Soft Drinks, Weight Status and Health: A Review

NSW Cetre for Public Health Nutritio NSW cph NSW Cetre for Public Health Nutritio Soft Driks, Weight Status ad Health: A Review The NSW Cetre for Public Health Nutritio is fuded by the NSW Departmet of Health ad supported by the Sydey Nutritio Research Foudatio

SOFT DRINKS, WEIGHT STATUS AND HEALTH: A REVIEW Debra Hector, Aa Raga, Jimmy Louie, Vicki Flood, Tim Gill A NSW Cetre for Public Health Nutritio project for NSW Health Suggested citatio: Hector D, Raga A, Louie J, Flood V, Gill T (2009). Soft driks, weight status ad health: a review. Sydey: A NSW Cetre for Public Health Nutritio (ow kow as Cluster of Public Health Nutritio, Prevetio Research Collaboratio, Uiversity of Sydey) project for NSW Health. This work is copyright. It may be reproduced i whole or i part for study traiig purposes subject to the iclusio of a ackowledgmet of the source ad o commercial usage or sale. NSW Cluster of Public Health Nutritio NSW Departmet of Health 2009. SHPN (CHA) 090049 ISBN 978 1 74187 356 6 For more iformatio please cotact: NSW Cluster of Public Health Nutritio Level 2, K25 Medical Foudatio Buildig The Uiversity of Sydey NSW 2006 Tel: +61 2 9036 3005 Fax: +61 2 9036 3184 http://www.cph.mmb.usyd.edu.au Dowload copies of this report from the NSW Cluster of Public Health Nutritio s website: http://www.cph.mmb.usyd.edu.au or NSW Health website: http://www.health.sw.gov.au Jue 2009

Cotets Executive Summary... 5 1. Itroductio... 7 1.1 Backgroud...7 1.2 Purpose...7 2. Soft Drik Cosumptio i NSW ad Australia... 9 2.1 Apparet Cosumptio Data...9 2.2 Beverage Idustry Data...9 2.3 Dietary Survey Data...10 2.3.1 1995 Natioal Nutritio Survey...10 2.3.2 Other Dietary Surveys i Australia...11 3. Factors Associated with Soft Drik Cosumptio... 13 3.1 Socio-Cultural Factors...13 3.1.1 Socio-Ecoomic Status ad Materal Educatio...13 3.1.2 Cultural Backgroud...13 3.1.3 Geder...13 3.2 Psycho-Social Factors...14 3.2.1 Persoal Factors...14 3.2.2 Paretig Practices...14 3.3 Evirometal Factors...15 3.3.1 Soft Drik Availability...15 3.3.2 Portio Size...16 3.3.3 Cost...16 3.3.4 Marketig...16 4. Costs ad Health Implicatios of Soft Drik Cosumptio... 18 4.1 Weight Status...18 4.1.1 Evidece of a Associatio...18 4.1.2 Evidece of Causality...21 4.2 Other Health Implicatios...22 4.2.1 Detal Health...22 4.2.2 Displacemet of Healthier Foods from Diet...23 4.2.3 Boe Health...23 4.2.4 Caffeie...23 4.2.5 Chroic Disease...24 4.2.6 Bezee i Soft Driks...24 4.3 The Ecoomic Cost of Soft Driks...24 4.4 The Evirometal Cost of Soft Driks...25 5. Other Sugary Beverages ad Health... 26 5.1 Fruit Juice...26 5.1.1 Weight Status...26 5.1.2 Other Health Effects...26 5.2 Artificially-Sweeteed or Diet Soft Driks...27 5.2.1 Weight Status...27 5.2.2 Other Health Effects...27 5.2.3 Safety...27 5.3 Milk...28 5.3.1 Health Beefits...28 5.3.2 Weight Status...28 5.4 Fuctioal Driks...28 5.4.1 Sports Driks...28 5.4.2 Eergy Driks...29 5.5 Summary...29 6. Strategies to Reduce Soft Drik Cosumptio... 30 6.1 Behavioural Goals...30 6.1.1 Reduce Uptake of Soft Driks by Youg Childre...30 6.1.2 Reduce Frequecy ad Quatity of Soft Drik Cosumptio...30 6.1.3 Replace Soft Driks with Artificially Sweeteed Driks...30 6.1.4 Replace Soft Driks with Water...31 Soft Driks, Weight Status ad Health: A Review PAGE 1

6.2 Social Marketig ad Public Educatio...31 6.2.1 Social Marketig ad Healthy Dietary Behaviours...32 6.2.2 Social Marketig ad Other Health Behaviours...32 6.2.3 Curret Social Marketig Iitiatives Aimed at Dietary Behaviours...33 6.2.4 Social Marketig Aimed Upstream...33 6.3 Potetial Evirometal Strategies...33 6.3.1 Reductio of Access to Soft Driks/ Icreased Access to Water...34 6.3.2 Price Icrease through Taxatio...34 6.3.3 Reducig Portio Sizes...35 6.3.4 Restrictig Marketig to Childre...35 6.3.5 Labellig ad Packagig...35 6.3.6 Product Reformulatio...36 7 Coclusios... 37 7.1 Ivestmet i Reducig Soft Drik Cosumptio...37 7.2 Target Populatios...38 7.3 Implicatios for Qualitative Research...38 7.4 Public Educatio/Social Marketig Campaig...39 7.5 Iovatio ad Applied Research Regardig Potetial Approaches...39 7.6 Evirometal Chages...40 7.7 Moitorig...40 Glossary... 41 Appedix 1 Lessos Leared from Social Marketig Strategies to Ecourage Healthy Behaviours... 43 Refereces... 45 Tables Table 1: Summary of Australia sources of data o cosumptio of soft drik...9 Table 2: Number of studies likig sugary driks, particularly soft driks, to obesity...18 Table 3: Logitudial studies showig a positive relatioship betwee sugary driks cosumptio ad weight status i childre, adolescets ad adults...20 Table 4: Summary of health implicatios of excessive soft drik cosumptio...22 Table 5: Coclusios cocerig priority actios to reduce soft drik cosumptio at the populatio level i NSW ad Australia...37 Figures Figure 1: Aerated ad carboated waters cosumptio i Australia from 1969 99: Apparet cosumptio data... 10 Figure 2: Sugar-sweeteed beverage cosumptio for differet age groups of childre aged 2 18 years...10 Figure 3: Cosumptio of differet sugar-sweeteed beverages amog adults, per capita per day, i 1995...10 Figure 4: Amouts of sugar-sweeteed soft driks cosumed amog childre aged 2 18 years by differet age groups 11 Figure 5: Volume of sugar-sweeteed soft driks cosumed amog adults i Australia, by age ad sex...12 Appedices Appedix 1: Lessos Leared from Social Marketig Strategies to Ecourage Healthy Behaviours...43 PAGE 2 Soft Driks, Weight Status ad Health: A Review

ABBREVIATIONS BMI CAPS FSANZ HFCS NNS OR SEIFA SES SMILE SPANS WIC Body mass idex Childhood Asthma Prevetio Study Food Stadards Australia New Zealad High-fructose cor syrup Natioal Nutritio Survey Odds ratio Socio-Ecoomic Idexes for Areas Socio-ecoomic status Study o Medical Iformatio ad Lifestyle i Eidhove Schools Physical Activity ad Nutritio Survey Wome, Ifats ad Childre Soft Driks The term soft drik i this report refers to carboated beverages. If o adjective is used, the the term refers to regular or sugar-sweeteed soft driks. I Australia, the sugar added is sucrose. However, some of the literature uses the term soft driks to iclude artificially sweeteed or diet carboated beverages. Where this is the case, we have clarified meaig i the surroudig text. Other termiology icludes sugary driks or sugar-cotaiig driks terms which ecompass carboated sugar-sweeteed soft driks as weell as fruit juices, fruit driks, cordials, sports driks, eergy driks ad iced teas. Throughout this report, amouts of soft driks are expressed i millilitres (1mL = approximately 1 gram). Soft Driks, Weight Status ad Health: A Review PAGE 3

PAGE 4 Soft Driks, Weight Status ad Health: A Review

Executive Summary The prevetio of overweight ad obesity, particularly amog childre, is a public health priority. A rage of iitiatives to address this problem have already bee developed ad implemeted i NSW. However, a broader rage of additioal strategies are eeded to effectively address this complex issue. The high cosumptio of soft driks, i.e. sugarsweeteed carboated beverages, ad other sugary driks is oe of a array of dietary behaviours which has bee idetified by a umber of policy documets as a importat, specific behaviour to address i the prevetio ad maagemet of obesity. This report aimed to: idicate how much soft drik is beig cosumed i NSW ad Australia ad by whom examie the reasos why soft driks are cosumed provide a overview of the health cosequeces of a high cosumptio of soft driks, particularly the evidece relatig soft drik cosumptio to overweight ad obesity explore behaviour chage optios ad strategies to reduce soft drik cosumptio. Australia is a high cosumer of soft driks; amog the top 10 coutries for per capita cosumptio. Sales data idicate that cosumptio of soft drik has remaied relatively stable i the recet past. Detailed iformatio from the 1995 Natioal Nutritio Survey shows that youg males ad adolescets are the highest cosumers, cosumig almost oe litre (approximately 3 cas) per day. Boys cosume sigificatly more soft driks tha girls. Youg adult males aged 19 24 years are the ext highest cosumers of soft driks. Cosumptio of soft driks i 1995 was highest amog the most socio-ecoomically disadvataged adults ad differed betwee states ad territories, but ot betwee urba ad rural/remote regios, i Australia. Smaller studies idicate that boys of Middle Easter ad Souther Europea descet ad Aborigial ad Torres Strait Islader commuities are high cosumers of soft driks. Also, oe study i NSW showed that a large proportio of toddlers aged 16 24 moths cosumed soft driks. I the most recet data reported from the NSW Populatio Health Survey (2005 2006) 20 per cet of 9 15 year olds reported regularly cosumig more tha 1.5 cups of sugary driks per day. Taste is reported to be a key factor i the decisio by adolescets to choose soft driks over other beverages but paretig style ad practices ad paretal cosumptio are also importat. Other importat factors associated with icreased itake are the availability of soft driks (especially i the home), portio size (icludig the small price differetial for larger portios) ad exposure to marketig. There is little iformatio about the determiats of soft drik cosumptio amog subgroups other tha adolescets. There has bee some cotetio over the stregth of the evidece likig soft drik cosumptio to overweight ad obesity. However a umber of recet, comprehesive systematic reviews ad meta-aalyses have show that the evidece is preset i a large umber of studies of various types, with studies of icreasig methodological power showig icreasig stregth of associatio. No studies showed a egative associatio. A strog biological plausibility supports the relatioship. High levels of soft drik cosumptio have bee liked to a rage of other ill-health cosequeces icludig type 2 diabetes, metabolic sydrome, osteoporosis, detal caries, ad the displacemet of healthier food ad beverage optios from the diet. Other health beefits are therefore likely to result from a ivestmet i reducig soft drik cosumptio. There is sufficiet evidece of the potetial beefits of reducig soft drik cosumptio to warrat actio o this issue. New South Wales, alog with some other Australia states, has already imposed a ba o the sale of soft driks i public schools. However, further strategies are eeded as most soft drik cosumptio is likely to occur outside of schools. There is curretly little itervetio evidece to iform actio, hece a rage of iovative iitiatives are required. The lack of awareess cocerig the ill-health cosequeces of soft drik cosumptio ad lack of Soft Driks, Weight Status ad Health: A Review PAGE 5

desire to chage this behaviour could be addressed through a social marketig campaig. Formative research is eeded to iform such a campaig, ad the campaig should have a log-term focus. There are four behaviour chage optios, or messages, to cosider: Reduce frequecy ad quatity of soft drik cosumptio Replace soft driks with artificially-sweeteed driks Replace soft driks with water Reduce uptake of soft drik cosumptio by youg childre. There are disadvatages to most alterative beverages to soft driks, other tha water ad reduced fat milk. Without supportig evirometal chages, idividuallevel behaviour chages are ulikely to occur ad be sustaied. Key policy ad structural issues that could ifluece soft drik cosumptio iclude: restrictig access (icludig reducig availability/visibility); pricig strategies; reducig portio sizes; restrictig marketig to childre (icludig through sposorship ad fudraisig); improvig labellig or utritio sigpostig; ad the reformulatio of products to iclude less sugar. I summary, reducig soft drik cosumptio is oe of a umber of importat behaviours to address i the prevetio of overweight ad obesity. A umber of coclusios are draw which ca iform actio i this area. These relate to: target populatios; implicatios for qualitative research; a public educatio/social marketig campaig; iovatio ad applied research for promisig approaches; evirometal chages; ad, moitorig. PAGE 6 Soft Driks, Weight Status ad Health: A Review

Sectio 1 Itroductio 1.1 Backgroud This report is oe of a series of reports by the NSW Cetre for Public Health Nutritio (CPHN) requested by NSW Health to support evidece-based policy ad plaig i public health utritio. This report complemets ad expads upo oe of the modules withi the recet evidece updates produced by the Prevetio Research Cetres (http://www.coo. health.usyd.edu.au) which reviews the evidece for itervetios to reduce the cosumptio of sugary driks ad icrease the itake of water i childre. It also supports the report Best Optios for Promotig Healthy Weight ad Prevetig Weight Gai i NSW (Gill et al. 2005). The 2006 NSW State Pla, A New Directio for NSW idetifies the prevetio of childhood overweight ad obesity as a priority (Priority S3). The Pla aims to prevet a icrease i the prevalece of childhood overweight ad obesity (curretly 25 per cet) i NSW over the ext 5 years, ad to reduce levels to 22 per cet by 2016. Sugar-sweeteed soft driks ad fruit juices have bee idetified as oe of the dietary cotributors to overweight ad obesity (Joit WHO/FAO Expert Cosultatio 2003). This report stated that each ca of soft drik cosumed per day icreases the risk of beig obese by 60 per cet. Other public health orgaisatios have ackowledged the lik betwee the cosumptio of sugar-sweeteed beverages ad obesity ad have advised a reductio i itake of such beverages to help prevet weight gai (Joit WHO/FAO Expert Cosultatio 2003; Committee o Prevetio of Obesity i Childre ad Youth 2004; Murray et al. 2004; Dietary Guidelies Advisory Committee 2005). Other dietary behaviours which likely cotribute to overweight ad obesity iclude the over-cosumptio of eergy-dese utriet-poor foods (ofte cosumed outside of meals as sacks), the low cosumptio of fruit ad vegetables, ad the lack of family meals. Low levels of physical activity ad high levels of sedetary activity also cotribute to a eergy imbalace. Over-cosumptio of ay sugary drik has the potetial to lead to a eergy imbalace. However soft driks ca be sigled out for specific attetio as a possible target of populatio-level obesity-prevetio programs for a umber of reasos. First, sugar-sweeteed carboated beverages, or soft driks, are the most popular waterbased beverages i Australia. Iteratioal market research data idicates Australia is raked amog the top 10 coutries for per capita cosumptio of soft driks (Beverage Digest 2006). Secod, they are well-idetified products that are readily available ad marketed extesively, especially to teeagers. Third, sugarsweeteed soft driks are a commo source of sugar ad eergy, with oe regular ca cotaiig 10 teaspoos of sugar ad 640 kj (150 cal), but provide o other utritioal value other tha fluid so-called empty calories (Jacobso 2005). They are idetified as a extra food i The Australia Guide to Healthy Eatig (NHMRC 2003a; 2003b), i.e. a food that should be cosumed oly occasioally ad i small amouts. Occasioally has bee defied as oce a week or less by The Commuicatio o Obesity Actio for Child Health (COACH) Referece Group (Wilde et al. 2007), which represeted the major NGO ad professioal groups commuicatig o childhood obesity issues i Australia. The beverage idustry coteds that soft driks have a valuable hydratio role i a cotiet that experieces mostly temperate weather with may extremes of heat (Australia Beverages Coucil 2004). However, the eed for hydratio could ormally be adequately filled by other beverages without the accompayig sugar ad eergy cotet, such as water. Moreover, soft driks are less hydratig tha water. 1.2 Purpose This report appraises a broad rage of issues relatig to soft drik cosumptio, ad reflects iformatio ad the literature available up to mid-2008. The report is ot a exhaustive review but is iteded to stimulate cosideratio of some of the wider issues associated with reducig soft drik cosumptio. It provides a overview of curret kowledge surroudig the relatioship betwee soft drik cosumptio ad weight status ad other health implicatios, ad reports o the ature ad extet of soft Soft Driks, Weight Status ad Health: A Review PAGE 7

drik cosumptio i NSW ad Australia. It cosiders the factors affectig soft drik cosumptio. It aims to build o the evidece-base for itervetios to reduce soft drik cosumptio, which is curretly extremely limited, by examiig some broader ideas for itervetios ad strategies that might impact o this problem. Specifically this report addresses the followig questios: Who cosumes soft driks ad how much is cosumed? Why are soft driks cosumed? What are the ill-health ad other cosequeces of soft drik cosumptio? How could we reduce the cosumptio of soft driks? Soft driks are chose as the focus of the review ad are targeted for desirable behaviour chage. However, other sugary beverages such as cordials, fruit driks, fruit juices, eergy driks ad sports driks are also discussed as they have the potetial to cotribute to a eergy imbalace. The iformatio i this report ca be used to support evidece-based policy ad plaig as part of a portfolio of itervetios aimed to reduce the prevalece of overweight ad obesity ad cotribute to a healthier diet. PAGE 8 Soft Driks, Weight Status ad Health: A Review

