Environmental Interventions To Reduce The Consumption of Sugar-Sweetened Beverages and Their Effects On Health (Protocol)

Cochrane Database of Systematic Reviews
Environmental interventions to reduce the consumption of

sugar-sweetened beverages and their effects on health
(Protocol)
von Philipsborn P, Stratil JM, Burns J, Busert LK, Pfadenhauer LM, Polus S, Holzapfel C, Hauner
H, Rehfuess E
von Philipsborn P, Stratil JM, Burns J, Busert LK, Pfadenhauer LM, Polus S, Holzapfel C, Hauner H, Rehfuess E.
Environmental interventions to reduce the consumption of sugar-sweetened beverages and their effects on health.
Cochrane Database of Systematic Reviews 2016, Issue 7. Art. No.: CD012292.
DOI: 10.1002/14651858.CD012292.
www.cochranelibrary.com
Environmental interventions to reduce the consumption of sugar-sweetened beverages and their effects on health (Protocol)
Copyright © 2016 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
TABLE OF CONTENTS
HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Figure 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Figure 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Figure 3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Figure 4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Figure 5. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Figure 6. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Figure 7. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Environmental interventions to reduce the consumption of sugar-sweetened beverages and their effects on health (Protocol) i
[Intervention Protocol]
Environmental interventions to reduce the consumption of

sugar-sweetened beverages and their effects on health
Peter von Philipsborn1 , Jan M Stratil2 , Jacob Burns3 , Laura K Busert3 , Lisa M Pfadenhauer3 , Stephanie Polus3 , Christina Holzapfel4 ,
Hans Hauner4 , Eva Rehfuess3
1 Faculty
of Medicine, Technical University Munich, 81677 Munich, Germany. 2 Faculty of Medicine, University of Tuebingen, Tue-
bingen, Germany. 3 Institute for Medical Informatics, Biometry and Epidemiology, Ludwig-Maximilians-University Munich, Munich,
Germany. 4 Institute for Nutritional Medicine, Technische Universität München Klinikum rechts der Isar, Munich, Germany
Contact address: Peter von Philipsborn, Faculty of Medicine, Technical University Munich, Stuntzstrasse 12, 81677 Munich, Germany.
peter.philipsborn@alumni.lse.ac.uk.
Editorial group: Cochrane Public Health Group.

Publication status and date: New, published in Issue 7, 2016.
Citation: von Philipsborn P, Stratil JM, Burns J, Busert LK, Pfadenhauer LM, Polus S, Holzapfel C, Hauner H, Rehfuess E.
Environmental interventions to reduce the consumption of sugar-sweetened beverages and their effects on health. Cochrane Database
of Systematic Reviews 2016, Issue 7. Art. No.: CD012292. DOI: 10.1002/14651858.CD012292.
ABSTRACT
This is the protocol for a review and there is no abstract. The objectives are as follows:
To assess the effects of environmental interventions (excluding taxation) targeted at sugar-sweetened beverages or low-calorie alternatives
to sugar-sweetened beverages on consumption levels, diet-related anthropometric measures and health outcomes, and on any reported
unintended consequences or adverse outcomes.
BACKGROUND Among the various potential dietary risk factors sugar-sweetened

