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Effectiveness of behavioural interventions to reduce the intake of SSBs in children and adolescents: What’s the Evidence?


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Health Evidence™ hosted a 60 minute webinar examining the effectiveness of behavioural interventions to reduce the intake of sugar-sweetened beverages (SSBs) in children and adolescents. Follow this link to access to the audio recording for this webinar:

Dr. Lamis Jomaa, Assistant Professor at the Department of Nutrition and Food Sciences, Faculty of Agricultural and Food Sciences at the American University of Beirut, presented an overview of findings from their latest systematic review and meta-analysis:

Rahman A, Jomaa L, Kahale L, Adair P, & Pine C. (2018). Effectiveness of behavioral interventions to reduce the intake of sugar-sweetened beverages in children and adolescents: A systematic review and meta-analysis. Nutrition Reviews, 76(2), 88-107.

Consumption of sugar-sweetened beverages (SSBs) among children has been associated with adverse health outcomes. Numerous behavioral interventions aimed at reducing the intake of SSBs among children have been reported, yet evidence of their effectiveness is lacking. This systematic review explored the effectiveness of educational and behavioral interventions to reduce SSB intake and to influence health outcomes among children aged 4 to 16 years. Of the 16 trials included, 12 were school based and 4 were community or home based. Only 3 trials provided data that could be pooled into a meta-analysis for evaluating change in SSB intake. Subgroup analyses showed a trend toward a significant reduction in SSB intake in participants in school-based interventions compared with control groups. Change in body mass index z scores was not statistically significant between groups. The quality of evidence from included trials was considered moderate, and the effectiveness of educational and behavioral interventions in reducing SSB intake was modest.

Published in: Education
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Effectiveness of behavioural interventions to reduce the intake of SSBs in children and adolescents: What’s the Evidence?

