartile of the population is consuming the majority of a product and overconsumption persists. He drew a parallel with per capita sugar-sweetened beverage intake in India and Latin America, in which intake in India is less and could be interpreted as a nonissue. The data from India, a country in which most of the population lives in rural

settings, reveal that the majority of intake is occurring in urban areas, noted Black. In thinking about impact, he suggested that the focus needs to be on understanding who is consuming sugar-sweetened beverages.

Building on Successes and Acknowledging Failures

Next, Black discussed voluntary efforts in which industry has engaged to address sugar-sweetened beverage consumption. A partnership with the Clinton Foundation, for example, led to the beverage industry agreeing to voluntarily eliminate full-calorie beverages from schools and follow guidelines for elementary, middle, and high schools. Subsequent to this agreement, calories shipped to U.S. schools decreased by 90 percent. Through the Healthy Weight Commitment Foundation, industry members have removed more than 6 trillion calories per year from the marketplace, exceeding its initial goal of 1.5 trillion calories.

Black used predictive models of the Healthy Weight Commitment Foundation calorie goal to again highlight challenges of interpreting data. One of the predictive models (a negatively accelerating curve) suggested the calorie reduction in the marketplace followed as expected, where another predictive model (linear time trend) suggested the reductions that took place were much greater than expected. Black’s point was not to argue the merits of the models, but instead to emphasize the importance of considering different perspectives.

Other voluntary initiatives taken by industry have included placing calorie information on the front of packages and reformulating and developing products to be lower in calories. Black noted that there have been attempts to reformulate existing sugar-sweetened beverages to have lower calorie content, but it continues to be a challenge owing, in part, to consumer expectation and acceptability. He acknowledged that not all consumers are receptive to health messages and, as such, there is not a “one size fits all” solution.

Black drew attention to what he perceives is a limitation of existing excise taxes on sugar-sweetened beverages. Using the tax in Mexico as an example, he highlighted that the existing taxes are graduated based on the volume of the product, which does not provide an incentive to companies to lower sugar content of the taxed products. He suggested that a graduated tax based on grams of sugar would incentivize such reductions. Black cited that analyses from Mexico indicate that per capita sugar-sweetened beverage consumption had significantly decreased after instituting the tax, but that consumption of taxed carbonated sodas has decreased less than their noncarbonated taxed counterparts.

Considering Impediments to and Opportunities for Forward Progress

With more than 3 billion people having access to the Internet and approximately 60 percent of the global population having access to a personal mobile device, Black expressed that there is an opportunity to better leverage digital media. He also emphasized the need to have countervailing voices to refute misinformation. Black concluded by saying that accountability is a key aspect of partnerships—for creating and meeting targets that can be measured and interpreted—and that partners need to be active supporters of such efforts.

PARTNERSHIPS WITH INDUSTRY TO IMPROVE BEVERAGE CHOICES OF YOUNG CHILDREN⁴

The Alliance for a Healthier Generation (hereafter referred to as the Alliance) was established in 2005 as a joint initiative of the American Heart Association and the Clinton Foundation. The Alliance strives to create healthier community environments and to work with companies to transform the marketplace in an effort to improve children’s health. To create a systemic change, the work of the Alliance extends beyond just the marketplace, and includes efforts in schools, after-school programs, summer camps, early care and education settings, and juvenile justice facilities.

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⁴ This section summarizes information presented by Anne Ferree.

Because there is no single cause for the health issues children face, noted Ferree, there cannot be a single solution.

Ferree provided an overview of the 2006 Alliance School Beverage Guidelines, which was the first agreement between the Alliance and the business sector. The voluntary guidelines, which predated the Healthy, Hunger-Free Kids Act of 2010, were brokered with the American Beverage Association, the Coca-Cola Company, PepsiCO, and Cadbury-Schweppes (now Dr. Pepper-Snapple). Ferree explained that through the partnership, companies agreed to a number of changes, including phasing out sales of full-calorie carbonated soft drinks, shifting product combinations to favor low- and no-calorie beverages, and reducing portion sizes of products sold in schools. The Alliance had an independent, third-party evaluator assess the effect of the agreement. Between 2004 and the 2009–2010 school year, beverage calories shipped to schools decreased by 90 percent; volume of beverages shipped to schools decreased by 77 percent; volume of full-calorie, carbonated soft drinks shipped to schools decreased by 97 percent; and volume of restricted beverages (including juice drinks, flavored water, and teas) shipped to schools decreased by 94 percent (Wescott et al., 2012).