beverages (SSB) have recently received particular attention. Fre-
quent consumption of SSB has been linked to an increased risk
for a number of adverse health outcomes, including obesity, type 2
Description of the condition
diabetes, cardiovascular disease and dental caries (Hu 2013; Malik
2010). It is estimated that due to their direct adverse health effects,
0.34% (95% confidence interval (CI): 0.23% to 0.46%) of the
Sugar-sweetened beverages and health global burden of disease can be attributed to diets high in SSB
Dietary and diet-related risk factors are a major cause of mortal- (IHME 2015; Lim 2012).
ity and morbidity worldwide. The association of unhealthy diets There is no established definition of SSB. In the broadest sense,
with non-communicable diseases is well established (Ezzati 2013; the term is used for liquids with added caloric sweeteners (USDA
Hunter 2013). It is estimated that 9% of the global burden of 2015, USDA 2015a). Contrary to the literal meaning of the term
disease can be attributed to diets of poor nutritional content, 4% SSB, alcoholic beverages with added sugar and sugar-sweetened
to overweight and obesity and 4% to hyperglycaemia (increased milk are generally not included in the definitions used in the liter-
blood glucose levels) (IHME 2015; Lim 2012).
Environmental interventions to reduce the consumption of sugar-sweetened beverages and their effects on health (Protocol) 1
ature (AAP 2015; Basu 2013; Malik 2010a; Ogden 2011; Singh comes linked to SSB. With regard to the causal role of SSB in
2015). Following this convention we define, for the purpose of weight gain, it has been shown that individuals incompletely com-
this review, SSB as non-alcoholic, non-dairy beverages with added pensate for calories consumed as SSB (Maersk 2012; Malik 2010;
caloric sweeteners. This definition includes, but is not limited to, Poppitt 2015; Vartanian 2007; Wolf 2008). Incomplete caloric
carbonated and caffeinated soft drinks (sodas), fruit juices with less compensation refers to the following phenomenon: when SSB are
than 100% fruit content and added sugar, sugar-sweetened energy added to a diet, calorie intake from other sources is generally re-
and sports drinks, sugar-sweetened vitamin waters and flavoured duced by an amount smaller than the amount obtained from the
water, and sugar-sweetened coffee and tea. SSB consumed. Two mechanisms may be responsible for this phe-
There is strong evidence for a causal role of SSB in the development nomenon: the inability of SSB to induce feelings of satiety equiv-
of overweight and obesity (Hu 2013). A review of reviews on the alent to their caloric content, and the tendency of individuals to
association between SSB intake and weight gain published in 2013 consume SSB regardless of hunger and satiety. A number of fac-
identified 17 systematic reviews (with 18 conclusions), of which tors may contribute to this bi-directional uncoupling of SSB con-
11 found positive associations. Of the seven systematic reviews sumption from normal feelings of hunger and satiety:
that did not find positive associations, five were written by authors • The lack of chewing and the lower orosensory response, as
with links to the food and beverage industry (Bes-Rastrollo 2013). well as the faster gastric emptying time and lower mechanical
Since then, a number of systematic reviews (Malik 2013; Zheng fullness sensations associated with liquids as compared to solid
2015) and high-quality randomised controlled trials (RCTs) (de foods (Cassady 2012; Poppitt 2015).
Ruyter 2012; Ebbeling 2012) have provided further evidence for • The limited capacity of liquid calories to induce a satiating
a causal role of SSB in weight gain. Reported effect sizes vary by hormone response, including an attenuated release of glucagon-
study design, population and follow-up. like peptide 1, and a lower ghrelin suppression, as compared to
Moreover, a number of systematic reviews have found positive solid calories (Cassady 2012).
associations between SSB intake and type 2 diabetes (Greenwood • The lower fullness sensation and satiating hormone
2014; Imamura 2015; Malik 2010a; Vartanian 2007; Wang 2015). response to SSB as compared to isocaloric beverages containing
Based on a systematic review and meta-analysis of prospective milk or other sources of protein (Maersk 2012; Poppitt 2015).
cohort studies, it was estimated that 4% to 13% of type 2 diabetes • The central nervous response to sugar, in particular its
incidence in the USA, and 2% to 6% in the UK can be attributed capacity to activate the endogenous reward system of the brain
to SSB (Imamura 2015). Furthermore, several systematic reviews (Johnson 2009; Poppitt 2015; Stice 2013).
have found positive associations between SSB consumption and • The caffeine content of many SSB, which can induce
cardiovascular risk factors and diseases, including hypertension, dependence effects (Keast 2015).
metabolic syndrome, and coronary heart disease, for some but • The reduced perception of sweetness, and of the sugar and
not all population groups (Hu 2013; Huang 2014; Jayalath 2015; caloric content of chilled foods and beverages.
Malik 2014; Xi 2015). However, no increased risk for stroke was • The relatively high glycaemic index (GI) and glycaemic
found (Xi 2015). load (GL) of SSB, as compared to beverages without added
In addition, in cross-sectional and longitudinal observational stud- sugars and unprocessed foods, which can result in postprandial
ies, frequent consumption of SSB has been associated with an in- hyperglycaemia, a subsequent rapid insulin response followed by
creased risk of dental caries, even after adjustment for possible a marked drop in plasma glucose levels and concomitantly
confounders (Armfield 2013; Bernabé 2014; Evans 2013; Park increased hunger (Ludwig 2002; Malik 2010).
2015; Vartanian 2007; Warren 2009). However, evidence from
The positive association of SSB with type 2 diabetes and cardio-
high-quality RCTs is still missing for the relationship between SSB
vascular disease seems to be mediated largely through adiposity,
consumption and oral health.
which is a known risk factor for these conditions (Malik 2015).
Findings for other health outcomes are less consistent, but posi-
However, it has been argued that additional direct causal path-
tive associations have been reported for reduced bone density and
ways may exist (Imamura 2015; Malik 2010; Malik 2015). More
increased risk of bone fracture (Vartanian 2007), hyperuricaemia
specifically, highly processed dietary sugars, as they are present in
(increased levels of uric acid in blood) and gout (Malik 2010) and
SSB, may have adverse metabolic effects above and beyond their
chronic kidney disease (Cheungpasitporn 2014). No significantly
caloric content (Johnson 2009; Lana 2014; Malik 2015; Raben
increased risks for cancer were found (Boyle 2014; Zhang 2010).
2011). The sugars most commonly used in SSB are either sucrose
(a disaccharide made up of equal parts of glucose and fructose) or
high-fructose corn syrup, which consists of glucose and fructose
The pathophysiology of sugar-sweetened beverage in monomeric form, with a fructose content ranging from 42% to
consumption 55% (Johnson 2009). The degree to which sucrose and high-fruc-
A number of physiological and psychological mediating mecha- tose corn syrup are used in SSB varies by product and geographic
nisms are discussed as explanations for the negative health out- region (Nestle 2015).
SSB constitute a source of empty calories, i.e. they contain energy that provide substantial amounts of nutrients and relatively few
but no micro- and macronutrients except water and sugars. SSB calories, is therefore a key recommendation in a number of na-
consumption can therefore lead to a reduced intake of micro- and tional and international dietary guidelines (Hauner 2012; USDA
macronutrients through alternative beverages as well as through 2015a). More specifically, the Dietary Guidelines for Americans
solid foods, even under conditions of incomplete caloric compen- 2010 recommend to limit intake of SSB and to increase intake
sation (Vartanian 2007). It is estimated that 6.6% (95% CI: 4.7% of unsweetened low-fat or fat-free milk (USDA 2015a), while the
to 8.4%) of the global burden of disease can be attributed to diets World Health Organization (WHO) guideline on dietary sugars
low in fruits, vegetables, fibre, milk and calcium (IHME 2015; strongly recommends to reduce the intake of free sugars (includ-
Lim 2012). To achieve healthy dietary patterns, nutrient needs ing sugars from SSB) throughout the life-course (WHO 2015).
must be met without exceeding energy needs (USDA 2015a). Re- Potentials causal pathways between SSB consumption and adverse
ducing intake of energy-dense but nutrient-poor foods and bev- health outcomes are shown in Figure 1.
erages, such as SSB, and replacing them with foods and beverages
Figure 1. Physiological and psychological mechanisms linking SSB intake with adverse health outcomes.
may be due to a concomitantly reduced intake of caloric bever-

