Decreasing Trends in Heavy Sugar-Sweetened Beverage ......Key Findings: Heavy sugar-sweetened...

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Decreasing Trends in Heavy Sugar-SweetenedBeverage Consumption in the United States,2003 to 2016

Kelsey A. Vercammen, MSc; Alyssa J. Moran, ScD, RD; Mark J. Soto, MA; Lee Kennedy-Shaffer, PhD; Sara N. Bleich, PhD

ARTICLE INFORMATION

Article history:Submitted 11 October 2019Accepted 7 July 2020

Keywords:Sugar-sweetened beveragesObesityTrends analysesNHANES

Supplementary materials:Figure 1, Table 3, and Table 5 are available at www.jandonline.org. Podcast available at www.jandonline.org/content/podcast.

2212-2672/Copyright ª 2020 by the Academy ofNutrition and Dietetics.https://doi.org/10.1016/j.jand.2020.07.012

ABSTRACTBackground Although previous studies have documented declines in intake fromsugar-sweetened beverages (SSB) in the United States, it is important to examinewhether heavy SSB intake (�500 kcal/day) is decreasing in parallel. Examining theintake patterns of heavy SSB consumers is imperative because these individuals face thegreatest health risks and thus may benefit the most from targeted policy and pro-grammatic efforts to reduce intake.Objective To provide the most recent national estimates for trends in heavy SSB intakeamong children and adults in the United States between 2003-2004 and 2015-2016, toexamine whether these trends differ by sociodemographic characteristics, and todescribe where SSB are acquired and consumed by the heaviest SSB consumers.Design Trend analyses of demographic and 24-hour dietary recall data in the 2003-2004 to 2015-2016 National Health and Nutrition Examination Survey.Participants/setting Participants were 21,783 children (aged 2 to 19 years) and 32,355adults (aged �20 years).Main outcome measures Heavy SSB intake (�500 kcal/day).Statistical analysis Survey-weighted logistic regression was used to estimate theproportion of heavy SSB consumers, overall and by age group, race/ethnicity, sex, andincome status (lower income ¼

RESEARCH SNAPSHOT

Research Question: What are the trends in heavy sugar-sweetened beverage intake (�500 kcal/day) among childrenand adults in the United States between 2003-2004 and2015-2016?

Key Findings: Heavy sugar-sweetened beverage intake hasdeclined in the US population overall, but attention must bepaid to certain subgroups with high intake for whom trendsare not decreasing, particularly 40- to 59-year olds and non-Mexican Hispanic adults.

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adults. A more recent study by Mendez and colleagues8

examined changes in the distribution of SSB intake amongchildren between 2003-2004 and 2013-2014 and found thatintake at the 90th percentile of SSB intake declined, butdisparities in heavy SSB intake persisted over time. Forexample, higher income was associated with lower SSB in-takes at the 90th percentile for non-Hispanic White, but notnon-Hispanic Black children.8

Our study adds to the existing literature by extending priorestimates of heavy SSB intake using the most recent datafrom the National Health and Nutrition Examination Survey(NHANES). First, this study makes an important contributionby updating trends among adults because Han and Powell’s7

estimates end in 2007-2008, leaving an 8-year gap in sur-veillance to the most recent 2015-2016 NHANES data. This isa particularly important gap in the literature in light of evi-dence that young adults have higher per capita energy intakefrom SSB than any other age group, suggesting they are animportant population to monitor.3 Second, whereas Mendezand colleagues’8 time trend estimates among children extendto 2013-2014, we still believe that updating estimates withthe most recent data is important given the number of SSBreduction policies that have passed since 2014. For example,beginning in 2014, several local and tribal governments, suchas the city of Berkeley, CA, and the Navajo Nation, passed SSBexcise taxes.9 In addition, since 2015, more than a dozenmunicipalities have passed policies requiring restaurants toserve only healthy beverages instead of SSB with children’smeals, and many of the leading chains have voluntarilyreplaced soda (ie, sweetened carbonated beverage) in kids’meals with milk and 100% juice.9,10 Although these localpolicies may not affect national intake levels, the increasingfrequency of beverage taxes and healthy default beveragelaws is indicative of growing recognition of the health harmsof SSB over the past several years. This increased awareness isreflected in declining SSB sales,11 yet trends in intake after2014 have not yet been published.In addition to updating time trends in heavy SSB intake

among children and adults, this study also contributes to theliterature by documenting where SSB are most frequentlyacquired (eg, restaurants and stores) and consumed (ie, athome or away from home) by heavy SSB consumers. A pre-vious study using 2005-2008 NHANES data found that abouthalf of the total energy intake from SSB is consumed at home,with products purchased in stores accounting for the vastmajority of this energy intake.12 However, these estimates arenow dated and were not specific to heavy SSB drinkers. Un-derstanding where heavy SSB drinkers are most likely toacquire and consume SSB could help target research, policy,and advocacy efforts to curb excessive SSB intake in theUnited States.The objectives of this study were to examine trends in

heavy SSB intake among children and adults between2003-2004 and 2015-2016; examine whether there aredifferences in these trends by age group, sex, race/ethnicity,and income; and describe where SSB are acquired andconsumed by the heaviest SSB consumers. We hypothesizethat there will be declines in heavy SSB intake, but thatthese declines will not be observed to as great an extentamong groups who are disproportionately exposed to SSBmarketing (ie, racial/ethnic minorities and low-incomepopulations). We hypothesize that most energy intake

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from SSB will be from products purchased in stores andconsumed at home.

MATERIALS AND METHODSData and Study PopulationThis trend analysis used data from seven survey cycles (2003-2004 to 2015-2016) of the NHANES, a repeated cross-sectional study released every 2 years and designed to berepresentative of the US noninstitutionalized population. Acomplete description of NHANES is available online.13 Thestudy sample consisted of individuals aged �2 years withcomplete data on all covariates. Because this study analyzedde-identified publicly available data, it does not constitutehuman subjects research and institutional review boardapproval was not required.

MeasuresSSB Intake. SSB intake was assessed using a 24-hour dietrecall. Survey respondents reported all food and beveragesconsumed in the previous 24-hour period, specifying thetype, quantity, source, and location of each intake occasion.Responses for children aged 2 to 5 years were provided by acaretaker, responses for participants aged 6 to 8 years wereprovided by a caretaker and assisted by the child, responsesfor participants aged 9 to 11 years were provided by the childand assisted by a caretaker, and participants aged 12 yearsand older responded independently. All reported food andbeverage items were systematically coded using the USDepartment of Agriculture Food and Nutrient Database forDietary Studies and the Food Patterns Equivalents Databaseto obtain energy and added sugar information.SSB were defined as any nondairy or nondairy alternative

beverage with >0 g added sugar. The beverage coding strat-egy used in this analysis updates a version used in previousSSB trends papers.3,14 In an effort to make identification ofSSB more objective, our updated beverage coding strategynow uses added sugar quantity to classify beverages, whereasthe previous coding scheme utilized beverage descriptions toidentify whether a beverage was sweetened or not.3 Inaddition, dairy and dairy alternatives are no longer catego-rized as SSB to be consistent with definitions used in manypolicies aimed at reducing SSB intake (although we alloweddairy and/or dairy alternatives to be included in nutrienttotals in the case that they were a minor addition to anotherbeverage such as sweetened coffee or tea).Consistent with a previous study,7 an individual was

considered to be a heavy SSB drinker in the case that s/he

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reported consuming �500 kcal per day from SSB. Thisquantity is comparable with definitions used by otherstudies15,16 and is equivalent to consuming about 3.5 cans ofregular soda (assuming 12 oz and about 150 kcal per can) perday. Because of the within-person variation in daily SSBintake, the distribution of intake from a single 24-hour recallis wider than the distribution of true usual (mean daily)intake.17 This means that estimates of the proportion of in-dividuals consuming �500 kcal/day from SSB using a single24-hour recall will likely be overestimated. The NationalCancer Institute (NCI) has developed a method to estimateusual intake from two 24-hour recalls and thus more validlyestimate the proportion consuming �500 kcal/day18; how-ever, this method has limited analytic flexibility to providecovariate-adjusted time trend estimates. Thus, our main re-sults are reported from a single 24-hour recall. Sensitivityanalyses indicate that unadjusted estimates from the NCIMethod are lower than those from a single 24-hour recall,although the overall decreasing trend in heavy SSB intake isevident in both methods. This is consistent with findings byMendez and colleagues8 who state that their trends in heavySSB intake estimated from the NCI method are not signifi-cantly different from studies that used a single 24-hour recall.Although our primary analyses utilized a 500 kcal/day

cutoff for all participants to enable comparisons across agegroups and with previous studies that have used the samemeasurement definition,7 we acknowledge that individualsvary in their daily energy requirements. Thus, we conductedsensitivity analyses wherein heavy SSB consumption wasalternatively defined as consuming �25% of daily energyintake from SSB.

