Online Study of the Effects of Sugary Drink Warning Labels on Consumption

Communicating the Health Risks of Sugar-Sweetened Beverages: A Randomized-controlled Experiment of Different Nutrition Labels on Purchases and Consumption

The aim of this study is to determine the degree to which sugar-sweetened beverages (SSB) warning labels increase consumers' knowledge about the potential health harms of SSBs and reduce SSB purchases and consumption. 216 racially and ethnically diverse parents of children 6-11 years old will be recruited to buy snacks and beverages for four weeks via an online store that ships participants their purchases. Participants will be randomized to either 1) calorie labels (control); or 2) sugar graphic warning labels. The investigators hypothesize that sugar graphic warning labels displayed in an online store in weeks 2-4 will lead to the greatest reductions from week 1 across both primary outcomes compared to the control group that will only see calorie labels.

Study Overview

• Status: Completed
• Conditions: Food Preferences
• Intervention / Treatment: Behavioral: Exposure to calorie information; Behavioral: Exposure to sugar-sweetened beverage warning labels

Detailed Description

During this study, participants will shop in an online store created using Shopify for four weeks. In this within-participant design, the first week of shopping is baseline. Participants will then be randomized to different store interfaces for the remaining three weeks based on one of two warning label conditions: 1) calorie labels (control); or 2) sugar graphic warning labels. Participants will complete a brief survey at the start of the study to assess demographic information, information about parent and child beverage consumption, and their online shopping experiences. At the end they will complete another survey about their beverage consumption, their experience shopping in the store, whether they noticed and used the warning labels, and their ability to recall the warning label message. Participants will also be asked about their perceptions of a specific type of warning label in this final survey. Upon completion of the survey, participants will be shown a debriefing statement explaining the study purpose. After they read the information, they will be asked whether or not they consent to allow their data to be used in this study.

• Study Type: Interventional
• Enrollment (Actual): 216
• Phase: Not Applicable

Contacts and Locations

Study Locations

• United States
  • Pennsylvania
    • Philadelphia, Pennsylvania, United States, 19104
      • University of Pennsylvania

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: Yes

Description

Inclusion Criteria:

• a primary caregiver of a child 6-to-11 years old;
• >=18 years old;
• can read and speak English;
• primary grocery shopper for their household;
• have regular Internet access; and
• report that the oldest of their children between 6 and 11 years old is consuming sugar sweetened beverages at least twelve times per month or approximately three times a week

Exclusion Criteria:

• not a primary caregiver of a child 6-to-11 years old;
• <18 years old;
• cannot read and/or speak English;
• not the primary grocery shopper for their household;
• does not have regular Internet access; and
• does not report that the oldest of their children between 6 and 11 years old is consuming sugar sweetened beverages at least twelve times per month or approximately three times a week

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Prevention
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Active Comparator: Calorie label; Calorie label (control) will display a calories per package label on all beverages, not just sugary drinks. This is modeled after the American Beverage Association's current "Clear on Calories" labels. Additionally, all snack items will have a calories per serving label.	Behavioral: Exposure to calorie information; Calories for all beverages and foods
Experimental: Sugar graphic warning label; All products in this arm will also have calorie labels. Beverages with added sugar will also have sugar graphic warning labels with the text: "WARNING: drinking beverages with added sugars contributes to obesity, diabetes, and tooth decay" along with graphics depicting the amount of sugar in the beverage.	Behavioral: Exposure to calorie information; Calories for all beverages and foods; Behavioral: Exposure to sugar-sweetened beverage warning labels; Graphic images of the amount of sugar (randomly assigned teaspoons, packets, or cubes) and text warning labels

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Beverage Calories Purchased, Week 1	Logged beverage calories/100mL purchased. Number of servings per item and number of items per package varied by product; therefore, calorie amounts were standardized to calories/100mL for beverages.	one week
Beverage Calories Purchased, Weeks 2-4	Logged average beverage calories/100mL purchased per week over Weeks 2-4. Number of servings per item and number of items per package varied by product; therefore, calorie amounts were standardized to calories/100mL for beverages.	three weeks
Beverage Added Sugars Purchased, Week 1	Beverage grams of added sugars/100mL purchased. Number of servings per item and number of items per package varied by product; therefore, added sugar amounts were standardized to grams of added sugar/100mL for beverages.	one week
Beverage Added Sugars Purchased, Weeks 2-4	Average beverage grams of added sugars/100mL purchased per week over Weeks 2-4. Number of servings per item and number of items per package varied by product; therefore, added sugar amounts were standardized to grams of added sugar/100mL for beverages.	three weeks