Alternatives to sugar-sweetened beverages
ages, and possibly also due to a reduced intake of solid foods when
Plain water has been the most commonly used source of hydra- water is consumed with or before meals, even though this sec-
tion for the largest part of the evolution of the human species ond effect is disputed (Davy 2008; Dennis 2010; Negoianu 2008;
(Wolf 2008). In the context of obesity and obesity-related dis- Van Walleghen 2007). Current dietary guidelines therefore rec-
eases, increased consumption of drinking water has been linked ommend drinking water as a preferred alternative to SSB (USDA
to a reduced total energy intake among certain populations 2015a).
(Daniels 2010; Davy 2008; Dennis 2010; Muckelbauer 2013; Van Another recommended alternative to SSB is low-fat or fat-free milk
Walleghen 2007). This effect of drinking water on energy intake (USDA 2015a), which is an important source of micronutrients
for which intake is lower than recommended among many popu- balance. Consequently, current dietary guidelines recommend to
lations, including calcium, vitamin D and potassium (AAP 2015; limit intake of 100% fruit juice among children and adolescents to
Johnson 2002). For the purpose of this review, and following the moderate amounts, particularly among those who are overweight
Scientific Report of the 2015 U.S. Dietary Guidelines Advisory and obese, and to replace full-fat milk with low-fat or fat-free
Committee, we consider fortified soy beverages, but not almond milk (USDA 2015a). Moreover, full-fat milk is relatively high in
or other plant-based “milk-type” products as a substitute for milk saturated fat (USDA 2015). By contrast, beverages prepared by
(USDA 2015; USDA 2015a). Furthermore, tea and coffee are rec- adding varying amounts of 100% fruit juice to carbonated or
ommended by the Dietary Guidelines for Americans 2015-2020 uncarbonated water without adding additional caloric sweeteners
as alternatives to SSB for the general public (USDA 2015a), but are generally considered acceptable alternatives to SSB (AAP 2015;
caffeine intake from coffee, tea and other sources should be limited DGE 2015).
to moderate amounts among children, adolescents and women Sugar-sweetend milk constitutes another grey area. While dietary
who are pregnant or considering pregnancy (USDA 2015). guidelines generally recommend to choose unsweetened milk (
Beverages containing non-nutritive sweeteners (NNS) are not gen- USDA 2015a), it remains controversial whether sugar-sweetened
erally recommended by dietary guidelines as preferred alternatives milk should be targeted in public health interventions or not (AAP
to SSB (USDA 2015a; USDA 2015). NNS, also known as low- 2015). It has been argued that limits on the consumption of sugar-
calorie, low-energy or artificial sweeteners, are chemically diverse sweetened milk could decrease overall milk intake, and thus overall
compounds with no or minimal caloric content and a sweet taste dietary quality (AAP 2015; Hanks 2014; Johnson 2002). We will
of varying intensity (Fitch 2012). In cross-sectional and cohort therefore consider interventions targeting sugar-sweetened milk
studies frequent consumption of beverages with NNS was asso- as a separate category. A table with all beverage categories to be
ciated with adverse health outcomes similar to those associated considered in this review, and relevant definitions, is provided in
with SSB, including an increased risk of obesity and type 2 dia- Appendix 3.
betes (Imamura 2015; Fowler 2008). However, most RCTs directly
comparing beverages sweetened exclusively with NNS with SSB
have shown results favouring the former with regard to weight gain Sugar-sweetened beverage consumption patterns
(Bellisle 2015; Miller 2014). Moreover, available prospective stud- SSB consumption varies considerably by geographic location, gen-
ies indicate that after adjustment for possible confounders con- der, age and socio-economic status. Based on a systematic review
sumption of beverages with NNS is associated with a lower risk of and pooled analysis of dietary surveys, global mean adult daily SSB
diabetes than consumption of equal amounts of SSB (Greenwood consumption was estimated at 137 mL (95% CI: 88 mL to 211
2014). Furthermore, safety reviews by regulatory and scientific mL) in 2010 (Singh 2015). Mean daily SSB consumption is higher
bodies have generally found NNS to be safe at the levels consumed in upper-middle income countries (189 mL) and lower-middle
by most populations (Fitch 2012; USDA 2015). income countries (140 mL) than in high-income (121 mL) and
Full-fat milk and 100% fruit juice are both relevant sources of low-income (83 mL) countries, with substantial variation within
essential nutrients and relatively energy-dense. Excessive amounts regions (see Figure 2) (Singh 2015). Consumption is generally
of these beverages can therefore contribute to a positive energy higher in younger age groups, among males, and in the Americas
as compared to other world regions (Singh 2015).
Figure 2. Estimated SSB consumption by country in 2010 (an 8 oz. serving is equivalent to approximately
237 ml). Reproduced with permission from Singh 2015.
Over the past decades, consumption of SSB has increased sub-

stantially in most countries, with decreases observed in some, but • Exposure to and consumption of other energy-dense,
not all countries beginning around 2000 (Bleich 2015; French micronutrient-poor foods both at and out of home
2003; Kit 2013; Malik 2010; Nielsen 2004; Tugendhaft 2015). (Denney-Wilson 2009; Mazarello Paes 2015; Verloigne 2012).
Among the populations with the highest intake, SSB constitute • Unawareness or disbelief in the association of SSB
a substantial source of energy (Malik 2010). It is estimated that consumption and weight gain (Park 2014).
in Mexico in 2012, SSB accounted for 7% of total energy intake • Mistrust in the safety of tap water (Onufrak 2014).
among children, youth, and adults (Stern 2014). For the USA, • Unfavorable parenting practices, including parental
mean SSB consumption was estimated to account for 8% of total consumption of SSB, access to SSB at home, irregular family
energy intake among youth in 2010, and for 6.9% of total energy dinners, and overly permissive and pressuring parenting styles
intake for adults (Kit 2013). In the USA, consumption levels have (Denney-Wilson 2009; Gillman 2000; Mazarello Paes 2015;
been shown to be particularly high among ethnic minority and Park 2015a; Vereecken 2009; Verloigne 2012).
low socioeconomic status (SES) groups (Ogden 2011).
The increase in the consumption of SSB observed over the past Description of the intervention
decades, and SSB consumption in general, have been attributed to
a number of factors. Positive associations, which may or may not Various interventions intended to reduce SSB intake and its effects
indicate causal relationships, have been shown for the following on health, or to increase the intake of low-calorie alternatives to
factors: SSB, have been implemented so far. Two approaches, which can
• Exposure to advertisements and other forms of marketing be implemented separately or jointly as part of multi-component