SSB Subtypes, Source, and Location of Intake. SSB weresubcategorized into soda, fruit drinks, energy/sports drinks,low-calorie SSB, and other SSB (see Figure 1, available atwww.jandonline.org, for SSB subtype coding scheme). Foreach food and beverage, the NHANES includes information onwhether the eating occasion occurred at or away from homeas well as where the food/beverage was acquired (ie, foodsource). In line with a previous study,19 we categorized thedifferent food source options into four mutually exclusivecategories: stores (grocery, supermarket, and conveniencestores), restaurants (restaurants with waiter/waitress, res-taurants with fast food/pizza, bar/tavern/lounge, streetvendor, sport, recreation, or entertainment facility), child oradult care (cafeteria in kindergarten through grade 12 school,child/adult care center, or home), or other source (soupkitchen or food pantry, Meals on Wheels, community foodprogram, fundraiser, mail-order purchase, grown or caughtby individual, vending machine, common coffee pot or snacktray, residential dining facility, a gift, other). Because of thesmall size of the child or adult care category, it was latercollapsed together with the other source category.

Covariates. To adjust for potential demographic shifts overtime, analyses included the following covariates: age group (2to 5 years, 6 to 11 years, 12 to 19 years, 20 to 39 years, 40 to59 years, or >60 years), sex (male or female), race/ethnicity(non-Hispanic White, non-Hispanic Black, Mexican Amer-ican, non-Mexican Hispanic, other race/ethnicity), and familyincome (lower income or higher income). Other race/



ethnicity included individuals reporting a race other thanWhite or Black or individuals reporting multiracial identity.Lower income was defined as

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restaurant, child or adult care, and other) was calculated asthe energy intake from SSB acquired from each sourcedivided by total energy from SSB.All analyses were conducted in 2019 and 2020 using Stata,

version 16.0.20

RESULTSThe total analytic sample included 21,783 children and32,355 adults. Table 1 reports unweighted sample sizes andproportions by age group, sex, race/ethnicity, and income.

Trends in Heavy SSB Intake between 2003-2004 and2015-2016The prevalence of heavy SSB intake declined significantlybetween 2003-2004 and 2015-2016 among children (10.9% to3.3%; P for trend < 0.001) and adults (12.7% to 9.1%; P fortrend ¼ 0.001) (Figure 2).Among children, the proportion of heavy SSB intake

declined significantly across all age groups, with 12- to 19-

Table 1. Unweighted sample sizes and proportions ofparticipants in analytic samplea by age group, sex, race/ethnicity, and income status, National Health and NutritionExamination Survey (NHANES) (2003-2016)

Characteristic Analytic sample

n (%)

Children (y) 21,783 (40)

2-5 5,178 (24)

6-11 7,010 (32)

12-19 9,595 (44)

Adults (y) 32,355 (60)

20-39 11,315 (35)

40-59 10,411 (32)

�60 10,629 (33)Sex

Male 26,702 (49)

Female 27,436 (51)

Race/ethnicity

Non-Hispanic White 21,271 (39)

Non-Hispanic Black 12,728 (24)

Mexican American 10,796 (20)

Non-Mexican Hispanic 4,531 (8)

Other race/ethnicity 4,812 (9)

Incomeb

Lower 19,956 (37)

Higher 34,182 (63)

aThe analytic sample consisted of 54,138 participants in NHANES 2003-2016 withcomplete data on all covariates (age, sex, race/ethnicity, income) and a valid first 24-hour dietary recall.bLower income defined as family income

A Heavy SSB intake, by children (2-19 years) and adults (≥20 years)

B Heavy SSB intake among children, by age group

02468

1012

2003-2004 2005-2006 2007-2008 2009-2010 2011-2012 2013-2014 2015-2016Pre

vale

nce

of H

eavy

SSB

In

take

(%)

Children Adults

0

5

10

15

2003-2004 2005-2006 2007-2008 2009-2010 2011-2012 2013-2014 2015-2016Pre

vale

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of H

eavy

SSB

In

take

(%)

2 to 5 years 6 to 11 years 12 to 19 yearsFigure 2. Trends in prevalence of heavy sugar-sweetened beverage (SSB) intake (�500 kcal/day) between 2003-2004 and 2015-2016 among National Health and Nutrition Examination Survey (NHANES) participants (A) for children and adults separately, (B) forchildren by age group, and (C) for adults by age group. To obtain trend estimates, separate models were fitted among children andadults, adjusting for survey year, sex, race/ethnicity, and income status. Negative predicted values were truncated at 0. (A) Theproportion of heavy SSB drinkers (�500 kcal/day) declined significantly among both children and adults in NHANES between 2003-2004 and 2015-2016 (P for trend for children < 0.001, P for trend for adults ¼ 0.001). (B) Among children in NHANES, the proportionof heavy SSB drinkers declined significantly between 2003-2004 and 2015-2016 across all age groups (P for trend for all < 0.001),with 12 to 19-year olds maintaining the highest prevalence of heavy SSB intake across all survey years. (C) Among adults inNHANES, the proportion of heavy SSB drinkers decreased significantly between 2003-2004 and 2015-2016 among 20-39-year olds (Pfor trend < 0.001), remained relatively constant among 40- to 59-year olds (P for trend ¼ 0.767), and increased significantly among�60-year olds (P for trend ¼ 0.007).

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compared with women, �60-year olds had a significantlylower prevalence compared to 20- to 39-year olds, adults ofother race/ethnicity had a significantly lower prevalencecompared to non-Hispanic White adults, and higher-incomeadults had a significantly lower prevalence compared withlower-income adults.There were no significant changes over time in the overall

per capita energy intake from SSB among heavy SSB drinkersfor children (735 kcal to 701 kcal; P for trend ¼ 0.788) oradults (772 kcal to 796 kcal; P for trend ¼ 0.102) (Figure 3 andsee also Table 5, available at www.jandonline.org). For



children, per capita energy intake of soda and fruit drinksdecreased significantly between 2003-2004 and 2015-2016(soda: 444 kcal to 303 kcal; P for trend ¼ 0.001; fruit drinks:202 kcal to 101 kcal; P for trend < 0.001), whereas per capitaenergy intake of other SSB increased significantly 64 kcal to254 kcal; P for trend < 0.001). Low-calorie SSB contributedminimal amounts of energy in all survey years, changingfrom 0 kcal in 2003-2004 to 3 kcal in 2015-2016. Per capitaenergy intake of energy/sports drinks by heavy SSB con-sumers did not change significantly (26 kcal to 40 kcal; P fortrend ¼ 0.199).

