Over the past five years, the national conversation around health and nutrition has become ā€™ Most prominently, Health and Human Services Secretary Robert F. Kennedy Jr.ā€™s blames these foods for a host of chronic health issues and has to remove some UPFs from the food supply.Ģż

But thereā€™s a glaring problem: Nobody can agree on how, exactly, to define ultra-processed foods. The lack of a clear definition has stymied legislative and regulatory efforts to curb UPF consumption, and caused confusion for people evaluating their own diets.Ģż

This spring, a panel of 14 nutrition, food science, policy and legal experts gathered to create a more practical and operational definition. The panelā€™s final report, , suggests an ingredient-based approach to identify ultra-processed foods, while also recommending a series of policies to reduce peopleā€™s exposure to them.Ģż

The panel was co-chaired by , clinical professor emeritus of health systems and population health at the UW and executive director of the nonprofit group . UW News sat down with Krieger to discuss the new definition, the debate around ultra-processed foods and how people can limit their consumption.

How have we traditionally defined ultra-processed foods, and where does that definition fall short?Ģż

Jim Krieger: The ultra-processed food concept was developed by who’s a physician and epidemiologist at the University of Sao Paolo in Brazil. He was trying to understand an increase in obesity and chronic disease rates, particularly in kids and young adults, and noticed some important changes in the diet that weren’t fully explained by just the usual nutrient profiling ā€” like fat, sugar, salt. Monteiro came up with this concept of ultra-processed foods. The categorization system is called , which means ā€˜newā€™ in Portuguese, and classifies foods across a spectrum beginning with unprocessed ingredients and ending in ultra-processed. Ultra-processed foods are the ones that are the most highly processed industrial products, basically.Ģż

The Nova definition is geared toward research, to really examine the effects of ultra-processed foods on a range of health outcomes. Using it, numerous studies have found ultra-processed foods to be associated with a whole host of health problems, like diabetes and heart disease and depression. Thatā€™s the basis to say, well, thereā€™s probably sufficient evidence to figure out what we can do to reduce exposure to ultra-processed foods by reducing sales and consumption. That requires policy, and to have policy you need to have a definition of ultra-processed food thatā€™s suitable for regulation or legislation, and thatā€™s where the rub comes. The definition for research doesnā€™t really work in a policy context, because the Nova research definition uses multiple factors, including ingredients, processing techniques, and other factors to identify products as ultraprocessed. Applying Nova can require individual-level review of ambiguous products by skilled nutrition experts that may not be feasible in policy contexts.

You co-chaired a panel of 14 experts who came up with a new definition. What did that work look like, and whatā€™s your new definition?

JK: We tried to come up with a simple definition that could be used in practice. We said the starting point, scientifically, is Nova, because thatā€™s where thereā€™s evidence linking UPFs to harms. But we wanted to come up with a way to identify products that would meet Nova classification using only ingredients on nutrition labels, which is a much more feasible approach compared to the method used in research studies.

We went through a fairly technical process. We got a database of all packaged foods in the U.S., looked at all the ingredients in there and cross-referenced them with technical functions that are listed in Novaā€™s definition ā€” emulsifiers, coloring agents, sweeteners, things like that. We also considered a bunch of nonculinary ingredients, which are the ones you wouldnā€™t use in your kitchen, like hydrolyzed protein and modified starches. This let us develop a list of ā€œmarkerā€ ingredients found in UPFs.

Under our definition, if a product has just one of these marker ingredients, then it is ultra-processed food. Now in reality, very few ultra-processed foods ended up having only one marker. Most had three, four, five or more. We also found that this approach successfully identified 98% of all UPFs.

One criticism of the movement against UPFs has been that some foods that are technically ultra-processed are actually quite nutritious. Iā€™m thinking of products like yogurts, whole-grain breads and tofu. How does your definition account for that?

JK: You want your definition to be sensitive enough to pick up most UPFs, but also specific ā€” that is, not capture foods that are not truly UPFs or even those that can be part of a healthy diet. The way we addressed that was the FDA, a couple years ago, developed criteria for what they call a . If a company wants to say its products are healthy and put that on the package, it has to meet .Ģż

We decided that even if a product is ultra-processed, if it meets the FDAā€™s criteria for a ā€˜Healthyā€™ food, then it should be exempted from policy. That cuts out edge cases ā€” healthier foods that are also UPFs.

