Stop the Pop: A Mixed-Methods Study Examining Children's Physical and Emotional Responses during Three Days of Sugary Drink Cessation.

Despite public health efforts to reduce sugary drink consumption, children's intake continues to exceed recommendations. While numerous barriers to lowering sugary drink consumption have been identified, aversive feelings during sugary drink cessation may further challenge sustained reduction in children's sugary drink consumption. Herein, we describe "Stop the Pop", an intervention to examine children's physical and emotional responses during three days of sugary drink cessation. Children (n = 150) ages 8-14, who reported habitual consumption of ≥12 ounces of sugary drinks daily, were instructed to avoid sweetened beverages for three days. At baseline and on each day of cessation, children completed a daily feelings questionnaire, and a subset of children (n = 30) also completed a qualitative interview following cessation. During sugary drink cessation, children reported physical and emotional improvements, including being less tired, angry, and annoyed; having less trouble sleeping; and less frequently arguing with others, getting in trouble, and getting mad. However, unfavorable responses, such as mood disturbances and having less energy, were reported by some participants. Our results suggest that children who habitually consume sugary drinks may experience physical and emotional improvements during short-term sugary drink cessation, although longer-term examination is needed and inter-individual variability in responses to cessation warrants further study.

Beverage Characteristics Perceived as Healthy among Hispanic and African-American Parents of Young Children.

BACKGROUND: It is recommended that children younger than 6 years of age avoid sugar-sweetened beverages (SSBs); yet, 25% of toddlers and 45% of preschool-aged children consume SSBs on a given day, with the highest intakes reported among Hispanic and African-American children. OBJECTIVE: To investigate characteristics that predominantly low-income Hispanic and African-American parents perceive to reflect a healthy beverage, and to examine the influence of these characteristics on parents' perceptions of the beverages they provide to their young children. DESIGN: This study consisted of two activities: a qualitative activity where parents (n = 102) were asked to report what characteristics they perceive to reflect a healthy beverage and a quantitative activity where parents (n = 96) indicated the extent to which each of the reported characteristics influence parents' perceptions of the beverages they provide to their young children. PARTICIPANTS AND SETTING: Hispanic and African-American parents of young children (younger than 6 years of age) were recruited from the District of Columbia metropolitan area. MAIN OUTCOME MEASURES: Beverage characteristics and influence scores. STATISICAL ANALYSES PERFORMED: Characteristics were categorized by the research team based on their perceived meaning. Perceived influence scores for each characteristic and category were compared across Hispanic and African-American parents using nonparametric, Mann-Whitney U tests, and false discovery rate adjustment was used to correct for multiple testing. RESULTS: The characteristics perceived to be most influential included those pertaining to perceived beverage sugar and sweetener content, being natural, and containing certain nutrients. Characteristics such as being homemade, made with fruit, and containing vitamins were reported to be more influential among Hispanic parents compared with African-American parents. CONCLUSIONS: Findings emphasize the need to address misperceptions about the healthfulness of beverages among Hispanic and African-American parents. Differences in the perceived influence of specific beverage characteristics across Hispanic and African-American parents underscore the importance of developing culturally relevant interventions to improve parents' beverage selection for their children.

Feasibility and acceptability of a randomized controlled trial to investigate withdrawal symptoms in response to caffeinated sugary drink cessation among children.

