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Appetite

Volume 150, 1 July 2020, 104675
Appetite

What makes a beverage healthy? A qualitative study of young adults’ conceptualisation of sugar-containing beverage healthfulness

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Abstract

Sugar-containing beverages are the leading source of added sugar consumption among young adults. The aim of this study was to explore how young adults conceptualise what influences the healthfulness of sugar-containing beverages.

Seven focus groups stratified by gender and educational institute were conducted with South Australians aged 18–25 years (n = 32). Focus groups were semi-structured and included a ranking activity where participants individually ranked eight beverages from least to most healthy. Focus groups were recorded, transcribed verbatim and thematically analysed.

Participants commonly selected soda (soft drink) and energy drink as the least healthy beverage and water as the healthiest, but those between varied in rankings. Four themes were identified relating to how participants conceptualise beverage healthfulness in the thematic analysis: ingredients harmful to health, properties beneficial to health, functionality, and packaging. While participants were aware that beverages can contain high amounts of sugar, and that this can be harmful to health, many other factors influence the perceptions of beverage healthfulness and these can outweigh the perceived harms of consumption.

Public health interventions and policies are needed to address misperceptions about the healthfulness of sugar-containing beverages to better put the harms of high sugar consumption in perspective for consumers.

Introduction

Over half of young Australian adults exceed the World Health Organization (WHO) recommendations to limit free sugar consumption (Gupta, Smithers, Braunack-Mayer, & Harford, 2018). Free sugar is defined by the WHO as “monosaccharides and disaccharides added to foods and beverages by the manufacturer, cook or consumer, and sugars naturally present in honey, syrups, fruit juices and fruit juice concentrates” (World Health Organization, 2015). Sugar-containing beverages are the leading source of free sugar consumption among young adults (Gupta et al., 2018). Regular consumption of sugar-containing beverages is associated with increased weight gain and obesity (Malik, Pan, Willett, & Hu, 2013), metabolic syndrome and type II diabetes (Imamura et al., 2016; Malik et al., 2010), development of dental caries (Bernabe, Vehkalahti, Sheiham, Aromaa, & Suominen, 2014), and risk of cardiovascular disease (Malik, 2017). Reducing population consumption of sugar-containing beverages has been identified as one way to help address the impact of overweight and related non-communicable disease on populations (Popkin & Hawkes, 2016).

Sugar-containing beverages are marketed ubiquitously through both traditional and new media platforms, in overt and subtle ways, and in environments popular with young people (Brownbill, Miller, & Braunack-Mayer, 2018b; Eisenberg, Larson, Gollust, & Neumark-Sztainer, 2017; Holmberg, Berg, Dahlgren, Lissner, & Chaplin, 2018; Holmberg, E. Chaplin, Hillman, & Berg, 2016). Previous research has found frequent exposure to sugar-containing beverage marketing enhances attitudes towards marketed sugar-containing beverages (Buchanan, Kelly, & Yeatman, 2017) and increases beverage selection (Battram, Piche, Beynon, Kurtz, & He, 2016) and consumption (Hennessy, Bleakley, Piotrowski, Mallya, & Jordan, 2015; Powell, Wada, Khan, & Emery, 2017). A recent trend in the marketing of sugar-containing beverages is the positioning of beverages as healthy or better-for-you. For example, we previously found better-for-you claims were present on 96.8% of sugar-containing beverage labels in Australia, with these claims commonly positioning the product as natural, emphasising fruit and nutrient content, associating consumption with general wellbeing, and suggesting the beverage has functional properties for maximising sporting performance (Brownbill, Miller, & Braunack-Mayer, 2018a). Other research has found similar marketing trends are also common on sugar-containing beverage labels in other countries (Dachner, Mendelson, Sacco, & Tarasuk, 2015; Perry, Chacon, & Barnoya, 2018; Mediano Stoltze et al., 2018). In an online study with U.S parents, Munsell, Harris, Sarda, and Schwartz (2016) found that at least a third of participants indicated that health related claims (low-calorie, real/natural, vitamin C, antioxidants, low-sodium) were important to their decision to purchase sugar-containing beverages for their children. While little research has specifically explored the influence of health-related marketing on consumption of sugar-containing beverages, there is strong evidence showing health-related marketing practices, such as the use of health and nutrition claims, influence the purchasing and consumption of food more generally (Kaur, Scarborough, & Rayner, 2017; Steinhauser & Hamm, 2018). Therefore, exploring consumer perceptions of the healthfulness of beverages is one way to provide insight into the likely effect of health-related marketing of sugar-containing beverages on consumer purchasing and consumption.