Your final report also dives into policy and makes recommendations for lawmakers to consider. What is the current status of ultra-processed food policy across the U.S.?Ģż

JK: Over the last couple of years there has been a flurry of activity, particularly at the state legislative level. Some states say theyā€™re getting rid of ultra-processed foods in school meals, for example, but they have a somewhat random list of ingredients or additives they donā€™t like.Ģż

A few states have tried to take a more evidence-based approach. The best example of that is California, where they passed . They used the same kind of ingredient-list approach that we recommend, simplified a little bit. However, for a food to be a UPF under Californiaā€™s definition, it must also be high in fat, sugar or salt, which raises a problem ā€” about 35% of all ultra-processed foods do not have those levels. Proposed legislation in states like Pennsylvania have avoided this problem by sticking with the Nova-based definition, as recommended by our expert panel, rather than adding on fat, sugar and salt criteria.ĢżĢż

Thereā€™s also been a huge amount of movement in a couple of countries, especially in Latin America. Furthest along is , where the government just issued a regulation to require ultra-processed food labels on packages. Theyā€™re basically using the Nova definition as well.

There are policies moving now, which is why we felt it was important to say, use a good definition of ultra-processed for what youā€™re doing, and then think about certain policy ideas as the best bets for doing something about the problem. For us, those ideas include requiring labels on packages identifying a product as ultra-processed and removing UPFs from food served in schools, childcare and in government facilities.Ģż

Many of the factors that lead people to choose ultra-processed foods are systemic. As an example, food deserts leave some people without easy access to affordable fresh foods. How did the panel consider those factors in making your policy recommendations?

JK: Increasing access to healthy foods gets into another set of policies that are well-described and, to varying extents, are being put into place. Our panel focused specifically on UPF policies. We did assess whether any of our policy recommendations would have unintended consequences of making food less available or affordable for people with low incomes and then we figured out strategies for mitigating those effects.Ģż

A great example would be if you tax even a subset of ultra-processed foods, thatā€™s going to make them less affordable, and thatā€™s a challenge. We recommend that the tax revenues raised from these policies go toward vouchers or incentives for people with lower incomes that they can cash in for fruits and vegetables at a more affordable price.Ģż

We also rejected some policy ideas. One was restricting the use of SNAP (the Supplemental Nutrition Assistance Program, commonly known as food stamps) benefits for purchasing ultra-processed foods. We felt that would have too much of a negative impact on food affordability for people using SNAP, so we did not recommend that.Ģż

What comes next for this research?Ģż

JK: Our next step is to share this definition with as many policymakers as we can, and then offer them technical support if they want to figure out how to use this in legislation or regulation. The second thing is if any legislators, policymakers or advocates want to pursue policies, weā€™re available to provide technical support and assistance.Ģż

Thereā€™s also a bunch of additional research that would be useful. We have some of those recommendations at the end of the report, but as an example, thereā€™s controversy right now over different subgroups of UPFs and whether some are more harmful than others. The research thatā€™s been done so far has been somewhat confusing and flawed. Thereā€™s also research on how, exactly, ultra-processed foods cause all these problems. There are a lot of great, interesting hypotheses, but I wouldnā€™t say any of them are definitive.Ģż

As an expert in this field, how do you approach ultra-processed foods in your own life, and how would you recommend people think about reducing their own consumption?Ģż

JK: Right now, about 60% of the calories that Americans consume are ultra-processed foods. Starting there, small and incremental steps are great. You canā€™t totally change your diet overnight, so the bottom-line message is to think about small things you can do.Ģż

The first challenge is identifying UPFs, which is where we started this conversation. If there are ingredients in food that you donā€™t have in your kitchen, itā€™s likely going to be a UPF, and if itā€™s a long ingredient list that looks like a chemistry lab, itā€™s probably a UPF. Then you can consider what the food looks like. If itā€™s super bright, like Froot Loops or Doritos, that probably means itā€™s a UPF.Ģż

But then once youā€™ve identified ultra-processed foods, what do you do? Letā€™s think about one thing you want to do. Say you drink a lot of sweetened beverages. You can think of what you can swap in that works for you, like sparkling water that doesnā€™t have a lot of additives, or coffee or tea.