  1. 1. Welcome! Effectiveness of behavioural interventions to reduce the intake of SSBs in children and adolescents: What's the evidence? You will be placed on hold until the webinar begins. The webinar will begin shortly, please remain on the line.
  2. 2. Poll Questions: Consent • Participation in the webinar poll questions is voluntary • Names are not recorded and persons will not be identified in any way • Participation in the anonymous polling questions is accepted as an indication of your consent to participate Benefits: • Results inform improvement of the current and future webinars • Enable engagement; stimulate discussion. This session is intended for professional development. Some data may be used for program evaluation and research purposes (e.g., exploring opinion change) • Results may also be used to inform the production of systematic reviews and overviews Risks: None beyond day-to-day living
  3. 3. After Today • The PowerPoint presentation and audio recording will be made available • These resources are available at: – PowerPoint: – Audio Recording: /videos 3
  4. 4. What’s the evidence? Rahman A, Jomaa L, Kahale L, Adair P, & Pine C. (2018). Effectiveness of behavioral interventions to reduce the intake of sugar-sweetened beverages in children and adolescents: A systematic review and meta-analysis. Nutrition Reviews, 76(2), 88-107. article.aspx?a=effectiveness-behavioral- interventions-reduce-intake-sugar- sweetened-beverages-33200
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  7. 7. Poll Question #1 How many people are watching today’s session with you? A. Just me B. 2-3 C. 4-5 D. 6-10 E. >10
  8. 8. Students: Sarah Neil-Sztramko (Postdoctoral fellow) Emily Belita (PhD candidate) Patricia Burnett (PhD candidate) Rawan Farran Research Assistant Kristin Read Research Coordinator Heather Husson Administrative Director The Health Evidence™ Team Maureen Dobbins Scientific Director Maureen Dobbins Scientific Director Claire Howarth Research Coordinator Kate Turner Research Assistant Emily Sully Research Assistant
  9. 9. What is Evidence Decision Making inform
  10. 10. Why use 1. Saves you time 2. Relevant & current evidence 3. Transparent process 4. Supports for EIDM available 5. Easy to use
  11. 11. A Model for Evidence- Informed Decision Making National Collaborating Centre for Methods and Tools. (revised 2012). A Model for Evidence-Informed Decision-Making in Public Health (Fact Sheet). []
  12. 12. Stages in the process of Evidence-Informed Public Health National Collaborating Centre for Methods and Tools. Evidence-Informed Public Health. []
  13. 13. Poll Question #2 Have you heard of PICO(S) before? A. Yes B. No
  14. 14. Searchable Questions Think “PICOS” 1.Population (situation) 2.Intervention (exposure) 3.Comparison (other group) 4.Outcomes 5.Setting
  15. 15. How often do you use systematic reviews to inform a program/services? A. Always B. Often C. Sometimes D. Never E. I don’t know what a systematic review is is Poll Question #3
  16. 16. Co-authors Lamis Jomaa, MSc, PhD • Assistant Professor, Department of Nutrition and Food Sciences, American University of Beirut, Lebanon • Affiliate assistant professor, Pennsylvania State University
  17. 17. Abir Abdel Rahman, MSc, PhD Assistant Director Medical Laboratory Sciences Program, Faculty of Health Sciences, University of Balamand, Lebanon Co-authors
  18. 18. Co-authors Lara A Kahale, RN, MSc, PhD(candidate) AUB GRADE center coordinator, Clinical Research Institute, AUB Medical Center, Lebanon
  19. 19. Effectiveness of behavioral interventions to reduce the intake of sugar-sweetened beverages in children and adolescents: a systematic review and meta- analysis Abir Abdel Rahman, Lamis Jomaa*, Lara Kahale, Pauline Adair, Cynthia Pine. Nutrition Reviews 2017; 76(2): 88-107 * Corresponding author:
  20. 20. Introduction • Systematic Review Registration: PROSPERO registration number CRD42014004432. • playPDF.php?ID=CRD42014004432
  21. 21. Introduction • SSBs defined as soft drinks, carbonated beverages, fruit juices, and sweetened milk. • Rich sources of energy with poor nutritional value • Primary source of added sugar among children & adolescents. Malik et al. Circulation 2010; Wang et al. Pediatrics 2008
  22. 22. Rosinger et al 2017
  23. 23. U.S. youth consumed an average 7.3% of their total daily calories from SSBs Rosinger et al 2017
  24. 24. Pathways Linking Sugar-Sweetened Beverage Intake with Health Source: copyright, D. Ludwig & W Willett, Harvard SPH, 2009
  25. 25. Introduction • Public health interventions targeting SSB consumption & aim at curbing the rising rates of overweight & obesity – Educational and behavioral interventions – Environmental interventions • In 2014 -- No systematic reviews were published exploring the effectiveness of interventions in reducing SSB consumption – Avery et al 2015: explored impact of interventions on reducing SSBs intake and changes in BMI among children aged 2–18 years
  26. 26. Aim & objectives To explore the impact of educational and behavioral interventions on (1) Reduce the intake of SSBs (2) Change in body weight, and other health outcomes among children and adolescents across different settings (school and non-school settings)
  27. 27. Parameter Inclusion Criteria Participants Children and adolescents aged 4 to 16 years in any setting (e.g., school, home or community) Intervention Educational or behavioral interventions targeting the reduction of SSBs consumption Comparison with no intervention Outcomes Primary outcome: change in SSB consumption (soft drinks, sweetened juices, or any sweetened drink (g/d, servings, ml/d)) Secondary outcomes: reduction in obesity; changes in body composition measures (e.g., body mass index [BMI] z scores based on age- and gender-specific growth charts)( kg, percentage, kg/m2); reduction in risk of any chronic disease (e.g., type II diabetes mellitus, hypertension) Study design Randomized controlled trials Methodology: PICOS criteria
  28. 28. Methodology: Search strategy • A comprehensive literature search (June- September 2014; updated search and screening - September 2016) o Databases : • Applied Social Sciences Index and Abstracts (ASSIA) • Cumulative Index of Nursing and Allied Health Literature (EBSCO) • Cochrane Central Register of Controlled Trials • Embase • MEDLINE (OVID & PubMed) • PsycINFO o Other sources – Web of Science – Google Scholar – References from other systematic reviews & studies included in this review
  29. 29. Methodology: Data collection and analysis Screening titles & abstracts Full-text reviewing Screening articles for eligibility using Cochrane guidelines Data abstraction about PICO based on Cochrane guidelines Meta–analysis using Review Manager software (version 5.3.5) • Conducted by two authors (A.A.R. and L.J.) in duplicate and independently • Disagreements resolved through discussion or by consulting a third author • Conducted by L.A.K
