What makes a beverage healthy? A qualitative study of young adults’ conceptualisation of sugar-containing beverage healthfulness
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.
References (73)
- et al.
Sugar-sweetened beverages and dental caries in adults: A 4-year prospective study
Journal of Dentistry
(2014) - et al.
“If it tastes good, I'm drinking it”: Qualitative study of beverage consumption among college students
Journal of Adolescent Health
(2013) - et al.
Marketing food and beverages to youth through sports
Journal of Adolescent Health
(2018) - et al.
Digital promotion of energy drinks to young adults is more strongly linked to consumption than other media
Journal of Nutrition Education and Behavior
(2018) - et al.
A thematic content analysis of how marketers promote energy drinks on digital platforms to young Australians
Australian & New Zealand Journal of Public Health
(2018) - et al.
Adolescent and young adult perceptions of caffeinated energy drinks: A qualitative approach
Appetite
(2013) - et al.
Young adolescents' perceptions, patterns, and contexts of energy drink use: A focus group study
Appetite
(2014) - et al.
What is a nutritious snack? Level of processing and macronutrient content influences young adults' perceptions
Appetite
(2017) - et al.
What are we drinking? Beverages shown in adolescents' favorite television shows
Journal of the Academy of Nutrition and Dietetics
(2017) - et al.
Water, juice, or soda? Mothers and grandmothers of preschoolers discuss the acceptability and accessibility of beverages
Appetite
(2017)
How much free sugar do Australians consume? Findings from a national survey
Australian & New Zealand Journal of Public Health
Growth patterns and emerging opportunities in nutraceutical and functional food categories: Market overview
Adolescents' presentation of food in social media: An explorative study
Appetite
Conducting school-based focus groups: Lessons learned from the CATS project
Journal of Pediatric Nursing
How category average reference points affect choice of sugary foods
Appetite
Sugar-sweetened beverages and weight gain in children and adults: A systematic review and meta-analysis
American Journal of Clinical Nutrition
Health warning labels correct parents' misperceptions about sugary drink options
American Journal of Preventive Medicine
Sweetening of the global diet, particularly beverages: Patterns, trends, and policy responses. The lancet
Diabetes & Endocrinology
Health discourse in Swedish television food advertising during children's peak viewing times
Appetite
Knowledge, perceptions, and behaviors of adults concerning nonalcoholic beverages suggest some lack of comprehension related to sugars
Nutrition Research
The importance of food naturalness for consumers: Results of a systematic review
Trends in Food Science & Technology
Nutrition and health claims in products directed at children via television in Spain in 2012
Gaceta Sanitaria
Consumer and product-specific characteristics influencing the effect of nutrition, health and risk reduction claims on preferences and purchase behavior – a systematic review
Appetite
Functional foods in line with young consumers: Challenges in the marketplace in Slovenia
Use and perceptions of caffeinated energy drinks and energy shots in Canada
American Journal of Preventive Medicine
Sugar-sweetened beverages: Children's perceptions, factors of influence, and suggestions for reducing intake
Journal of Nutrition Education and Behavior
Determinants of adolescents' soft drink consumption
Public Health Nutrition
Holistic nutrition proves to be tailored across age groups
Digital marketing of unhealthy foods to Australian children and adolescents
Health Promotion International
Using thematic analysis in psychology
Qualitative Research in Psychology
Thematic analysis
Industry use of ‘better-for-you’ features on labels of sugar-containing beverages
Public Health Nutrition
The marketing of sugar-sweetened beverages to young people on Facebook
Australian & New Zealand Journal of Public Health
Exposure to digital marketing enhances young adults' interest in energy drinks: An exploratory investigation
PloS One
Children's and parents' health perception of different soft drinks
British Journal of Nutrition
It's good for me: It has added fibre! an exploration of the role of different categories of functional foods in consumer diets
Journal of Consumer Behaviour
Cited by (22)
Adolescents’ perspectives on soft drinks after the introduction of the UK Soft Drinks Industry Levy: A focus group study using reflexive thematic analysis
2022, AppetiteCitation Excerpt :Additional similarities were found with our research and previous study findings, including the importance of ‘functionality’ of drinks, which in some instances impacted choice of beverage over and above sugar content, particularly the use of drinks for sporting purposes (Brownbill et al., 2020; Fairchild, Broughton, & Morgan, 2017; J. Francis et al., 2017; Sylvetsky et al., 2020). The contradiction between awareness of the health consequences of excess sugar, perceptions of drink healthiness and actual consumption is mirrored in other studies; that is participants are aware they and others should not consume SSBs, but they discuss doing so (Brownbill et al., 2020; MacGregor et al., 2019). In addition, the impact of parental restriction on moderating adolescent SSB consumption was also found in work by Visram et al. (2017).
Perceived healthiness of foods: A systematic review of qualitative studies
2021, Future FoodsCitation Excerpt :The most frequent categories found were functional foods, ultra-processed foods, plant products, veggie foods, junk foods, meat products, fruit and vegetables, snack foods, drinks, dairy products, insect foods, organic foods, among others. In general, some categories had mixed perceptions: snacks were considered as junk food, perceived as both healthy (e.g., meal) and unhealthy (e.g., candy) food (Adams and Savage, 2017; Ford et al., 2020; Younginer et al., 2016); energy drink was related to ‘crap’ and nutritive (Brownbill et al., 2020); cereals were associated with intensive agriculture, genetic manipulation, intolerance, high in proteins, ‘hospital’, ‘no benefits’(Banovic et al., 2018), but also high in antioxidants, low in calories, healthy (Gaspar et al., 2020). Organic and flower products were perceived as healthy, safe, expensive, green food, pure, natural, nutritious, and medicine (Banovic et al., 2018; Peura-Kapanen et al., 2017); moreover, ginseng food products were also associated to healthy, high priced, premium quality, rare, traditional, and good appearance (Doungtip et al., 2019).