As for me, I donā€™t eat many ultra-processed foods. When I started doing this work, when my kids were younger, I fed them all sorts of UPFs. I certainly wouldnā€™t do that now and wish I had known better. But if I want to have something thatā€™s ultra-processed, thatā€™s fine, itā€™s not going to kill you to have just a little bit. As long as your , then thatā€™s great.Ģż

The panel was co-chaired by Krieger and Lindsey Smith Taillie of the University of North Carolina at Chapel Hill and convened by Mary Story and Megan Elsener Lott of Duke University. A full list of panel members is included in the panelā€™s This work was funded by Healthy Eating Research and the Robert Wood Johnson Foundation.Ģż

For more information or to contact Krieger, email Alden Woods at acwoods@uw.edu.Ģż

Call it the sweetness paradox. In grocery stores across America, foods that were once saturated with sugar now contain noneĢżā€” yet they taste just as sweet. Ģż

The secret is an assortment of additives that replicate sugarā€™s sweetness, but not its calorie count. Broadly classified as non-sugar sweeteners (NSS), these additives are creeping into everything from diet sodas (aspartame) to no-sugar-added fruit cups (sorbitol, sucralose, acesulfame potassium).

The rise of NSS has made it easier for conscious consumers to reduce their sugar intake, but these products may present their own health risks. in the journal JAMA Pediatrics, , a UW clinical professor of health systems and population health and executive director of , and a team of co-authors argue for better and more comprehensive data on the proliferation and possible health effects of non-sugar sweeteners. They also call for reducing childrenā€™s exposure to NSS by restricting their use in kidsā€™ food and beverages.

ā€œThe growing presence of (non-sugar sweeteners) in the food supply, combined with mounting concerns about their use… suggest that caution in adding them to foods and beverages is needed,ā€ Krieger and his colleagues wrote.Ģż

UW News sat down with Krieger to discuss what we know ā€” and what we need to know ā€” about these ever-present products.Ģż

NSS have been getting a lot of attention lately, from their possible health effects to their impact on our overall diets despite having been used for decades. Whatā€™s the debate surrounding these products, and why are they drawing so much attention now?Ģż

James Krieger: Thereā€™s been a longstanding controversy over the safety and efficacy of non-sugar sweetened products. The debate has just been lifted up recently because of a couple of things. Last year, the World Health Organization recommended that NSS not be used to achieve weight control or reduce the risk of non-communicable diseases, which means chronic diseases like diabetes or heart disease. That created quite a stir. The food industry, particularly those who rely on these products, reacted negatively to the WHO report, while many public health officials and advocates said this is a great and long- overdue statement.Ģż

Thereā€™s also growing use of these products in the food system, particularly as more consumers are looking for and demanding products with less sugar in them. This is because there is widespread awareness of the negative health consequences of too much sugar consumption. Industry is substituting NSS for sugar. They donā€™t want to change the overall sweetness of their product, because they know really well that sweet foods attract consumers. Instead, theyā€™re maintaining sweetness by substituting NSS for sugar.Ģż

Just how much of these products is the average American eating?ĢżĢż

JK: Thereā€™s not great data on consumption of NSS, and thatā€™s a real gap in the knowledge right now. Thereā€™s better evidence on consumption of sugars, and that is going down.ĢżĢż

The challenge is that the food industry is not very transparent about how much non-sugar sweeteners are in their products. They have to list sweeteners on the ingredients list, but they donā€™t have to list the amount. So we know in more of a binary yes/no fashion, are people eating products with non-sugar sweeteners? And the trend line of that looks like itā€™s going up. For example, from the Environmental Working Group found that the number of food and beverage products containing non-sugar sweeteners increased three- to five-fold between 2013 and 2022.Ģż

We need a lot more research and better data to know what the exposures to these products are. We donā€™t really know how much people are consuming right now.Ģż

On a quick trip through the grocery store, one might come across a dozen different non-sugar sweeteners. Thereā€™s the classics, aspartame and sucralose, the sugar alcohols like erythritol and xylitol, and the ā€œnaturalā€ NSS like stevia and monk fruit extract. Do different sweeteners interact with our bodies differently? Do some carry greater potential health risks than others?ĢżĢżĢż

JK: Itā€™s not clear. Most of the studies, particularly the long-term studies, have looked at these products as a group. But each one has a distinct pharmacologic and toxicologic profile. Some of the older NSS have been directly assessed by the FDA, but those assessments are very dated now. The way the newer NSS get into the food supply now is that industry just needs to send in a statement to the FDA saying that, in their estimation, these are safe.ĢżĢż