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C Heavy SSB intake among adults, by age group

0

5

10

15

20

2003-2004 2005-2006 2007-2008 2009-2010 2011-2012 2013-2014 2015-2016Pre

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In

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20 to 39 years 40 to 59 years ≥60 yearsFigure 2. continued

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For adults, per capita energy intake of soda decreasedsignificantly between 2003-2004 and 2015-2016 (483 kcal to364 kcal; P for trend < 0.001), whereas per capita energyintake of energy/sports drinks and other SSB increasedsignificantly (energy/sports drinks: 13 kcal to 67 kcal; P fortrend < 0.001; other SSB: 146 kcal to 327 kcal; P < 0.001).There was evidence of a significant nonlinear trend over timefor per capita energy intake of fruit drinks (119 kcal to 35kcal), which were relatively constant from 2003-2004 to2011-2012 and then declined substantially in the 2013-2014and 2015-2016 surveys. Low-calorie SSB contributed nominalamounts of energy intake in all survey years, changing from11 kcal in 2003-2004 to 3 kcal in 2015-2016.

Patterns in Current Heavy SSB IntakeFor both children and adults, most energy intake from SSBconsumed by heavy SSB drinkers was acquired from stores(64% for children, 74% for adults), followed by restaurants(22% for children, 17% for adults), and other locations (14% forchildren, 9% for adults). About half of all energy intake fromSSB was consumed at home compared to away from home(46% for children, 58% for adults).

DISCUSSIONThe overall prevalence of heavy SSB intake declined signifi-cantly between 2003-2004 and 2015-2016 for both childrenand adults. For children, these declines were relativelyconsistent across age group, race/ethnicity, sex, and incomestatus. For adults, the story was less clear. Whereas heavy SSBintake declined among 20- to 39-year olds and most race/ethnicities, there was no significant change in heavy SSBintake among 40- to 59-year olds and non-Mexican Hispanicadults, and an increase in intake among older adults (�60years). In the most recent years of the data (2015-2016), non-Hispanic White adults, male adults, and adults aged 20 to 59years had the highest overall levels of heavy SSB intake.Overall, the findings of this study suggest that although therehave been promising declines in heavy SSB intake, attentionmust be paid to certain subgroups with high intake for whom



trends are not decreasing, particularly 40- to 59-year olds andnon-Mexican Hispanic adults.The trends in heavy SSB intake reported in this study are

similar to previously documented declines in the proportionof the total population consuming SSB,3 suggesting thatheavy SSB intake appears to be dropping in parallel to meanSSB intake. Moreover, our findings confirm the decliningtrend in heavy SSB intake among adolescents and youngadults first documented by Han and Powell7 using data from1999-2008. However, the trend among children appears tohave changed over time: from 1999-2008, heavy SSB intakeamong children was rising, but our more recent data show apromising decline. There are many possible reasons whyheavy SSB intake has declined over the past decade. Unfor-tunately, evaluations of SSB reduction strategies rarelyexamine effects among heavy SSB drinkers alone, so in-ferences regarding which strategies have been most effectivefor decreasing heavy SSB intake are limited.More recently, nutrition interventions have shifted toward

policy, systems, and environment strategies that aim to makethe healthy choice, the easy choice and rely less on individualbehavior change. One example is SSB excise taxes22-25 thatare currently implemented in seven US cities and the NavajoNation and appear to significantly reduce purchases andintake of SSB.26-28 Another example is healthy kids’ mealspolicies, which have been passed by many US states and citiesand require restaurants to only offer healthy drinks (eg, 100%juice, milk, or water) with children’s restaurant meals insteadof SSB.10 These and other SSB reduction policies haveattracted wide media coverage of the role of SSB in drivingobesity and other negative health outcomes.29 Thus, thesepolicies and the awareness they have generated may bedriving some of the declines seen in recent years of the data.Our results generally suggest that as people age, the trend

in SSB intake flattens (or even increases, as among the oldestadults). This may be attributable to shifts in the cohort ofpeople comprising each age group over time. For example,many individuals who would have been in the 40- to 59-yearage group during 2003-2004 would be in the �60-year agegroup during 2015-2016. This generation of older adultswould have grown up during the 1960s to1990s, a time when

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Table 2. Trends in prevalence of heavy sugar-sweetened beverage (SSB) intake (�500 kcal/day) between 2003-2004 and 2015-2016 for children and adults participatingin National Health and Nutrition Examination Survey, by race/ethnicity, income status, and sex

CharacteristicaStudy Year

P value for linear trend2003-2004 2005-2006 2007-2008 2009-2010 2011-2012 2013-2014 2015-2016

��% (95% CI)��!Children n ¼ 3,654 n ¼ 3,851 n ¼ 2,878 n ¼ 3,000 n ¼ 2,907 n ¼ 2,825 n ¼ 2,668Race/ethnicity

Non-Hispanic White 12.1 (9.4- 14.8) 11.1 (8.8- 13.4) 8.7 (5.6- 11.9) 6.7 (5.0- 8.5) 6.9 (4.9- 9.0) 7.2 (5.2- 9.1) 3.7 (2.5- 4.9) < 0.001

Non-Hispanic Black 10.9 (8.4- 13.5) 8.8 (6.9- 10.7) 5.4 (3.5- 7.3) 6.2 (4.4- 8.0) 5.6 (4.4- 6.8) 4.2 (1.2- 7.2) 3.3 (0.9- 5.6) < 0.001

Mexican American 10.7 (8.4-13.0) 6.7 (4.8- 8.5) 4.4 (1.6- 7.1) 7.5 (4.7- 10.3) 3.7 (1.3- 6.1) 2.3 (0.9- 3.7) 2.5 (1.1- 3.9) < 0.001

Non-Mexican Hispanic 8.0 (2.0- 14.0) 6.4 (2.4- 10.4) 9.5 (6.6- 12.5) 4.8 (2.6- 7.0) 5 (1.8-8.1) 6.8 (3.6- 10.0) 2.8 (0.6- 5.1) 0.028

Other race/ethnicity 3.4 (0.0-7.7) 3.4 (0.9- 5.9) 2.2 (0.5- 3.8) 4.5 (1.0- 8.1) 1.9 (0.0-4.0) 1.9 (0.2- 3.6) 1.8 (0.0- 3.5) 0.194

Income

Lower 9.6 (7.6- 11.5) 9.2 (6.8- 11.5) 8.6 (5.3- 11.9) 7.4 (5.2- 9.6) 7.7 (5.0- 10.3) 5.9 (3.5- 8.3) 3.3 (1.7- 4.9) < 0.001

Higher 11.5 (8.8-14.1) 9.3 (7.4- 11.2) 6.6 (4.9- 8.3) 6.0 (4.8- 7.2) 4.6 (3.3- 5.8) 5.4 (3.9- 6.9) 3.3 (2.4- 4.1) < 0.001

Sex

Female 7.1 (5.5-8.8) 5.6 (3.7- 7.5) 5.4 (2.8- 8.0) 3.6 (2.4- 4.8) 4.1 (2.3- 5.9) 3.2 (1.5- 5.0) 2.8 (1.8- 3.7) < 0.001

Male 14.5 (11.8-17.1) 12.8 (10.7- 15.0) 9.2 (7.1- 11.3) 9.2 (8- 10.4) 7.4 (5.6- 9.1) 7.7 (6.0- 9.5) 3.7 (2.8- 4.6) < 0.001

Adults n ¼ 4,211 n ¼ 4,325 n ¼ 4,934 n ¼ 5,228 n ¼ 4,434 n ¼ 4,686 n ¼ 4,537Race/ethnicity

Non-Hispanic White 12.1 (9.8- 14.4) 9.7 (8.1- 11.3) 10.7 (7.0- 14.3) 8.5 (7.0- 10.0) 8.6 (7.5- 9.6) 8.7 (6.9- 10.4) 9.9 (8.1- 11.7) 0.036

Non-Hispanic Black 17.6 (13.5- 21.8) 15.2 (11.6- 18.8) 12.6 (10.3- 14.9) 11.4 (9.3- 13.5) 12.7 (10.6- 14.8) 12.0 (9.6- 14.3) 9.1 (6.1- 12.1) < 0.001