(Andreyeva 2011; Hennessy 2015). interventions, can be distinguished (CDC 2015; Roberto 2015;
• Availability of SSB at school and in other educational WCRFI 2015):
settings (Fernandes 2008; Mazarello Paes 2015; Verloigne 2012; • Environmental interventions, targeting the environment,
Wiecha 2006). physical, socio-economic, socio-cultural or legal, in which
• Increases in unit and serving sizes (Flood 2006; Steenhuis individuals make food and beverage choices.
2009). • Behavioural interventions, targeting the dietary preferences,
• Low relative and absolute prices (Jones 2014). knowledge, attitudes, motivations, skills and abilities of
• Television watching and other screen-based activities individuals, as well as their subjective perception of social norms
(Demissie 2013; Mazarello Paes 2015). on food and beverage consumption.
• Low household and individual income, and insecure The difference between environmental and behavioural interven-
employment status (Mazarello Paes 2015; Verloigne 2012). tions is not always clear-cut. Interventions, such as marketing reg-
• Availability and regular visits of fast food restaurants serving ulations, may aim to influence individual preferences by altering
SSB (Denney-Wilson 2009; Mazarello Paes 2015; Wiecha 2006). the environment encountered by individuals. In the present re-
view, we will classify interventions as environmental when they municipalities. Alternative terms include jurisdiction-based or
aim to alter the food and beverage environment in a permanent macro-level interventions.
way. Interventions that alter the food and beverage environment • Setting-based interventions, which are adopted and
temporarily with the aim of influencing individual preferences implemented within individual settings, such as schools, work
(e.g. a one-off public media campaign) will be considered as be- sites, local retail, food service or recreational facilities. Synonyms
havioural interventions. are community interventions, or meso-level interventions.
In the present review, behavioural interventions will only be con-
sidered when they are part of larger interventions that also in- Some interventions may be implemented either within individual
clude environmental components, as a separate systematic review settings or on a policy level, or they may even target both levels
specifically on behavioural interventions is ongoing (PROSPERO at the same time. Examples include bans on the sale of SSB at
2014a). In addition, we will exclude taxation, as a systematic re- schools, which may be mandated by a local school director for
view and meta analysis on SSB taxes has been published (Cabrera his or her individual school, or by national legislation as part of
Escobar 2013), and another one is ongoing (Cochrane 2015a). a national school nutrition policy. Similarly, interventions such as
To categorise included studies by intervention area we will use labelling or content disclosure requirements are often first evalu-
the NOURISHING framework, which has been developed by the ated by trials within specific settings, e.g. an individual shop or
World Cancer Research Fund International to classify nutrition restaurant, before they are implemented on a policy level, e.g. as
interventions (WCRFI 2015). It is consistent with the interven- part of national regulation. Such pilot trials can help to identify
tion categories used in the WHO Global Action Plan for the Pre- intervention options worth scaling up, and thus provide valuable
vention and Control of Non-Communicable Diseases 2013-2020 information for policymakers. However, scaling up interventions
(WHO 2013) and the INFORMAS food environment bench- which have proven successful within individual settings to the pol-
marking network (INFORMAS 2015). It distinguishes seven en- icy level poses specific challenges. Evaluations of interventions im-
vironmental and policy intervention areas (including the food sys- plemented within individual settings therefore provide only indi-
tem): rect and limited evidence on whether the intervention will or will
• Labelling and food claim rules. not work on a policy level. In the present review, we will there-
• Interventions changing the availability of different foods fore classify interventions only as policy level when they are im-
and beverages in public institutions and other settings. plemented on the level of a geographically-defined political or ad-
• Pricing interventions (including both fiscal and non-fiscal ministrative unit, and when the original studies reporting on them
interventions altering the absolute and relative prices of SSB or evaluate their effects on the same level (e.g. by analysing the effects
low-calorie alternatives to SSB; in the present review, we will of a national school nutrition policy on the SSB consumption of
exclude fiscal interventions, as they are covered by a separate school children in that country). All other interventions, includ-
review). ing pilot trials and evaluations restricted to individual settings will
• Advertisement regulation. be classified as setting-based interventions, regardless of whether
• Reformulation. the intervention in question is suitable for implementation on a
• Changes to the beverage retail and food service policy level or not.
environment.
• Food system approaches (including health-in-all policies
approaches in sectors such as agriculture and trade).
How the intervention might work
In addition, the NOURISHING framework distinguishes three
All environmental nutrition interventions ultimately aim to
behavioural intervention areas:
change human food and beverage intake by providing conductive
• Information on food and nutrition.
environments at different levels. A theoretical framework com-
• Nutrition counselling in health-care settings.
monly used to conceptualise the effects of such interventions is the
• Nutrition education and skills building.
social-ecological model. It postulates that dietary behaviour is in-
Appendix 4 presents the NOURISHING framework in more de- fluenced by a host of individual and environmental factors, which
tail, as well as relevant examples for interventions targeted at SSB can interact to create complex, multi-layered systems (see Figure
or low-calorie alternatives to SSB identified in a scoping literature 3) (CDC 2015; Moodley 2015; Sacks 2009; Swinburn 1999;
search. Swinburn 2011). Environmental interventions generally target the
Moreover, interventions can be classified by their level of imple- macro- and meso-level, i.e. policies and settings. Behavioural in-
mentation (CDC 2015): terventions generally target the micro-level, i.e. interpersonal fac-
• Policy interventions, which are adopted and implemented tors such as social norms and networks of social support, and in-
on the level of geographically-defined political or administrative trapersonal factors such as personal preferences, attitudes and skills
units, such as supra-national organisations, states, regions or (see Figure 3).
Figure 3. Socio-ecological model of food and beverage intake. Adapted from CDC 2015.
Behavioural interventions are often informed by theories of human