Sectio 2 Soft Drik Cosumptio i NSW ad Australia Data relatig to soft drik cosumptio i Australia ad NSW are obtaied from a umber of sources icludig the most recet atioal dietary survey, state-level populatio surveys, a umber of smaller-scale surveys ad retail sales data (Table 1). Table 1: Summary of Australia sources of data o cosumptio of soft drik (ordered accordig to appearace i curret report) Source Apparet cosumptio data; Australia Bureau of Statistics 2000 Australia Beverages Coucil website Australia Beverages Coucil; McPherso 2005 Euromoitor report; Euromoitor Iteratioal 2006 Levy ad Tapsell 2007 Natioal Nutritio Survey 1995; Australia Bureau of Statistics 1998 NSW Populatio Health Surveys; NSW Departmet of Health 2002 ad 2008 Cosumptio of itese sweeteers i Australia ad New Zealad report; FSANZ 2003 Schools Physical Activity ad Nutritio Survey; Booth 2006 Childhood Asthma Prevetio Study; Webb 2006 Descriptio Apparet cosumptio data are estimates of per capita cosumptio derived usig iformatio relatig to the supply (productio, chage i stocks, imports), ad utilisatio (exports, o-food use, ad use i processed food) of foods Iformatio o average per capita cosumptio of soft driks obtaied from sales data Report cotaiig sales data used to estimate treds i eergy itake Market report o retail sales data Research paper used sales data from the Australia beverage idustry to describe treds i purchasig patters of o-alcoholic, water-based beverages, 1997 2006. Most recet Australia atioal utritio survey, used a stadardised 24-hour recall to obtai dietary itake data from 3008 childre ad 10,851 adults The New South Wales Populatio Health Survey is a ogoig telephoe survey which moitors populatio health. Short questios are used to moitor itakes of selected foods icludig sugary driks. Phoe survey, carried out by Roy Morga Research, ivestigated cosumptio patters ad exposure to itese sweeteers amog Australias ad New Zealaders aged 12 years ad over. Short questios were used to examie cosumptio of sugar-sweeteed ad itesely-sweeteed soft driks. NSW health survey of 5500 schoolchildre aged 5 16 years. Dietary itake was assessed usig a series of short questios amog 11 16 year old studets. This study examied dietary itake usig 3 day weighed food records of 429 toddlers aged 16 24 moths i Wester Sydey 2.1 Apparet Cosumptio Data The most recet apparet cosumptio data (based o supply) i Australia idicate that the per-capita cosumptio of carboated ad aerated beverages, icludig sugarsweeteed ad artificially sweeteed or diet driks, i 1998 99 was 113.0 litres. This equated to a icrease of 240 per cet over 30 years (Figure 1) (Australia Bureau of Statistics 1998a). Similarly, the soft drik idustry reported that the average per capita cosumptio of soft driks was 110 litres i 2003. This amout equates to approximately 300 ml of soft drik (regular ad diet) cosumed per perso, per day (Australia Beverages Coucil 2007b). 2.2 Beverage Idustry Data Data from the soft drik idustry have idicated that the rapid market growth observed over previous years has slowed over the past 5 years. This slower growth has bee accompaied by a icrease i sales of artificiallysweeteed driks. For example, recet research used idustry-based Australia sales figures to aalyse purchasig patters of water-based beverages from 1997 2006 (Levy ad Tapsell 2007). Durig this time, the total volume of sales of all soft driks (diet ad regular) icreased by 5 per cet ad this icrease was maily due to a icrease i sales of diet soft driks which icreased by 28 per cet, with sales of sugar-sweeteed soft driks Soft Driks, Weight Status ad Health: A Review PAGE 9

remaiig relatively stable. The volume share of regular compared to diet soft driks chaged from 76:23 i 1997 to 69:31 i 2006. These treds i sales of the differet beverages are observed from other data sources, such as the Euromoitor Report o carboated soft driks i 2006 (Euromoitor Iteratioal 2006) ad a earlier beverage idustry report i Australia (McPherso 2005). Apart from diet soft driks, other growth areas i water-based beverages i Australia iclude sports driks, drik mixers (used with alcoholic driks) ad eergy driks (Levy ad Tapsell 2007). Figure 1: Aerated ad carboated waters cosumptio i Australia from 1969 99: Apparet cosumptio data Apparet Cosumptio (L) 120 100 80 60 40 20 0 1969 1979 1989 1999 Year Source: Australia Bureau of Statistics 1998a 2.3.1.1 Cosumptio amog childre Cosumptio of all sugar-sweeteed driks by childre icreased with age (Figure 2). Most of this icrease was due to soft drik cosumptio, with similar itakes of cordials, fruit juices ad fruit driks across age groups. For childre of all ages (2 18 years), the largest cotributor to sugar-sweeteed driks cosumptio was soft driks, followed by cordials, fruit juice, fruit driks ad sports driks. Similarly for adults, the largest cotributor to sugar-sweeteed driks was soft driks, followed by fruit juice, fruit driks, cordials ad sports driks (Figure 3). Figure 2: Sugar-sweeteed beverage cosumptio for differet age groups of childre aged 2 18 years: data from the 1995 Natioal Nutritio Survey; aalysis by NSW Cetre for Public Health Nutritio Volume Cosumed (L) 700 600 500 400 300 200 100 Sports Driks Sugar-sweeteed Soft Driks Cordials Fruit Driks Fruit Juices 2.3 Dietary Survey Data 0 2 3 4 7 8 11 12 15 16 18 Age group (year) 2.3.1 1995 Natioal Nutritio Survey The most recet survey of dietary behaviours, icludig beverage cosumptio, at the atioal level was the 1995 Natioal Nutritio Survey (1995 NNS) (Australia Bureau of Statistics 1998b). The 1995 NNS used a 24-hour recall iterview by traied dietitias to estimate the food ad drik cosumptio of a atioally-represetative sample of the populatio aged 2 years ad over. Figure 3: Cosumptio of differet sugar-sweeteed beverages amog adults, per capita per day, i 1995; data from the 1995 Natioal Nutritio Survey; aalysis by NSW Cetre for Public Health Nutritio Volume (ml) 140 120 Basic data were published from this survey but foodspecific data were ot origially published. The NSW Cetre for Public Health Nutritio therefore udertook a i-depth aalysis of these survey data to provide a detailed picture of cosumptio patters i Australia. Amouts of soft driks cosumed, which are reported i grams i the NNS data, have bee coverted to millilitres i this documet to avoid cofusio ad make them comparable to other reported studies. 100 80 60 40 20 0 Sugarsweeteed soft driks Fruit juices Cordials Fruit Driks Sports driks PAGE 10 Soft Driks, Weight Status ad Health: A Review

O the survey day, soft driks were cosumed by approximately a quarter of 2 7 year olds, a third of 8 15 year olds ad half of 16 18 year olds. Per-capita itake icreased with age amog childre, from 53 ml for 2 3 year olds to 364 ml for 16 18 year olds. Also, per-cosumer itake (the average itake amog those who cosumed soft driks) icreased with age, ragig from 222 ml (approximately two thirds of a ca) for 2 3 year olds to 714 ml (approximately 2 cas) for 16 18 year olds (Figure 2). Util 12 years of age, boys ad girls cosumed similar amouts of soft driks but after this age cosumptio i males surpassed that of females. For example the average per-capita cosumptio amog boys aged 16 18 years was double that cosumed by girls, a average of 480 ml compared to 240 ml per day. Amog those cosumig soft driks, itakes were 836 ml for boys ad 545 ml for girls, represetig 10.8 per cet of total eergy itake for boys ad girls i this age group. Figure 4: Amouts of sugar-sweeteed soft driks cosumed amog childre aged 2 18 years by differet age groups, data from the 1995 Natioal Nutritio Survey; aalysis by the NSW Cetre for Public Health Nutritio Volume (ml) 800 Per cosumer 700 Per capita 2.3.1.3 Cosumptio by State, Regio ad Socio-ecoomic Status Socio-ecoomic status Socio-ecoomic status (SES), SEIFA (Australia Bureau of Statistics Socio-Ecoomic Idexes for Areas) ad curret occupatio were idetified as beig associated with soft drik cosumptio amog adults i the 1995 NNS. Cosumptio of soft driks was sigificatly higher amog those i the quitile of highest socio-ecoomic disadvatage compared to those i the quitile of lowest socio-ecoomic disadvatage 161 ml compared with 117 ml per capita respectively. Socio-ecoomic status was ot associated with soft drik cosumptio amog childre. Havig a o-professioal occupatio was associated with higher cosumptio of sugar-sweeteed soft driks compared to havig a maagerial or professioal occupatio 192 ml compared with 108 ml per capita respectively. State/Territory Lowest per capita itake was i the Australia Capital Territory for childre (138 ml), ad Tasmaia for adults (90 ml). Highest per capita itake was i South Australia for childre (228 ml) ad the Norther Territory for adults (177 ml). 600 500 400 Regio There were o sigificat differeces i soft drik cosumptio patters betwee people livig i urba areas compared to those livig i rural/remote areas. 300 200 100 0 2 3 years (=383) 4 7 years (=799) 8 11 years (=739) Age 2.3.1.2 Cosumptio amog Adults 12 15 years (=653) 16 18 years (=433) Amog adults, the highest cosumers of soft driks were youg adult males, aged 19 24 years, with 58 per cet cosumig a average of 800 ml per day. The ext highest cosumers were males aged 25 44 years, with 34 per cet cosumig a average of 642 ml, ad females aged 19 24 years, with 36 per cet cosumig a average of 562 ml. The percetage cosumig ad amouts cosumed decreased with icreasig age amog adult males ad females (Figure 5). 2.3.2 Other Dietary Surveys i Australia 2.3.2.1 NSW Populatio Health Survey The most recet report o Child Health from the NSW Populatio Health Survey, usig short questios to assess dietary behaviours, idicates that half of childre aged 2 8 years ad three quarters of childre aged 9 15 years cosumed sugary driks (soft driks, cordials or sports driks) weekly. Twety per cet of 9 15 year olds reported regularly cosumig more tha 1.5 cups of sugary driks per day (Cetre for Epidemiology ad Research 2008). A earlier survey (2001), usig the same questios but stratified by differet age ad frequecy categories, foud that over oe quarter of childre aged 2 4 years were reported to drik at least oe cup of sugary driks per day, with 13 per cet reported to drik two or more cups per day. Childre aged 5 12 years cosumed more of these driks, with 42 per cet reported to cosume oe or more cups per day, ad half of these reported to drik two or more cups per day (Cetre for Epidemiology Soft Driks, Weight Status ad Health: A Review PAGE 11

Figure 5: Volume of sugar-sweeteed soft driks cosumed amog adults i Australia, by age ad sex; data from the 1995 Natioal Nutritio Survey; aalysis by NSW Cetre for Public Health Nutritio 900 800 Per cosumer Per capita 700 600 Volume (ml) 500 400 300 200 100 0 Male Female 19 24 Male Female 25 44 Male Female 45 64 Male Female 65+ A ad Research ad NSW Departmet of Health 2002). 2.3.2.1 FSANZ Survey A phoe survey coducted for the Food Stadards Australia New Zealad (FSANZ) i 2003 to determie the itake of itese sweeteers i Australia ad New Zealad, showed high cosumptio of soft driks by Australia adolescets (12 17 years) ad youg adults (18 24 years) (Food Stadards Australia New Zealad 2003a). Over three-quarters of 12 24 year olds reported cosumig soft driks i the previous seve days, with males more likely to be cosumers tha females. 2.3.2.3 Childhood Asthma Prevetio Study Several studies iteratioally have show that soft driks are cosumed i surprisigly large amouts by toddlers, but data are lackig for this age group i Australia. A study of food itake i toddlers i Wester Sydey as part of the Childhood Asthma Prevetio Study (CAPS) foud that sugary beverages (excludig fruit juice) cotributed substatially to eergy ad carbohydrate itakes (Webb et al. 2006). O average, soft driks were cosumed o alterate days by 29 per cet of the childre aged 16 24 moths. 2.3.2.2 Schools Physical Activity ad Nutritio Survey I a recet state-wide survey, the Schools Physical Activity ad Nutritio Survey (SPANS), schoolchildre i Years 6 to 10 i New South Wales were asked about their usual itake of soft driks usig a short dietary questio (Booth et al. 2006). Approximately 55 per cet of boys ad 40 per cet of girls reported drikig more tha 250 ml of soft drik per day (defied as all types of soft drik icludig fruit flavoured driks ad sport driks but excludig fruit juice); with 25 30 per cet of boys ad 10 20 per cet of girls drikig at least 400 ml per day. Of these, about 10 per cet of boys ad 5 per cet of girls cosumed more tha 1 litre per day. PAGE 12 Soft Driks, Weight Status ad Health: A Review

Sectio 3 Factors Associated with Soft Drik Cosumptio The majority of research examiig factors affectig soft drik cosumptio, albeit somewhat limited, has bee carried out amog childre, ad amog adolescets i particular. Cosequetly they are the mai focus of this sectio. Adolescece is a time whe childre have more autoomy over food ad drik choices, both withi ad away from school. There is a lack of iformatio about the barriers to limitig or reducig soft drik cosumptio ad about attitudes ad beliefs cocerig soft drik cosumptio amog other subgroups of the populatio. 3.1 Socio-Cultural Factors 3.1.1 Socio-Ecoomic Status ad Materal Educatio The 1995 Natioal Nutritio Survey data oly showed differeces i soft drik cosumptio amog differet levels of socio-ecoomic disadvatage for adults (sectio 2.3). However two Australia studies (Booth et al. 2006; Scully et al. 2007) showed that a higher itake of soft driks was associated with lower socio-ecoomic status (SES) i school studets. A study i Victoria foud that SES, measured usig materal educatio, was associated with the availability of sugary driks at home; a higher proportio of adolescets of low SES reported that soft driks, sports ad eergy driks were always or usually available at home (MacFarlae et al. 2007). The WHO collaborative cross-atioal study of Health Behaviours amog School-aged Childre 2001 02 (Vereecke et al. 2005b) showed a relatioship betwee lower SES, as determied by family affluece, ad higher soft drik cosumptio, across may Europea coutries. However amog coutries still i socio-ecoomic trasitio, i.e. coutries i Cetral ad Easter Europea coutries, soft driks were cosidered luxury items ad cosumed more by affluet families. This study also showed that cosumptio of soft driks is ot oly iflueced by the SES of idividual childre but also by the SES of the school populatio. That is, it may be more difficult to cosume soft driks i a eviromet where other pupils are ot stimulated or are less stimulated to do so. Mother s educatioal level is associated with soft drik cosumptio (Vereecke et al. 2004) but this associatio was ot completely explaied by the mother s cosumptio ad other food paretig practices, which is the case with fruit ad vegetable cosumptio i childre. Soft drik cosumptio i 18-moth-old childre i the UK was associated with lower educatioal level of mothers (Northstoe et al. 2002). The Food Stadards Australia New Zealad (FSANZ) phoe survey of adolescets ad youg adults foud that, amog youg adults, the highest cosumers of sugar-sweeteed soft driks were those with a lower aual icome, with o tertiary level educatio, ad those with either o occupatio or a uskilled occupatio (Food Stadards Australia New Zealad 2003a). A study i The Netherlads showed that adolescets plaig to go to college or uiversity had lower odds of cosumig soft driks (Bere et al. 2007), although this factor became less sigificat whe psychosocial variables such as accessibility, modellig ad attitudes were itroduced ito the model. 3.1.2 Cultural Backgroud The FSANZ phoe survey of adolescets ad youg adults i Australia foud that Aborigial ad Torres Strait Isladers were more likely to cosume sugar-sweeteed soft driks compared to other Australias (72 per cet versus 50 per cet) ad cosumed sigificatly larger amouts (249 ml versus 128 ml per day) (Food Stadards Australia New Zealad 2003a). The 2004 SPANS survey of childre i Years 6 10 i NSW foud cosumptio of soft driks to be lowest amog studets of Asia backgroud ad highest amog boys of Souther Europea ad Middle Easter backgroud (Booth et al. 2006). 3.1.3 Geder Fewer girls tha boys cosume soft drik i Australia, ad amog those that do, girls cosume smaller amouts of soft drik tha boys (sectio 2.2). This geder effect has bee observed i Europe also. For example, the large WHO collaborative cross-atioal study of Health Behaviours amog School-aged Childre 2001 02 showed that girls geerally Soft Driks, Weight Status ad Health: A Review PAGE 13

cosume less soft drik tha boys (Vereecke et al. 2005b). At least some of the factors affectig soft drik cosumptio i boys appear to have o effect i girls. A study of adolescets i Belgium foud that oe of the psychosocial or family-related factors were associated with soft drik cosumptio i girls (Haeres et al. 2007). Similarly, earlier studies i the US have oted that, although may of the same predictors for soft drik cosumptio were foud i girls as boys (Kassem et al. 2003; Kassem ad Lee 2004), girls with egative attitudes towards drikig regular soft driks were more likely to believe that they would gai weight ad have too much caffeie thus they teded to avoid it. Nevertheless, the average female studet moderately believed that regular soft driks teded to make them gai weight ad strogly believed it was importat ot to gai weight, yet the majority drak regular soft driks regularly (Kassem et al. 2003). This study was aimed particularly at examiig the attitudes towards detal health. Although studets strogly uderstood ad believed the messages cocerig soft driks ad tooth decay, they did ot chage their behaviour accordigly. 3.2 Psycho-Social Factors 3.2.1 Persoal Factors Persoal factors appear to moderate the relatioship betwee evirometal factors ad behaviour. I Norway, persoal prefereces, i.e. taste, was the umber oe determiat of soft drik cosumptio, ad attitude was the fourth most importat determiat of soft drik cosumptio i adolescets, with the evirometal factors of accessibility ad modellig (cosumptio behaviour of sigificat others) i betwee (Bere et al. 2007). Soft drik cosumptio i school-aged childre has bee otably correlated with taste prefereces i other studies (Grimm et al. 2004). I oe study of 8 13 year olds i the US, those who reported the strogest taste preferece were 4.5 times more likely to cosume soft driks five or more times per week compared with those with a lower taste preferece. A focus group study with groups of childre aged 8 9 years ad 13 14 years showed that youger childre prefer the taste of still, fruit-flavoured driks ad adolescets prefer the taste of carboated driks (May ad Waterhouse 2003). Attitude ad subjective orm (perceptio of other people s views ad attitudes towards soft drik cosumptio), together with perceived behavioural cotrol, explaied 60 per cet of the variace i itetio to drik regular soft driks i 13 18 year olds i the US (Kassem et al. 2003; Kassem ad Lee 2004). However, taste ejoymet was oe of the most predictive expected outcome beliefs of regular soft drik cosumptio. I these studies, quechig of thirst was the secod most importat predictor of attitude, after taste, towards drikig soft driks yet soft driks have bee foud to be poor at quechig thirst whe compared to water (Rolls et al. 1990; Brous et al. 1998). Parets ad frieds have bee idetified as beig more ifluetial tha peers i the cosumptio patters of youger childre aged 8 9 years i the UK (May ad Waterhouse 2003), although peer groups are cosidered to play a greater role i adolescece (Buchaa ad Coulso 2006). Cost, availability ad thirst were more importat i older childre aged 13 4 years. I the NSW Schools Physical Activity ad Nutritio Survey 2004 (SPANS) of childre aged 5 16 years, peer iflueces were ot particularly apparet i soft driks attitudes ad iteded cosumptio (Booth et al. 2006). Adolescets who perceived more social pressure to limit soft drik cosumptio were foud to be more likely to cosume more i the Study o Medical Iformatio ad Lifestyle i Eidhove (SMILE) study i The Netherlads (de Bruij et al. 2007). The SMILE study also showed that moderate agreeableess (a measure of adolescets willigess to comply with paretal practices ad rules) of adolescets is associated with less soft drik cosumptio, however, those that were most agreeable cosumed a lot (de Bruij et al. 2007). This was attributed to pressures outside of the home eviromet pro-social motives where those most agreeable wated to fit i. It is postulated that the more agreeable adolescets were more iclied to live up to expectatios raised by prototype-based advertisemets ad marketig. Oe of the few studies examiig the factors affectig soft drik cosumptio i adults showed that cosumptio of sugar-sweeteed soft driks was associated with less restraied ad more exteral eatig, i.e. sesitive to exteral stimuli such as taste (Elfhag et al. 2007). The study, coducted amog 3265 adults i Swede showed that, i cotrast, diet soft driks were cosumed by persos with a higher body mass idex (BMI) (possibly i a attempt to reduce their weight), more restraied eatig ad more emotioal eatig. 3.2.2 Paretig Practices Parets as Models A study i Australia showed that the ifluece of mothers, either as models of eatig behaviours or as the providers of food, is pervasive (Campbell et al. 2007). Paretal soft drik cosumptio was positively associated with youger PAGE 14 Soft Driks, Weight Status ad Health: A Review