Mexican American 15.8 (12.0- 19.7) 14.6 (11.7- 17.6) 9.8 (6.5- 13.2) 11.5 (9.4- 13.6) 11.1 (7.4- 14.7) 13.5 (11.3- 15.7) 8.4 (5.9- 10.9) 0.009

Non-Mexican Hispanic 7.5 (0.4- 14.7) 9.7 (5.4- 13.9) 11.6 (8.5- 14.6) 11.9 (8.8- 15.0) 9.8 (5.5- 14.0) 10.4 (6.1- 14.6) 9.1 (6.8- 11.3) 0.969

Other race/ethnicity 8.3 (2.2- 14.5) 7.7 (3.1- 12.4) 3.5 (1.6- 5.3) 4.6 (1.5- 7.6) 9.0 (4.9- 13.0) 9.3 (4.5- 14.2) 3.9 (2.0- 5.9) Nonlinearb

Incomec

Lower 16.7 (13.3- 20.0) 16.0 (11.8- 20.2) 14.8 (10.3- 19.4) 13.9 (12.2- 15.6) 13.7 (11.5- 15.8) 16.6 (13.3- 19.9) 11.7 (9.2- 14.1) 0.122

Higher 11.5 (9.4- 13.6) 9.1 (7.8- 10.4) 9.2 (6.9- 11.5) 7.6 (6.3- 8.8) 8.1 (6.8- 9.5) 7.5 (6.0- 8.9) 8.3 (7.3- 9.4) 0.001

Sex

Female 7.8 (6.1-9.5) 6.3 (5.0- 7.6) 7.0 (4.8- 9.3) 6.8 (5.7- 7.9) 13.9 (12.2- 15.6) 6.5 (4.8- 8.3) 5.9 (4.5- 7.3) 0.174

Male 18.1 (15.6- 20.6) 15.2 (12.4-17.9) 14.1 (10.7- 17.6) 11.2 (9.4- 13.1) 12.4 (11.1- 13.8) 13.0 (10.9- 15.1) 12.5 (10.7- 14.4) Nonlineard

aTo obtain trend estimates, separate models were fitted within each subgroup, adjusting for all other covariates (eg, model was fit among non-Hispanic White children, adjusting for survey year, sex, age category, and income). Negative predictedvalues were truncated at 0.bEvidence of a nonlinear trend in heavy SSB intake over time, as indicated by statistically significant joint Wald test of the quadratic and cubic terms for survey year (P ¼ 0.0398).cLower-income defined as family income

Table 4. Differences in prevalence of heavy sugar-sweetened beverage (SSB) intake (�500 kcal/day) acrosssociodemographic groups among National Health andNutrition Examination Survey participants, 2015-2016

Demographiccharacteristica Proportion of heavy SSB drinkers

% (95% CI)

Children

Sex

Female 2.6 (1.6-3.7)

Male 3.6 (2.6-4.5)

Age category (y)

2-5 0.4 (0-1.0)

6-11 1.6 (0.8-2.5)

12-19 5.5 (4.3-6.7)b

Race/ethnicity

Non-Hispanic White 3.5 (2.0-5.0)

Non-Hispanic Black 3.2 (0.8-5.7)

Mexican American 2.5 (0.8-4.2)

Non-Mexican Hispanic 3.0 (0.3-5.6)

Other race/ethnicity 1.9 (0-3.7)

Income

Lower 3.3 (1.4-5.2)

Higher 3.0 (2.1-3.9)

Adults

Sex

Female 5.6 (4.2-6.9)

Male 12.1 (10.2-14)b

Age category (y)

20-39 9.6 (7.5-11.8)

40-59 11.4 (9.4-13.5)(continued on next page)

Table 4. Differences in prevalence of heavy sugar-sweetened beverage (SSB) intake (�500 kcal/day) acrosssociodemographic groups among National Health andNutrition Examination Survey participants, 2015-2016(continued)

Demographiccharacteristica Proportion of heavy SSB drinkers

�60 3.9 (2.4-5.3)bRace/ethnicity

Non-Hispanic White 9.9 (8-11.9)

Non-Hispanic Black 8.4 (5.6-11.2)

Mexican American 6.7 (4.2-9.3)

Non-Mexican Hispanic 7.8 (5.1-10.4)

Other race/ethnicity 3.6 (1.7-5.5)b

Income

Lower 11.8 (8.9-14.6)

Higher 8.0 (6.9-9.0)b

aEstimates reported here are slightly different than the estimates reported in Table 1 for2015-2016. This is because different models were used to estimate these results, with theTable 1 estimates coming from a model incorporating all years of data and thus borrowingdata across years to improve the fit, whereas the estimates for this table come from a modelincluding only 2015-2016 data. Negative predicted values were truncated at 0.bIndicates statistically significant difference (P < 0.05) in proportion of heavy SSBdrinkers compared with reference group. The reference group for age category was 2 to5 years for children and 20 to 39 years for adults. The reference group for race/ethnicitywas non-Hispanic White for both children and adults.

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the food environment was becoming increasingly obesogenic(ie, greater availability of ultraprocessed foods and beveragesand increased marketing to children and adolescents).Compared with their predecessors, who would have come ofage during the 1920s to 1960s, this generation of older adultsmay be more likely to have developed heavy SSB intakehabits, which could explain the increasing trend among thisage group over time. Similarly, the number of federal, state,and local policies and campaigns aimed at reducing SSBintake has increased since the early 2000s, particularly invenues serving children and adolescents, such as schools andearly child education and care. This may explain lower anddeclining heavy SSB intake levels seen in younger generationsof children, adolescents, and young adults. In other words,differences in trends across age groups may reflect thechanging cohort of people in each age group and theirexposure to predominant societal norms and health promo-tion efforts during childhood and adolescence.



Although our results suggest that heavy SSB intake isdeclining overall, there is still a need for further efforts toreduce excessive SSB intake in the United States. This studyhighlights several important elements that should be incorpo-rated into future efforts. First, our study’s finding that per capitaenergy intake of soda has declined while intake of other SSBhas increased among heavy SSB drinkers for both children andadults indicates the growing popularity of nontraditional SSB.These results are consistent with previous research doc-umenting the rising number of beverages available to con-sumers at chain restaurants, with much of this increase inbeverage offerings driven by nontraditional SSB like sweetenedcoffees, teas, and blended dairy-based beverages (althoughprimarily dairy-based beverages were not included in ourdefinition of SSB).30 The growing popularity of nontraditionalSSB may be due in part to consumer’s perceptions that thesebeverages are healthier alternatives to traditional SSB like soda,a notion that may be driven by marketing of nontraditional SSBusing nutrition-related health claims.31 Overall, this suggeststhat that SSB reduction strategies must incorporate a greaterawareness of the types of SSB being consumed and shouldinclude wide SSB coverage to ensure success.Next, consistent with a past study,12 we found that stores

and restaurants were the most common source for SSBamong both children and adults. This suggests that futureefforts must continue to focus on these settings. In additionto SSB taxes discussed above, another store-based SSBreduction strategy could be restricting SSB from purchasewith Supplemental Nutrition Assistance Program (SNAP)

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Figure 3. Per capita intake of sugar-sweetened beverage (SSB) calories among heavy SSB drinkers (�500 kcal/day) between 2003-2004 and 2015-2016 for children and adults participating in National Health and Nutrition Examination Survey. There were nosignificant changes between 2003-2004 and 2015-2016 in the overall per capita energy intake from SSBs among heavy SSB drinkersfor children (735 kcal to 701 kcal; P for trend ¼ 0.788) or adults (772 kcal to 796 kcal; P for trend ¼ 0.102). (A) For children, per capitaenergy intake of soda (ie, sweetened carbonated beverage) and fruit drinks decreased significantly between 2003-2004 and 2015-2016, whereas per capita energy intake of other SSBs increased significantly. Low-calorie SSBs contributed minimal amounts ofenergy in all survey years, whereas per capita energy intake of energy/sports drinks by heavy SSB consumers did not changesignificantly. (B) For adults, per capita energy intake of soda decreased significantly between 2003-2004 and 2015-2016, whereasper capita energy intake of energy/sports drinks and other SSBs increased significantly. There was evidence of a significantnonlinear trend over time for per capita energy intake of fruit drinks. Low-calorie SSBs contributed nominal amounts of energyintake in all survey years. Negative predicted values were truncated at 0.