behaviour, including the Theory of Planned Behaviour, and Social overlap.
Cognitive Theory. The Theory of Planned Behaviour postulates Environmental interventions targeting the macro- and meso-level
that behavioural intentions depend on the personal attitudes (or are generally considered to have a larger potential population
preferences) of individuals and their perception of social norms, effect, and more likely to be cost-effective and equitable when
as well as on their perceived behavioural control (Ajzen 2011). compared to micro-level interventions (Gortmaker 2011; Roberto
Social Cognitive Theory focuses on the influence of role models, 2015; Swinburn 2011). At the same time, it is more difficult to
outcome expectancies, self-efficacy and identification (Bandura achieve political consensus regarding their implementation, and
2001). In practice, both theories and their constitutive concepts to evaluate them with rigorous scientific study designs (Swinburn
2011) (See Figure 4).
Figure 4. Determinants of diet-related health outcomes and related interventions. Adapted from Swinburn
2011.
How a given intervention will work additionally depends on a

number of collateral factors, such as the characteristics of the tar-
get population, the delivery mechanisms, implementation aspects
and further contextual factors. The intervention is thus nested in
a complex system, as illustrated by the system-based logic model
shown in Figure 5, which we developed for this systematic review
and which will guide our data extraction, analysis and interpreta-
tion.
Figure 5. System-based logic model for the influence of environmental interventions to reduce SSB intake
on beverage choices and diet-related health and non-health outcomes.
Public health and health promotion interventions can have unin-