Now that said, there are some specifics. Some credible researchers and agencies within the WHO have raised concerns that aspartame may be linked to cancer. Others disagree. Itā€™s clear that saccharine is probably a carcinogen, and itā€™s not used much now. A recent study that came out on erythritol looked at its association with cardiovascular disease, that is death or non-fatal heart attacks or strokes, and found they were increased. The researchers found a possible mechanism for that, linking non-sugar sweeteners to platelet clumping and blood clotting in vitro, which could explain that link, because these can block blood flow and cause heart attacks and strokes. So thereā€™s a plausible mechanism that it could do that.Ģż

My guess is that itā€™s probably going to be a class effect ā€” theyā€™ll all have kind of the same effect. And the reason I suspect that is because the common mechanism they all work by is they all bind to sweet receptors, and those arenā€™t just in your mouth, theyā€™re also in organs and blood vessels, everywhere in the body. All of these products bind to those sweet receptors, no matter where they are. And then they might have effects ranging from insulin sensitivity, glucose metabolism, to vascular reactivity, platelet activation and so on.

Thereā€™s really pretty good evidence from long-term epidemiological diet studies that link exposure to non-sugar sweeteners to Type II diabetes, to weight gain, to heart disease. Those certainly are three big public health problems right now. Thatā€™s what has gotten me concerned about these and why I think we need to be taking a more active, aggressive approach toward limiting peopleā€™s exposure to them.Ģż

You write in the article that itā€™s especially important to understand kidsā€™ exposure to non-sugar sweeteners. Why is that?ĢżĢż

JK: In general, for any kind of environmental exposure, kids are more vulnerable because theyā€™re going through these developmental windows when their bodies are more sensitive to the effects. Exposure early in life, can actually set up lifelong metabolic and physiological changes. So avoiding early exposure to substances associated with unhealthy biological processes isĢża really good opportunity to set kids on a trajectory to a healthy life as opposed to problems.ĢżĢż

Also, taste preferences get set early in life. Thereā€™s evidence that kids who are exposed to more sweetness will develop a lifelong preference for sweetness, and that sets them up to either consume more sugar or non-sugar sweeteners. And children donā€™t make choices for themselves. Theyā€™re more vulnerable, so we have to do more to protect them from any kind of thing thatā€™s going to jeopardize their health.Ģż

That leads me to another thing thatā€™s a little scary. The USDA released preliminary guidelines about the amount of added sugar that can be served in school foods and meals. The guidelines say that by 2027, no more than 10% of the calories in school food can come from added sugars, which is consistent with the US dietary guidelines. Thatā€™s great, but then I worry that the food industry will put more NSS in the foods available at schools, and kidsā€™ exposure will go up.ĢżĢż

You highlight other countries, most notably Chile, that require food manufacturers to be transparent about the type and amount of NSS in their products. Do you see that as an effective strategy in the U.S.?Ģż

JK: Chile is one of the few countries that requires the amount of non-sugar sweetener to be put on labels of their food products. I think thatā€™s a great idea, and I would love to see that happen in the U.S.Ģż

Another approach, short of putting the actual quantitative amounts on nutrition labels, is putting labels indicating the presence of NSS on the front of packages, which is what Mexico, Colombia and Argentina have done. Many countries, predominantly in Latin America, have put front-of-package labels warning about added sugars, salt and saturated fat, which are three ingredients of public health concern. Mexico, Colombia and Argentina have added a fourth, warning that the products contain these non-sugar sweeteners and that children should avoid them. Thatā€™s probably not going to happen in the U.S. anytime soon given industry opposition and slow action by the FDA.Ģż

Thereā€™s more potential for either FDA or USDA to require more transparency by the food industry. I could see them saying that manufacturers must disclose how much and what types of non-sugar sweeteners are in their products to a database that could be made available to researchers. It could also help if federal agencies or nutrition groups and nonprofits take this data and package it in a way to make it accessible to consumers who want to know how much of this stuff is in there. It could increase the publicā€™s ability to access that information, and those who are really motivated might make choices about what to buy or not buy.Ģż

And finally, letā€™s protect children. Thereā€™s no place for NSS in foods commonly consumed by or marketed to kids. Until we have reliable data that NSS are safe for children, letā€™s do all we can to make sure they do not consume them.Ģż

For more information, contact Krieger at jwkrieg@uw.edu.