  30. 30. Methodology Risk of Bias Cochrane tool Heterogeneity Forest plots I2 statistic Subgroup analyses Stratification (school vs non- school)
  31. 31. Data synthesis  Measure of relative effect (Mean Difference and SD) for continuous outcomes  Random effects model  Conversion and standardization of outcome units • Nutritionist Pro software (version 7.1.0, First Data Bank, Axxya Systems, San Bruno, CA) • SSBs consumption : g/d, servings per day  milliliters per day (mL/d)
  32. 32. RESULTS
  33. 33. Results n =16 studies
  34. 34. 16 trials n=19,925 participants 12 school-based 8 educational 4 educational & environmental 4 non-school based 1 educational 3 educational & environmental Brief summary of characteristics Follow up period ranged from 4 months – 36 months
  35. 35. Results Risk of Bias
  36. 36. Meta-analysis of Change in SSB intake (Primary Outcome)
  37. 37. Reduction in SSB intake (Primary outcome)
  38. 38. Change in SSB (Primary Outcome)
  39. 39. Primary outcome: Reduction in SSB intake
  40. 40. Meta-analysis of Change in BMI (Secondary Outcome)
  41. 41. Secondary outcomes: Reduction in prevalence of overweight and obesity and reduction in BMI
  42. 42. Conclusion Behavioral school interventions shown to : • Reduce SSB intake with relatively modest evidence • Insufficient evidence to support a positive effect on reduction in the prevalence of overweight and obesity among children and adolescents or BMI z scores
  43. 43. Why School interventions can work? Reduced SSBs intake Activities promoting healthy behaviors Spending prolonged periods at school Use of behavioral theories Parental involvement Role modeling from teachers and peers Improve food selection through environmental changes
  44. 44. No positive impact Secondary outcome: Reduction in prevalence of overweight and obesity and reduction in BMI Focused on a single message The multifactorial nature and complexity of obesity Possibility of compensatory behaviors adopted by children Variations in study design, sample size, & duration High dropout rates, lack of follow-up, & potential selection bias
  45. 45. Supportive evidence • Recently 2 other systematic reviews were published exploring the effects of interventions – Vezina-Im et al 2017: school-based only interventions; 12-17 year olds – Vargas Gracias et al 2017: effect of interventions on both SSBs and water intake among children, adolescents, and adults • Support our results: – Moderate evidence in reducing SSB consumption among children and adolescents – Home environment interventions had greater effects than school based interventions.
  46. 46. Strengths Rigorous methodology Single and multi- component interventions conducted in various settings Various characteristics of the studies and the behavioral change techniques
  47. 47. Limitations Variability in the setting, baseline characteristics of participants, or intervention strategies of different trials  heterogeneity Variability in scales & units of measure used  difficult to include in the meta- analysis Exclusion of non-English studies
  48. 48. Implications Practical Implications: • Behavioral interventions in schools can be effective , although evidence is still modest • Combining educational and environmental strategies to reduce SSB consumption and associated adverse health outcomes Research Implications: • Develop well-designed prospective cohort studies and RCTs that report on continuous outcomes • Utilize standardized evaluation schemes to assist researchers in improving study protocols and minimizing risks of bias • Explore what constructs from the TBC can be most effective to reduce SSB consumption • Examine the effectiveness of single-strategy interventions (educational strategies alone) vs combined-strategy interventions (with educational and environmental components)
  49. 49. References • Avery A, Bostock L, McCullough F. A systematic review investigating interventions that can help reduce consumption of sugar-sweetened beverages in children leading to changes in body fatness. J Hum Nutr Diet. 2015;28:52–64. • Hu FB. Resolved: there is sufficient scientific evidence that decreasing sugarsweetened beverage consumption will reduce the prevalence of obesity and obesity-related diseases. Obes Rev. 2013;14:606–619. 5. Ng SW, Mhurchu CN, Jebb SA, et al. Patterns and trends • Leung, C. W., Laraia, B. A., Needham, B. L., Rehkopf, D. H., Adler, N. E., Lin, J., ... & Epel, E. S. (2014). Soda and cell aging: associations between sugar-sweetened beverage consumption and leukocyte telomere length in healthy adults from the National Health and Nutrition Examination Surveys. American journal of public health, 104(12), 2425-2431. • Malik VS, Pan A, Willett WC, et al. Sugar-sweetened beverages and weight gain in children and adults: a systematic review and meta-analysis. Am J Clin Nutr. 2013;98:1084–1102. • Mattes RD, Shikany JM, Kaiser KA, et al. Nutritively sweetened beverage consumption and body weight: a systematic review and meta-analysis of randomized experiments. Obes Rev. 2011;12:346–365. • Rosinger, A., Herrick, K., Gahche, J., & Park, S. (2017). Sugar-Sweetened Beverage Consumption among US Youth, 2011-2014. NCHS Data Brief. Number 271. National Center for Health Statistics. • Singh, G. M., Micha, R., Khatibzadeh, S., Shi, P., Lim, S., Andrews, K. G., ... & Global Burden of Diseases Nutrition and Chronic Diseases Expert Group (NutriCoDE. (2015). Global, regional, and national consumption of sugar-sweetened beverages, fruit juices, and milk: a systematic assessment of beverage intake in 187 countries. PloS one, 10(8), e0124845. • Vargas‐Garcia, E. J., Evans, C. E. L., Prestwich, A., Sykes‐Muskett, B. J., Hooson, J., & Cade, J. E. (2017). Interventions to reduce consumption of sugar‐sweetened beverages or increase water intake: evidence from a systematic review and meta‐analysis. Obesity Reviews, 18(11), 1350-1363. • Vezina-Im L-A, Beaulieu D, Be´langer-Gravel A, et al. Efficacy of school-based interventions aimed at decreasing sugar-sweetened beverage consumption among adolescents: a systematic review. Public Health Nutr. 2017;20:2416–2431. • Wang YC, Bleich SN, Gortmaker SL. Increasing caloric contribution from sugarsweetened beverages and 100% fruit juices among US children and dolescents, 1988–2004. Pediatrics. 2008;121:e1604– 1614.
  50. 50. Poll Question #4 The information presented today was helpful A. Strongly agree B. Agree C. Neutral D. Disagree E. Strongly disagree
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