tended consequences, including boomerang effects and other ad- improve concentration among certain populations, such as shift
verse outcomes (Byrne 2011). Boomerang effects are effects op- workers (Ker 2010; Liira 2014), which suggests that a decrease
posite to those intended by the intervention, and may be due to in the consumption of caffeinated SSB might have the potential
a number of phenomena, including psychological reactance, fac- to decrease productivity and safety among certain occupational
tual misunderstanding of health messages, reduced perceptions of groups. Nutrition interventions targeted at specific foods or bev-
self-effectiveness, increased stigmatisation as well as adverse forms erages may lead to adverse compensatory behaviour, such as in-
of compensatory behaviour, among others (Byrne 2011; Ramos creased consumption of alternative but likewise unhealthy foods
Salas 2015). In our scoping literature search, we found no re- and beverages, or decreased physical activity (Byrne 2011). Fur-
ports on adverse outcomes of interventions targeted at reducing thermore, nutrition interventions may increase stigmatisation of
SSB consumption, or increasing the consumption of low-calorie overweight and obese individuals, including internalised stigma
alternatives to SSB. However, a number of adverse outcomes of (MacLean 2009), as well as stigmatisation of disadvantaged groups
such interventions are conceivable. Interventions focused on re- who are perceived as practicing unhealthy lifestyles (Byrne 2011).
ducing SSB intake may lead to decreased fluid intake and dehy- Additionally, nutrition interventions may exacerbate body image
dration, in particular in settings where access to safe drinking wa- and eating disorders, including unhealthy weight control and diet-
ter is limited. Insufficient hydration has been documented for a ing practices, and psychosocial distress (Byrne 2011; Ramos Salas
number of populations and has been linked to diverse negative 2015). Given the popularity of SSB, it can be assumed that many
health outcomes (Kenney 2015). In settings where access to safe people enjoy their consumption. It has therefore been suggested
drinking water is limited, we will pay particular attention to po- that limits on SSB may have the potential to decrease the quality
tential effects on health outcomes related to unsafe drinking water, of life of targeted populations, even though a cohort study among
such as diarrhoeal disease, although we are not currently aware the adult population in Spain found no evidence for a beneficial
of any reports to this end. Moreover, caffeine has been shown to effect of SSB consumption on health-related quality of life (Lana
2015). Finally, policy interventions in particular can have reper- published or registered yet.
cussions on the society and economy as a whole, including vary- Numerous global, regional and national policy initiatives in
ing effects on employment and resource use in different sectors the field of nutrition and health call for action to reduce in-
(Powell 2014). take of added sugars (European Commission 2007; FAO/WHO
2014; Public Health England 2015; USDA 2015a; WHO 2013;
Why it is important to do this review
WHO-EURO 2014), for which SSB are the most important
Numerous studies have explored the effects of interventions aimed source among many population groups, including the USA gen-
at reducing the consumption of SSB or at increasing the consump- eral population (Drewnowski 2014). Environmental interventions
tion of low-calorie alternatives to SSB. A number of systematic show particular promise to be effective and cost-effective on a pop-
reviews on nutrition interventions in general have been published, ulation level (Gortmaker 2011; Roberto 2015; Swinburn 2011).
some of which include studies on interventions targeting SSB, A systematic synthesis of the available evidence in this field will
among others (Oldroyd 2008; Seymour 2004). Moreover, there help policymakers, regulators, health promotion authorities and
are systematic reviews on interventions altering specific aspects of professionals, and other relevant stakeholders to identify and im-
food and beverage environments, such as labelling (Hersey 2013; plement effective interventions in their own constituencies.
Rayner 2013; Swartz 2011), pricing (Andreyeva 2010; Wall 2006)
and portion sizes (Steenhuis 2009).
A number of non-systematic reviews on interventions to reduce
SSB consumption or to increase consumption of low-calorie al- OBJECTIVES
ternatives to SSB, including drinking water, have been published
(Hsiao 2013; Mello 2008; Moise 2011; Patel 2010; Pomeranz To assess the effects of environmental interventions (excluding tax-
2012; Tipton 2015). One systematic review and meta-analysis ation) targeted at sugar-sweetened beverages or low-calorie alter-
on SSB taxes has been published (Cabrera Escobar 2013), and natives to sugar-sweetened beverages on consumption levels, diet-
a Cochrane review on taxation of SSB for preventing obesity or related anthropometric measures and health outcomes, and on any
other adverse health outcomes is ongoing (Cochrane 2015a). One reported unintended consequences or adverse outcomes.
systematic review on interventions directed at SSB consumption
of youth has been published (Levy 2011), as well as one systematic
review on interventions to reduce SSB intake among children lead- METHODS
ing to changes in body fatness (Avery 2015). One mixed-methods
review on policies to reduce the intake of added sugar has been
published (Public Health England 2015). A Cochrane review pro-
Criteria for considering studies for this review
tocol on drinking extra water or other non-caloric beverages for
Types of studies
promoting weight loss or preventing weight gain has been pub-
lished (Burls 2016). We will consider the following study types, as recommended by
One systematic review on behavioural interventions to reduce SSB the Cochrane Effective Practice and Organization of Care (EPOC)
intake has been registered with the International Prospective Reg- Group (EPOC 2013a), using the definitions proposed by EPOC:
ister of Systematic Reviews (PROSPERO 2014a), as well as one • Randomised controlled trials (RCTs): Experimental studies
systematic review on interventions to reduce SSB intake in chil- in which people are allocated to different interventions using
dren and adults (PROSPERO 2014b). According to the published methods that are random. This includes both individually-
protocol, the latter will include behavioural and environmental randomised controlled trials, in which the randomisation occurs
interventions, considering randomised and non-randomised con- on the level of individuals, and cluster-randomised controlled
trolled trials from a number of academic databases (Vargas-Garcia trials (cluster-RCTs), in which the randomisation occurs on the
2015). In contrast, our review will focus on environmental in- level of clusters of individuals, e.g. study groups or study sites.
terventions only, and consider additional, uncontrolled study de- • Non-randomised controlled trials (NRCTs): Experimental
signs which are commonly used to assess the effects of policy in- studies in which people (individuals or clusters of individuals)
terventions. We will also search additional databases to identify are allocated to different interventions using methods that are
studies in the grey literature and policy documents. In addition, not random.
we will report a different set of outcome measures, including un- • Controlled before-after (CBA) studies: Studies in which
intended consequences, adverse outcomes and measures of cost- observations are made before and after the implementation of an
effectiveness that may be of relevance to policymakers. To the best intervention, both in a group that receives the intervention and
of our knowledge, no comparable systematic review, focusing on in a control group that does not. Unlike in NRCTs, the
environmental interventions (other than taxation) to reduce the allocation to the intervention and control groups is not
consumption of SSB among children, youth and adults has been determined by the investigators, but by nature or by other factors
outside the control of the investigators.
• Interrupted-time-series (ITS) study: A study that uses We will consider both ready-to-use SSB and SSB prepared from
observations at multiple time points before and after an syrups, concentrates or powder. We will also include interventions
intervention (the ‘interruption’). The design attempts to detect that use beverages with NNS as a substitute for SSB, or in which
whether the intervention has had an effect greater than any the energy content of SSB is reduced by substituting caloric sweet-
underlying trend over time. eners with NNS through reformulation. Full-fat milk and 100%
• Repeated measures study (RMS): An ITS study where fruit juice are, for the purpose of this review, not considered rec-
measurements are made in the same individuals at each time ommended alternatives to SSB. Interventions targeting these bev-
point. erages will not be included. We will try to present results sepa-
rately and examine and discuss differences in results for interven-
For the exact classification of study designs we will use the algo-
tions targeting SSB, sugar-sweetened milk, beverages with NNS,
rithm provided by EPOC (see Appendix 5).
or unsweetened beverages. Appendix 3 presents a list of all bever-
We will include only study designs that satisfy the following criteria
age categories included in this review and relevant definitions.
specified by EPOC (EPOC 2013a):
We will exclude the following:
• For cluster-RCTs, NRCTs and CBA studies: studies with at
• Studies conducted in laboratory or virtual settings, as the
least two intervention and two control sites.
results may not be generalisable to real-world environments.
• For ITS and RMS: a clearly defined point in time when the
• Studies with a follow-up period of less than three months,
intervention occurred and at least three data points before and
as the effects of environmental interventions may peter out due
three data points after the interventions.
to habituation, which may severely limit their long-term public
Randomised and non-randomised cross-over trials will be included health impact. In this review, we define the follow-up period as
if they satisfy the criteria specified by EPOC for their respective the time span between the start of the intervention and the last
study design. outcome assessment.
The inclusion of evidence from non-randomised controlled and • Very small studies with less than 20 individuals in the
uncontrolled study designs in systematic reviews is controver- intervention or control group, as the results may not be
sial (EPOC 2013a; Reeves 2008). While non-randomised study generalisable.
designs are commonly used for the evaluation of public health • Studies in which participants are administered SSB or