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benefits.32 Evidence from simulation studies indicates thatrestricting SSB purchases in SNAP could significantly reduceSSB intake among SNAP participants by a daily average of24 kcal/person.33 Moreover, given the reach of SNAP (one inseven Americans participate) and the fact that more than$4 billion SNAP dollars are estimated to be spent on SSBannually,34,35 this approach could have a substantialpopulation-level influence. However, these benefits shouldbe weighed in light of the equity and ethical concerns thatcome with restricting SNAP benefits.36 In addition tohealthy kids’ meals policies discussed above, anotherrestaurant-based SSB reduction strategy is to reduce theportion size of SSB either by making default serving sizessmaller or reducing the availability of larger portion sizes.For example, New York City’s Sugary Drinks Portion CapRule, which was passed in 2013 and later repealed, pro-hibited the sale of sugary drinks larger than 16 fl oz inrestaurants and similar settings. When implementedwidely, these types of strategies could be used to continueand accelerate the declines in heavy SSB intake observed inthis study.



Our study was also able to examine the extent to whichdeclining trends in heavy SSB intake are occurring amongpeople who are disproportionately exposed to SSB marketing(ie, racial/ethnic minorities and low-income populations).Consistent with a previous study,8 declines in heavy SSBintake were similar across racial/ethnic groups among chil-dren. Among adults, heavy SSB intake declined among non-Hispanic Blacks, non-Hispanic Whites, and Mexican Ameri-cans, with the largest percentage point decline observedamong non-Hispanic Blacks. With respect to income, signif-icant declines were observed for both lower- and higher-income groups among children; among adults, significantdeclines were only observed among higher-income adults.Taken together, the findings for children and adults may haveimportant implications for reducing health inequities, giventhe strong associations between SSB intake and negativehealth outcomes,4-6 as well as the inordinate burden of diet-related diseases among low-income individuals and racial/ethnic minorities.37,38 Although most of the results arepromising, the prevalence of heavy SSB intake remainedrelatively constant among non-Mexican Hispanic adults,



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Figure 3. continued

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suggesting that more targeted efforts may be needed withinthis population to reduce heavy intake.This study has a number of limitations. First, because

NHANES is a cross-sectional study, making causal inferencesabout the relationship between sociodemographic charac-teristics and trends in heavy intake of SSB limited. Moreover,because NHANES is national data released every 2 years, re-sults from this study cannot be definitively tied to any singlepolicy at the local or state level (eg, SSB taxes). Rather, ourfindings are suggestive that SSB reduction strategies aregenerally working but cannot identify a single strategy thathas led to the observed declines. Second, as discussed in theMethods, the use of a single 24-hour dietary means that theproportion of heavy SSB drinkers is overestimated.17 How-ever, comparison of our results to the NCI Method, whichestimates usual intake, indicates that the overall trendsidentified by the primary analysis hold for the NCI method aswell. Next, because the 24-hour dietary recall for childrenyounger than age 12 years was completed or assisted byprimary caregivers, SSB intake may be underestimated in thecase that children consume beverages without their care-giver’s knowledge (eg, at daycare settings). In particular, thismay mean that the proportion of beverages reported to beconsumed outside the home and/or acquired by childrenfrom school or daycare settings may be underestimated.Despite these limitations, this study has a number ofstrengths, including using the most recently available na-tionally representative data, reporting on both children andadults, and using a systematic beverage coding scheme.



CONCLUSIONSHeavy SSB intake has declined in the US population overall,but attention must be paid to certain subgroups with highintake for whom trends are not decreasing, particularly 40- to59-year olds and non-Mexican Hispanic adults.

References1. Mesirow MS, Welsh JA. Changing beverage consumption patterns

have resulted in fewer liquid calories in the diets of US children:National Health and Nutrition Examination Survey 2001-2010. J AcadNutr Diet. 2015;115(4):559-566.

2. Welsh JA, Sharma AJ, Grellinger L, Vos MB. Consumption of addedsugars is decreasing in the United States. Am J Clin Nutr. 2011;94(3):726-734.

3. Bleich SN, Vercammen KA, Koma JW, Li Z. Trends in beverage con-sumption among children and adults, 2003-2014. Obesity.2018;26(2):432-441.

4. Malik VS, Li Y, Pan A, et al. Long-term consumption of sugar-sweetened and artificially sweetened beverages and risk of mortal-ity in US adults. Circulation. 2019;139(18):2113-2125.

5. Malik VS, Popkin BM, Bray GA, Després JP, Willett WC, Hu FB. Sugar-sweetened beverages and risk of metabolic syndrome and type 2diabetes: A meta-analysis. Diabetes Care. 2010;33(11):2477-2483.

6. Malik VS, Schulze MB, Hu FB. Intake of sugar-sweetened beveragesand weight gain: A systematic review. Am J Clin Nutr. 2006;84(2):274-288.

7. Han E, Powell LM. Consumption patterns of sugar-sweetened bev-erages in the United States. J Acad Nutr Diet. 2013;113(1):43-53.

8. Mendez MA, Miles DR, Poti JM, Sotres-Alvarez D, Popkin BM.Persistent disparities over time in the distribution of sugar-sweetened beverage intake among children in the United States.Am J Clin Nutr. 2018;109(1):79-89.

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9. Healthy Food America. Sugary beverages: Map and chart themovement. http://www.healthyfoodamerica.org/map. AccessedSeptember 22, 2019.

10. California Legislative Information. Senate Bill No. 1192: Children’smeals. https://leginfo.legislature.ca.gov/faces/billTextClient.xhtml?bill_id¼201720180SB1192. Accessed August 26, 2019.

11. Taylor K. People are drinking less Pepsi and Coke than ever—and itreveals the power of the ‘biggest marketing trick of the century.’https://www.businessinsider.com/pepsi-coke-decline-while-bottled-water-grows-2018-5. Accessed August 7, 2020.

12. Ogden CL, Kit BK, Carroll MD, Park S. Consumption of sugar drinks inthe United States, 2005-2008. NCHS Data Brief. 2011;71:1-8.

13. National Center for Health Statistics. NHANES survey methods andanalytic guidelines. https://wwwn.cdc.gov/nchs/nhanes/analyticguidelines.aspx. Accessed February 2, 2020.

14. Wang YC, Bleich SN, Gortmaker SL. Increasing caloric contributionfrom sugar-sweetened beverages and 100% fruit juices among USchildren and adolescents, 1988-2004. Pediatrics. 2008;121(6):e1604-e1614.

15. Park S, Blanck HM, Sherry B, Brener N, O’Toole T. Factors associatedwith sugar-sweetened beverage intake among United States highschool students. J Nutr. 2012;142(2):306-312.

16. White AH, James SA, Paulson SW, Beebe LA. Sugar sweetenedbeverage consumption among adults with children in the home.Front Nutr. 2018;5(34):1-8.

17. Willett W. Nutritional Epidemiology. New York, NY: Oxford Univer-sity Press; 2012.

18. Tooze JA, Midthune D, Dodd KW, et al. A new statistical method forestimating the usual intake of episodically consumed foods withapplication to their distribution. J Acad Nutr Diet. 2006;106(10):1575-1587.

19. Barrera CM, Moore LV, Perrine CG, Hamner HC. Number of eatingoccasions and source of foods and drinks among young children inthe United States: NHANES, 2009e2014. Nutrients. 2019;11(4):897.