childre s itake i two studies (Grimm et al. 2004; Vereecke et al. 2004). Mother s cosumptio was foud to be a idepedet predictor for regular soft drik cosumptio amog childre i Belgium (Vereecke et al. 2004). I the US, childre aged 8 13 years whose parets regularly drak soft driks were early three times more likely to cosume soft driks five or more times per week compared with those whose parets did ot regularly drik soft driks (Grimm et al. 2004). A higher frequecy of preparig food was foud to be related to lower itakes of carboated beverages amog female adolescets i the US (Larso et al. 2006). Paretig Styles Less restrictive paretig practices are associated with a higher cosumptio of healthier food optios such as fruit ad vegetables i childre; however the evidece is ot as equivocal for soft driks. Ideed, the coverse has bee foud i some recet studies. For example, va der Horst et al foud that i The Netherlads less restrictive paretig practices, relatig to specific behaviours such as food rules, were associated with higher cosumptio of sugar-sweeteed beverages amog 383 adolescets (va der Horst et al. 2007). This associatio was idepedet of perceived paretig practices by the adolescets, ad was mediated by attitude, self-efficacy ad modellig from parets (paretal cosumptio). The associatio was strogest amog adolescets who perceived their parets as beig moderately strict ad highly ivolved. These authors cocluded that parets should be ivolved i itervetios aimed at chagig dietary behaviours icludig soft drik cosumptio ad that itervetios aimed at the promotio of healthy paretig practices are best tailored to the geeral paretig style of the participats (for example, strict ad/ or ivolved). More restrictive paretig practices were also foud to be associated with less soft drik cosumptio (De Bourdeaudhuij ad Va Oost 2000) ad stricter paretig practices were foud to be associated with less soft drik cosumptio i a recet study i The Netherlads (de Bruij et al. 2007). However, fidigs from studies amog youger childre suggest that strict paretal practices ca i fact icrease childre s prefereces for, ad itake of, the restricted foods. These differet fidigs may relate to differeces i the type of practices used betwee age groups. For example, parets of youger childre might use pressure to get their childre to eat more or may restrict access to certai foods. For adolescets, parets might use clearly defied rules about the times whe a certai food ca be eate ad how much of a certai food they ca eat. Buchaa ad Coulso cosidered that the role of parets ifluece ad cotrol i adolescets patters of soft drik cosumptio remais uclear ad warrats further ivestigatio (Buchaa ad Coulso 2006). 3.3 Evirometal Factors 3.3.1 Soft Drik Availability Availability at School Icreased soft drik cosumptio has bee related to the availability of soft driks i vedig machies i the school eviromet i a umber of studies. However, it appears that whe soft driks are ubiquitous i schools the lik betwee cosumptio ad availability is less discerible (Frech et al. 2003; Grimm et al. 2004; Vereecke et al. 2005a). Access to vedig machies sellig soft driks i schools i the US was ot related to cosumptio i either boys or girls (Kassem et al. 2003; Kassem ad Lee 2004). I Norway, most soft drik cosumptio occurs outside of school despite soft driks curretly still beig available i schools (Bere et al. 2007). Vedig machies were ot available i schools ivolved i a study of adolescet soft drik cosumptio i the UK (Buchaa ad Coulso 2006); ad this study foud that cosumptio of soft driks was higher at the weekeds. Nevertheless, the availability of soft driks at school, either i the school catee or i vedig machies, may sed messages to childre that they are suitable driks; also their easy availability at schools egates the eed to provide water. The sale of foods ad driks at schools is likely to have a ripple effect i the commuity (Bell ad Swibur 2005), thus baig soft driks at schools coveys a healthy message to childre ad this message has the potetial to affect commuity attitudes. I recet years four Australia state govermets (New South Wales, Victoria, South Australia ad Wester Australia) have accordigly imposed a ba o the sale of soft driks ad other sugar-sweeteed driks by catees i public schools (Bell ad Swibur 2005). I NSW this ba o sugar-sweeteed driks is part of Fresh Tastes @ School, the NSW Healthy School Catee Strategy. Sugar-sweeteed driks with more tha 300 kj per serve or more tha 100 mg of sodium per serve have ot bee allowed i school catees ad vedig machies i NSW sice Term 1, 2007 (NSW Departmet of Health ad NSW Departmet of Educatio & Traiig 2006). These driks iclude: soft driks, eergy driks, fruit driks, flavoured mieral waters, sports driks, cordials, iced teas, sweeteed waters, sports waters, ad flavoured crushed ice driks. I Victoria the ba exteds to high-eergy, high-sugar soft driks brought i to school. Soft Driks, Weight Status ad Health: A Review PAGE 15

Availability at Home A umber of studies have highlighted that the amout ad diversity of soft driks available ad accessible at home is importat (Frech et al. 2003; Grimm et al. 2004). Haeres et al recetly showed that adolescet boys i Belgium who had more uhealthy food products available at home cosumed more soft driks tha those who had fewer uhealthy food products available at home. However this relatioship was ot observed i girls (Haeres et al. 2007). Home availability was foud to be a importat predictor of soft drik cosumptio i 8 13 year olds i a study i the US (Grimm et al. 2004). Aother study with adolescet boys ad girls i the US showed that availability of regular soft driks at home was the strogest predictor of beig able to cotrol itake (Kassem ad Lee 2004). Availability i the wider eviromet Few studies lik the wider availability of soft driks to cosumptio; however, a study of food itake patters amog adolescets i Victoria foud that those livig i metropolita areas had a higher frequecy of sugarsweeteed soft drik itake compared to those livig i o-metropolita areas (Savige et al. 2007). The authors attributed this differece, i part, to the accessibility ad availability of these foods with a higher proportio of adolescets i the metropolita area livig ear a fast food outlet. 3.3.2 Portio Size The beverage idustry has steadily icreased cotaier sizes over the last 50 years. I the 1950s the stadard servig size was a 200 ml bottle, which icreased to a 375 ml ca, which was superseded by a 600 ml bottle. Studies have show that the larger the cotaier, the more people are likely to drik, especially whe they assume they are buyig sigle-serve size cotaiers. For example, Flood et al have show that icreasig beverage portio size from 350 ml to 530 ml sigificatly icreased the weight of beverage cosumed regardless of beverage type i this case regular cola, diet cola or water (Flood et al. 2006). As a cosequece, eergy itake icreased 10 per cet for wome ad 26 per cet for me whe there was a 50 per cet icrease i the portio of regular cola served. Food itake did ot differ uder the cotrolled coditios; thus overall eergy itake was icreased as a result of the extra eergy from the larger beverage itake. Most recetly, a study showed that icreasig portio sizes of all foods ad beverages cosumed by study participats by 50 per cet of baselie icreased eergy itake from all food ad beverage categories, except fruit as a sack ad vegetables, for a 11-day period (Rolls et al. 2007). The amout of beverage cosumed icreased from about 470 ml i both wome ad me to 557 ml i wome ad 630 ml i me. Disproportioate pricig practices also ecourage people to drik large servigs as these ofte cost just a fractio more tha the smaller servigs (Youg ad Nestle 2002). Large serve sizes cotribute to a obesogeic eviromet, as they facilitate excess cosumptio of eergy (Dietary Guidelies Advisory Committee 2005). Dietary guidelies ad public campaigs have highlighted the importace of portio size as a cetral cocept related to eergy itake (Matthiesse et al. 2003). 3.3.3 Cost I a umber of papers, Drewoswki ad co-workers purport that the mai issue i relatio to utriet-poor foods ad beverages ad obesity is the cost; that is, utriet-dese diets are more costly tha utriet-poor, eergy-dese foods which are relatively cheap. Drewowski ad Bellisle (2007) coclude that the obesity-promotig capacity of differet beverages is liked ot so much by their sugar cotet but by their low price, although these researchers cocur that taste is likely to be the mai factor affectig the obesitypromotig capacity of soft driks (Refer to Sectio 3.1). Cost was reported as beig a importat determiat of carboated soft drik cosumptio, as opposed to fruit juice ad still fruit driks, i childre aged 13 14 years i a study i the UK (Buchaa ad Coulso 2006). Availability ad thirst were also recogised as importat determiats, although foremost was taste. 3.3.4 Marketig Soft drik compaies use a wide variety of marketig techiques to icrease sales. These techiques iclude easy accessibility i a wide variety of veues, heavy media advertisig, sposorships of cocerts ad professioal orgaisatios, targetig of schools (e.g. through vedig machies), tie-is with movies ad music groups, ad merchadise (Jacobso 2005). Pre-tees ad youg adults are particularly vulerable to forceful advertisig, with peer group pressure playig a additioal role (Grimm et al. 2004). The marketig of uhealthy foods, icludig soft driks, to childre is recogised as a probable cotributory factor i childhood obesity ad subsequetly is the subject of much political ad public debate. As Nestle suggested food compaies view schoolchildre as a attractive market ad use every possible meas to promote their products to this youg, impressioable, ad captive audiece (Nestle 2000). She also provided 23 examples PAGE 16 Soft Driks, Weight Status ad Health: A Review

of how soft drik compaies market their products to childre i ad outside schools (Nestle 2000). A recet study i Australia has show that soft driks are the food products most commoly advertised aroud primary schools, comprisig about oe-quarter of all food advertisemets (Kelley et al. 2008). The ethics of marketig uhealthy foods ad soft driks to childre has bee highlighted (Mehta 2007). Over ad above the direct effect of marketig o brad recogitio ad purchasig behaviour (by self or requests to parets i.e. pester power ), Mehta cosiders that marketig leads to developmet of cosumerist values, acquisitiveess, dissatisfactio ad uhappiess. Soft drik maufacturers i Australia have recetly itroduced polices which state their itetio ot to market their products directly to youg childre. However, idirect marketig (e.g. through product placemet, marketig through websites ad promotios, ad exposure to marketig directed at older childre ad adults) may udermie the impact of this commitmet. Amog adolescets i the US, the reported secod most importat factor affectig their ability to cotrol their behaviour was seeig advertisemets to ecourage drikig soft driks (Kassem ad Lee 2004). Marketig commuicatios may have a disproportioate effect o people who cosume uhealthy products frequetly, i.e. those who cosume uhealthy food products most are those who are most receptive to advertisemets (Hoek 2005). Exposure to TV advertisig Televisio is a medium through which childre are commoly exposed to food marketig. Food marketers advertise heavily durig childre s programmig i Australia (Hastigs et al. 2007; Kelly et al. 2007), ad soft drik is cosistetly featured ear the top of the list of advertised food items i differet coutries, icludig Australia (Kotz ad Story 1994; Lemos 2004). 2004, examied iflueces over soft drik cosumptio i boys ad girls i years 6, 8, ad 10. This survey showed that boys ad girls disagreed with statemets that they were iflueced to buy soft driks as a result of advertisemets. The majority of childre reported that they did ot purchase the driks with the best advertisemets or were they iflueced by competitios or prizes i their choice of soft driks, although a large proportio either agreed or disagreed with these statemets (Booth et al. 2006). Product Placemet Marketig occurs i a sublimial way via product placemets i TV programs ad movies. Accordig to Greer, whe a product is embedded i the cotet of a movie of show, it ca carry icreased credibility with the target audiece (Greer 2003). A cotet aalysis of popular America movies has show that braded soft driks are ofte promietly positioed i movies (Cassady et al. 2006). This study showed that braded soft driks appeared more commoly tha other braded o-alcoholic beverages, braded beer ad other braded alcoholic beverages. Actors cosumed soft driks i five times the umber of movies compared to their cosumptio of other o-alcoholic beverages (such as water, tea, coffee or milk). Sposorship ad promotio of sport Soft driks, which icreasigly iclude sports driks, are frequetly promoted through associatio with sports teams ad clubs at the atioal, state, ad local levels. A recet aalysis of sports sposorship i New Zealad showed that, at the juior level the largest share (a quarter) was for the advertisemet of uhealthy foods, icludig soft driks, with oly three per cet promotig healthy foods (Maher et al. 2006). The sposorship listigs icluded those that specifically metioed sposorship for juior clubs, juior teams, or school-aged touramets. Icreased soft drik cosumptio has bee related to TV exposure i a umber of studies (Grimm et al. 2004; va de Bulck ad va Mierlo 2004; Utter et al. 2006). The relatioship was observed for adolescet boys oly ot girls i a recet study of childre i grades 7 8 i Belgium (Haeres et al. 2007). A study of childre aged 5 6 years ad 10 12 years i Melboure showed that childre who watched TV for more tha 2 hours per day were 2.3 times more likely to cosume 1 serve/day of high-eergy driks tha childre who watched less tha or equal to 2 hours of TV per day (Salmo et al. 2006). The NSW Schools Physical Activity ad Nutritio Survey, Soft Driks, Weight Status ad Health: A Review PAGE 17

Sectio 4 Costs ad Health Implicatios o Soft Drik Cosumptio 4.1 Weight Status 4.1.1 Evidece of a Associatio The 2003 World Health Orgaizatio (WHO) report Diet, Nutritio ad the Prevetio of Chroic Diseases classified the scietific evidece o the associatio betwee sugary driks cosumptio ad icreased risk of obesity as probable (Joit WHO/FAO Expert Cosultatio 2003). Sice this report there has bee substatial debate about the stregth of the relatioship betwee the cosumptio of sugary driks ad obesity. A recet review cocluded that the evidece o this topic remais equivocal ad that usatisfactory methodological rigour i may of the experimetal ad prospective studies makes it difficult to draw firm coclusios (Pereira 2006). The limitatios of these studies, may of them cross-sectioal, have also bee recetly highlighted by other researchers (Drewowski ad Bellisle 2007). However, the majority of systematic reviews ad meta-aalyses support the view that sugary driks, particularly soft driks, have a causative role i obesity (Taylor et al. 2005; Malik et al. 2006; Vartaia et al. 2007). The type of sugar used to sweete soft driks has bee raised as a issue by some researchers. I America, where may of the studies have bee carried out, soft driks are sweeteed usig high-fructose cor syrup (HFCS). HFCS cosists of a slightly higher ratio of fructose to glucose tha sucrose the sugar used to sweete soft driks i Australia does, ad the molecules are separated, compared to the disaccharide sucrose. HFCS i soft driks has bee particularly implicated i cotributig to the obesity epidemic (Bray et al. 2004). However the idea that HFCS acts ay differetly to sucrose i soft driks i terms of weight gai has bee heavily disputed ad experimetal ad cliical studies show that ay added sugars i soft driks are likely to cotribute equally to a eergy imbalace (Aderso 2007; Forshee et al. 2007; Mosivais et al. 2007). The fidigs of the stregth of the evidece from the studies icluded i the most recet systematic reviews are summarised i Table 2. I total, 26 out of 42 studies showed a sigificat positive associatio betwee the cosumptio of sugary driks (maily soft driks) ad uhealthy weight gai, ad o studies showed a egative associatio. As the methodological stregth or power of the studies icreases, i.e. from cross-sectioal to prospective through to experimetal, the proportio of studies showig a positive associatio betwee sugary driks ad weight icreases, as does the stregth of effect. The earlier review by Taylor et al (2005) examied the impact of sugary driks o body weight i childre ad cocluded that overall there is extesive evidece that sugary driks cotribute to uhealthy weight gai i childre. Table 2: Number of studies likig sugary driks, particularly soft driks, to obesity (sourced from Taylor et al. 2005, Malik et al 2006, Vartaia et al 2007) Icreasig stregth of evidece Associatio Cross-sectioal studies Prospective studies Experimetal (E)/ Itervetio (I) studies Total umber of studies Positive (p < 0.05) Noe/ot-sigificat (p > 0.05) Negative (p < 0.05) 13 8 3 E / 2I 26 12 4 0 16 0 0 0 0 PAGE 18 Soft Driks, Weight Status ad Health: A Review