BACKGROUND: Sugary drinks (SDs) are key contributors to excess added sugar intake and the predominant source of caffeine among children. Chronic caffeine intake causes dependence, and evidence for sugar dependence is emerging. Development of withdrawal symptoms may pose an obstacle to SD cessation among children. We examined the feasibility and acceptability of a three-arm randomized controlled trial (RCT) designed to investigate withdrawal symptoms resulting from replacement of children's usual caffeinated SD intake with either caffeine-free alternatives or caffeine-free and sugar-free alternatives, compared with continued consumption of caffeinated SDs. METHODS: Twenty-nine children 8-12 years old, who consumed ≥12 ounces caffeinated SDs daily, enrolled. The two-week RCT required three in-person meetings and daily completion of electronic questionnaires to assess withdrawal symptoms and intervention adherence. Children were randomized to replace their usual caffeinated SD consumption with 1) caffeine-free alternatives, 2) caffeine-free and sugar-free alternatives, or 3) caffeinated SDs (control), provided by the study team. Feasibility and acceptability were assessed quantitatively and qualitatively. RESULTS: Twenty-eight participants (97%) completed the study. Adherence was high, with 73% reporting compliance with beverage assignments, and 76% completing all questionnaires. In qualitative interviews at follow-up, children described feelings of importance and commitment, and parents did not find the procedures to be overly burdensome. While challenges to adherence were reported (e.g., child wanting other SDs, time commitment), participants described innovative strategies (e.g., designating a place for study drinks in the refrigerator) to maintain adherence. CONCLUSION: Results indicated high levels of RCT feasibility and acceptability. The reported barriers and strategies for adherence will inform modifications required to design a larger and longer-term trial investigating withdrawal symptoms after SD cessation in children.

Rationale and design of DRINK-T1D: A randomized clinical trial of effects of low-calorie sweetener restriction in children with type 1 diabetes.

BACKGROUND: Low-calorie sweeteners (LCSs) provide sweetness without sugar or calories and are used to replace added sugars by many children with type 1 diabetes (T1D). However, the role of LCSs in diabetes management and cardiometabolic health is unclear. OBJECTIVE: The Diabetes Research in Kids Study (DRINK-T1D) aims to investigate effects of LCS restriction on glycemic variability, visceral adiposity, lipid profiles, and systemic inflammation among children 6-12 years old with T1D. METHODS: Children with T1D, who report habitual consumption of foods and beverages containing LCSs, are recruited from the Washington Nationals Diabetes Care Complex (DCC) at Children's National Hospital (CNH) in Washington, DC. Following a phone screening and two-week run-in period involving continuation of usual LCS intake, children are randomized to 12 weeks of LCS restriction (replacement of diet beverages with still or sparkling water and avoidance of other sources of LCSs) or continued usual LCS intake (control). The primary outcome is the difference in change in glycemic variability in the LCS restriction group versus the control group. Change in glycemic variability will be assessed as the difference in daily average time-in-range (TIR), measured using continuous glucose monitoring (CGM) during two weeks at the end of the 12-week intervention, compared with during the two-week run-in period prior to randomization. Participants also complete a variety of anthropometric, metabolic, dietary, and behavioral assessments throughout the 14-week study. CONCLUSIONS: DRINK-T1D is an innovative, randomized controlled trial, evaluating effects of LCS restriction on glycemic variability and cardiometabolic health in children with T1D. Findings of DRINK-T1D will support or challenge the common practice of recommending LCS use in this patient population and will have clinically relevant implications for pediatric T1D management. TRIAL REGISTRATION: ClinicalTrials.gov Identifier NCT04385888.

SODA MAPS: A Framework for Understanding Caffeinated Sugary Drink Consumption Among Children.

Excess sugary drink (SD) consumption is associated with childhood obesity and development of cardiometabolic disease. In addition to having high added sugar content, many SDs also contain caffeine, which may further encourage excess SD consumption among children. The objective of this study was to develop a conceptual framework of children's caffeinated SD consumption using group concept mapping, an applied social research multimethodology that collectively harnesses qualitative and quantitative data from participants to generate a visual representation of their ideas and input. Children, 8-14 years old, who reported consuming ≥12 ounces of caffeinated SDs (e.g., sodas, sweet teas) per day were recruited throughout Washington, D.C. and invited to participate. Concept mapping included three participant-driven activities: (1) brainstorming (n = 51), during which children reported reasons for their SD consumption, from which 58 unique reasons were identified; (2) sorting (n = 70), during which children sorted each of the reported reasons into categories and named each category; and (3) rating (n = 74), during which children rated the influence of each reason on their own caffeinated SD consumption. Similarity matrices, multidimensional scaling, and hierarchical cluster analysis were used to generate concept maps (hereafter "SODA MAPS"), which display the 58 reasons organized within eight overarching clusters. Among these eight clusters, Taste and Feel, Something to Do, and Energy were rated as particularly influential. Children's caffeinated SD consumption is encouraged not only by the palatable taste and reported preferences for these beverages (e.g., Taste and Feel), but also by psychological (e.g., Mood and Focus), biological (e.g., Energy), social (e.g., Something to Do) and environmental reasons (e.g., Nothing Better Available). Thus, the SODA MAPS can inform the development of tailored, multi-level SD reduction interventions that incorporate strategies to address important and currently overlooked reasons for caffeinated SD consumption among children.