20. Stata [computer program]. Version 16.0. College Station, TX: Stata-Corp; 2019.

21. Ingram DD, Malec DJ, Makuc DM, et al. National Center for HealthStatistics guidelines for analysis of trends: Data evaluation andmethods research. https://stacks.cdc.gov/view/cdc/53672. AccessedAugust 7, 2020.

22. Falbe J, Thompson HR, Becker CM, Rojas N, McCulloch CE,Madsen KA. Impact of the Berkeley excise tax on sugar-sweetenedbeverage consumption. Am J Public Health. 2016;106(10):1865-1871.

23. Colchero MA, Salgado JC, Unar-Munguía M, Molina M, Ng S, Rivera-Dommarco JA. Changes in prices after an excise tax to sweetenedsugar beverages was implemented in Mexico: Evidence from urbanareas. PloS ONE. 2015;10(12):e0144408.

24. Colchero M, Guerrero-López CM, Molina M, Rivera JA. Beveragessales in Mexico before and after implementation of a sugar sweet-ened beverage tax. PloS ONE. 2016;11(9):e0163463.



25. Colchero MA, Molina M, Guerrero-López CM. After Mexico imple-mented a tax, purchases of sugar-sweetened beverages decreasedand water increased: Difference by place of residence, householdcomposition, and income level. J Nutr. 2017;147(8):1552-1557.

26. Lee MM, Falbe J, Schillinger D, Basu S, McCulloch CE, Madsen KA.Sugar-sweetened beverage consumption 3 years after the Berkeley,California, sugar-sweetened beverage tax. Am J Public Health.2019;109(4):637-639.

27. Roberto CA, Lawman HG, LeVasseur MT, et al. Association of abeverage tax on sugar-sweetened and artificially sweetened bever-ages with changes in beverage prices and sales at chain retailers in alarge urban setting. JAMA. 2019;321(18):1799-1810.

28. Healthy Food America. Taxing sugary drinks. http://www.healthyfoodamerica.org/taxing_sugary_drinks. Accessed August 26,2019.

29. Koplan JP, Liverman CT, Kraak VI. Preventing childhood obesity:health in the balance: Executive summary. J Acad Nutr Diet.2005;105(1):131-138.

30. Frelier JM, Moran AJ, Vercammen KA, Jarlenski MP, Bleich SN. Trendsin calories and nutrients of beverages in US chain restaurants, 2012-2017. Am J Prev Med. 2019;57(2):231-240.

31. Harris J, Schwartz MB, LoDolce M, et al. Sugary Drink FACTS 2014:Some Progress but Much Room for Improvement in Marketing toYouth. New Haven, CT: Rudd Center for Food Policy and Obesity;2014.

32. Cuffey J, Beatty TK, Harnack L. The potential impact of Supple-mental Nutrition Assistance Program (SNAP) restrictions on ex-penditures: A systematic review. Public Health Nutr. 2016;19(17):3216-3231.

33. Basu S, Seligman HK, Gardner C, Bhattacharya J. Ending SNAP sub-sidies for sugar-sweetened beverages could reduce obesity and type2 diabetes. Health Aff. 2014;33(6):1032-1039.

34. US Department of Agriculture, Food and Nutrition Service. Charac-teristics of Supplemental Nutrition Assistance Program households:Fiscal year 2017. https://www.fns.usda.gov/snap/characteristics-supplemental-nutrition-assistance-program-households-fiscal-year-2017. Accessed August 7, 2020.

35. Franckle RL, Moran A, Hou T, et al. Transactions at a North-eastern supermarket chain: Differences by Supplemental Nutri-tion Assistance Program use. Am J Prev Med. 2017;53(4):e131-e138.

36. Barnhill A. Impact and ethics of excluding sweetened beveragesfrom the SNAP program. Am J Public Health. 2011;101(11):2037-2043.

37. Kurian AK, Cardarelli KM. Racial and ethnic differences in cardio-vascular disease risk factors: A systematic review. Ethn Dis.2007;17(1):143-152.

38. Ogden CL, Carroll MD, Fryar CD, Flegal KM. Prevalence of obesityamong adults and youth: United States, 2011e2014. NCHS Data Brief.2015;219:1-8.



http://www.healthyfoodamerica.org/maphttps://leginfo.legislature.ca.gov/faces/billTextClient.xhtml?bill_id=201720180SB1192https://leginfo.legislature.ca.gov/faces/billTextClient.xhtml?bill_id=201720180SB1192https://leginfo.legislature.ca.gov/faces/billTextClient.xhtml?bill_id=201720180SB1192https://www.businessinsider.com/pepsi-coke-decline-while-bottled-water-grows-2018-5https://www.businessinsider.com/pepsi-coke-decline-while-bottled-water-grows-2018-5https://wwwn.cdc.gov/nchs/nhanes/analyticguidelines.aspxhttps://wwwn.cdc.gov/nchs/nhanes/analyticguidelines.aspxhttps://stacks.cdc.gov/view/cdc/53672http://www.healthyfoodamerica.org/taxing_sugary_drinkshttp://www.healthyfoodamerica.org/taxing_sugary_drinkshttps://www.fns.usda.gov/snap/characteristics-supplemental-nutrition-assistance-program-households-fiscal-year-2017https://www.fns.usda.gov/snap/characteristics-supplemental-nutrition-assistance-program-households-fiscal-year-2017https://www.fns.usda.gov/snap/characteristics-supplemental-nutrition-assistance-program-households-fiscal-year-2017

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AUTHOR INFORMATIONK. A. Vercammen is a doctoral degree candidate, Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA. L.Kennedy-Shaffer is an assistant professor, Department of Mathematics and Statistics, Vassar College, Poughkeepsie, NY; at the time of the study,he was a doctoral degree candidate, Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA. M. J. Soto is aprogrammer, Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA. A. Moran is an assistantprofessor, and S. N. Bleich is a professor, Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, MA.

Address correspondence to: Kelsey Vercammen, MSc, Department of Epidemiology, Harvard T.H. Chan School of Public Health, 677 HuntingtonAve, Boston, MA 02115. E-mail: [email protected]

STATEMENT OF POTENTIAL CONFLICT OF INTERESTNo potential conflict of interest was reported by the authors.

FUNDING/SUPPORTK. Vercammen was supported by a Canadian Institute of Health Research doctoral foreign study award (no. 0492002603).

AUTHOR CONTRIBUTIONSK. Vercammen developed the research question, conducted the statistical analysis, interpreted the data, and drafted the manuscript. S. Bleichdeveloped the research question, interpreted the data, provided manuscript revisions, and approved the final version of the manuscript. A.Moran, M. Soto, and L. Kennedy-Shaffer gave input on the statistical analysis, provided critical manuscript revisions, and approved the finalversion of the manuscript. M. Soto created the analytic dataset. All authors provided critical feedback on manuscript drafts.

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SSB category Definition

Soda Carbonated beverage with added sugar; not identified as diet or low-calorie.

Fruit drinks Fruit drinks, fruit juice, and fruit nectars with added sugar; not identified asdiet or low-calorie; does not include 100% fruit juices.

Sports/energydrinks

Energy drinks, sports drinks, and thirst quenchers; not identified as diet or low-calorie.

Low-calorieSSB

Any beverage listed as having added sugar in FPEDa that is additionally identified as low-caloriethrough terminology such as “low-calorie,” “reduced calorie,” or “light”; drinks labeled as“diet” but with >5 kcal were categorized as low-calorie.

Other SSB Beverage listed as having added sugar that is not categorized as soda, fruit drinks and punches,sports and energy drinks, or low-calorie SSBs; “other” beverage categories include sweetenedcoffees and teas, sweetened nonalcoholic drinks (eg, nonalcoholic malt beverage), andsweetened waters.