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Number Purchasing a Sweetened Beverage, Week 1	Number of parents buying a sweetened beverage within each condition	one week
Number Purchasing a Sweetened Beverage, Weeks 2-4	Number of parents buying a sweetened beverage at any point during Weeks 2-4, within each condition	three weeks
Snack Calories Purchased, Week 1	Logged snack calories/100g purchased. Number of servings per item and number of items per package varied by product; therefore, calorie amounts were standardized to calories/100g for snacks.	one week
Snack Calories Purchased, Weeks 2-4	Logged average snack calories/100g purchased per week over Weeks 2-4. Number of servings per item and number of items per package varied by product; therefore, calorie amounts were standardized to calories/100g for snacks.	three weeks
Snack Added Sugars Purchased, Week 1	Snack grams of added sugars/100g purchased. Number of servings per item and number of items per package varied by product; therefore, added sugar amounts were standardized to grams of added sugar/100g for snacks.	one week
Snack Added Sugars Purchased, Weeks 2-4	Average snack grams of added sugars/100g purchased per week over Weeks 2-4. Number of servings per item and number of items per package varied by product; therefore, added sugar amounts were standardized to grams of added sugar/100g for snacks.	three weeks
Total Calories Purchased, Week 1	Log of the summed beverage and snack calories purchased	one week
Total Calories Purchased, Weeks 2-4	Log of the average summed beverage and snack calories purchased per week over Weeks 2-4	three weeks
Total Added Sugars Purchased, Week 1	Summed grams of beverage and snack added sugars purchased	one week
Total Added Sugars Purchased, Weeks 2-4	Average summed grams of beverage and snack added sugars purchased per week over Weeks 2-4	three weeks
Volume of Sweetened Beverages Consumed by Child, Baseline	Ounces of sweetened beverages (labeled in sugar condition) consumed per day in the last month by the child as measured by the Beverage Intake Questionnaire (BEV-Q) parent self-report survey.	baseline
Volume of Sweetened Beverages Consumed by Child, Final	Ounces of sweetened beverages (labeled in sugar condition) consumed per day in the last month by the child as measured by the Beverage Intake Questionnaire (BEV-Q) parent self-report survey.	Week 4
Volume of Sweetened Beverages Consumed by Parent, Baseline	Ounces of sweetened beverages (labeled in sugar condition) consumed per day in the last month by the parent as measured by the Beverage Intake Questionnaire (BEV-Q) self-report survey.	baseline
Volume of Sweetened Beverages Consumed by Parent, Final	Ounces of sweetened beverages (labeled in sugar condition) consumed per day in the last month by the parent as measured by the Beverage Intake Questionnaire (BEV-Q) self-report survey.	Week 4
Noticing the Label	Participants will respond "yes," "no," or "I don't know" to the item: "When you selected a beverage to purchase in the store, did you notice any labels on the beverages other than calorie information?"	Week 4
Perceived Label Influence	Participants will respond: "yes", "no," or "I did not notice any labels" in response to the question of whether the label influenced their purchase.	Week 4
How Much do You Trust the Information on This Label	"How much do you trust the information on this label?". Responses will be measured with a 7-point Likert scale where 1=Not at all and 7=Extremely. Higher numbers indicate greater trust in the label.	Week 4
Likelihood of Label Changing Thoughts	"If this government warning label were on a beverage, how much would it change your thoughts about the healthiness of that beverage for your child?" Responses will be measured with a 5-point Likert scale where 1=Not at all and 5=A lot. Higher numbers indicate the label would be more likely to change perceptions of beverage healthiness.	Week 4
Encourage You to Give Fewer Beverages to Your Child	"If you saw this government warning label on a beverage, would the label encourage you to serve your child that beverage less often?" Responses will be measured with a 5-point Likert scale where 1=Definitely no and 5=Definitely yes. Higher numbers indicate greater likelihood of serving unhealthy beverages less often.	Week 4
Negative Reactions to the Label	Average negative emotional response to the label will be examined (said the warning label made them feel worried, fearful, guilty, or disgusted or grossed out). Responses will be measured with a 5-point Likert scale averaging across the 4 negative emotions where 1=Not at all and 5=Extremely. Higher numbers indicate more negative reactions.	Week 4
Child Enjoyment of Water	"How much do you think your child would enjoy this product?" Responses will be measured with a 7-point Likert scale where 1=Not at all and 7=Extremely. Higher numbers indicate greater enjoyment of the product.	Week 4
Child Enjoyment of Orange Juice	"How much do you think your child would enjoy this product?" Responses will be measured with a 7-point Likert scale where 1=Not at all and 7=Extremely. Higher numbers indicate greater enjoyment of the product.	Week 4
Child Enjoyment of Soda	"How much do you think your child would enjoy this product?" Responses will be measured with a 7-point Likert scale where 1=Not at all and 7=Extremely. Higher numbers indicate greater enjoyment of the product.	Week 4
Child Enjoyment of Sports Drink	"How much do you think your child would enjoy this product?" Responses will be measured with a 7-point Likert scale where 1=Not at all and 7=Extremely. Higher numbers indicate greater enjoyment of the product.	Week 4
Likely to Serve or Buy Water	"How likely are you to serve or buy this product for your child in the next 4 weeks?" Responses will be measured with a 7-point Likert scale where 1=Not at all and 7=Extremely. Higher numbers indicate greater likelihood of serving or buying the product for their child.	Week 4