When schools closed during the first year of the pandemic, an immediate and potentially devastating problem surfaced: How would millions of children in struggling families get the school meals many of them depended on?

The U.S. Congress responded by authorizing the Department of Agriculture to roll out two major programs. It launched the ā€œgrab and go school meals,ā€ which helped schools provide prepared meals for off-site consumption and distributed funding for the state-operated Pandemic EBT (P-EBT) program, which gave parents debit cards so they could purchase groceries from food retailers.

A new study led by the Harvard and °®¶¹ÉēĒų schools of public health found that the programs reached more than 30 million children and either directly provided meals or, through the P-EBT program, cash for nearly 1.5 billion meals a month in 2020.

In the new study , the researchers found:

• The P-EBT program reached 26.9 million of the 30 million children whose families qualified because of low income at a cost of $6.46 per meal, providing access to 1.1 billion meals a month.
• The grab-and-go program reached 8 million children not eligible for P-EBT at a cost of $8.07 per meal, providing 429 million meals a month.

ā€œWhen schools had to close across the country during the spring of 2020 due to COVID-19, kids all of a sudden lost access to school lunches and breakfasts. From a public health and nutrition securityĢżperspective, this was an urgent concern, given that these meals are critical for students at risk of food insecurity and are also an essential source of nutrition for millions of children,ā€ said , study lead author and assistant professor of public health nutrition at Harvard.

Kenney said when these programs began, no one really knew how effectively they would reach kids who needed them and at what cost per meal. So the researchers set out to try to answer how these two major policy responses to the loss of regular school meal access worked.

ā€œThis study suggests that, in many states, P-EBT can reach the most eligible children at relatively low cost to the government, while a meal distribution model such as grab-and-go school meals can also ensure families directly receive meals and reach children beyond those who are P-EBT-eligible,ā€ said , senior author and clinical professor of health systems and population health in the UW School of Public Health.

Now, Krieger said, extensions of these two key projects are being debated in Congress. On July 27, the House Education and Labor Committee sent its 2022 Child Nutrition Reauthorization bill (H.R. 8450), the ā€œ“ā€Æto the House floor.

In the following Q&A, Krieger and Kenney discuss what their findings mean for this or similar policy.

What would the new ā€œkids actā€ do?

Krieger: The act proposes a comprehensive, science-driven reauthorization of federal child nutrition programs that meets the needs of children and families. It includes many familiar and essential programs, such as school meals and the WIC program. It would address food insecurity among children during the summer, when schools are closed, by significantly expanding access to summer meals and creating a nationwide Summer-EBT program. The Summer-EBT program would operate similarly to P-EBT in many ways and provide $75 per month per household on an electronic debit card. It supports school efforts to increase access to summer meals using methods that worked in the grab-and-go school meals program during COVID school closures.

Based on your findings, what should Congress do for kids?

Krieger: Our study offers evidence that these components of the proposed act ā€” an EBT program to distribute the value of school meals, similar to the proposed summer-EBT program, combined with expanded distribution of meals in the community, similar to the expanded summer meals programā€” were effective in feeding millions of children when schools were closed due to COVID and suggests that they will also likely be effective in delivering food to children during school summer recess. Including both programs in the act would help to assure food access when schools are closed during summer breaks.

Kenney: An important takeaway from our study that may be relevant for the conversation about the Healthy Meals, Healthy Kids Act is that these should be considered together, as a two-pronged strategy. The two approaches complement one another: P-EBT can help make sure that at least the cash value of those missed meals can get out to low-income families efficiently, and grab-and-go meals can ensure that families who may be struggling but may not have a low-enough income to qualify for P-EBT can still get meals. They can also ensure that families who may have more difficulty preparing food ā€” like families experiencing homelessness or with limited kitchen facilities, or even just with limited time ā€” can access nutritionally adequate meals.

What else should Congress consider?

Krieger: The federal government should be investigating strategies for optimizing the cost-effectiveness of grab-and-go school meals. It should also expand the P-EBT program or its equivalent to cover 60 meals per month instead of 40 to match the grab-and-go school meals benefit level. And, it should work to optimize the nutritional quality of the foods provided.

Co-authors include Lina Pinero Walkinshaw and Jessica Jones-Smith, UW Department of Health Systems and Population Health; Ye Shen and Sara Bleich, Harvard T.H. Chan School of Public Health; and Sheila E. Fleischhacker of the Georgetown University Law Center. This research was funded by the Robert Wood Johnson Foundation.