Other SSBs also include beverage combinations with �2 nonwater beverages or anycombination of at least one beverage with food (eg, hot chocolate with marshmallow).

aFPED ¼ Food Patterns Equivalents Database.Figure 1. Coding Scheme to categorize beverages reported by National Health and Nutrition Examination Survey (NHANES) participantsin 24-hour dietary recall into sugar-sweetened beverage (SSB) subtypes for analysis.

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-- 2020 Volume - Number - JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS 12.e1

Table 3. Trends in prevalence of heavy sugar-sweetened beverage (SSB) intake (�500 kcal/day) between 2003-2004 and 2015-2016 for children and adults participatingin National Health and Nutrition Examination Survey, stratified by sex and other sociodemographic characteristics

Sociodemographiccharacteristica

Survey Year P valueforlineartrend2003-2004 2005-2006 2007-2008 2009-2010 2011-2012 2013-2014 2015-2016

��% (95% CI)��!Children

Male

Age group (y)

2-5 4.7 (1.5-7.9) 0.9 (0.2- 1.5) 2 (0-4.8) 1.2 (0.2-2.2) 1.5 (0-3.3) 0.6 (0-1.6) NA 0.003

6-11 11.1 (4.6-17.7) 5.3 (1.1-9.5) 7.3 (4.3-10.3) 2.6 (0.7-4.5) 4.6 (1.9-7.3) 4.6 (2.4- 6.8) 2.1 (1.1-3.1) 0.001

12-19 21.8 (17.4-26.1) 23.8 (20.2-27.5) 14.1 (9.4-18.8) 18.3 (14.9-21.6) 12.2 (8.7-15.6) 13.5 (8.9-18) 6.7 (4.4-9) < 0.001

Race/ethnicity

Non-Hispanic White 16.6 (13.1-20.1) 15.3 (11.9-18.7) 10.5 (7.5-13.5) 9.7 (7.7-11.7) 8.2 (6-10.4) 10.1 (7.6-12.6) 4.8 (2.6-6.9) < 0.001

Non-Hispanic Black 13.9 (10.2-17.6) 12.4 (9.5-15.3) 6.8 (2.8-10.8) 7.5 (5-10) 6.6 (4.8-8.4) 4.4 (0-8.9) 2.2 (1.0- 3.4) < 0.001

Mexican American 16.0 (12.4-19.6) 7.6 (4.9-10.3) 5.8 (1.5-10) 11 (5.8-16.3) 5.8 (0.9-10.7) 2.9 (0.9-4.9) 2.6 (0.9-4.3) < 0.001

Non-Mexican Hispanic 4.5 (0-9.4) 8 (0.1-15.9) 13.5 (7.3-19.7) 8.4 (3.8-13.1) 7 (1.2-12.9) 9.4 (5-13.8) 2.6 (0-5.1) Nonlinearb

Income

Lower 12.8 (10.4-15.3) 12.2 (9.5-15) 9.7 (6-13.4) 11.7 (8.1-15.2) 9.6 (5.4-13.7) 6.6 (3.8-9.4) 2.8 (1.1-4.4) Nonlinearc

Higher 15.2 (11.4-19) 13.1 (10.4-15.7) 8.8 (6.1-11.5) 8.3 (6.5-10.2) 5.8 (3.6-8) 8.4 (6-10.7) 4.1 (2.9-5.4) < 0.001

Female

Age group (y)

2-5 3.2 (0-6.5) 1.2 (0.1-2.2) 2.1 (0.6-3.7) 0.5 (0.1-0.9) 0.3 (0-0.8) NA 0.7 (0-1.9) 0.014

6-11 3.2 (1.8-4.6) 2.3 (0.4-4.3) 3.9 (1.5-6.3) 1.4 (0.3-2.5) 1.1 (0.3-2) 1.1 (0.2-2) 1.2 (0.2-2.3) 0.001

12-19 11.8 (8.2-15.5) 10 (6.8-13.2) 8.1 (3.8-12.4) 6.7 (4.1-9.3) 8.1 (4.6-11.7) 6.4 (3.1-9.8) 4.9 (3.3-6.4) 0.001

Race/ethnicity

Non-Hispanic White 7.3 (4.8-9.9) 6.5 (3.6-9.5) 6.8 (2.8-10.9) 3.6 (1.4-5.8) 5.5 (2.1-8.9) 3.9 (1.3-6.6) 2.5 (1.6-3.4) 0.001

Non-Hispanic Black 8 (5.7-10.2) 5.4 (2.9-7.9) 4 (2.4-5.6) 4.9 (1.9-8) 4.6 (2.7-6.5) 3.9 (0-8.2) 4.5 (0.6-8.4) 0.173

Mexican American 5.2 (3.6-6.9) 5.8 (3.3-8.2) 2.9 (0-6.4) 3.7 (1.3-6) 1.3 (0.1-2.6) 1.7 (0.1-3.2) 2.3 (0.6-4.1) 0.002

Non-Mexican Hispanic 13.3 (3.3-23.3) 4.8 (2.1-7.5) 5.5 (1.7-9.3) 1 (0-2) 2.7 (0.1-5.4) 3.8 (0-7.8) 3.1 (0-6.7) 0.061

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Table 3. Trends in prevalence of heavy sugar-sweetened beverage (SSB) intake (�500 kcal/day) between 2003-2004 and 2015-2016 for children and adults participatingin National Health and Nutrition Examination Survey, stratified by sex and other sociodemographic characteristics (continued)



��% (95% CI)��!Income

Lower 6.4 (3.7-9) 6.3 (3.7-9) 7.7 (2.6-12.7) 3.9 (2.7-5) 5.8 (3.1-8.5) 5.2 (1.5-8.9) 3.7 (0.7-6.8) 0.180

Higher 7.5 (5.6-9.5) 5.2 (2.9-7.5) 4.1 (1.5-6.7) 3.4 (1.7-5.2) 3.2 (1.3-5.1) 2.1 (1-3.1) 2.2 (0.8-3.7) < 0.001

Adults

Male

Age group (y)

20-39 29.7 (23.1-36.4) 24.1 (19.4-28.7) 21.1 (16.1-26.1) 17 (13.3-20.6) 17.6 (14.6-20.7) 19.4 (15.9-22.9) 14 (10.6-17.5) < 0.001

40-59 16.5 (12.3-20.7) 12.7 (7.8-17.6) 14.2 (9.4-19) 10.5 (7.5-13.5) 11.8 (8.8-14.7) 11.9 (8.7-15.1) 16 (11.9-20.1) Nonlineard

>60 1.4 (0.3-2.4) 4.4 (2.7-6) 2.5 (1.6-3.4) 3 (1.5-4.5) 4.9 (2.4-7.4) 4.2 (2.4-6) 4.8 (1.2-8.3) 0.047

Race/ethnicity

Non-Hispanic White 17.7 (14.4-21) 13.9 (11.4-16.4) 14.5 (9.8-19.3) 11 (8.8-13.1) 11 (9.4-12.7) 11.4 (9-13.9) 13.8 (11.3-16.3) Nonlineare

Non-Hispanic Black 20.3 (15.3-25.2) 21.1 (15.4-26.8) 16.6 (12.6-20.6) 13.1 (9.4-16.7) 15.8 (12.5-19) 14 (10.5-17.5) 12.7 (6.6-18.8) 0.009

Mexican American 21.7 (15.7-27.8) 23.4 (16.5-30.4) 13.8 (9.4-18.2) 12.3 (8.2-16.4) 14.7 (9-20.4) 21.8 (17.2-26.4) 10.1 (5.4-14.8) 0.022

Non-Mexican Hispanic 11.9 (0-26.6) 13.8 (5.3-22.2) 17 (11.3-22.8) 17.6 (14.2-21) 15.1 (7.8-22.3) 13.1 (6.5-19.6) 14.3 (10.5-18.1) 0.927