Subsequetly the systematic review by Malik et al examied publicatios from 1966 to May 2005 o the relatioship betwee sugar-sweeteed beverages ad risk of weight gai i childre ad adults. Thirty publicatios were selected 15 cross-sectioal, 10 prospective ad 5 experimetal based o relevace ad quality of desig ad methods. These authors cocluded that the weight of epidemiological ad experimetal evidece idicates that a greater cosumptio of sugar-sweeteed soft driks is associated with weight gai ad obesity; ad that sufficiet evidece exists for the eed for public health strategies to reduce sugary driks cosumptio, particularly i childre ad adolescets (Malik et al. 2006). The most recetly published systematic review ad meta-aalysis separated out studies that examied the associatio betwee soft drik cosumptio (sugared soda equivalet to sugar-sweeteed soft driks) ad eergy itake from those studies that examied the relatioship betwee soft drik cosumptio ad body weight (Vartaia et al 2007). As expected, the fidigs showed a weaker relatioship betwee soft drik cosumptio ad body weight tha with total eergy cosumptio, as soft driks are ot the oly source of eergy i the diet. Nevertheless, although cross-sectioal studies ad logitudial studies showed oly small positive associatios betwee soft drik cosumptio ad BMI (r = 0.05 ad 0.09 respectively), a moderate associatio was observed for experimetal studies that cotrolled for may extraeous variables (r = 0.24). Also, 10 of 12 cross-sectioal studies, five of five logitudial studies ad all four log-term experimetal studies examied showed that eergy itake rises whe soft drik cosumptio icreases. The effect sizes for these studies, respectively, were 0.13, 0.24 ad 0.30. The evidece also supports the idepedet cotributio of soft driks to a higher eergy cosumptio overall. The authors of this extesive review cocluded that recommedatios to reduce populatio soft drik cosumptio are strogly supported by the available evidece (Vartaia et al. 2007). The logitudial studies showig a positive associatio betwee sugary driks ad weight status are detailed i Table 3. The associatio betwee soft drik cosumptio ad BMI was particularly oted from two studies ivolvig very large sample sizes, oe i childre (Berkey et al. 2004) ad oe i wome (Schulze et al. 2004). Two studies showig a associatio betwee sugarsweeteed beverages ad weight status were coducted after the systematic reviews (Dhigra et al. 2007; Dubois et al. 2007). A uusual fidig of the latter study, which was part of the Framigham Heart Study, was that the relatioship for soft drik cosumptio was see for diet as well as regular soft driks (Sectio 5.2). The potetial cotributios of sugar-sweeteed beverages to weight gai are supported by the results of three small cliical trials i adults. Two of these short-term trials, oe i the US ad oe i Demark, foud that those adults who cosumed large amouts of sugar-sweeteed driks gaied weight while those cosumig artificiallysweeteed driks lost weight (Tordoff ad Alleva 1990; Rabe et al. 2002). The other short-term trial, coducted i the US, compared the effect of cosumptio of sugar i liquid form (soft drik) ad as jelly beas, o dietary compesatio, i.e. eergy itake from other food ad beverages, ad BMI (DiMeglio ad Mattes 2000). Body weight ad BMI icreased sigificatly durig cosumptio of the sugary fluid oly. There have bee two cotrolled itervetio trials that have examied the effect of soft drik reductio o weight status i childre. Oe itervetio trial showed that a decrease i soft drik cosumptio led to a decrease i BMI but this effect was oly observed for subjects i the upper tertile for baselie BMI (Ebbelig et al. 2006). The itervetio study the Beverages ad Studet Health (BASH) study ivolved the home delivery of bottled water ad other o-caloric beverages (diet soft driks) to 103, 13 18 year old studets who regularly cosumed at least oe 360 ml serve of soft drik per day, i the US. The 25-week study also ivolved writte educatioal iformatio ad telephoe cousellig. Post-itervetio, eergy itake from caloric beverages had reduced sigificatly, by 82 per cet i the itervetio group compared to o chage i the cotrol group. Some of the success of this itervetio amog the most overweight childre may stem from the iclusio of oly relatively high cosumers of soft drik i the study. Aother itervetio study CHOPPS (Christchurch Obesity Prevetio Project i Schools) aimed to reduce all carboated driks (sweeteed ad usweeteed) as a meas of prevetig iappropriate weight gai i school childre aged 7 11 years i the UK (James et al. 2004). This school-based educatioal program achieved a sigificat differece i BMI betwee itervetio ad cotrol studets of 7.7 per cet after 12 moths of itervetio, maily due to a icrease i BMI i the cotrol group. However, this differece i BMI could ot be directly attributed to a reductio i sweeteed soft drik cosumptio i the itervetio group as o sigificat differece i cosumptio of these driks was observed (Frech et al. 2004). Other limitatios of this study iclude that there was low itesity of itervetio ad that itakes were self-reported by each child. Effects Soft Driks, Weight Status ad Health: A Review PAGE 19

Table 3: Logitudial studies showig a positive relatioship betwee sugary driks cosumptio ad weight status i childre, adolescets ad adults (chroological order) Referece Study populatio Duratio of follow-up Types of beverages ivestigated Fidigs Childre Ludwig et al. 2001 548 middle-school childre, aged 11 12 years, from Bosto, USA 19 moths Sugar-sweeteed beverages (regular soft driks, fruit driks, iced teas) Baselie sugar-sweeteed drik cosumptio (p< 0.02) ad chage i cosumptio (p< 0.03) positively associated with chage i BMI; chage i cosumptio associated with icidet obesity (p < 0.02). Each additioal serve of soft drik/day = icrease i BMI of 0.24. OR icreased by 60%. Berkey et al. 2004 11,654 childre, aged 9 14 years, from 50 states i the USA Two oe-year periods Sugar-added beverages (regular soft driks, fruit driks, iced teas) Cosumptio of sugar-added beverages was associated with small BMI gais durig the correspodig year (boys p < 0.05; girls p < 0.1).Childre who icreased itakes by 2 or more servigs/d from the prior year gaied weight (boys p < 0.05; girls p < 0.05). Adjustmets for eergy itake atteuated the associatio. Phillips et al. 2004 132 girls, aged 8 12 years, from Massachusetts, USA 10 years Sugar-sweeteed soft driks Eergy from regular soft driks related to higher BMI z-score (p < 0.001) but ot to % body fat. Girls i the third ad fourth quartiles of higher itake had BMI z-scores that were 0.17 uits higher tha subjects i the first quartile (lowest itake) Welsh et al. 2005 10,904 childre aged 2 3 years, from Missouri, USA 1 year Sweet driks (soft driks, fruit driks, fruit juice) Overweight childre (at baselie) who drak at least oe servig of soft drik or fruit driks per day had approximately twice the risk of overweight at follow-up compared to overweight childre who cosumed less tha 1 servig per day. Striegel- Moore et al. 2006 2371 girls, aged 9 10 years, from 3 states i USA 10 years Sugar-sweeteed soft driks (from 3-day food dairy) Also examied diet carboated driks, coffee/tea, fruit juice, fruit driks Positive relatioship betwee icrease i regular soft drik cosumptio ad icrease i BMI (p < 0.05) after adjustig for eergy itake (0.01 uit of BMI per 100g soft drik). No relatioship betwee itake of other beverages ad BMI Tam et al. 2006) 281 childre, aged 7 8 years, from Wester Sydey, Australia 5 years Sugar-sweeteed soft driks ad cordials Itake of soft drik/cordial was higher i childre who were overweight/obese at follow-up compared to those who had a acceptable BMI at both baselie ad follow-up (p = 0.002) 1 Dubois et al. 2007 1944 childre aged 2.5 years at baselie 2 years Sugar-sweeteed beverages (regular soft driks ad fruit driks, ot juice) Sugar-sweeteed beverage cosumptio betwee meals more tha doubled the odds of beig overweight (multivariate aalysis). Childre from families with isufficiet icome who cosumed sugar-sweeteed beverages regularly betwee ages 2.5 ad 4.5 years were more tha 3 times more likely to be overweight at age 4.5 years compared to o-cosumig childre from sufficiet households. Adults Schulze et al. 2004 51 603 females (baselie age 24-44 years); Nurses Health Study II 8 years Sugar-sweeteed soft driks (also examied diet soft driks ad fruit juice) For two time periods, wome who icreased their cosumptio of sugar-sweeteed soft driks from low to high had sigificatly larger icreases i weight (multivariate-adjusted meas, 4.69 kg durig 1991 95 ad 4.20 kg durig 1995 99) ad BMI (multivariate adjusted meas, 1.72 durig 1991 95 ad 1.53 durig 1995 99) tha wome who maitaied a low or a high itake or substatially reduced their itake (p = 0.001). PAGE 20 Soft Driks, Weight Status ad Health: A Review

Referece Study populatio Duratio of follow-up Types of beverages ivestigated Fidigs Bes- Rastrollo et al. 2006 7194 adults; mea age 41 years 28.5 moths (media) Sugar-sweeteed soft drik (also examied diet soft driks, milk) I the participats who had gaied > or =3 kg i the 5 y before baselie, the adjusted odds ratio of subsequet weight gai for the fifth quitile compared with the first quitile of sugar-sweeteed soft drik cosumptio was 1.6 (95% CI: 1.2, 2.1; p for tred = 0.02). 1 Dhigra et al. 2007 6039 adults; mea age 52.9 years; Framigham Heart Study 4 years (mea) Regular (sugarsweeteed) versus diet soft driks Cosumptio of 1 soft drik/day associated with icreased odds of obesity (OR 1.31, 95% CI 1.02,1.68). [NB: same effect sugar-sweeteed ad/or diet soft driks] 1 Study published sice most recet systematic review (Vartaia et al. 2007). might also have bee limited due to the cohort havig low baselie soft drik itakes. 4.1.2 Evidece of Causality Although there is some evidece of a lik betwee soft drik cosumptio ad weight status from a large umber of cross-sectioal studies, such studies do ot ifer causality by themselves. Ideed, it could be iterpreted that high cosumptio of soft driks is a marker for poorer dietary habits overall ad that it is ot the soft driks per se that are cotributig to body weight. However, the substatial umber of studies of stroger methodological quality ad desig strogly support the recommedatio that soft drik cosumptio be reduced at the populatio level to help prevet weight gai ad reduce the prevalece of obesity. A causal relatioship betwee soft drik cosumptio ad weight status appears likely as may of the coditios ecessary to establish a causal relatioship are met from the evidece (Hill 1965). Statistically sigificat associatios have bee idetified i at least eight prospective or logitudial studies. These idicate a temporal relatioship, i.e. soft drik cosumptio preceded the chage i weight status. The relatioship shows cosistecy it is foud i various age, sex ad racial sub-groups ad with varyig socio-ecoomic status. A dose-respose effect has bee observed i at least four logitudial studies (Ludwig et al. 2001; Berkey et al. 2004; Phillips et al. 2004; Striegel-Moore et al. 2006) ad this, i particular, has bee cosidered to provide sufficiet evidece of causality (Dietz 2006). There is coherece i that the associatio does ot coflict with curret kowledge about weight gai. Eve small imbalaces i eergy itake ad expediture ca have a major impact o weight gai at the idividual level. Theoretically, daily cosumptio of oe ca of sweeteed soft drik (500 kj) over a 10-year period i a costat eviromet could lead to a 50 kg icrease i weight; although this level of weight gai is ulikely i practice (Ebbelig et al. 2006). Coversely, reducig daily itake by a omial amout of eergy or by icreasig eergy expediture (the eergy gap ) may help to prevet uhealthy weight gai. Usig data from atioal surveys, Hill et al suggested that alterig the eergy gap by 420 kj/day, equivalet to oe ca of sugar-sweeteed soft drik, would prevet excessive weight gai i most adult Americas (Hill et al. 2003). To have a similar prevetive effect i childre the eergy gap may have to be more tha 840 kj/day (Butte ad Ellis 2003). The theoretical uderpiigs of the lik betwee eergy itake from soft driks ad weight status are supported by cosumptio data. Researchers have show that, amog adults i the US, there has bee a overall icrease of 930 kj per perso per day betwee 1965 ad 2002, ad this icrease was foud to result largely from icreased itake of sugar-sweeteed beverages (Duffey ad Popki 2007). The data i Australia are less precise as they refer to o-alcoholic, o-milk beverages oly; however they provide a idicatio of sugary driks cosumptio. A compariso of dietary data from atioal surveys i Australia i 1983, 1985 ad 1995 showed that adults icreased their eergy itake by aroud 3 4 per cet (about 350 kj/day) betwee 1983 ad 1995 (Cook et al. 2001). This was associated with a icrease of 166 ml i me ad 92 ml of o-alcoholic, o-milk beverages (ot icludig plai water) over the same time period. Betwee these dates, mea daily eergy itake also icreased sigificatly i childre, by 11 per cet for girls ad 15 per cet for boys aged Soft Driks, Weight Status ad Health: A Review PAGE 21

10 15 years. Correspodigly, the itake of oalcoholic, o-milk beverages icreased by 200 g i boys ad 150 g i girls over the same time period. Soft drik cosumptio i Australia adolescets cotributed approximately 10 per cet to overall eergy itake o a per cosumer basis i 1995 (Raga et al. 2007). There are several hypothesised mechaisms to support the biological plausibility of the relatioship betwee soft drik cosumptio ad weight gai: 4.2 Other Health Implicatios The health implicatios of soft drik cosumptio i additio to overweight ad obesity are listed i Table 4 ad explaied more fully i the text. Table 4: Summary of health implicatios of excessive soft drik cosumptio Displacemet of healthier foods from the diet leadig to poorer diet quality Detal caries ad detal erosio There is usually limited compesatio for the eergy itake from such beverages, through reduced eergy itake from other dietary sources; therefore cosumig sugary driks leads to a overall icrease i eergy itake (Vartaia et al. 2007; Wolf et al. 2008). Ideed, Vartaia ad co-workers (2007) coted that oe of the most cosistet ad powerful fidigs is the lik betwee soft drik itake ad icreased eergy cosumptio (see above). Short-term experimetal evidece supports the lack of compesatio hypothesis (Drewowski ad Bellisle 2007). Eergy-rich fluids have low satiatig properties compared with solids ad it is proposed that this leads to a lack of compesatio for the eergy itake (DiMeglio ad Mattes 2000; Swibur et al. 2004; DellaValle et al. 2005). Wolf et al (2008) examied the history of beverages cosumptio ad idicated that the failure to secrete importat satiety factors that may occur after the igestio of soft driks may cotribute i a sigificat way to the failure to compesate whe these beverages are igested. Aother possible mechaism icludes the glycaemic load of sugary driks such that appetite cotrol is reduced (Bachma et al. 2006). Similarly soft drik cosumptio might simply calibrate people to a high level of sweetess that geeralises to prefereces i other foods (Davidso ad Swithers 2004). I their recet review, Drewowski ad Bellisle dispute the evidece for a causal lik betwee cosumptio of sugary driks ad weight gai based o physiologic ad metabolic grouds (Drewowski ad Bellisle 2007). These researchers coted that the effect of sugar cosumptio o body weight should ot cotiue to be framed i biological terms, but also depeds o behavioural itet ad cotext, ad the mode of use, availability ad cost of sweeteed liquids (refer to Sectio 3). Boe fractures, low boe desity, osteoporosis, hypocalcemia Disturbed sleep patters, bedwettig ad axiety (youger childre)* Headache, fatigue, decreased alertess, depressed mood ad irritability* Chroic disease icludig metabolic sydrome, high blood pressure Possible adverse effects due to Bezee *caffeie-cotaiig soft driks 4.2.1 Detal Health Soft driks cotai large amouts of sugar ad are highly acidic, properties which cotribute to eamel erosio ad detal caries. I the 2003 report o Diet, Nutritio ad Chroic Disease (Joit WHO/FAO Expert Cosultatio 2003), WHO foud the evidece for the associatio betwee soft drik ad fruit juice cosumptio ad risk of detal erosio to be probable ad the evidece of free sugars cotributig to detal caries to be covicig. A recet review of soft driks ad detal health idicated that the low ph of soft driks may lead to erosio of the eamel surface, ad the sugars are metabolised by plaque micro-orgaisms to geerate orgaic acids that brig about demieralisatio leadig to detal caries (Tahmassebi et al. 2006). Oe study foud that youg childre (4 7 years) with caries had higher media itakes of regular soft driks tha childre without caries (Marshall et al. 2003). Assessmet of erosio i 14-year-old childre i the UK revealed highly sigificat correlatios with carboated beverages, sports driks ad fruit juices (Al-Dlaiga et al. 2001). Detal erosio is particularly detrimetal i youg childre, util all permaet teeth are established ad eamel maturatio is reached (Tahmassebi et al. 2006). The Australia Detal Associatio discourages the frequet cosumptio of soft driks as well as diet soft driks, sports driks ad fruit juices due to their high sugar ad/ or acid cotet (Australia Detal Associatio 2002). PAGE 22 Soft Driks, Weight Status ad Health: A Review

4.2.2 Displacemet of Healthier Foods from Diet Soft drik cosumptio ca lead to the displacemet of healthier food ad beverage choices. A high level of soft drik cosumptio is associated with lower itakes of a umber of vitamis ad mierals, ad dietary fibre (Harack et al. 1999; Ballew et al. 2000). A umber of studies have show that soft driks displace milk, particularly, from the diet of childre ad adolescets. Natioal utritio surveys i Australia (1985 ad 1995) idicated that as soft drik cosumptio by adolescets icreased, milk cosumptio declied by approximately10 per cet (Cook et al. 2001). A logitudial study of childre aged 6 13 years foud that excessive cosumptio of sweeteed driks (> 360 ml/day) displaced half a cup of milk (about 125 ml) from their diet (Mrdjeovic ad Levitsky 2003). The cosequeces were lower daily protei, calcium, magesium, phosphorus ad vitami A itakes. A early study had also show that soft drik itake was egatively associated with milk, calcium, magesium, vitami A, ad vitami C itake i teeagers livig i the US (Guether 1986). Other logitudial studies at the populatio level have foud that milk cosumptio has decreased over time ad that this has correlated with a icrease i soft drik cosumptio (Lytle et al. 2000; Blum et al. 2005; Striegel-Moore et al. 2006). The displacemet of milk ad thus reduced itake of calcium, particularly amog adolescet girls, has implicatios for short-term ad log-term boe health (see below). 4.2.3 Boe Health Prelimiary research suggests a associatio betwee soft drik cosumptio ad boe mieral desity ad boe fractures i childre ad adults (Petridou et al. 1997; Wyshak 2000; McGartlad et al. 2003). Possible explaatios for this relatioship iclude the displacemet of milk i the diet, or a direct effect of soft drik compoets. For example, a Australia study attributed the positive associatio betwee cola cosumptio ad the risk of wrist ad forearm fractures i 9 16 year old childre to the effect of caffeie (Ma ad Joes 2004). Also, the itake of cola, but ot other carboated soft driks, has bee associated with low boe mieral desity i wome, suggestig caffeie as the cause (Tucker et al. 2006). Caffeie has bee show to icrease the excretio of calcium i the urie (Kyast-Gales ad Massey 1994), a potetial cotributor to osteoporosis. A epidemiological study i Mexico foud that cosumptio of soft driks with phosphoric acid, icluded i may soft driks to give them bite, was a idepedet risk factor for developig hypocalcemia (low serum calcium) i postmeopausal wome (Ferado et al. 1999). 4.2.4 Caffeie Cola-type soft driks, which cotai caffeie, curretly have the largest share of the beverages market i Australia (Euromoitor Iteratioal 2006). Caffeie is a mildly addictive stimulat drug which occurs aturally i tea, coffee ad chocolate but soft driks are the mai source of caffeie i childre s diets (Elliso et al. 1995; Nestle 2000). Levels of caffeie i soft driks occur i the rage of 40 50 mg per 375 ml ca. Higher amouts are foud i eergy driks (80 120 mg per ca, equivalet to oe cup of strog coffee), which are formig a icreasig share of beverages cosumed. The curret Australia Food Stadards Code allows the additio of caffeie i cola-type soft driks, flavoured cordials ad flavoured syrups, ad the total caffeie cotet must ot exceed 145 mg/kg (36 mg / 250 ml serve) i the drik as cosumed (Smith et al. 2000). The lik betwee caffeie i soft driks ad boe health has bee idicated i the previous sub-sectio. I additio, several studies have foud a coectio betwee cola driks ad kidey stoes (Rodgers 1999; Massey ad Sutto 2004) ad the US Natioal Istitutes of Health curretly recommed that people tryig to take prevetative actio should limit their caffeie cosumptio, icludig that from cola beverages (Natioal Kidey ad Urologic Diseases Iformatio Clearighouse 2004). More immediate effects of caffeie o health are also apparet. Caffeie sesitivity (the amout of caffeie that will produce a effect i someoe) varies from perso to perso. O average, the smaller the perso, the less caffeie eeded to produce side effects. The short-term affirmig effects of caffeie iclude icreased eergy ad attetio, ehaced mood ad motivatio as well as ehaced motor activity, eve at low doses (20 200 mg) (Smith et al. 2000). Nevertheless there are cosiderable egative effects of caffeie cosumptio, particularly i childre ad youg adults. Negative effects, especially i youg childre, iclude disturbed sleep patters, bedwettig ad axiety, from eve modest cosumptio of caffeie-cotaiig soft driks. Withdrawal symptoms such as headache, fatigue, decreased alertess, depressed mood ad irritability ca be experieced 6 24 hours after caffeie abstiece, agai eve for low doses (Juliao ad Griffiths 2004). Avoidace of withdrawal symptoms plays a cetral role i the habitual cosumptio of caffeie by icreasig the reiforcig effects of caffeie ad preferece for tastes paired with caffeie (Juliao ad Griffiths 2004). This is of particular cocer for soft driks sold to childre ad adolescets as eve low doses ca suppress withdrawal symptoms (Evas ad Griffiths 1999) which may lead to icreased soft drik cosumptio. Soft Driks, Weight Status ad Health: A Review PAGE 23