interventions, cluster-randomisation is feasible for most setting- alternatives to SSB as part of clinical trials on the physiological
based interventions which are of relevance to this review. Indeed, effects of SSB consumption, as these studies provide only limited
a number of RCTs of setting-based interventions targeting SSB evidence on the feasibility and effectiveness of public health
or low-calorie alternatives to SSB have been done (Bergen 2006; interventions aimed at reducing SSB intake among free-living
Giles 2012; Sichieri 2009). However, NRCTs and CBA studies are individuals outside controlled research settings. This may
more common (Bleich 2014; Block 2010; Blum 2008; Cradock include studies in which participants consume pre-defined
2011; Muckelbauer 2009; van de Gaar 2014; Visscher 2010). Even amounts of beverages under supervision, or in which bottled
though NRCTs, CBA studies, ITS studies and RMS are generally beverages are delivered for free to the homes of participants with
of higher risk of bias than RCTs, we have decided to include these additional measures taken to ensure and monitor compliance.
non-randomised study designs in order to cover a broader set of • Studies on interventions that combine components to
study populations, interventions types, and intervention contexts. reduce the consumption of SSB with broader components to
improve diet or increase physical activity, as it would be difficult
to attribute effects to the environmental or policy intervention of
Types of participants
interest. During the screening process we will document which
Any participants, including adults, adolescents and children, re- studies we exclude for this reason. We will provide a list of the
gardless of their weight and health status. citations to allow reflection on the quantity of relevant evidence
contained therein and consider to some extent how inclusion of
Types of interventions these studies might have influenced conclusions.
We will consider interventions that are intended to reduce the The comparison will be no intervention, minimal or alternative
consumption of SSB and sugar-sweetened milk, or their adverse interventions, such as behavioural intervention only.
effects on health, or to increase the consumption of low-calo-
rie alternatives to SSB, implemented at an environmental level.
Where these include behavioural (individual-level) components in Types of outcome measures
addition to environmental components, this will be clearly doc- Based on structured feedback from our Review Advisory Group,
umented. Stand-alone behavioural interventions will not be in- we identified a set of outcome measures that reflects short- and
cluded. We will exclude studies on taxation, as a separate Cochrane long-term health and non-health, and intended and unintended
review on taxation to reduce the consumption of SSB is ongoing. outcomes (see table 1). We will use SI units (i.e. the metric system)
to report results, except for energy, for which we will report both
joules and calories. Values reported in the primary studies will
be converted where necessary. To meet inclusion criteria, studies
must report at least one primary outcome. For reformulation in-
terventions that report effects on SSB consumption levels, at least
one additional primary outcome is needed to justify inclusion.
Table 1: Primary and secondary outcomes
Outcomes Examples
Primary outcomes
Direct and indirect measures of SSB intake The amount of SSB consumed or purchased in mL/day/person, en-
ergy intake from SSB and total energy intake in kcal/day/person
Diet-related anthropometric measures Body mass index (BMI), age- and sex-standardised body mass index
(zBMI or BMI z-scores), waist circumference, waist-to-hip ratio, body
weight change, incidence and prevalence of overweight and obesity,
body composition or total body fat
Diet-related health outcomes (other than body weight) Incidence and prevalence of pre-diabetes and diabetes, insulin resis-
tance, blood lipids and blood pressure, incidence of dental caries and
other indicators of oral health
Any reported adverse outcomes or unintended consequences Compensatory behaviour, reduced fluid intake and dehydration, re-
duced intake of essential nutrients, body image changes, unhealthy
dietary practices, unhealthy weight control, perceived reduction of
freedom of choice and other forms of target group and stakeholder
dissatisfaction, negative effects on employment or other adverse eco-
nomic consequences
Secondary outcomes
Measures of financial and economic viability Costs, cost-effectiveness, return on investment, and staff time require-
ments
Diet-related psychosocial variables Perceived dietary self-efficacy, general self-efficacy, health-related and
general quality of life
Target group perceptions of the intervention Satisfaction with the intervention, satisfaction with the way the in-
tervention was implemented, support for the continuation of the in-
tervention
• Health:
Search methods for identification of studies ◦ MEDLINE
We will perform searches in the following databases: ◦ Embase (Excerpta Medica dataBASE)
◦ CENTRAL (Cochrane Central Register of Controlled be conducted in English, but we will consider studies published
Trials) in English, French, Spanish, Italian or German for inclusion. For
eligible studies in other languages we will attempt to arrange for
• Multidisciplinary:
translation. No restriction based on the year of publication will be
◦ Scopus
applied. The MEDLINE, Embase and CENTRAL search strate-
◦ Google Scholar
gies are shown in Appendix 6. They will be adapted to the rest of
◦ Social Science Citation Index
the above-mentioned databases.
• Public health, health promotion and occupational health
databases:
• ◦ BiblioMap (EPPI-Centre database of health Data collection and analysis
promotion research)
◦ TRoPHI (EPPI-Centre Trials Register of Promoting
Health Interventions)
Selection of studies
• Nutrition:
◦ eLENA (WHO e-Library of Evidence for Nutrition After removal of duplicate studies, we will perform a multistage
Actions) screening process to select those studies which meet the inclusion
criteria:
• Sources for grey literature: • Two review authors (PvP, JMS, JB, LKB, LMP or SP) will
◦ openGrey (formerly openSIGLE) independently assess all titles and abstracts, removing those
• Unpublished studies: which are not relevant. Disagreement will be resolved by
◦ ClinicalTrials.gov discussion, and where necessary by consulting a third review
◦ ICTRP (International Clinical Trials Registry author.
Platform) • In the second step, two review authors (PvP, JMS, JB, LKB,
• Databases with a regional focus: LMP, or SP) will independently assess all full texts selected in the
◦ LILACS first step. Disagreement will be resolved by discussion, and where
◦ SciELO Citation Index necessary by consulting a third review author.
We will use the Ovid search interface for MEDLINE, Embase and
At stage two of the screening process, we will document the rea-
CENTRAL.
sons for exclusion. EndNote will be used to collect and de-dupli-
In addition, we will search the websites of key organisations in
cate studies. For the screening of titles and abstracts and to doc-
the area of health, health promotion and nutrition, including the
ument inclusion and exclusion decisions, we will consider using
following:
appropriate software, including Abstrackr and Rayyan. Abstrackr
• EU platform for action on diet, physical activity and health
and Rayyan are web-based applications for facilitating citation
• U.S. National Institutes of Health
screening for systematic reviews (AHRQ 2015; Elmagarmid 2014;
• U.S. Centers for Disease Control and Prevention
Rathbone 2015). We will also consider using the web-based soft-
• Rudd Center for Food Policy and Obesity
ware application Covidence for full-text screening, ’Risk of bias’
• Harvard TH Chan School of Public Health Obesity
assessment, data extraction, and exporting of data to ReviewMan-
Prevention Source
ager 5.3. Covidence has been developed to streamline the writ-
• World Obesity
ing of systematic reviews, including Cochrane Reviews (Cochrane
We will handsearch reference lists of included studies and previ- 2015c; Covidence 2015).
ously published reviews, and we will contact the corresponding
author of included studies and previously published reviews as
well as the members of the Review Advisory Group to identify Data extraction and management
additional studies, including unpublished or ongoing studies. In Two review authors (PvP, JMS, JB, LKB, LMP, SP, CH, HH or
addition, we will conduct a citing studies search with Scopus, i.e. ER) will independently extract study characteristics and study data
we will search for studies that have cited included studies and pre- to the data extraction form. Inconsistencies between the two re-
viously published reviews and screen them for inclusion. view authors will be resolved by discussion, and where necessary
Our search strategy is based on three search sets, namely a bev- by consulting a third review author. The final agreed data will be
erage search set (including terms related to SSB and low-calorie entered into Review Manager 5.3 by PvP, and checked by a second
alternatives to SSB as well as to nutritive and non-nutritive sweet- review author (JMS, JB, LKB, LMP, or SP). In case of uncertain-
eners) an intervention search set (including terms on interven- ties, a third review author will be consulted.
tion areas, intervention types and study designs) and an outcome Based on our logic model (see Figure 5, page 9), we will extract
search set (including terms on outcome measures). Searches will and categorise data on the study population, intervention goals,
intervention areas, level and setting, comparison, delivery agents, EQUATOR (Enhancing the Quality and Transparency of Health
mode of delivery, and time frame of delivery, as well as on primary Research) network in collaboration with the CONSORT (Con-
and secondary outcomes and on intervention context and imple- solidated Standards of Reporting Trials) steering group to improve
mentation, including equity considerations. reporting of intervention characteristics in primary studies and in
A sufficiently detailed description of intervention characteristics systematic reviews (Hoffmann 2014), and has been recommended
is necessary for a meaningful interpretation of intervention out- to be used in Cochrane reviews (Cochrane 2015b; Köpke 2015).
comes. We will therefore use the TIDieR (Template for Interven- It contains items on 12 key intervention characteristics (see table
tion Description and Replication) framework to extract and report 2).
relevant data. The TIDieR framework has been developed by the
Table 2: The TIDieR framework (Template for Intervention Description and Replication)
Domain Description
BRIEF NAME The name or phrase that describes the intervention
WHY The rationale, theory, or goal of the elements essential to the