###

For more information, contact Kenney at ekenney@hsph.harvard.edu or Krieger at jkrieger@hfamerica.org.

Sugar-sweetened beverages are a known contributor to several health issues, including poor diet quality, weight gain and diabetes. While several studies have shown that taxing sweetened beverages significantly reduces purchasing, questions have been raised about whether the taxes place a greater economic burden on lower-income households.

New research from the °®¶¹ÉēĒų, , addressed the issue by examining the economic equity impacts of sweetened beverage taxes in three cities: Seattle, San Francisco and Philadelphia.

ā€œSugar-sweetened beverages are the new tobacco,ā€ said , senior author and clinical professor of health systems and population health in the UW School of Public Health. ā€œPublic health researchers and others have been working for some time to reduce sales of these beverages. Taxes worked well to reduce tobacco purchases, and theyā€™ve been applied and appear to work equally well in sugary drinks.ā€

The study showed the tax paid by households accounted for a larger proportion of income for lower-income households, but still only 0.01% to 0.05%. The annual per capita dollar amount that households paid toward the tax, between $5.50 and $31, didnā€™t differ by income level.

The researchers also found that sweetened beverage taxes redistributed dollars from higher- to lower-income households. More dollars went toward funding programs that benefit lower-income communities than those households paid in taxes. The annual net benefit to lower-income communities ranged from $5.3 to $16.4 million per year across the three U.S. cities.

ā€œCities have prioritized funding programs that benefit lower-income populations, which makes sweetened beverage tax policies more economically equitable,ā€ Krieger said.

For example, revenue raised by has been used to fund programs and services that increase access to healthy food and support child health and learning in early childhood. In 2020, sweetened beverage tax revenue was also used to provide support to communities disproportionately impacted by the COVID-19 pandemic.

The researchers studied the volume of beverage purchases made in stores by 1,141 households in the three U.S. cities to estimate taxes paid by households during the first year after tax implementation. They then used city population data to calculate the per capita amount of sweetened beverage tax paid by income level.

The authors also reviewed public documents and contacted city representatives to find the dollar amount of annual tax revenue and the amount invested in programs serving lower-income communities.

ā€œThere arenā€™t a lot of studies right now that look at actual household purchases of these taxed beverages,ā€ said co-lead author , UW associate teaching professor of economics. ā€œThey mostly look at retail-level data. But you donā€™t know what people are doing at a household level. They could be going to another city to buy their sweetened beverages and bringing them back to Seattle. This study catches all of that. Weā€™re just looking at households that live in these cities and the totality of everything they report having purchased.ā€

The study shows that sweetened beverage taxes ā€œcan be an economically progressive policy,ā€ Krieger said. Seven local jurisdictions in the United States, the Navajo Nation and at least 45 other nations have implemented sweetened beverage taxes.

ā€œThese taxes selectively and specifically benefit people with lower incomes to a greater extent than people with higher incomes, because the money thatā€™s raised by taxes goes toward programs serving lower-income communities,ā€ Krieger said. ā€œThatā€™s from the economic point of view.

ā€œThe taxes also benefit people with lower incomes because they drive down consumption more and sales more for that population. People will consume less of an unhealthy product and theyā€™ll be healthier because of that. Itā€™s a win for health, itā€™s a win for the pocketbook and itā€™s a win for their communities.ā€

, UW associate professor of health systems and population health and of epidemiology, was a corresponding author and co-principal investigator.

Other co-authors from the UW were , clinical instructor of health systems and population health; , senior research scientist in the Center for Studies in Demography and Ecology, , affiliate associate professor of urban design and planning; and , who recently graduated with a masterā€™s degree in epidemiology. , associate professor at the University of Pennsylvania Perelman School of Medicine, was also a co-author.

The study was funded by the Robert Wood Johnson Foundationā€™s with partial support from an NICHD grant to the at the °®¶¹ÉēĒų.

For more information, contact James Krieger at jkrieger@hfamerica.org and Melissa Knox at knoxm@uw.edu.

Correction on 7/13: A previous version of this story said that the annual net benefit to lower-income communities ranged from $5.3 to $19.1 million per year across the three U.S. cities. The latter number is actually $16.4 million.

The UW-led study set out to assess the effect of culturally tailored countermarketing messages on drink choices, similar to stark anti-smoking campaigns, and involved more than 1,600 Latinx parents who participated by joining Facebook groups. Study authors focused on this demographic because Latinx children have a , and the beverage industry , said Dr. , lead author and clinical professor of health systems and population health in the UW School of Public Health.