The taste beefit which the beverage idustry cites as the reaso for addig caffeie to soft driks has recetly bee cotested by researchers i the US (Griffiths ad Verotica 2000) ad Australia (Keast ad Riddell 2007). A Australia tastig pael could ot detect ay differece i flavour betwee decaffeiated cola ad caffeie-added cola, demostratig that there is o flavour-based ratioale to add caffeie to soft driks (Keast ad Riddell 2007). The soft drik idustry maitais, however, that caffeie cotributes to the flavour profile of cola-type driks (Australia Beverages Coucil 2007a). 4.2.5 Chroic Disease Data from the Framigham Heart Study i the US showed that cosumptio of greater tha or equal to 1 soft drik per day (350 ml) was associated with, i additio to a icreased risk of obesity, a sigificatly icreased risk of metabolic sydrome (OR 1.44), waist circumferece (OR 1.3), impaired fastig glucose (OR 1.25), higher blood pressure (OR 1.18), higher hypertriglyceridemia (OR 1.25) ad higher low-desity lipoprotei cholesterol (OR 1.32) (Dhigra et al. 2007). Similarly i the Nurses Health Study II, also i the US, wome cosumig oe or more sugar-sweeteed soft driks per day had a icreased risk of type 2 diabetes (RR 1.83) compared with those who cosumed less tha oe of these beverages per moth (Schulze et al. 2004). 4.2.6 Bezee i Soft Driks There have bee a umber of recet reports of detectable levels of bezee i soft driks. The presece of the preservative sodium bezoate ad ascorbic acid i driks ca react to produce bezee (Gardet ad Lawrece 1993), especially i the presece of light ad heat. These reports have caused cocer as bezee is a kow carcioge. I 2005, the Food ad Drug Admiistratio (FDA) i America tested a umber of soft driks for bezee levels (CFSAN/Office of Food Additive Safety 2007). Four out of 100 products were foud to cotai levels of bezee above 5 ppm, the acceptable limit for drikig water. These products were subsequetly reformulated ad the FDA believes that the level of bezee foud i soft driks is ot a cause for cocer. Similarly, the Food Stadards Agecy i the UK cosiders that the levels of bezee reported would make oly a egligible impact o people s overall exposure to bezee ad ay additioal risk to health is miimal (Food Stadards Agecy 2006). I Australia, FSANZ aalysed 68 flavoured beverages ad foud that five cotaied bezee levels above 10 ppm, with a rage of 1 40 ppb. FSANZ cosiders that these levels are ot of public health cocer, but cotiues to work with idustry to esure that levels of bezee i beverages are miimised (Food Stadards Australia New Zealad 2006). 4.3 The Ecoomic Cost of Soft Driks The burde of disease directly related to soft drik cosumptio is ukow as there are curretly o data available for the risk attributable to this dietary behaviour. Nevertheless, the poor health implicatios of soft drik cosumptio, particularly obesity ad related metabolic diseases icludig diabetes, ad detal caries, are related to substatial health care costs i Australia. Also, may of these diseases are spread iequitably across the socio-ecoomic strata; that is those that are most socio-ecoomically disadvataged suffer the most from these health problems. Thus targeted actio towards reducig soft drik cosumptio is likely to beefit those groups most at risk of ill-health. Australia, like may other coutries, is experiecig a rapid icrease i the levels of overweight ad obesity. I Australia, more tha 10 per cet of the 2000 01 atioal health budget (approximately $6.3 billio) was spet o cardiovascular diseases ad diabetes, much of which ca be directly related to obesity (Australia Istitute of Health ad Welfare 2005). Overweight ad obesity was cosidered to cause a estimated 7.5 per cet of the total burde of disease ad ijury i Australia i 2003 (Begg et al. 2007). With over 60 per cet of the burde of diabetes attributed to obesity ad lack of physical activity, the cosequeces of icreasig obesity will be further magified by reductios i case-fatality from cardiovascular disease the major cause of mortality i people with diabetes through successful tobacco cotrol ad cholesterol ad blood pressure lowerig strategies (Begg et al. 2007). This icreased survival will mea a icrease i the risk of developig other largely o-fatal but disablig cosequeces of diabetes such as real failure, retiopathy, europathy ad peripheral vascular disease. Thus a reductio i soft drik cosumptio ca cotribute to reducig this burde. Oral ill-health accouted for 6.7 per cet (approximately $3.4 billio) of Australia s healthcare expediture i 2001 02 (Begg et al. 2007). PAGE 24 Soft Driks, Weight Status ad Health: A Review

4.4 The Evirometal Cost of Soft Driks The processig, maufacturig, distributio ad disposal of all cotaiers used for soft driks uses extesive amouts of eergy ad water ad create evirometal emissios. Maufacturig processes such as cleaig, coolig, ad risig use large amouts of water. Additioal water ad eergy resources are used i the productio of packagig, the trasport ad the storage of soft driks. A audit by the UK Govermet agecy Evirowise foud that 2.5 litres of water was used i the bottlig process to produce each litre of soft drik i the UK (Evirowise 2005). Coca-Cola Amatil (CCA) Australia specifies that it has reduced this water usage dow to 1.5 litres per litre of soft driks produced (South East Water 2007) but this is still a large amout. Excessive water use for productio, trasport ad maufacturig of soft driks ad their cotaiers is a particular problem i Australia due to the very limited ad fiite water resources of the cotiet. The eergy ivested i the productio of the soft driks cotaiers is lost whe the cotaier is ot recycled. Although all cotaier types glass, alumiium cas, ad polyethylee terephthalate (PET) bottles ca be recycled, a large proportio of soft driks are cosumed away from the home, i areas where there may be limited opportuities for recyclig. Bottled water is ot exempt from may of the evirometal costs. The evirometal impact ca start at the source, where some evirometal lobbyists claim that local streams ad udergroud aquifers may become depleted whe there is excessive withdrawal for bottled water. I additio to the eergy cost of producig, bottlig, packagig, storig ad trasportig bottled water, there is also the evirometal cost of the oil-derived plastic eeded to make the PET bottles. Although the evirometal impact of PET bottles has bee estimated to be less tha that of alumiium cas or glass, the cost remais substatial. The evirometal cost of bottled water overall, although ot as large as that of soft driks, is thus still substatial ad should be bore i mid whe cosiderig strategies for reducig soft drik cosumptio (see Sectio 6.1). Soft Driks, Weight Status ad Health: A Review PAGE 25

Sectio 5 Other Sugary Beverages ad Health 5.1 Fruit Juice I cotrast to most sugar-sweeteed beverages, pure fruit juices provide additioal utritioal value beyod eergy. They are curretly icluded as a core food i the Australia Guide to Healthy Eatig i which ½ cup (125 ml) of fruit juice is cosidered equivalet to oe serve of fruit. It is geerally recommeded that fruit juice cosumptio be restricted to oe small glass per day as a excessive juice itake ca cotribute sigificat calories ad may result i substitutio for fresh fruit which cotais fibre plus a umber of beeficial phytochemicals ot preset i the juice of fruits. 5.1.1 Weight Status The eergy cotet of fruit juice is similar to sugarsweeteed beverages such as soft driks ad may cotribute to excess eergy itake if cosumed i large amouts. However, evidece for the lik betwee cosumptio of fruit juice ad obesity is coflictig (Taylor et al. 2005; Vartaia et al. 2007). The review by Taylor et al (2005) cocluded that fruit juice may be less obesogeic tha other beverages with added sugars ad that if ay relatioship betwee fruit juice ad weight gai i childre exists, it is weaker tha that of soft driks ad sweeteed driks i geeral. However, they cautio that it is udesirable that childre develop a taste for sweet driks hece fruit juice cosumptio should be limited. Two out of four recet studies that have examied the effect of fruit juice o weight i childre ad adolescets have show a positive relatioship betwee fruit juice cosumptio (O Coor et al. 2006; Saigorski et al. 2007) ad weight gai, whilst two have show o associatio (Faith et al. 2006; Tam et al. 2006). I a study i the US ivolvig 2801 childre aged 1 4 years recruited from Wome, Ifat ad Childre (WIC) cliics, the relatioship betwee fruit juice itake ad adiposity (fat) gai, after cotrollig for geder ad ethicity, was foud to be depedet o iitial overweight status (Faith et al. 2006). I already overweight childre, each additioal servig of fruit juice daily was associated with a excess adiposity (fat) gai of 0.009 SD per moth. I cotrast, O Coor et al usig data from the Natioal Health ad Nutritio Examiatio Survey (NHANES) 1999 2002, did ot fid ay associatios betwee type of beverage cosumed (icludig fruit juice) ad the weight status of preschoolers (O Coor et al. 2006). A study of 1944 kidergarte ad primary school studets i south-west Victoria foud that those childre who had more tha two servigs (more tha 500 ml) of fruit juice or fruit drik (diluted fruit juice with added water or sugar) the previous day were more likely to be overweight/obese tha childre who did ot, with the odds icreasig as the amout of fruit juice/drik cosumed icreased (Saigorski et al. 2007). However, i a study ivolvig 268 childre (mea age 7.7 years at baselie, 13 years at follow-up) i NSW, itakes of fruit juice/juice drik ad milk, were ot associated with excess weight gai i early adolescece whilst itake of soft drik ad cordial was associated with weight gai (Tam et al. 2006). Oe of the mechaisms by which fruit juices might be less obesogeic tha soft driks ad other sweeteed beverages is that they are cosumed maily by youger childre who have better compesatio for eergy provided i driks tha older childre ad adults. I additio, water-based beverages make a smaller cotributio to the total eergy itake of youger childre (Alexy et al. 1999; Webb et al. 2006; Raga et al. 2007). It has also bee suggested that fruit juices are more satiatig tha soft driks, particularly fresh juices with some fibre cotet ad juices such as apple which have a low glycaemic idex (Apovia 2004). 5.1.2 Other Health Effects The evidece for the erosive potetial o teeth of fruit juices was cosidered to be probable, as it was for sugar-sweeteed driks, i the 2003 report o Diet, Nutritio ad Chroic Disease (Joit WHO/FAO Expert Cosultatio 2003). Fruit juice cosumptio was ot associated with risk of diabetes, as soft driks were, i the Nurses Health II Study (Schulze et al. 2004). PAGE 26 Soft Driks, Weight Status ad Health: A Review

5.2 Artificially-Sweeteed or Diet Soft Driks 5.2.1 Weight Status Some studies have liked the cosumptio of food ad beverages cotaiig itese artificial-sweeteers to overeatig ad weight gai (Bludell ad Hill 1986; Davidso ad Swithers 2004; Swithers ad Davidso 2008). Also data from the prospective Framigham Heart Study (Dhigra et al. 2007) ad the Sa Atoio Heart Study (Fowler 2005; Fowler et al. 2008) recetly showed a positive associatio betwee BMI ad the cosumptio of regular ad diet soft driks. Similar fidigs have come from studies of elemetary school childre (Blum et al. 2005). It is hypothesised that artificially-sweeteers stimulate appetite or affect mechaisms that regulate huger ad satiety (Rolls et al. 1990; Black et al. 1991; Gougeo et al. 2004) ad thus icrease appetite for sweet foods. A alterative mechaism is that diet soft driks might lead to weight gai by disruptig the sesory mechaisms associatig sweetess with eergy, although Appleto ad Bludell (2007) have recetly show that this disruptio of the sesory mechaisms might work towards reduced appetite for sweet tastes i habitually high cosumers of artificially-sweeteed beverages compared to low cosumers (Appleto ad Bludell 2007). Aother explaatio for a mechaism by which diet soft driks might lead to weight gai is that of cosumer ratioalisatio, i.e. diet soft drik cosumers might cosider that they are reducig eergy itake through drikig diet driks ad hece might cosciously feel that they ca eat other eergy-dese foods more freely tha they might otherwise have doe. A recet study i the US examied this possibility. The grocery purchases of buyers of diet soft driks were compared to buyers of regular soft driks with the aim of ivestigatig the overall eergy itake of the differet buyers (Bikley ad Golub 2007). The study results suggest that the use of diet soft driks does ot lead to compesatio by icreased purchase (ad therefore assumed itake) of high-eergy foods. However, the study did show that the highest purchasers of diet soft drik were also the highest purchasers of processed sack foods. Therefore it was cosidered that sacks have the greatest potetial for udermiig a strategy based o the cotrol of eergy itake through cosumptio of diet driks. I cotrast, two recet reviews cocluded that itese sweeteers ca have a measurable impact o satiety ad lower eergy itakes (Bellisle ad Drewowski 2007). De La Huty et al (2006) coducted a meta-aalysis of maily short-term radomised cotrolled trials ad demostrated that cosumptio of driks sweeteed with aspartame istead of sucrose resulted i a sigificat reductio i eergy itakes ad body weight (de la Huty et al. 2006). I a review of laboratory, cliical ad epidemiological studies, Bellisle ad Drewowski (2007) suggested that humas compesate poorly for previously igested eergy due to a imprecise eergy homeostatic mechaism (Bellisle ad Drewowski 2007). Cosequetly, they argue that diet beverages may represet a plausible strategy for weight cotrol. A recet radomised cotrolled itervetio trial ivolvig the home delivery of o-calorific beverages icludig diet driks ad bottled water led to a reductio of 82 per cet i cosumptio of sugar-sweeteed soft driks i 103 adolescets (13 18 years) after a 25 week period (Ebbelig et al. 2006). The itervetio was also associated with sigificat weight loss, particularly i those childre with a higher BMI at baselie. However, the reductio i BMI could ot be related directly to diet driks as o data o the proportio of diet driks versus bottled water was provided. 5.2.2 Other Health Effects Diet soft driks are ofte promoted as a healthy alterative but they retai some of the compoets of sugar-sweeteed soft driks which have bee associated with ill-health cosequeces. Diet soft driks also have high levels of acidity (from carboic acid, phosphoric acid ad citric acid i cola-type driks) which may cotribute to detal erosio whe cosumed regularly. I additio the diet cola driks cotai caffeie which has bee liked to disturbaces of the cetral ervous system (especially i childre ad adolescets) ad to loss of boe mass (see Sectio 4.2.4). 5.2.3 Safety The most prevalet artificial sweeteers used i diet driks i Australia are aspartame ad acesulfame potassium, used either sigly or i combiatio (Food Stadards Australia New Zealad 2003a). Both sweeteers have udergoe rigorous toxicological studies ad have bee show to be safe for cosumptio by humas icludig pregat wome, childre ad for people with diabetes (Leo et al. 1989; Yost 1989; Mukhopadhyay et al. 2000; Butchko et al. 2002). Regulatory groups i over 100 coutries, icludig Australia have approved the use of these sweeteers (Food Stadards Australia New Zealad 2003b). FSANZ commissioed a dietary survey i 2003 which idicated that the daily exposure of the populatio to all itese or artificial sweeteers is below acceptable daily itake (ADI), (Food Stadards Australia New Zealad 2003a). However cocer was expressed for the potetial for high cosumers of low-joule products to reach their ADI Soft Driks, Weight Status ad Health: A Review PAGE 27