Income

Lower 24.7 (18.8-30.7) 23.4 (17.5-29.4) 19.4 (14-24.8) 15.8 (11.9-19.8) 17.2 (13.2-21.1) 23.6 (17.9-29.3) 15.6 (10.9-20.4) 0.089

Higher 16.3 (13.7-18.9) 13.2 (10.8-15.6) 12.8 (9.6-16.1) 10.1 (8.3-12) 11.2 (9.5-12.9) 10.1 (8.1-12.1) 11.8 (10.1-13.4) Nonlinearf

Female

Age group (y)

20-39 12 (9.4-14.5) 9.5 (6.5-12.6) 11.2 (7.5-15) 11 (8.1-13.9) 10.3 (7.4-13.2) 9 (6.6-11.3) 5.9 (4.2-7.5) Nonlinearg

40-59 7.8 (3.9-11.7) 6.5 (5-8) 6.6 (3.8-9.4) 5.6 (3.5-7.6) 7.1 (4.1-10.2) 7.1 (3.6-10.5) 7.4 (5.2-9.7) 0.900

>60 2.1 (1.3-2.9) 1.6 (0.3-2.8) 1.8 (1-2.5) 2.7 (1.4-4) 0.7 (0-1.4) 2.3 (0.7-3.8) 3.4 (1.3-5.4) 0.260

Race/ethnicity

Non-Hispanic White 7 (5.1-8.8) 5.8 (4.3-7.3) 7.1 (4.1-10) 6.2 (4.8-7.6) 6.3 (4.5-8.1) 6.1 (3.8-8.4) 6.2 (3.9-8.6) 0.668

Non-Hispanic Black 15.5 (11.1-19.8) 10.4 (7.4-13.4) 9.4 (6.5-12.4) 9.9 (7.4-12.4) 10.3 (6.8-13.8) 10.4 (7-13.8) 6.2 (3.7-8.7) 0.005

(continued on next page)

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Table 3. Trends in prevalence of heavy sugar-sweetened beverage (SSB) intake (�500 kcal/day) between 2003-2004 and 2015-2016 for children and adults participatingin National Health and Nutrition Examination Survey, stratified by sex and other sociodemographic characteristics (continued)



��% (95% CI)��!Mexican American 9.6 (3.6-15.5) 5.2 (1.6-8.9) 5.6 (3.1-8.2) 10.6 (7-14.2) 7.3 (2.9-11.6) 4.6 (1.9-7.2) 6.5 (5.1-7.8) 0.343

Non-Mexican Hispanic 3.8 (-1.2-8.8) 6.2 (0.6-11.8) 6.6 (2.7-10.6) 7 (3.1-10.9) 5 (2-7.9) 7.8 (2.5-13.2) 4.4 (2.6-6.3) 0.953

Income

Lower 10.6 (7.9-13.3) 10.1 (5.7-14.5) 11.3 (6.9-15.7) 12.2 (9-15.4) 11.1 (8.9-13.3) 11.2 (8.4-13.9) 8.6 (4.4-12.8) 0.672

Higher 6.9 (4.8-8.9) 5.1 (4-6.3) 5.6 (3.8-7.4) 5.1 (3.9-6.3) 5.1 (3.4-6.9) 5 (3-6.9) 5 (3.7-6.3) 0.171

aTo obtain trend estimates, separate models were fitted among each subgroup, adjusting for all other covariates (eg, model was fit among non-Hispanic White girls, adjusting for survey year, age category, and income). Results are not reported forchildren and adults of other race/ethnicity due to small sample sizes. Negative predicted values were truncated at 0. NA indicates non-estimable due to small sample sizes.bEvidence of a nonlinear trend in heavy SSB intake over time, as indicated by statistically significant joint Wald test of the quadratic and cubic terms for survey year (P ¼ 0.0357).cEvidence of a nonlinear trend in heavy SSB intake over time, as indicated by statistically significant joint Wald test of the quadratic and cubic terms for survey year (P ¼ 0.0206).dEvidence of a nonlinear trend in heavy SSB intake over time, as indicated by statistically significant joint Wald test of the quadratic and cubic terms for survey year (P ¼ 0.0380).eEvidence of a nonlinear trend in heavy SSB intake over time, as indicated by statistically significant joint Wald test of the quadratic and cubic terms for survey year (P ¼ 0.0076).fEvidence of a nonlinear trend in heavy SSB intake over time, as indicated by statistically significant joint Wald test of the quadratic and cubic terms for survey year (P ¼ 0.0212).gEvidence of a nonlinear trend in heavy SSB intake over time, as indicated by statistically significant joint Wald test of the quadratic and cubic terms for survey year (P ¼ 0.0382).

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Table 5. Per capita intake (kilocalories) by sugar-sweetened beverage (SSB) subtype among heavy SSB drinkers (�500 kcal/day)between 2003-2004 and 2015-2016 for children and adults participating in the National Health and Nutrition ExaminationSurvey. This table provides point estimates and 95% confidence intervals for the results presented in Figure 3

Variablea Soda Fruit drinks Energy/sport drinks Low calorie SSB Other SSB

��point estimate (95% CI)��!Children

2003-2004 444 (408-479) 202 (173-232) 26 (7-44) 0 (0-1) 64 (38-90)

2005-2006 389 (293-485) 192 (150-235) 77 (56-97) 1 (0-3) 109 (57-162)

2007-2008 387 (341-433) 131 (91-171) 72 (32-113) 6 (0-15) 95 (57-133)

2009-2010 429 (328-530) 166 (111-222) 48 (18-78) 16 (4-29) 161 (66-256)

2011-2012 232 (141-323) 204 (150-257) 55 (28-83) 6 (0-11) 226 (17-435)

2013-2014 352 (237-467) 78 (48-108) 96 (25-167) 9 (1-17) 249 (122-376)

2015-2016 303 (233-373) 101 (42-160) 40 (15-64) 3 (0-7) 254 (150-358)

P value for linear trend 0.001 < 0.001 0.199 Nonlinearb < 0.001

Adults

2003-2004 483 (430-537) 119 (83-154) 13 (1-24) 11 (0-22) 146 (118-173)

2005-2006 429 (383-475) 113 (91-135) 30 (18-42) 2 (0-3) 187 (130-244)

2007-2008 422 (348-496) 97 (78-116) 53 (32-74) 5 (2-8) 178 (135-220)

2009-2010 395 (359-432) 125 (104-145) 30 (15-44) 7 (4-9) 229 (186-272)

2011-2012 312 (264-360) 132 (98-165) 60 (29-91) 12 (3-22) 268 (224-312)

2013-2014 386 (338-434) 53 (35-71) 55 (35-75) 15 (3-28) 294 (250-337)

2015-2016 364 (301-426) 35 (24-47) 67 (42-93) 3 (0-8) 327 (271-382)

P value for linear trend < 0.001 Nonlinearc < 0.001 Nonlineard < 0.001

aNegative predicted values were truncated at 0.bEvidence of a nonlinear trend over time, as indicated by statistically significant joint Wald test of the quadratic and cubic terms for survey year (P ¼ 0.0162).cEvidence of a nonlinear trend over time, as indicated by statistically significant joint Wald test of the quadratic and cubic terms for survey year (P ¼ 0.0001).dEvidence of a nonlinear trend over time, as indicated by statistically significant joint Wald test of the quadratic and cubic terms for survey year (P ¼0.0153).

RESEARCH


-- 2020 Volume - Number - JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS 12.e5

Decreasing Trends in Heavy Sugar-Sweetened Beverage Consumption in the United States, 2003 to 2016Materials and MethodsData and Study PopulationMeasuresSSB IntakeSSB Subtypes, Source, and Location of IntakeCovariates

Statistical Analysis

ResultsTrends in Heavy SSB Intake between 2003-2004 and 2015-2016Patterns in Current Heavy SSB Intake

DiscussionConclusionsReferences

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