ā€œThe negative health effects associated with the consumption of sugary drinks ā€” such as tooth decay or, later in life, diabetes ā€” are disproportionately affecting this community,ā€ Krieger said. ā€œWe want these and other kids to be able to avoid developing strong taste preferences for a product thatā€™s ultimately going to harm them.ā€

To design their study, , researchers consulted focus groups involving dozens of Latinx parents from across the country to get their perceptions of how marketing works, how they think about what they are buying for their children, as well as how to culturally tailor messages that would resonate in their community.

ā€œThey know that targeted marketing happens all the time in the digital era, but what really got them was the fact that they were given deceptive information that they felt was leading them to make unhealthy choices on behalf of their kids,ā€ Krieger said.

That industry marketing, Krieger added, led parents to believe fruit drinks are healthy beverages by creating a ā€œhalo of healthā€ around the product. Ads, labels, and even online games and cartoons often contain claims about nutrients such as vitamin C and images of healthy kids drinking their products while participating in sports.

With information from those focus groups and the aid of a Latinx marketing firm, the researchers created countermarketing graphics and messages in Spanish and English designed to elicit outrage, fear of the harmful effects on children and other negative emotions. The messages called out specific brands and images, along with describing the adverse effects of these products.

ā€œWe looked at anti-tobacco messages and the words and types of images they used,ā€ Krieger said. ā€œWe wanted messages that would appeal to folks on an emotional level as well as a cognitive one, because thatā€™s what research shows drives people to make choices.ā€

The researchers then enrolled 1,628 Latinx parents ā€” predominantly female and from lower-income households ā€” to participate in Facebook groups for six weeks to study the impact of countermessages on those parentsā€™ beverage choices and fruit drink perceptions.

Sample messages

Message text: Your body turns sugar you drink into fat which can result in diabetes.

Message text: WARNING: Calling it natural does not make it good for your kids.

Message text: Activate your kidā€™s health by giving them thirst quenching water instead of sugary fruit drinks. The choice is clear.

The study divided parents into three groups. The two ā€œinterventionā€ groups were those who received fruit drink countermessages only, and those receiving a combination of countermessages plus water promotion messages. The third group, the control group, saw safety messages about car seats. Using a simulated online store that offered fruit drinks, soda, water, milk or 100% fruit juice, parents from all three groups chose a drink for their kids and received money they could use to buy the drink in a real store.

The researchers found that parents who saw countermarketing messages alone or combined with pro-water messages were less likely to buy a fruit drink and more likely to buy water. Specifically, parents in the fruit-drink countermarketing group decreased their virtual purchases of these drinks by 31% compared to the control group, and by 43% by the group receiving the combined messages. Parents in the combination group did choose water more often than the first group.

Based on those choices, the authors estimated that children in the combination group consumed 22% less added sugar than the average for children two- to five-years-old. In exit surveys, the authors wrote, the parents in both intervention groups were also ā€œsignificantlyā€ less likely to trust fruit drink brands.

The researchers said the study is the first to ā€œdemonstrate the efficacy of countermessages delivered solely via social media as well as the first to specifically target sweetened beverage consumption among young children.ā€ As a result of this study, the researchers have also created for use by anyone to campaign against fruit drink purchases for children.

As executive director of and with an extensive background in the development and evaluation of community-based chronic disease prevention programs, including a stint with Public Health-Seattle & King County, Krieger hopes the study will be used widely to curb consumption of sugary fruit drinks.

ā€œFor me, thereā€™s no point in doing a study if it is not going to be applied to changing things in the world, so weā€™ve formed an advisory group and created the toolkit and a plan to reach out to national organizations and encourage them to use the messages,ā€ Krieger said.

Co-authors include Taehoon Kwon, who worked on the study while a UW graduate student in economics; Rudy Ruiz, of Interlex, a multicultural advocacy marketing agencyĢżin San Antonio; , a clinical instructor in the UW School of Public Health; and Jiali Yan and Christina Roberto at the University of Pennsylvania. This research was funded by the Healthy Eating Research Program of the Robert Wood Johnson Foundation; and the Arcora Foundation, the foundation of Delta Dental of Washington.

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For more information, contact Dr. Krieger at jwkrieg@uw.edu.