Likely to Serve or Buy Orange Juice	"How likely are you to serve or buy this product for your child in the next 4 weeks?" Responses will be measured with a 7-point Likert scale where 1=Not at all and 7=Extremely. Higher numbers indicate greater likelihood of serving or buying the product for their child.	Week 4
Likely to Serve or Buy Soda	"How likely are you to serve or buy this product for your child in the next 4 weeks?" Responses will be measured with a 7-point Likert scale where 1=Not at all and 7=Extremely. Higher numbers indicate greater likelihood of serving or buying the product for their child.	Week 4
Likely to Serve or Buy Sports Drinks	"How likely are you to serve or buy this product for your child in the next 4 weeks?" Responses will be measured with a 7-point Likert scale where 1=Not at all and 7=Extremely. Higher numbers indicate greater likelihood of serving or buying the product for their child.	Week 4
Health Beliefs and Risk Perceptions Index for Water	Summed responses to the following 7 health perception questions, 6 of which are prompted with the statement "Drinking this product often would…". The statements end with the following health belief and risk perception language: "lead my child to gain weight," "increase my child's risk of heart disease," "increase my child's risk of diabetes," "make my child feel energized," "help my child focus at school", and "help my child live a healthy life." The other item is: "How healthy do you think this product is for your child?" Responses to questions about weight gain, heart disease, and diabetes will be reverse coded, so higher scores on the summed index will indicate a stronger positive health perception of the beverages. This index ranges 7 to 49.	Week 4
Health Beliefs and Risk Perceptions Index for Orange Juice	Summed responses to the following 7 health perception questions, 6 of which are prompted with the statement "Drinking this product often would…". The statements end with the following health belief and risk perception language: "lead my child to gain weight," "increase my child's risk of heart disease," "increase my child's risk of diabetes," "make my child feel energized," "help my child focus at school", and "help my child live a healthy life." The other item is: "How healthy do you think this product is for your child?" Responses to questions about weight gain, heart disease, and diabetes will be reverse coded, so higher scores on the summed index will indicate a stronger positive health perception of the beverages. This index ranges 7 to 49.	Week 4
Health Beliefs and Risk Perceptions Index for Soda	Summed responses to the following 7 health perception questions, 6 of which are prompted with the statement "Drinking this product often would…". The statements end with the following health belief and risk perception language: "lead my child to gain weight," "increase my child's risk of heart disease," "increase my child's risk of diabetes," "make my child feel energized," "help my child focus at school", and "help my child live a healthy life." The other item is: "How healthy do you think this product is for your child?" Responses to questions about weight gain, heart disease, and diabetes will be reverse coded, so higher scores on the summed index will indicate a stronger positive health perception of the beverages. This index ranges 7 to 49.	Week 4
Health Beliefs and Risk Perceptions Index for Sports Drinks	Summed responses to the following 7 health perception questions, 6 of which are prompted with the statement "Drinking this product often would…". The statements end with the following health belief and risk perception language: "lead my child to gain weight," "increase my child's risk of heart disease," "increase my child's risk of diabetes," "make my child feel energized," "help my child focus at school", and "help my child live a healthy life." The other item is: "How healthy do you think this product is for your child?" Responses to questions about weight gain, heart disease, and diabetes will be reverse coded, so higher scores on the summed index will indicate a stronger positive health perception of the beverages. This index ranges 7 to 49.	Week 4
Estimate of How Many Teaspoons of Added Sugar Are in Water	This variable will be measured continuously based on a text box provided to participants. Median teaspoons in each condition will be assessed	Week 4
Estimate of How Many Teaspoons of Added Sugar Are in Orange Juice	This variable will be measured continuously based on a text box provided to participants. Median teaspoons in each condition will be assessed	Week 4
Estimate of How Many Teaspoons of Added Sugar Are in Soda	This variable will be measured continuously based on a text box provided to participants. Median teaspoons in each condition will be assessed	Week 4
Estimate of How Many Teaspoons of Added Sugar Are in Sports Drinks	This variable will be measured continuously based on a text box provided to participants. Median teaspoons in each condition will be assessed	Week 4
Perceived Amount of Added Sugar in Water	This variable will be measured with a 3-point ordinal Likert scale with values: 1 = "too little for my child", 2 = "just right for my child" and 3 = "too much for my child". Higher scores indicate beverage is perceived as having too much added sugar.	Week 4
Perceived Amount of Added Sugar in Orange Juice	This variable will be measured with a 3-point ordinal Likert scale with values: 1 = "too little for my child", 2 = "just right for my child" and 3 = "too much for my child". Higher scores indicate beverage is perceived as having too much added sugar.	Week 4
Perceived Amount of Added Sugar in Soda	This variable will be measured with a 3-point ordinal Likert scale with values: 1 = "too little for my child", 2 = "just right for my child" and 3 = "too much for my child". Higher scores indicate beverage is perceived as having too much added sugar.	Week 4
Perceived Amount of Added Sugar in Sports Drinks	This variable will be measured with a 3-point ordinal Likert scale with values: 1 = "too little for my child", 2 = "just right for my child" and 3 = "too much for my child". Higher scores indicate beverage is perceived as having too much added sugar.	Week 4