level of these itese sweeteers (Food Stadards Australia New Zealad 2007). 5.3 Milk 5.3.1 Health Beefits The Dietary Guidelies for Australia Adults (NHMRC 2003a) state the followig i relatio to milk: Milk itself is oe of the most complete of all foods, cotaiig early all the costituets of utritioal importace to humas. Milk foods are the richest source of calcium i the Australia diet but are also importat cotributors to protei, vitami A, riboflavi, vitami B12 ad zic. Few other foods provide such a readily absorbable ad coveiet source of calcium. Calcium is required for the ormal developmet ad maiteace of the skeleto. It is stored i the teeth ad boes, where it provides structure ad stregth. I Wester cultures low itakes of calcium have bee associated with osteoporosis, which ofte results i boe fracture ad is oe of the mai causes of morbidity amog older i Australias, particularly wome. The Dietary Guidelies for Childre ad Adolescets i Australia (NHMRC 2003b) recommed water ad reduced-fat milk as the best driks for childre ad adolescets over the age of 2 years. (Reduced-fat milks are ot suitable for youg childre uder 2 years because of their high eergy eeds.) Research shows that i Australia may childre are ot gettig eough calcium for healthy growth ad developmet. Therefore, cosumptio of calcium-rich foods, icludig reduced-fat plai milk, is ecouraged. Flavoured milk ofte cotais added sugar. 5.3.2 Weight Status A modest umber of studies have show that a high milk cosumptio is associated with overweight ad obesity (e.g. Berkey et al. 2005) although other studies have show o relatioship (e.g. Rajpathak et al. 2006; Wager et al. 2007). More recetly a rage of studies i the US have show that milk cosumptio is associated with a healthier weight status ad may aid weight loss. I a cross-sectioal study of over 4000 middle school studets, overweight studets had a sigificatly lower cosumptio of milk tha all other studets (Rosema et al. 2007). Healthy weight was associated with cosumig fruits, vegetables, breakfast ad milk. A 8-week prospective study i overweight/obese pre-meopausal wome showed that soy milk was as effective as skim milk i promotig weight loss (Lukaszuk et al. 2007). A short-term metabolic study by St-Oge et al. (2007) cocluded that, over the loger-term, cosumptio of milk beverages may have more favourable effects o eergy balace tha cosumptio of fruit-flavoured beverages (St-Oge et al. 2007). This fidig was based o data relatig to a higher daily eergy expediture ad thermal effect of food after cosumptio of milk. The evidece from experimetal studies is coflictig. Some studies have idicated that there are o differeces i satiety or subsequet eergy itake after preloads with differet driks of equal calorific cotet: High-fructose cor syrup-sweeteed ad sucrose-sweeteed soft driks ad milk (Soee ad Westerterp-Platega 2007). Other studies support the hypothesis that iso-eergetic milk products (chocolate milk drik) are more satiatig tha sweeteed soft driks (cola) ad decrease short-term huger, although differeces i subjective appetite scores were ot traslated ito differeces i eergy itake i the followig meal (Harper et al. 2007). Some studies have idetified a role for calcium i improved weight status ad weight loss; however whether it is milk per se or whether it is the calcium i milk which impacts o weight status is uclear. A group of studies have show that calcium itake or dairy itake overall is associated with a healthier weight status (Zemel et al. 2005). Milk has also bee foud to be beeficial i relatio to aspects of the metabolic sydrome (Pfeuffer ad Schrezemeir 2007), as has calcium ad dairy products overall (Zemel et al. 2005). For example, i oe cross-sectioal study i me aged 45 59 years, adjusted odds ratio of metabolic sydrome i me who regularly drak a pit of milk or more daily was 0.38 (0.18 0.78) ad that for dairy cosumptio was 0.44 (0.21 0.91) (Elwood et al. 2007). 5.4 Fuctioal Driks 5.4.1 Sports Driks Sports driks were desiged to aid sport performace as well as provide rehydratio after sportig evets. They cotai 6 8 per cet carbohydrates, usually i the form of sugar, plus other electrolytes (Sports Dietitias Australia 2007). As the ame implies, sport driks are desiged for sports participats. Usig sport driks for ormal hydratio purposes is ot recommeded because of their eergy cotet (oe 600 ml bottle of sport driks provides aroud 780 kj) ad their acidity which is associated with the same detal health problems as soft driks. I Australia sports driks curretly accout for less tha 5 per cet of the more tha 1.3 billio litres of o-alcoholic beverages sold per aum, but the sale of sports driks is growig faster tha most other beverages (Australia Coveiece Store News 2006). PAGE 28 Soft Driks, Weight Status ad Health: A Review

Sports driks are ofte marketed ad therefore cosumed o a health basis. For example over 60 per cet of males who cosume sports driks claim to do so to give them eergy ad 25 per cet to give them cotrol, a factor deemed associated with health beefits, ad their eergy cotet is idicated to be less tha fruit juice (although without referece to relative portio sizes). Marketig messages frequetly refer to the eed to rehydrate after what might be cosidered quite modest activity. Sports driks are promoted by may elite sports teams ad are edorsed by some sports medicie ad dietetic groups. The category has also expaded to flavoured waters for kids that geerally iclude a mixture of water (sometimes carboated), cocetrated fruit juice, vitamis, mierals ad electrolytes. Sports driks are geerally cosidered by health professioals as beig suitable oly for elite athletes ad should oly be cosumed by childre takig part i log periods of streuous activity, such as at a sports carival durig hot weather. However, most marketig for these beverages is ow aimed at the o-athlete (Meadows- Oliver ad Rya-Krause 2007) ad they curretly have a regular place i the itake of miimally active childre or adolescets who already have a high degree of body fat ad who may be at risk of excessive eergy itake. 5.4.2 Eergy Driks I recet years, eergy driks have also bee itroduced as alterative premium products to ordiary soft driks. Their sales have rise quickly ad it has bee reported that i the Uited States eergy driks outperformed all other beverage categories, with more tha 500 per cet growth i sales from 2001 06 (Motalvo 2007). The Australia Coveiece Store News (Nov/Dec 2006) idicates that eergy driks accouted for 22 per cet of total drik sales. Most cosumers were i the 15 39 age bracket ad cosumptio is slightly skewed towards males (Australia Coveiece Store News 2006). The amout of carbohydrate preset i eergy driks (e.g. 10 12 per cet) is similar to soft driks. The major costituet of eergy driks are sugar ad caffeie or guaraa (which cotais caffeie), but other igrediets such as B vitamis, taurie, ephedrie, iositol ad giseg are usually added as well (Watso 2007). Diet versios which replace sugar with artificial sweeteers are also available. The major cocer about eergy driks arises from their caffeie cotet. I geeral a 237 ml ca of eergy drik cotais at least 80 mg of caffeie, with some drik sizes cotaiig more tha 300 mg. It has bee reported that over-cosumptio of these eergy driks may eve lead to death i certai circumstaces (Dasey 2007), ad oe popular eergy drik has bee baed i Frace based o its excessive caffeie cotet (Watso 2007). Eergy driks may also cotai a wide rage of other igrediets. May of these are vitamis, particularly vitami A ad some of the B group vitamis (B2, B3, B5, B6 ad B12). Although vitami supplemetatio remais popular i Australia, there is o evidece of beefit i healthy idividuals or athletes who are ot vitami deficiet. Cosumptio of two servigs of some eergy driks may also exceed the recommeded safe daily itake of vitami A ad iaci-b3, particularly for childre. Oe popular use for eergy driks is as mixers to alcohol by youg adults. Combiig eergy driks ad alcohol ca lead to several problems, particularly relatig to the fact that alcohol is a depressat while eergy driks are a stimulat. Cosumptio of eergy driks obscures perceptio of fatigue from drikig; cosequetly, the mixig of substaces teds to icrease the amout of alcohol cosumed. 5.5 Summary Sugar-sweeteed beverages such as cordials ad sweeteed fruit driks, which are cosumed more regularly by youg childre, are likely to have a similar impact o icreasig eergy ad reducig utriet itake (Gill et al. 2006). Other sugary beverages, such as fuctioal driks icludig eergy driks ad sports driks, are emergig ad gaiig popularity i the market. As they cotai large amouts of sugar they have the potetial to cotribute to a eergy imbalace also; however these products still comprise a modest ad particular sectio of the market, ad their cotributio to overweight ad obesity is ukow. Fruit juice is curretly cosidered part of the core food groups i Australia, although itake should be limited. Milk is a core food ad is a good source of calcium, a utriet which may be margial i the diets of Australia adolescets (NHMRC 2003b). Soft Driks, Weight Status ad Health: A Review PAGE 29

Sectio 6 Strategies to Reduce Soft Drik Cosumptio I terms of dietary behaviour chage, soft drik cosumptio is probably oe of the more straight-forward issues to tackle. Sugar-sweeteed beverages are easy to idetify ad defie; they do ot costitute a itegral part of a meal; cosumptio requires a coscious decisio; ad there are direct substitutes. I additio soft driks are of limited utritioal cosequece ad there is geeral acceptace by health professioals of the value of reducig their cosumptio. Curretly there have bee too few itervetio trials aimed at reducig the cosumptio of sugar-sweeteed soft driks to make ay firm recommedatios cocerig the most effective strategies to achieve this objective (Hattersley ad Hector 2008). Like may other public health issues it is likely that a combiatio of strategies will be eeded to achieve ad sustai behavioural chages. A rage of potetial health promotio ad evirometal strategies have bee proposed by advocates for chage ad some of these are examied below. 6.1 Behavioural Goals Four o-discrete optios or itetios for idividual-level behavioural chages are: Reduce uptake of soft drik cosumptio by youg childre. Reduce frequecy ad quatity of soft drik cosumptio Replace soft driks with artificially sweeteed driks Replace sweeteed soft driks with water. 6.1.1 Reduce Uptake of Soft Driks by Youg Childre As taste is the mai reaso soft driks are cosumed, prevetig childre from gaiig a taste for soft driks from a early age would likely result i a fall i soft drik cosumptio at the populatio level after a period of time. The emphasis i this approach is o prevetig toddlers ad youg childre drikig soft driks, or sugary driks, regularly ad i large amouts i the first istace. Ay itervetios to achieve this chage would likely be most effectively aimed at the family ad local commuity. 6.1.2 Reduce Frequecy ad Quatity of Soft Drik Cosumptio This optio would ot etail baig or prohibitig sweeteed soft drik cosumptio but would recommed cosumptio i much smaller amouts ad less ofte, i lie with the recommedatios of the Australia Guide to Healthy Eatig. The curret high levels of sugar-sweeteed beverage cosumptio amog Australia childre meas that small reductios i itake should be relatively easy to achieve ad ay reductio i soft drik itake has the potetial to cotribute to a sigificat reductio i total eergy itake. However, relyig o this strategy requires costat ad cosistet reiforcemet of the message. Also there is a potetial for cofusio aroud the message ad for soft driks to be replaced with other high eergy, sugary beverages. 6.1.3 Replace Soft Driks with Artificially-Sweeteed Driks The use of itese sweeteers as a substitute for sugar may provide a viable strategy to help people reduce their eergy itake without ay loss of palatability ad has bee advocated by several researchers. This optio is likely to be the easiest behaviour chage to make as it ivolves a simple substitutio with a similar product (Chacko et al. 2003) ad as oted i Sectio 3.2, taste is a major driver i soft drik cosumptio. This strategy is also more likely to prevet the replacemet of sweeteed soft driks with other high eergy driks. Itervetio studies usig this approach resulted i a reductio i body weight i adults (Tordoff ad Alleva 1990) ad had a beeficial effect o body weight i adolescets i the highest tertile for BMI, i.e. those most overweight (Tordoff ad Alleva 1990; Ebbelig et al. 2006). However, there are several cocers about this approach (see Sectio 5.2). I summary, some studies have suggested that diet soft driks may have cotributed to the tred of icreasig obesity, although these fidigs are cotetious. A possible threat to the success of diet driks as substitutes for soft driks i the prevetio of obesity is that cosumers of diet driks might cosume more high-eergy sacks. Also, ad libitum cosumptio of artificially sweeteed beverages is ot recommeded, PAGE 30 Soft Driks, Weight Status ad Health: A Review

as the caffeie ad acid cotet of artificially-sweeteed soft driks ca have similar egative health cosequeces to regular soft driks, such as detal erosio ad boe demieralisatio. I additio the same evirometal cocers exist from the eed to collect ad recycle o-refillable bottles (Sectio 4.4). A recet study showed that mixed alcoholic driks made with a diet mixer resulted i faster gastric emptyig ad alcohol absorptio compared to those driks made with a sugar-sweeteed mixer (Wu et al. 2006). Therefore the use of diet driks i associatio with alcohol might ot be advisable. 6.1.4 Replace Soft Driks with Water This optio overcomes the health issues associated with cosumptio of artificially-sweeteed beverages ad would cotribute to better hydratio. Driks high i sugar such as soft driks ad fruit juice slow fluid absorptio by the body ad hece are ot as good as water for re-hydratio, particularly after sports. However, water may ot have a immediate appeal to high-level soft drik cosumers ad poor availability of water i public places ad the premium price of bottled water is a likely deterret to icreased water cosumptio i childre ad those of lower socio-ecoomic status. Also, bottled water curretly does ot cotai fluoride (although this is uder cosideratio by FSANZ) ad has evirometal costs (Sectio 4.4) hece ay itervetio ivolvig this behaviour chage should be aimed at usig refillable water cotaiers. There is some evidece that replacig the cosumptio of sweeteed soft driks with drikig water ca help lower total eergy itake i cosumers who are overweight. A recet itervetio i the US evaluated chages i beverage patters ad total eergy itakes i 118 overweight wome who regularly cosumed sugar-sweeteed beverages (Stookey et al. 2007). The replacemet of sweeteed beverages with water was associated with sigificat decreases i total eergy itake of 840 kj per day that were sustaied over a 12-moth period. A Australia itervetio study, The Fresh Kids program, aimed to ifluece the luchbox cotets ad catee orders for fruit, water ad sweet driks amog culturally-diverse ad socio-ecoomically disadvataged childre i the ier-west of Melboure (Laurece et al. 2007). The itervetio used the Health Promotig Schools Approach, ad compoets relatig to sweeteed driks icluded the distributio of studet-desiged water bottles ad water ad soft drik policies i the classrooms. Although this study did ot employ a compariso group, all schools showed a icrease i the proportio of studets brigig filled water bottles to school at the ed of the two-year period (betwee 15 60 per cet). There was also a sigificat decrease (betwee 8 38 per cet) i the observed proportio of childre brigig sugary driks to school throughout the itervetio period. The limitatios of this study iclude a lack of measuremet of cosumptio throughout the day; thus the study was uable to idicate whether compesatio might occur, i.e. that studets might cosume more sugary driks outside of school to compesate for ot brigig them to school. Nevertheless, whole-of-school strategies to promote replacemet of sugary driks cosumptio with water cosumptio are cosidered a promisig optio for itervetio (Hattersley ad Hector 2008). I aother study, water did ot substitute for soft driks i a study i high schools i the UK. A utritio educatio campaig combied with the provisio of water foutais icreased the cosumptio of water i itervetio schools, but had o effect o soft drik sales, although this was i a eviromet where soft driks were readily available (Loughridge ad Barratt 2005). A recet qualitative study reported o adolescets attitudes to overweight/obesity ad what they felt would work for them (Wilso 2007). This study oted that adolescets are willig to drik more water but are ot willig to give up soft driks. Istead of water, the cosumptio of lower eergy healthier alteratives could be promoted. This could iclude beverages such as flavoured waters (carboated ad o-carboated) for childre (see Sectio 5.4). However, such products do ot ecourage childre to cosume plai water; o the cotrary they habituate childre towards havig beverages that are flavoured ad sweet-tastig. There are also issues with may of the alterative beverages i terms of acidity. I additio, may are packaged i PET bottles, with associated evirometal problems (Sectio 4.4). 6.2 Social Marketig ad Public Educatio The limited social research o attitudes to soft drik has show that there is a lack of awareess of the potetial health cosequeces of excessive soft drik cosumptio ad that a reductio i cosumptio is ot see as a high priority dietary chage, particularly amog those high risk cosumers. Icreased awareess of the issue of soft driks is therefore eeded. Social marketig is oe way to achieve this awareess, ad also fuctios to move people alog the pathway to achievig dietary chage, i.e. iitiatig ad maitaiig chage. Soft Driks, Weight Status ad Health: A Review PAGE 31

Social marketig is the systematic applicatio of marketig cocepts ad techiques to achieve specific behavioural goals, to improve health ad reduce health iequalities (Frech ad Blair-Steves 2005). Social marketig ca reiforce, by cosistet ad appealig imagery, the educatioal messages which cosumers are receivig from more direct sources (Lyle 2004). It has bee show to be a effective ad cost-efficiet approach i addressig the health eeds of low-icome populatios throughout the world. 6.2.1 Social Marketig ad Healthy Dietary Behaviours There have bee several recet reviews of social marketig approaches to promotig health ad healthy utritio practices ad eviromets (Gordo et al. 2006). The earlier review by Alcalay ad Bell (2000) foud that the evidece showed limited effectiveess, although the reviewers oted that social marketig may be effective at prevetig adoptio of uhealthy behaviours, as opposed to chagig igraied behaviour (Alcalay ad Bell 2000). However, the later reviews of Thorley et al. (2007) ad Gordo et al. (2006) have foud that, although social marketig itervetios aimed at improvig utritio are relatively ew ad a empirical evidece-base is still emergig, there is strog evidece that social marketig utritio-related itervetios ca be highly effective. Importatly the reviews showed that effective utritio-related social marketig ca occur with early ay target group (whole populatio, ethic groups, childre, low icome) ad i early ay settig (schools, home, workplaces, churches, ad the wider commuity). Evidece was relatively stroger for itervetios targeted to low icome populatios i home ad school eviromets. The review by Thorley et al (2007) highlights two papers that ivolved social marketig to reduce sugar-sweeteed driks cosumptio. These papers were icluded i a recet evidece update of itervetios to reduce cosumptio of soft driks ad icrease cosumptio of water (Hattersley ad Hector 2008). Both programs aimed to reduce the availability of sugar-sweeteed drik at home. The itervetio by McGarvey et al (2004), was a o-radomised, cotrolled, oe-year prospective study ivolvig 186 WIC (Wome, Ifats ad Childre) program parets with 2 4 year old childre (McGarvey et al. 2004). The itervetio ivolved educatio, staff reiforcemet, ad commuity reiforcemet, grouded i social cogitive theory ad self-efficacy theory. A educatioal group met every two moths ad meetigs were held with a WIC utritioist every 6 moths. Oe of the educatioal messages was drik water istead of sweeteed beverages. Spaish-speakig participats reported at the ed of the program offerig their child water istead of sweeteed beverages more frequetly compared with Eglish-speakig participats. The Memphis GEMS (Girls Health Erichmet Multi-Site Studies) Program (Beech et al. 2003) was aimed at prevetig excess weight gai i pre-adolescet Africa- America girls, ad oe of the utritio objectives was to icrease water cosumptio ad reduce sweeteed beverage itake. A treatmet group which ivolved paretal educatio sessios ad take-home materials to reiforce key poits led to a 34 per cet decrease i servigs of sweet beverages ad 1.5 per cet icrease i water servigs. There was some idicatio, as i the WIC itervetio, that there may be cultural differeces i prefereces for, ad the effectiveess of, this particular approach. May participats also idicated they would have preferred a joit paret-child itervetio. 6.2.2 Social Marketig ad Other Health Behaviours There have bee large ad successful campaigs aimed at other health behaviours i the US ad Australia. For example, the VERBTM campaig, a social marketig campaig aimed to icrease physical activity amog youth, has bee show to positively ifluece childre s attitudes about physical activity ad their physical activity behaviours (Huhma et al. 2007). These authors cocluded that, with adequate ad sustaied ivestmet, health marketig shows promise to affect the attitudes ad behaviour of childre. Wog et al (2004) described the essetial compoets of the campaig ivolvig the four P s of marketig. The four P s are: Product is the desired behaviour for the targeted audiece. Price represets a balace of product beefits ad costs to a cosumer. Place is where the target audiece either performs the behaviour or accesses programs or services place must be readily available to eable the desired actio. Promotio is ot simply the placemet of advertisemets commuicatio messages ad activities are icluded as well. Those i charge of Promotio must cosider multiple ways to reach the target audiece to promote the beefits of the behaviour chage, icludig its product, price, ad place compoets. The four P s were used to pla social marketig PAGE 32 Soft Driks, Weight Status ad Health: A Review