Beyond taste and easy access: Physical, cognitive, interpersonal, and emotional reasons for sugary drink consumption among children and adolescents.

Consumption of sugary drinks is associated with the development of obesity and cardiometabolic diseases among children and adolescents. In addition to high added sugar content, many sugary drinks also contain caffeine. However, whether the combination of sugar and caffeine uniquely influences children's sugary drink intake is presently unknown. This study aimed to evaluate contextual factors surrounding children's sugary drink consumption and investigate reasons for sugary drink intake among children and adolescents, with a specific focus on caffeinated sodas and sweet tea. We also evaluated how sugary drink consumption makes children feel and how they anticipated that they would respond if sugary drinks were restricted. Focus group discussions (n = 9, 2-8 participants per group) were conducted with 37 predominantly AfricanAmerican children and adolescents, ages 8-14 years, who consumed ≥1 caffeine-containing sugary drink(s) daily, based on parental report. Focus groups were audio-recorded and transcribed verbatim. Transcripts were independently coded by two coders, after which emergent themes were identified. Reported reasons for sugary drink consumption encompassed five themes: 1) perceived need (e.g., satisfy cravings, quench thirst); 2) physical and cognitive benefits (e.g., provide energy, improve attention); 3) emotional and interpersonal benefits (e.g., relieve anger, facilitate socializing); 4) sensory properties (e.g., taste, carbonation); and, 5) external cues (e.g., family/peer modeling, availability). Negative consequences resulting from excess intake were also reported, including gastrointestinal symptoms, headaches, fatigue, hyperactivity, and chronic disease. Perceived physical, cognitive, emotional, and interpersonal benefits encourage sugary drink consumption and exacerbate well-described challenges of sugary drink reduction, including their palatability, accessibility, and affordability. Findings also suggest that incorporation of strategies to enhance physical, cognitive, and emotional health may hold promise in reducing sugary drink consumption among children and adolescents.

Parental Concerns about Child and Adolescent Caffeinated Sugar-Sweetened Beverage Intake and Perceived Barriers to Reducing Consumption.

Sugar-sweetened beverage (SSB) consumption contributes to obesity and chronic disease. SSB intake in children and adolescents remains well above recommendations and reducing intake is challenging. In addition to high sugar content, SSBs are the predominant source of caffeine among youth. However, whether caffeine in SSBs presents unique barriers to reducing consumption is unknown. Herein, we examine parental concerns about child caffeinated-SSB (CSSB) intake and describe parent-reported barriers to lowering their child's consumption. In-depth qualitative interviews were conducted with 21 parents of children and adolescents 8-17 years of age. Interviews were audio-recorded and transcribed verbatim. Transcripts were coded using Nvivo™, and key themes were identified. Most parents expressed concern about child CSSB consumption, primarily with regard to dietary (e.g., excess sugar), health (e.g., obesity, diabetes) and/or behavioral (e.g., hyperactivity) consequences of frequent intake. Several key barriers to CSSB restriction were reported, encompassing six emergent themes: widespread availability and accessibility; child non-compliance when asked not to drink CSSBs; peer and cultural influences; negative child response to CSSB restriction; family eating behaviors; and, child preferences for CSSBs versus other beverages. Consideration of these barriers, along with the development of novel approaches to address these challenges, will likely bolster success in interventions aimed at reducing CSSB intake among children and adolescents.