Ferree explained that the Alliance believes that there is “a place at the table for every single company in this country,” large or small, and she shared lessons her organization has learned through its range of partnerships across various sectors. First, Ferree emphasized the importance of taking a systems approach to researching an issue, identifying gaps, and considering solutions. As an example, she showed a diagram of the various elements of the food system (e.g., food production, distribution and aggregation, marketing, preparation and consumption), and stated that trying to understand the issues to the fullest extent possible helps in the identification of companies to engage.

Ferree then noted that there is no single approach to developing meaningful and impactful partnerships. The Alliance has found success by engaging entire sectors, and she noted that finding a shared value is a foundational step to forming such relationships. She acknowledged that collaboration with companies in the same sector can be complex, and it requires attention to issues of confidentiality, accountability, and impartiality. When an entire sector is not amenable to coming to the table at one time, the Alliance intentionally structures agreements with companies with the largest market share to create a domino effect. Such an approach was taken in the Alliance’s efforts to improve children’s menus. Ferree said, “Sometimes one large company can make such a difference that [it is] worth going ahead and working with them in a really concerted way.” Another key to the Alliance’s enduring partnerships has been seeking top-down backing from “high-level champions” within the partner companies, Ferree stated. To that end, she emphasized the importance of understanding where a business

is coming from and to being able to “speak their language.” Because public health issues are not constantly at the forefront of their partners’ minds, and shareholder monetary value is, Ferree explained that the Alliance brings that knowledge and challenges the thinking of their partners.

Ferree emphasized the value of maintaining transparency and preserving integrity over the lifetime of a partnership. The Alliance has included having a credible, third-party, nongovernmental organization involved from the beginning to set goals and determine how the agreement will be evaluated and communicated, as well as retaining an evaluator to not only verify that each agreement is being executed, but also to measure the results of each agreement.

Changing consumer behavior toward products with less sugar and fewer calories has been challenging, Ferree remarked. She said that the Alliance’s second agreement with the beverage industry, which is built on long-term relationships, has a goal of reducing beverage calories consumed per person per day in the United States by 20 percent by 2025 (from 199 calories per day in 2014, to 159 calories per day by 2025). Through the agreement, partners will:

• Continue to promote calorie and sugar awareness on all company-owned equipment, which includes millions of vending machines, retail coolers, and fountains in convenience stores, restaurants, and other locations.
• Transform consumer palates through innovating, reformulating, distributing, and marketing no- and low-calorie beverages.
• Create incentives and engagement through consumer education and outreach at the community level.

Ferree added that the companies are also engaging in work in 8 to 10 communities to test and learn what works in creating the desired shifts. Ferree concluded her presentation by reminding the audience that engaging the business sector is about individual relationship building, trust building, understanding their business, and finding a common goal.

FACILITATED DISCUSSION WITH THE AUDIENCE

Following Ferree’s presentation, she, Black, and Harris took part in a facilitated discussion with the audience, moderated by Devaney. Topics that emerged during the conversation included unintended consequences, marketing and advertising, use of technology, and partnerships.

Unintended Consequences

Devaney opened the discussion by asking the speakers to broadly discuss the possibility of unintended consequences as a result of any of the strategies. Harris explained that the focus of CFBAI was on advertising to children younger than 12 years of age and that after it was implemented, advertising to children 12 to 17 years of age dramatically increased. As another example, Harris thought that there may be unintended consequences of some of the healthy children’s meal initiatives. She suggested that fewer parents are buying children’s meals for their children. “I’m afraid we may be pushing parents to the cheaper, but less nutritious higher-calorie options on the menu,” stated Harris. She also noted that as sugar is going down in the beverages, the artificial sweeteners or the nonnutritive sweeteners are being added. Harris felt that the topic of artificial sweeteners is an area where the nutrition community needs to weigh in, and perhaps more disclosure about what is in the products is needed.

In response to Devaney’s question, Ferree reminded the audience that one of the challenges is that beverage companies and restaurants react to the wants of the customer. She explained that the Alliance’s most recent beverage agreement included 100 percent juice as part of the goal because an unintended consequence of earlier initiatives to reduce soda consumption may have led to increases in consumption of 100 percent juice. Black thought that an unintended consequence of Philadelphia’s tax is that it does not incentivize the companies to change, as it is applied to all sweetened beverages. He suggested that the tax might potentially fail to maximize the opportunity for behavioral change.

Later in the session, Devaney posed an audience member question, specifically asking about unintended consequences related to product reformulation. Harris replied, there are brand managers who are responsible for profit across all products within their brands and their goal is to increase sales for all of those products. She stated that a recommendation made in a Healthy Eating Research report was that if a product is marketed on children’s television, all the products within that brand should meet the nutrition standards that are set. Ferree pointed out that another way of thinking about it is to incentivize companies to incrementally introduce products that are lower in calories and eventually replace the higher-calorie, higher-sugar products.