strategies to reduce the cosumptio of alcohol o ad off campus amog uiversity studets i the US (Zimmerma 1997). Iterestigly, oe of the messages of this program was to promote soft drik as a alterative to alcohol, with the sloga cold oe as a reward for hard work, with soft drik cas promietly displayed i the advertisig material. Ivestigatio of the materials used i this program ad other alcohol-prevetio programs could perhaps iform a campaig to reduce soft drik cosumptio ad/or drik more water. Aother social marketig campaig i the US has achieved steady positive chages i attitudes, beliefs ad itetios related to cigarette smokig as well as reachig the ultimate target of reducig cigarette smokig i youth. Cigarette use amog high schoolers dropped from 28 per cet to less tha 23 per cet a drop of more tha 1 millio smokers i the 2 years followig the debut of the program. The focus of the Truth sm campaig is ot solely o the health effects of tobacco or does it war youth ot to smoke; it provides iformatio about tobacco, the tobacco idustry, ad the social costs of tobacco use while ecouragig tees to take cotrol of their lives ad to reject the ifluece of the idustry s advertisig practices (Eiseberg et al. 2004). A valuable fidig from the campaig was the usefuless of the Truth sm tour field marketig activities ivolvig edgy youth travellig throughout the US as ambassadors of the campaig (Eiseberg et al. 2004). Evaluatio of the tour showed that social marketig campaigs should also create likages at the local level to esure that the brad ad message are sustaied i the commuity after the tour leaves tow. These likages should be carefully chose to esure that they embody the image of the campaig. Ultimately field marketig techiques were cosidered importat to the success of the campaig (Eiseberg et al. 2004). Particular poits that emerge from the literature aroud social marketig ad healthy behaviours amog adolescets ad youg adults are summarised i Appedix 1, which also cotais a list of more geeral lessos leared from reviews of social marketig of utritio-related behaviours. 6.2.3 Curret Social Marketig Iitiatives aimed at Dietary Behaviours Iformatio ca also be gleaed from curret, as yet ot evaluated, social marketig programs aimed at chagig dietary behaviours. For example, a curret social marketig strategy i New Zealad Feedig our Futures (delivered by the Health Sposorship Coucil NZ) is aimed at ecouragig parets ad caregivers to adopt ew strategies to improve their childre s diets. Make water or milk the first choice for your childre is oe of the key messages of this program. Other useful hits towards program plaig ad developmet i utritio-related campaigs ca be foud at the followig website: www.sms.org.uk. This website icludes details of the Healthy Livig Social Marketig Iitiative report which provides aswers to the followig key questios: What i people s behaviours place them at risk of uhealthy weight gai? What drives their curret behaviours? How might they be motivated to chage? Who might be able to ifluece them? What might act as barriers to chage? I additio, the Kids Healthy Eatig ad Physical Activity Program curretly beig implemeted withi the Huter / New Eglad regio of NSW has a social marketig elemet which focuses o replacig sweeteed driks with water. 6.2.4 Social Marketig Aimed Upstream There is a importat role of social marketig beyod the focus o the public cosumer; there is evidece that social marketig ca work upstream as well as with idividuals (Gordo et al. 2006). That is, social marketig ca be used to ifluece policy makers who ca address the broader social ad evirometal determiats of health. As Doova ad Heley (2004) ote, social marketig should target idividuals ad groups i legislative bodies, govermet departmets, corporatios, ad o-profit orgaisatios, who have the power to make policy, regulatory ad legislative chages that would affect soft drik availability ad accessibility. 6.3 Potetial Evirometal Strategies Public health theory ad practice has show that idividual-level behaviour chages are ulikely to occur ad be sustaied without supportig evirometal chages. Actio at the macro-evirometal level should aim to decrease the availability ad appeal of soft driks while cocurretly icreasig the availability ad access to alterative beverages. A variety of reports have idetified some key structural issues that could ifluece soft drik cosumptio (Joit WHO/FAO Expert Cosultatio 2003; Jacobso 2005; World Health Orgaizatio Europe 2007). These relate clearly to the idetified determiats ad factors affectig soft drik cosumptio (Sectio 3) ad iclude: access, price, portio size, marketig, labellig ad packagig ad product reformulatio. Soft Driks, Weight Status ad Health: A Review PAGE 33

6.3.1 Reductio of Access to Soft Driks/ Icreased Access to Water A umber of govermet agecies have already moved to reduce the access of childre to soft driks ad icrease their access to alterative beverages, i particular water. I recet years, sugary driks such as soft driks, have bee baed for sale from school catees i public schools i New South Wales, Victoria ad South Australia ad Wester Australia. These restrictios could be exteded to other govermet istitutios such as hospitals ad state-cotrolled recreatio ad sportig veues. However, it is difficult to directly ifluece the ready access to soft driks i most other public places i Australia through vedig machies, coveiece stores, supermarkets or kiosks. A preferable strategy i these situatios might be to improve the access to alterative beverages. The provisio of clea ad free water i public places may decrease the demad for sweeteed driks. I Swede it is compulsory to provide access to free water i all veues where food is served, ad i New South Wales ad Wester Australia it is madatory to serve cold tap water either free of charge or at a reasoable price if the restaurat is licesed to serve alcohol (Departmet of Racig Gamig & Liquor 2007; NSW Office of Liquor Gamig ad Racig 2007). The provisio of chilled water dispesers i commuity stores i rural ad remote Australia could be explored. A very modest charge could be made for the fillig of re-useable bottles. The provisio of cooled water filters i the APPLE Project was part of a multi-compoet two-year pilot utritio ad physical activity itervetio program i primary schools i New Zealad (Taylor et al. 2007). Immediately post-itervetio, childre i the itervetio schools reported cosumig fewer carboated beverages, fruit juice or driks ad total sweet driks tha cotrol childre, although these differeces were primarily due to icreases i cosumptio of sweet driks i the cotrol childre durig this period. Water cosumptio did ot differ sigificatly betwee groups postitervetio ad BMI was oly reduced i studets who were ot overweight at baselie. 6.3.2 Price Icrease Through Taxatio The itroductio of a tax o soft driks ad other sack/ juk foods (sack tax) has bee the subject of cosiderable discussio i past years (Battle ad Browell 1996). The suggestio has arise from the log history of successfully taxig tobacco products ad alcoholic beverages (Kuchler et al. 2005) ad such sack taxes have already bee i practice i may developed coutries, such as Caada ad the USA (Leicester ad Widmeijer 2004; Chouiard et al. 2007). A recet study usig ovel empirical evidece has show strog associatios betwee the presece of state-level taxatio o soft driks or sack foods betwee 1991 ad 1998 ad relative chages i obesity prevalece over the same time period (Kim ad Kawachi 2006). This article emphasises some of the gaps ad priorities regardig this approach which should be addressed i future research ad policies. O average, cosumers aroud the world allocate about 1.1 per cet of their icome o soft driks (Selvaatha ad Selvaatha 2005). Some researchers cosider that the relatively low cost of soft driks is a major factor affectig their cosumptio (e.g. Drewowski ad Bellisle 2007) as soft driks ad other extra foods are relatively cheap compared to healthier alteratives. However, soft drik is cosidered to be relatively price ielastic as the itake of soft drik does ot appear to be bluted much by icreases i price. A worldwide value for the elasticity coefficiet has bee determied to be -0.6 (Selvaatha ad Selvaatha 2005). That is, a 10 per cet icrease i the price of soft driks would likely result i oly a 6 per cet decrease i purchases. Although small taxes o soft driks have bee suggested to be the most viable solutio (Jacobso ad Browell 2000), a larger tax would eed to be imposed to affect cosumer choice to the extet that health improvemets are see (Kuchler et al. 2004; 2005). However smaller taxes could be sufficiet if taxig is combied with alterative approaches to reducig soft drik cosumptio (Caraher ad Cowbur 2005). Also, propoets of the impositio of a soft driks tax suggest the earmarkig of reveue geerated from such taxes for utritio educatio programs, that are curretly uder-fuded (Jacobso ad Browell 2000). Eve a modest taxig of soft driks would likely retur substatial reveue. For example it has bee estimated that cotiued fudig of the highly successful $300 millioa-year youth ati-smokig social marketig campaig i the US, Truthsm, would require oly 1.5 cets per pack of cigarettes (Krisberg 2004). The reveues could also subsidise the cost of core, healthier foods such as fruit ad vegetables (Browell 1994; Battle ad Browell 1996; Kuchler et al. 2004; Kim ad Kawachi 2006), or, specifically i the case of soft driks, improved availability ad access to fresh water. Adversaries of a soft drik or sack tax argue that such taxig violates basic taxatio priciples as people from the lower socio-ecoomic groups are amog those who are the highest cosumers of soft driks; thus it is imposig a fiacial burde o them (Pasour Jr 1995; Bahl 1998). PAGE 34 Soft Driks, Weight Status ad Health: A Review

However, as this group i the commuity are also the most price sesitive, it could be argued that it is reasoable to target them i this way to achieve a appropriate health outcome. Pasour also speculates that reveues from the tax are ot geerally used to provide special beefits to cosumers or busiesses affected by the tax although there is evidece that these beefits to cosumers ca be attaied, such as has happeed with the fuel tax i Australia. Additioally, oppoets to such a tax idicate that reveue collected will gradually dimiish as cosumers buy fewer sack foods ad soft driks (Kuchler et al. 2005). Thus, with the reveue decreased, there will ot be sufficiet moey to fud the utritio educatio programs i the log term; ad short-term utritio educatio programs were deemed ulikely to offer log-term weight reductio (Kuchler et al. 2005). However the excise tax imposed o alcohol ad cigarettes has bee demostrated to be successful i reducig cosumptio of both products through price icreases whe combied with public health educatio programs fuded from the tax. Also, va Baal et al cosidered that eve if the tax reveues geerated by the tobacco tax are ot earmarked specifically to the healthcare budget, icreasig the tax o tobacco is still a cost-effective itervetio for decreasig cigarette smokig (va Baal et al. 2007). This may be true for soft driks also. 6.3.3 Reducig Portio Sizes The tred of icreasig portio sizes has occurred i parallel with the prevalece of overweight ad obesity (Youg ad Nestle 2002; Nielse ad Popki 2003). Thus it has bee postulated that the icrease i portio sizes of sugar-sweeteed beverages may play a role i the obesity epidemic (Youg ad Nestle 2002; Matthiesse et al. 2003). Data aroud the world has provided solid evidece of a icrease i portio size for may food products icludig soft driks over time (Youg ad Nestle 2002; Matthiesse et al. 2003; Smiciklas-Wright et al. 2003; Youg ad Nestle 2003). The size of cotaiers for beverages has icreased 2 3 fold over the last 50 years. I the 1950s the stadard servig size was a 200 ml bottle, i compariso with the most commoly cosumed cotaiers today which are the 390 ml ad 600 ml bottles. Also, with the price of the 600 ml bottle beig oly margially higher tha its 390 ml couterpart, this makes the 600 ml bottle appeared to be a bargai buy as suggested by Youg ad Nestle (Youg ad Nestle 2002). The choice of the larger cotaier size would result i a extra itake of 378 kj. Also, the prevalece of the 600 ml bottle meas that it becomes the orm ad is viewed as a sigle serve, further icreasig the possibility of overcosumptio of eergy. Other evidece of the positive associatio betwee portio size ad cosumptio was summarised i Sectio 3.3.2. 6.3.4 Restrictig Marketig to Childre Sectio 3.3.4 idicated that exposure to food ad beverages advertisig via TV is associated with a higher cosumptio of soft driks. Over 30 coutries, icludig the UK, Australia ad Caada, have already imposed some limitatios o televisio advertisig to childre, while Norway, Swede ad parts of Caada (Quebec ad, most recetly, Toroto) have imposed a ba o televisio food ad beverages advertisemets to childre uder 13 years (Hawkes 2004). There is some evidece to suggest that the icrease i proportio of overweight childre i coutries which limit juk-food advertisig has bee slower tha i those without such limits (James et al. 2002) but the real impact of advertisig restrictios is difficult to assess. Recet aalyses suggest that the TV advertisig of soft driks to childre may be decliig but more pervasive forms of electroic marketig such as websites, childre s magazies, product placemet ad star edorsemets are replacig them (Kelly ad Chapma 2007). There are large umbers of advertisemets for soft driks aroud primary schools i Australia, ad probably i trai statios ad bus shelters too (Kelly et al. 2008). Recetly the US Cetre for Sciece i the Public Iterest developed the Global Dump Soda Campaig aimed at curtailig the promotio of soft driks to childre. I 2007, Cosumers Iteratioal called for compaies to cease the marketig of all sugar-lade beverages to childre uder 16 years, icludig prit ad broadcast advertisig, product placemet, the iteret, mobile phoes, athletic sposorship, sigage, packagig promotios, merchadisig ad other meas. Restrictig marketig of soft driks to childre will require cosiderable actio across may sectors with sustaied advocacy of decisio makers. However, local actio ca be implemeted at the level of schools, workplaces, sports evets ad commuity settigs. 6.3.5 Labellig ad Packagig A potetial strategy to discourage soft drik cosumptio is the iclusio of a label with either a warig message, e.g. excessive cosumptio of soft driks ca lead to udesirable weight gai, ad/or the caloric cotet of the beverage i the cotaier i big prit. A recet US Soft Driks, Weight Status ad Health: A Review PAGE 35

study by Berge ad Yeh demostrated that brightlycoloured 0 calorie, 0 carbs labels o the selectio paels together with motivatioal posters aroud vedig machies which sold driks sigificatly ecouraged uiversity members (studets ad staff) to select either bottled water or diet soft driks over sugar-sweeteed soft driks (Berge ad Yeh 2006). 6.3.6 Product Reformulatio A reductio i the sugar cotet of sugar-sweeteed beverages ad soft driks may assist i reducig the poorer health cosequeces of soft drik cosumptio. With a icreasig public desire for healthier products i geeral, reduced sugar variatios of some soft drik products have bee maufactured ad sold i the USA ad Europe. Despite predictios that this would be a growig market, may of these driks, icludig a reduced sugar versio of Coca Cola, have bee withdraw from sale after oly a short period. The flatess of sales of carboated driks has pushed producers to expad their product rage towards products which ca be marketed as healthier optios with o artificial colours, flavours or preservatives ad added vitamis ad mierals or cocetrated fruit juice. Such products are available for older childre ad adults ad are also aimed at the youger cosumer. For example, bleds of fruit juice ad carboated water have bee desiged to meet Australia tastes. PAGE 36 Soft Driks, Weight Status ad Health: A Review

Sectio 7 Coclusios The review of the literature surroudig cosumptio of soft driks has led to a umber of coclusios i support of actio to reduce soft drik cosumptio at the populatio level i NSW ad Australia. These are listed i Table 5, below, ad discussed more fully i the text. Table 5: Coclusios cocerig priority actios to reduce soft drik cosumptio at the populatio level i NSW ad Australia 1. Soft drik cosumptio is oe of a portfolio of dietary behaviours that should be targeted i the prevetio of obesity. 2. Promotioal efforts to reduce soft drik cosumptio should comprise a whole-of-populatio approach as well as targetig vulerable ad high-risk subgroups of the populatio. 3. Research ito the determiats of soft drik cosumptio, particularly amog differet target groups, is eeded to guide actio. 4. Reductio of populatio soft drik cosumptio requires a multi-faceted commuicatio strategy. 5. Additioal high quality iovatio ad applied research will help improve the effectiveess of curret itervetios to reduce soft drik cosumptio: a. Research ad evaluatio of promisig populatio approaches to decreasig soft drik cosumptio is eeded. b. Research is also required to fill gaps i the evidece base o behavioural itervetios to decrease soft drik cosumptio, such as reducig soft drik availability i the home ad improvig paretal modellig, ad itervetios amog youg adults. c. Soud evaluatio methods should be employed ivolvig measuremet of daily cosumptio of all beverages (icludig water), ideally for several or more days icludig weekdays ad weeked days. 6. I additio to populatio commuicatio ad behavioural strategies, more evirometal strategies to reduce soft drik cosumptio are eeded. 7. The regular moitorig of dietary behaviours, icludig soft driks ad other sugary driks cosumptio, as well as water cosumptio, is ecessary at the state ad atioal level. a. The cotiuous NSW Populatio Health Survey is a source of data o populatio soft drik cosumptio; however other questios relatig to sugary beverages ad water cosumptio would be a useful additio for future surveys. 7.1 Ivestmet i Reducig Soft Drik Cosumptio Coclusio 1 Soft drik cosumptio is oe of a portfolio of dietary behaviours that should be targeted i the prevetio of obesity. There is sufficiet evidece to idicate that soft drik cosumptio is cotributig to levels of overweight ad obesity. Soft drik is a distict beverage that is easilyidetifiable ad does ot provide ay utritioal value, other tha sugar (eergy), ad hydratio which ca be readily obtaied from less eergy-dese sources. Soft drik is cosidered a extra food i the Australia Guide to Healthy Eatig (AGHE). A reductio i cosumptio will accrue other health beefits, icludig improved detal ad boe health. Soft Driks, Weight Status ad Health: A Review PAGE 37