Existing research indicates that consumers hold erroneous views about the healthfulness of certain sugar-containing beverages. For example, previous research has indicated that beverages such as juice, flavoured waters, sports drinks (e.g. Gatorade) and iced teas, are perceived to be healthy, or healthier, and as less likely to lead to disease development, compared to soda (or ‘soft drink’ e.g. Coca-Cola; Sprite) or energy drinks (e.g. Red Bull) (Eli, Hornell, Etminan Malek, & Nowicka, 2017; Hess, Lilo, Cruz, & Davis, 2019; Moran & Roberto, 2018; Munsell et al., 2016). While some research has shown that consumers' perceived healthfulness of sugar-containing beverages influences consumption of these beverages (Hennessy et al., 2015; Kim & House, 2014), much research to date has focused on sugar content and health-related consequences, indicating that there is general awareness among consumers that sugar-containing beverages can be high in sugar and frequent consumption can lead to weight gain and long-term health consequences (Hattersley, Irwin, King, & Allman-Farinelli, 2009; Hess et al., 2019; Miller, Braunack-Mayer et al., 2019). Little research exists exploring what factors beyond sugar content and adverse health consequences contribute to consumers' overall conceptualisation of beverage healthfulness. An experimental sorting study among Swiss parents and their children by Bucher and Siegrist (2015) provides some insight into the topic. The authors found that parent and child participants commonly used sugar content and presence of additives, caffeine and fruit when sorting beverages by healthfulness and these factors predicted perceptions of beverage healthfulness (Bucher & Siegrist, 2015). Although the study noted several other factors mentioned by parents and children as influencing their sorting of beverages by healthfulness (e.g. naturalness and presence of vitamins) it did not provide an analysis of the influence of these factors on the perceptions of beverage healthfulness, or consider how all factors interact in the overall conceptualisation of beverage healthfulness. Given marketing research has suggested that better-for-you marketing is currently used in attempt to address increasing consumer concerns of the sugar content in beverages and has forecasted that this marketing trend is likely to continue and increase (Euromonitor International, 2016), further consideration should be given to how consumers' concerns about the sugar content and adverse health consequences of frequent consumption are more broadly assessed in the overall conceptualisation of beverage healthfulness.

This study builds on previous research to gain a better understanding of how the health-related marketing of sugar-containing beverages may influence consumers’ perceptions of these beverages. To do this, the study aims to develop an understanding of how young adults conceptualise beverage healthfulness through exploring what characteristics and properties of beverages are perceived as healthy or unhealthy and how these perceptions are processed and reasoned to form an assessment of whether a beverage is healthy, healthier, or not healthy. We focused on young adults as they are among the highest consumers of sugar-containing beverages (Gupta et al., 2018; Lundeen, Park, Pan, & Blanck, 2018) and are a prime target for food and beverage marketing (Freeman, Kelly, Vandevijvere, & Baur, 2015). Further, to our knowledge, no research has specifically explored the perceptions of beverage healthfulness among young adults and how health-related marketing may influence their perceptions. Our specific research question for the present study was “How do Australian young adults conceptualise what makes a beverage healthy, or healthier?”

Section snippets

Materials and methods

We used a critical realist theoretical approach to examine how young adults conceptualise what makes a beverage healthy, or healthier. Through this approach, we focus on both individuals’ views of what influences beverage healthfulness and the ways that the broader social (i.e. through group discussion) and environmental (i.e. through marketing) context might influence those views (Braun & Clarke, 2006; Fletcher, 2017). We chose semi-structured focus groups for data collection and incorporated

Results

There was a wide range of beverages reportedly consumed, with participants across all groups reporting that they consumed common beverages including: cordial; coconut waters; energy drinks; iced teas; juices/fruit drinks; sodas (soft drinks); sports drinks; smoothies, milks and waters. In the individual beverage ranking activity, most participants identified the water as the healthiest beverage (ranked ‘8’, n = 29), followed by coconut water (ranked ‘7’, n = 21) as the second healthiest

Discussion

This study has explored how young adults conceptualise the healthfulness of sugar-containing beverages. Much of the existing literature on consumer perceptions of sugar-containing beverages have focused on energy drinks (Bunting, Baggett, & Grigor, 2013; Costa, Hayley, & Miller, 2014; Francis et al., 2017; McCrory et al., 2017; Thorlton & Collins, 2018; Visram, Crossley, Cheetham, & Lake, 2017; Wiggers, Reid, White, & Hammond, 2017) and sodas (Bere, Glomnes, te Velde, & Klepp, 2008; Hattersley

Conclusions

While young adults are aware that beverages can contain high amounts of sugar, and that this can be harmful to health, many other factors influence young adults’ conceptualisation of beverage healthfulness. Public health interventions and policies are needed to address misperceptions about the healthfulness of sugar-containing beverages to better put the harms of high sugar consumption in perspective for consumers. Properties and packaging of beverages also influence how young adults

Financial support

Funding for this study was provided by an Australian Government Research Training Program Scholarship (AB) and an Ian Wilson Liberal Research Scholarship (AB). The funders were not involved in the study design or collection, analysis and interpretation of data, thus the authors were independent of the funder. It was the authors’ decision to publish the findings of this study and the funders were not involved in the preparation of this manuscript.

Authors’ contributions

AB facilitated and transcribed the focus groups. AB coded and analysed the data, with scientific input from CM and ABM. AB drafted the article. All authors contributed to the conceptualisation and design of the study and reviewed and revised the final version of the article.

Ethical standards disclosure

We obtained ethics approval from The University of Adelaide Human Research Ethics Committee (approval number H-2018-057). All participants involved in this research gave written informed consent before participating and consent was confirmed verbally before recording devices were turned on during focus groups.

Declaration of competing interest

None.

Acknowledgements

The authors are grateful to the young adults who participated in this research and would like to acknowledge Ms Joanne Dono and Dr Kerry Ettridge for their help during the conducting of the study's focus groups.

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