Suggesting that it could possibly be an unintended consequence, Devaney asked the speakers if juice concentrates are being used in place of other sweeteners. Black expressed his concerns over “stripped” juice concentrates, which, in his view, are indistinguishable from sugar water because the characterizing aspects of the juice, and likely the beneficial components, have been removed. Ferree responded that the Alliance fo-

cuses on all calories and all sugars, in an effort to avoid the swapping of one caloric sweetener for another. An audience member, identified as a representative from the Juice Products Association, said that if a juice concentrate is reconstituted to the Brix level of 100 percent juice, it is not considered a sweetener, but if the juice concentrate is added to a product to sweeten and not reconstituted to its 100 percent level, then it would be considered a sweetener.

Marketing and Advertising

Devaney combined several audience member questions to ask the speakers about differences in the effects of marketing by race, ethnicity, or socioeconomic status, and the consistency of efforts to reduce advertising across population groups. Harris replied that there has been limited research to date regarding the effects of marketing on different population groups. She described one hypothesis that currently exists: advertising portrays images of the world that are aspirational for lower-income individuals or recent immigrants, and, as such, would be more effective with those audiences. Harris also noted that targeted marketing to black or Hispanic audiences—groups who have not been traditionally reflected in advertising—appears to be creating goodwill and could potentially be more effective. Disparities in exposure to advertising between black and white youths are growing, Harris noted. Exposure appears to be decreasing for white youths but remaining unchanged for black youths, she elaborated.

An audience member asked the speakers if the definition of child-targeted marketing should be changed. Harris explained that there is a fair amount of marketing not covered by CFBAI. She added that a HER report recommended that CFBAI’s definition of children be extended to include children up to 14 years of age and be applied to television programming viewed by this age group. Harris added that First Amendment issues arise when such restrictions are applied to television programs with a sizable adult audience.

One audience member proposed replacing advertising for sugar-sweetened beverages with advertising for more nutrient-dense beverages and healthier food choices. Harris responded that the 2006 Institute of Medicine food marketing to children report recommended that companies use their creativity and resources to market healthier foods to children in place of the unhealthy food that is typically advertised (IOM, 2006). This recommendation has long been discussed, but has yet to be executed, she noted. Harris acknowledged that foods, such as fruits, vegetables, and milk do not have the profit margins that packaged processed foods do. She also said there is also the philosophical question—should children be advertised to at all? She acknowledged that parents ultimately decide what to serve

their children, and reiterated that young children’s cognitive abilities really are not developed enough to understand the marketing. Drawing on an idea he credited to Hank Cardello, Black suggested that the tax deduction for advertising expenses could be reduced for less healthy foods so it is more expensive for the company to advertise, and conversely the tax deduction could be increased for the healthier food items.

Use of Technology

When asked if there are specific success stories of how technology or social media is used to improve food and beverage consumption, Black responded that one person, owing to the platform of the Internet, can actually cause a company to respond and change. He said that campaigns have sped up the rate or the pace at which companies respond, but can also be a platform for exaggeration and misinformation. Harris indicated that the food industry has been at the forefront of digital and social media marketing. She acknowledged that viral social media campaigns are a low-cost approach that can have an effect. Black added, “The beauty of the Internet is that you [do not] need money, you need creativity.”

An audience member asked the speakers if it was possible to have an intervention that would give parents the ability to control their children’s exposure to advertisements. Harris suggested that parents monitor and track what websites their children are visiting. She added that children should only be exposed to high-quality media, such as noncommercial media.

Partnerships

Devaney posed a question from the audience regarding federal involvement in partnerships. Ferree said that she did not know about federal support specifically, but indicated that there is a role for government (e.g., local departments of health) so there is alignment of messages and campaigns. Black stated that the examples tend to be more on the research side, as opposed to outreach and consumer education. He noted that the International Life Sciences Institute, for example, led an initiative with the U.S. Department of Agriculture (USDA) to develop a branded foods database. At present, the database is populated with approximately 200,000 branded foods and is used for the dietary assessment portion of the National Health and Nutrition Examination Survey. He explained that the food industry supplies the data. From the audience, Robert Post added that the MyPlate strategic partners’ effort with the USDA Center for Nutrition Policy and Program serves as an example. Through this partnership, he elaborated, MyPlate programming is used by more than 100 large multisector organizations.

In thinking about partnership, an audience member asked the speakers

if changes in consumption of sugar-sweetened beverages should be considered the measure of success. Ferree responded that, ideally, measurements would be taken in different ways (e.g., changes in consumption, across product type, in availability) to really understand what is having an effect, but she acknowledged that it is not always feasible, primarily because it is resource intensive. Black said he is in favor of using very specific measures and suggested that the measure to limit sugar-sweetened beverages is straightforward.