Collaborators and Investigators

• Sponsor: University of Pennsylvania
• Collaborators: National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)
• Investigators: Principal Investigator: Christina A Roberto, PhD, University of Pennsylvania

Study record dates

Study Major Dates

• Study Start (Actual): October 6, 2021
• Primary Completion (Actual): January 17, 2023
• Study Completion (Actual): January 17, 2023

Study Registration Dates

• First Submitted: September 15, 2021
• First Submitted That Met QC Criteria: October 12, 2021
• First Posted (Actual): October 15, 2021

Study Record Updates

• Last Update Posted (Actual): April 4, 2024
• Last Update Submitted That Met QC Criteria: March 6, 2024
• Last Verified: March 1, 2024

More Information

Terms related to this study

• Keywords: food labeling; sugar-sweetened beverages; eating; drinking; choice behavior; child
• Other Study ID Numbers: 844786; R01DK111558 (U.S. NIH Grant/Contract)

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: YES
• IPD Plan Description: In the consenting process, participants agreed that de-identified data produced from this project may be distributed for future research studies without additional informed consent. Any de-identified data shared will be done so via PennBox, a secure method to transfer files.
• IPD Sharing Time Frame: starting 6 months after publication
• IPD Sharing Access Criteria: The PI will review requests to use de-identified study data.
• IPD Sharing Supporting Information Type: SAP

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No