7.2 Target Populatios Coclusio 2 Promotioal efforts to reduce soft drik cosumptio should comprise a whole-of-populatio approach as well as targetig vulerable ad high-risk subgroups of the populatio. Whole-of-populatio Not everyoe i the commuity cosumes soft drik but oe- half of adolescets ad youg adults ad aroud oe-third of adults i geeral report beig cosumers (1995 NNS; sectio 2.3.1). The value of a whole-ofpopulatio approach is supported by the lack of awareess i the geeral commuity about the health issues associated with excessive soft drik cosumptio. Also, evirometal strategies relatig to price, taxatio, access, marketig, labellig ad portio size ca geerally be applied oly at the populatio level. High risk cosumers: There are several sub-groups whose soft drik cosumptio patters ad/or icreased susceptibility to health cosequeces of excess cosumptio make them high risk cosumers. This approach cocurs with a ecessary equity focus where the Four steps towards equity tool developed by South Easter Sydey Area Health Service provides a useful guidig tool. (http:// www.health.sw.gov.au/pubs/2003/pdf/4-stepstowards-equity.pdf). These groups are: Teeagers, especially males ad particularly those of Middle Easter ad Souther Europea descet. Overweight ad obesity is prevalet ad soft drik cosumptio is high amog male adolescets of certai cultural backgrouds. Adolescet males might require tailored assistace to reduce their soft drik cosumptio with messages highlightig the disadvatages of soft drik cosumptio, the edorsemet of healthy alteratives ad targetig self-efficacy with specific behavioural advice. Cultural groups will require appropriate, culturally-targeted health promotio messages ad programs. Youg adults, aged 19 24 years are high cosumers. Messages to reduce soft drik cosumptio should ot coflict with other health promotio programs, particularly those aimed at a reductio i alcohol cosumptio. Idigeous commuities. As well as cosumig more soft driks tha o-idigeous Australias (Sectio 3.1.2, ad Flood V pers. comm.), Idigeous Australias are more susceptible to weight gai ad obesity, have poorer detal health ad are more likely to have diets low i importat utriets. High levels of overweight ad obesity, ad diabetes, i this target group have bee highlighted i several recet papers (Craig et al. 2007; McDermott et al. 2007). Families, particularly of lower socio-ecoomic status ad/or where the mother has a low level of educatio. Ay portfolio of itervetios should iclude a focus o the family uit. The family uit is importat as may utritio beliefs, attitudes ad behaviours are modelled by parets to childre, ad parets purchase the household food ad beverages cosumed by childre. They are a importat group to target i order to limit uptake of soft driks i youger childre, prevetig regular cosumptio becomig a established behaviour. Families of low socio-ecoomic status, particularly where the mother has a low level of educatio, have high rates of overweight ad obesity ad high rates of soft drik cosumptio. Promotioal efforts aimed at parets of youg childre, particularly those that are more socioecoomically disadvataged, should therefore be a itegral compoet of a portfolio of itervetios aimed at reducig soft drik cosumptio overall. Promotioal activities should target: reduced persoal cosumptio (role modellig) reduced soft drik availability i the home ot offerig soft drik to youg childre ot offerig soft drik to ay childre i the home o a regular basis. 7.3 Implicatios for Qualitative Research Coclusio 3 Research ito the determiats of soft drik cosumptio, particularly amog differet target groups, is eeded to guide actio. There is curretly isufficiet kowledge cocerig the barriers to reducig soft drik cosumptio, ad to the beliefs, attitudes ad facilitators of soft drik cosumptio amogst various populatio subgroups. Most of the qualitative research has bee i adolescets, where the fidigs to date have limited potetial to iform actio. Qualitative research ito the determiats of soft drik cosumptio amog differet target groups will iform promotioal efforts icludig itervetio research (Coclusio 5). I particular there is o clear idicatio of which behavioural approach will work best ad it is likely that differet approaches will work best with differet target groups. PAGE 38 Soft Driks, Weight Status ad Health: A Review

7.4 Public Educatio/Social Marketig Campaig Coclusio 4 Reductio of populatio soft drik cosumptio requires a multi-faceted commuicatio strategy. There is a lack of awareess of the potetial health cosequeces of excessive soft drik cosumptio i the geeral commuity i NSW ad Australia. There is strog evidece that social marketig ca be highly effective i chagig utritio-related attitudes, beliefs ad behaviours. Public educatio ca make people more receptive to other promotioal efforts. A multifaceted commuicatio strategy could be employed, ivolvig a umber of campaig waves or stages, addressig the whole populatio as well as specific target groups listed above (Coclusio 2). Differet groups will require differet messages, although a overarchig message should be that of the AGHE, i.e. soft driks should oly be cosumed occasioally ad i small amouts. Formative research, as idicated i Coclusio 3, would iform such a campaig. There may be value i targetig aother utritio or health-related behaviour cocurretly. 7.5 Iovatio ad Applied Research Regardig Potetial Approaches Coclusio 5 Additioal high quality iovatio ad applied research will help improve the effectiveess of curret itervetios to reduce soft drik cosumptio Coclusio 5a Research ad evaluatio of promisig populatio approaches to decreasig soft drik cosumptio is eeded. Coclusio 5b Research is also required to fill gaps i the evidece base o behavioural itervetios to decrease soft drik cosumptio, such as reducig soft drik availability i the home ad improvig paretal modellig, ad itervetios amog youg adults. Coclusio 5c Soud evaluatio methods should be employed ivolvig measuremet of daily cosumptio of ALL beverages, ideally for several or more days icludig weekdays ad weeked days. The four behavioural approaches to eablig a populatio-level decrease i soft drik cosumptio are: Reduce uptake of soft driks by youg childre Reduce frequecy ad quatity of soft drik cosumptio Replace soft driks with water (or low sugar alteratives) Replace soft driks with artificially-sweeteed driks However the evidece-base for behavioural itervetios to reduce cosumptio ad limit uptake of soft driks is curretly extremely limited. Several approaches that hold promise, but require further research ad evaluatio, iclude: Promotig the use of refillable water bottles (Laurece et al. 2007) Ecouragig parets to offer water to childre (McGarvey et al. 2004) Paret-child educatio (Beech et al. 2003) Usig electroic media to promote a reductio i soft drik cosumptio amog youg adults (Hattersley ad Hector 2008). There are a umber of potetial poits of itervetio that have ot yet bee trialled hece are areas for future research; for example itervetios aimed at reducig soft drik availability i the home ad improvig paretal modellig behaviours to reduce soft drik cosumptio amog childre ad adolescets. Youg adults are a target group that has received little attetio to date. The curretly scat itervetio evidece is further limited by a lack of complete evaluatio of beverages cosumptio. For example, may studies have measured water ad/or soft drik cosumptio oly while at school thereby ot allowig for compesatory effects, i.e. icreased cosumptio outside of the school eviromet. Few studies have measured cosumptio at weekeds ad durig the week. Also, there is a lack of evidece that promotig ad icreasig water cosumptio leads to a reductio i soft drik cosumptio. Therefore itervetio studies must iclude a soud evaluatio compoet that uses reliable ad valid methods ivolvig measuremet of all driks (icludig soft driks, fruit juices, water, milks, alcohol etc) cosumed daily, ideally o several or more days icludig weekdays ad weeked days. Soft Driks, Weight Status ad Health: A Review PAGE 39

7.6 Evirometal Chages 7.7 Moitorig Coclusio 6 I additio to populatio commuicatio ad behavioural strategies, more evirometal strategies to reduce soft drik cosumptio are eeded. Such strategies should aim to address issues such as access, price, portio size, marketig, labellig ad packagig, ad product formulatio. Idividual-level behaviour chages are ulikely to occur ad be sustaied without supportig evirometal chages. Although evirometal chages are largely outside the direct ifluece of NSW Health, there is a eed to support such chages wherever possible. Support could iclude direct actio such as leadig by example, e.g. icreasig the placemet of bubblers i health services waitig rooms ad removig vedig machies sellig soft driks from health services. Coclusio 7 The regular moitorig of dietary behaviours, icludig soft driks ad other sugary driks cosumptio, as well as water cosumptio, is ecessary at the state ad atioal level. Coclusio 7a The cotiuous NSW Populatio Health Survey is a source of data o populatio soft drik cosumptio; however other questios relatig to sugary beverages ad water cosumptio would be a useful additio for future surveys. There is a lack of data relatig to dietary behaviours i Australia. Dietary surveys are carried out irregularly ad ifrequetly at the atioal level despite the regular moitorig of particular dietary behaviours, such as soft driks cosumptio, beig essetial to determie if promotioal efforts are workig. Ideally such moitorig would eable determiatio of cosumptio patters ad amouts amog differet populatio sub-groups. The cotiuous NSW Populatio Health Survey icludes a utritio module cotaiig short questios to determie frequecies of food ad beverage cosumptio, icludig two questios about sugary beverages. It therefore provides some data about the cosumptio of sugary driks i NSW, over time. Other questios relatig to amout ad determiats of sugary beverages ad water cosumptio would be useful additios to all future surveys, icludig questios about soft drik, diet soft drik, fruit juice, ad water cosumptio. PAGE 40 Soft Driks, Weight Status ad Health: A Review

Glossary Term Acceptable daily itake Adiposity BMI z-score Body mass idex (BMI) Chroic diseases Cofidece iterval (CI) Cross-sectioal study Efficacy Giseg Glycemic idex (GI) Glycemic load (GL) Guaraa Hypertriglyceridemia Idigeous Itervetios Low-desity lipoprotei cholesterol Morbidity Mortality Defiitio The amout of a specific substace that ca be igested throughout the lifetime without a appreciable adverse health effect. Usually expressed i milligrams per kilogram body weight per day. The quality or state of beig fat. BMI z-scores are a way of defiig how far childre s curret BMI varies from the mea. As a child s BMI will aturally vary with age ad differ betwee geder ad so it is useful to trasform their actual BMI measuremet ito a z-score which allows compariso over time ad across differet age groups ad geders. The BMI z-score is calculated usig referece BMI for age percetiles ad determiig the umber of stadard deviatios from the mea. BMI is the body weight i kilograms divided by the square of height i metres (km/m 2 ). I Caucasia adults, 18.5 BMI < 25 represets ormal weight, 25 BMI < 30 represets overweight, ad BMI 30 represets obese. This term applies to a diverse group of diseases, such as heart disease, cacer ad diabetes (to ame a few), that ted to be log-lastig ad persistet i their symptoms or developmet. Although these features also apply to some commuicable diseases (ifectios), the geeral term chroic diseases is usually cofied to o-commuicable diseases. A cofidece iterval is a rage of values that icludes the parameter with kow probability, called the cofidece level. The cofidece level represets the probability that a sample will actually have the value of the parameter i the cofidece iterval. A study that examies differet variables i a populatio to describe the ature ad icidece of disease or behaviours at a particular poit i time. Risk factors ad outcome measures are determied simultaeously, i.e. o temporal relatioship ca be idetified. Efficacy relates to the ability to produce a beeficial effect uder ideal coditios ad effectiveess relates to the demostratio of a beeficial effect withi the commuity or populatio group. The root of Paax sp., usually Paax giseg. It is a well kow medicial plat i Chia, maily used for its metal ad revitalizig effect o the body. Glycemic idex is a rakig of carbohydrates based o their immediate effect o blood glucose levels. Carbohydrates that break dow quickly have the highest GIs; the glucose respose is fast ad high. Low GI foods affect appetite by keepig a feelig of fulless for loger, while low GI diets may help weight loss. Glycemic load is give by multiplyig the carbohydrate cotet of a food (i grams) by its glycemic idex (as percetage). A herb that cotais a alkaloid similar to caffeie. A excess of triglycerides i the bloodstream. I Australia this term usually describes a perso of Aborigial ad/or Torres Strait Islader descet who idetifies as a Aborigial ad/or Torres Strait Islader ad is accepted as such by the commuity with which he or she is associated. Itervetios iclude policies, programs or actios iteded to brig about idetifiable outcomes. A form of cholesterol i the body which carries cholesterol from the liver to the peripheral tissues. Whe oxidised, it forms atherosclerotic plaque which arrows the arteries, therefore commoly kow as the bad cholesterol. Refers to ill health i a idividual ad to levels of ill health i a populatio or group. Death. Soft Driks, Weight Status ad Health: A Review PAGE 41

Term Neuropathy Defiitio Disturbace or damage to the erves. Nurses Health Study II A prospective cohort study of 116,686 wome from the ursig professio i the US aged 25 42 years at baselie. A rage of diet, lifestyle factors ad health outcomes have bee ivestigated. Dietary iformatio has bee obtaied by food frequecy questioaire at four-yearly itervals sice 1989. Obesogeic Odds ratio (OR) Peripheral vascular disease Phytochemicals Prospective study Real failure Retiopathy Cotributig to a positive eergy balace ad weight gai. The term is usually applied to the prevailig physical, social ad political eviromet. The odds ratio is a measure of risk or associatio used i comparative studies. It is a measure of the odds of the disease or evet i the exposed or itervetio group compared to the odds of the disease or evet i the cotrol group. A OR of 1 represets o associatio, OR > 1 represets a icreased risk ad OR < 1 represets a decreased risk. Narrowig or blockage of the arteries other tha those of the heart. A o-utritive bioactive plat substace, such as a flavooid or caroteoid, cosidered to have a beeficial effect o huma health. Also called phytoutriet. A study where participats are followed forward i time, usually to assess the relatioship betwee a exposure variable ad future health outcome(s). Also kow as a cohort study. A declie i the ability of the kideys to remove excess fluid ad filter the blood. Damage to the retia, frequetly affectig the small blood vessels. PAGE 42 Soft Driks, Weight Status ad Health: A Review

Appedix 1 Lessos Leared from Social Marketig Strategies to Ecourage Healthy Behaviours There are particular poits that emerge from the literature aroud social marketig with regard to adolescets ad youg adults: Projects that use media with etertaimet value (movies, soap operas, radio plays, music, theatre, comics) are likely to be particularly successful with adolescets ad youg adults. Members of the target group ca idetify with the heroie/hero or with a well-kow idol ad this has a motivatig effect i the desired directio of chage. Use of electroic media, icludig the iteret ad mobile phoes, has the potetial to be reach large umbers of this age group, ad offer strategies that are appropriate ad sustaiable (Rodgers et al. 2005; Arthur et al. 2006; Cousieau et al. 2006). There have bee recommedatios that makig the risks kow ad makig the alterative if ot cool, the at least a acceptable choice withi peer groups, is importat. Defiig the product as edgy (o the leadig edge of popular youth culture) as i the VERB ad Truth sm social marketig programs appears to be especially appealig, particularly to the high risk target groups. Heley ad Doova (2003) showed that youg Australias do ot cosider themselves immortal ad respoded equally well to death-threats ad o-death threats i relatio to ati-smokig messages (Heley ad Doova 2003). Adams ad Geues (2007) have recetly showed that, amog adolescets i Belgium, a uhealthy food product received better results i combiatio with a uhealthy sloga tha with a healthy oe, ad vice versa (Adams ad Geues 2007). Highly cocered adolescets respoded more favourably to a healthy sloga i terms of attitudes. Other lessos leared from the reviews of social marketig of utritio-related behaviours ad programs aimed at other health behaviours are: Customer as the focus: Essetially social marketig campaigs have the customer (the public) as the focus of the campaig. They start from where people are ad focus o what support they eed to make behavioural chages. Social chage campaigers ow realise that a approach focused etirely o alertig the public to the dagers of certai health-related behaviours is ofte iadequate i fosterig chages i attitudes, opiios ad, above all, behaviours. Social campaigs coceived simply to educate or admoish ( victim-blamig ) ofte tur out to be relatively ieffective. Appropriate, cosistet messages: Appropriate messages are a key feature of effective social marketig (Sheeha 2005). Not oly do they have to be culturally tailored to a target group, but they must also be well accepted by service providers ad other stakeholders so that messages are delivered cosistetly i a collaborative maer, ad do ot compete with other messages. Persoal relevace: It is importat to establish persoal relevace (a emotive coectio) ad to iitiate people to take the desired actio, icreasig people s readiess to chage. The challege is to persuade people to chage their behaviours without givig up activities they truly value (Klie 2005). I other words the perceived beefits, particularly ay immediate oes, should be maximised ad the perceived short-term costs faced by the target audiece miimised (Adrease 2002). Use of existig settigs: Existig settigs that lowicome populatios, i particular, come ito cotact with o a regular basis are more successfully used to preset a social marketig itervetio tha tryig to ecourage people to atted ew settigs ad services (Havas et al. 1998). Use of existig settigs or commuicatio chaels meas that messages are perceived as beig credible. Use of commuity groups: Use of commuity groups to support behaviour chage efforts ad targetig those who have a reaso to care have bee highlighted as crucial compoets (Sheeha 2005). Early egagemet ad ivolvemet i the campaig plaig ad developmet is also importat. Cultural appropriateess: Differet cultural uderstadigs ad models of health are of cetral importace to behaviour chage. I studies with Maori ad Pacific Isladers i New Zealad, Sheeha (2005) has highlighted that culturally-tailored social marketig itervetios that iclude commuity cotrol, commuity participatio ad leadership are critical features of effectiveess. Soft Driks, Weight Status ad Health: A Review PAGE 43

Build parterships: Egagemet of orgaisatios outside of the health sector is eeded. Joit commitmet ad a co-ordiated approach across govermet, idustry ad volutary sectors is eeded, with strog parterships betwee agecies. Formative research: The report by Sheeha (2005) also emphasised the importace of formative research. Customs, orms, values, ad leadership patters must be cosidered i formulatig social chage strategies targeted o society as a whole or o a sigle commuity. People eed to be listeed to, to fid out what s i it for them. Research ad evaluatio: As well as formative research, ogoig moitorig ad evaluatio i additio to workforce developmet is eeded to support social marketig campaigs (Sheeha, 2005). Research ad evaluatio have bee foud to be vital igrediets of the Slip! Slop! Slap! ad SuSmart campaigs i Australia (Motague et al. 2001). Log-term focus: Permaet, large-scale behavioural chage is best achieved through chagig commuity orms, which ca take geeratios. Larger campaigs ofte move from raisig public awareess i iitial phases to attemptig specific behaviour chage i later phases (Thorley et al. 2007). Cosistecy ad cotiuity was idetified as the other foudatio basis for Slip! Slop! Slap! ad SuSmart campaigs i Australia (Motague et al. 2001). PAGE 44 Soft Driks, Weight Status ad Health: A Review

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