intervention
WHAT (Materials) The physical or informational materials used in the intervention
WHAT (Procedures) The procedures, activities, and/or processes used in the interven-
tion
WHO PROVIDED The expertise, background and training of intervention providers
HOW The modes of delivery of the intervention (e.g. face-to-face, or by

internet or telephone)
WHERE The type(s) of location(s) where the intervention occurred
WHEN and HOW MUCH The schedule, duration, intensity or dose of the intervention
TAILORING Any personalisation, titration or adaption of the intervention to

individual participants
MODIFICATIONS Modification of the intervention during the study
HOW WELL (planned) Strategies for the assessment and maintenance of intervention ad-
herence or fidelity
HOW WELL (actual) Extent of the intervention adherence or fidelity
The effectiveness and the potential for unintended consequences

of public health interventions are often highly dependent on the ticular importance. Information on the context in which included
broader context in which they are implemented. For policy inter- studies were done can therefore be essential for assessing the trans-
ventions the political, economic and legal context, including poli- ferability and applicability of their results to other contexts, and
cies implemented in parallel or in close sequence, can be of par- thus for the relevance of results for policymakers and other prac-
titioners (Armstrong 2008; Pfadenhauer 2015). We will therefore interests on SSB research (Bes-Rastrollo 2013; Cope 2009;
extract contextual data, using the categories defined by the CICI Massougbodji 2014), we will extract and document detailed infor-
(Context and Implementation of Complex Interventions) frame- mation on potential conflicts of interests and sources of funding
work. The CICI framework aims to capture relevant contextual of included studies.
data on several levels (including setting, community, the national The full data extraction form, including the CICI and the TI-
and international level) within the following eight thematic do- DieR frameworks and details on the included items, as well as a
mains (Pfadenhauer 2016): detailed version of the PROGRESS-Plus framework, are provided
• Locational in Appendix 7. We have piloted this form, using a selection of
• Geographical studies that would clearly be included to ensure that it allows ac-
• Epidemiological curate and reliable extraction of relevant data.
• Socio-economic
• Socio-cultural
• Political Assessment of risk of bias in included studies
• Legal Risk of bias of included studies will be independently assessed by
• Ethical two review authors (PvP, JMS, JB, LKB, LMP, SP, CH, HH or ER)
with the EPOC-adapted Cochrane Collaboration ’Risk of bias’
Large social gradients in SSB consumption and in SSB-related tool (Higgins 2008a, EPOC 2015, EPOC 2013b). Inconsistencies
health outcomes have been observed (Ogden 2011). Moreover, will be resolved by discussion, and where necessary by consulting
there is evidence that the recent decreases in average SSB consump- a third review author.
tion observed in some countries, such as the USA, have mainly The EPOC-adapted Cochrane ’Risk of bias’ tool has been vali-
been driven by decreases in consumption among relatively priv- dated, and is commonly used in Cochrane and non-Cochrane re-
ileged social groups (Bleich 2015). This suggests that recent at- views. For controlled study designs (RCTs, NRCTs, and CBA), the
tempts to curb SSB consumption may have reached disadvan- assessment is based on the following nine criteria (EPOC 2015):
taged groups to a lesser extent, a phenomenon observed with many • Was the allocation sequence adequately generated?
public health and health promotion interventions (Armstrong • Was the allocation adequately concealed?
2008). We will therefore examine whether included studies al- • Were baseline outcome measurements similar?
low conclusions with regard to differential outcomes for groups • Were baseline characteristics similar?
with varying levels and forms of disadvantage, as recommended by • Were incomplete outcome data adequately addressed?
the Cochrane-Campbell Equity Working Group (Tugwell 2010). • Was knowledge of the allocated interventions adequately
We will apply the PROGRESS-Plus framework for this pur- prevented during the study?
pose, which distinguishes nine domains in which social disadvan- • Was the study adequately protected against contamination?
tage may exist (Cochrane Campbell Methods Group 2011; Evans • Was the study free from selective outcome reporting?
2003; O’Neill 2014): • Was the study free from other risks of bias?
• Place of residence
• Race or ethnicity For ITS, the following seven criteria are applied (EPOC 2015):
• Occupation • Was the intervention independent of other changes?
• Gender • Was the shape of the intervention effect pre-specified?
• Religion • Was the intervention unlikely to affect data collection?
• Education • Was knowledge of the allocated interventions adequately
• Socio-economic status prevented during the study?
• Social capita • Were incomplete outcome data adequately addressed?
• Plus any additional dimensions of inequality discussed or • Was the study free from selective outcome reporting?
reported in the included studies • Was the study free from other risks of bias?
For each of these criteria, one of the following assessments is given:
On a global scale, the highest SSB consumption levels have been
• Low risk of bias: plausible bias unlikely to alter the results.
reported for upper- and lower-middle-income countries (Singh
• Unclear risk of bias: plausible bias that raises some doubt
2015). However, we expect that most studies eligible for inclusion
about the results.
will be from high-income countries. We will therefore pay special
• High risk of bias: plausible bias that seriously weakens
attention to issues of transferability and applicability of our con-
confidence in the results.
clusions to low- and middle-income countries, extracting, report-
ing and discussing contextual data concerning this issue, including We will use Review Manager 5.3 to apply the EPOC-adapted
data on resource needs. Cochrane ’Risk of bias’ tool, and to document results with traffic-
Given the controversies around the influence of conflicts of light coded ’Risk of bias’ tables (EPOC 2013b). In applying the
tool we will follow the relevant instructions as provided by EPOC tervention or control groups, and include two or more compar-
(EPOC 2015) and the Cochrane Handbook for Systematic Reviews isons, as specified by Cochrane guidelines (Higgins 2008b). In-
of Interventions (Higgins 2008a). dividually-randomised controlled trials and cluster-RCTs will be
For cluster-RCTs, additional potential sources of bias, including combined in the same meta-analyses or harvest plots, but will be
failure to take the correlated nature of within-cluster data into ac- clearly identified (Higgins 2008b).
count in the analysis will be considered within the domain “Was
the study free from other risks of bias?” (Higgins 2008b). For
multi-arm and cross-over trials, potential sources of bias specific Dealing with missing data
to these study designs will be considered as recommended by In case that missing data on study characteristics or outcome mea-
Cochrane guidelines (Higgins 2008b). sures precludes study inclusion or limits the use of a study at fur-
Conflicts of interests by study authors can introduce further ther stages of the review, we will contact the corresponding author.
sources of bias not captured by standardised assessment tools. For Missing data may include standard deviations for continuous out-
studies on SSB, two potential sources of bias relating to conflicts of come measures, sample sizes, standard errors or follow-up times
interest have been discussed: financial or other links to the food and (Higgins 2008b). For registered but unpublished trials, we will
beverage industry (Bes-Rastrollo 2013; Massougbodji 2014), and contact the corresponding investigator to request relevant data. If
“white hat bias” introduced by the zeal to achieve ends perceived studies do not report outcomes based on intention-to-treat analy-
as righteous, as well as by anti-corporate feelings, which might be ses, we will consider this as a source of bias within the domain “Was
present in researchers without industry links (Cope 2009). In the the study free from selective outcome reporting?” of the EPOC-
present review, we will extract and document any conflicts of in- adapted Cochrane ’Risk of bias’ tool. We will examine the effect of
terest reported in primary studies. If relevant conflicts of interest including results from studies without intention-to-treat analysis
are found, we will conduct sensitivity analyses, and discuss impli- by performing a sensitivity analysis for high or unclear risk of bias
cations for the interpretation of results. in the selective outcome reporting domain.
Measures of treatment effect Assessment of heterogeneity

Across outcomes, we expect the intervention effect to be expressed We will assess methodological and clinical heterogeneity with ta-
in a range of forms. We will, therefore, decide what form is most bles documenting the following characteristics of the included
appropriate, after we have extracted data from included studies, studies:
but before we begin the evidence synthesis. We will extract both • Implementation level
adjusted and unadjusted results, but will preferably use adjusted • Intervention area
results for our evidence synthesis. For continuous outcome mea- • Use of behavioural co-interventions
sures, such as the consumption of SSB in mL/day/person or the • Setting (e.g. schools, workplaces, shops, restaurants)
average BMI, the standardised mean difference (SMD) will be the • Population (e.g. age group, weight and health status,
preferred measure of treatment effect. For dichotomous outcomes, baseline SSB consumption, occupational status)
such as the rate of new-onset diabetes or obesity, we will use the • Methods (outcome measures, outcome assessment)
risk ratio (RR). It is expected that most outcome measures will be • Mode of delivery (by permanent staff of the setting or
continuous. We will include 95% confidence intervals (CIs) for institution in which the intervention takes place, or by members
all SMD and RR intervention effects. of the research group or staff contracted by the research team)
• Type of SSB or alternative to SSB targeted by the
intervention (e.g. SSB, sugar-sweetened milk, beverages with
Unit of analysis issues NNS, beverages without added sweeteners).
Where possible, we will re-analyse data for cluster trials that have For those studies assessing the impacts of a given intervention cat-
not taken clustering into account in their analysis. If feasible, we egory (as defined by the NOURISHING framework) on compa-
will calculate effective sample sizes and adjusted standard errors rable outcomes (e.g. measures of SSB consumption) in the same
using the design-effect method. We will try to obtain estimates population group (e.g. individuals below or above 18 years of age),
for intra-cluster correlation coefficients from study authors. Al- thus making pooling through meta-analysis feasible, statistical het-
ternatively, we will use external estimates obtained from compa- erogeneity will be assessed graphically with a forest plot by exam-
rable studies, as recommended by Cochrane guidelines (Higgins ining the extent to which confidence intervals overlap, and statis-
2008b). If re-analysis is not feasible, this will be documented. For tically with the I2 statistic. We will consider an I2 value greater
studies with more than two intervention or control groups we will than 50% to indicate substantial statistical heterogeneity, and will
combine groups to create a single pair-wise comparison. Alterna- consider it statistically significant if the P value for the Chi2 test
tively, if this is not feasible, we will consider dividing shared in- is < 0.1. Statistical heterogeneity will be documented but will not
have any direct consequences for meta-analysis (see below). We Where meta-analysis is deemed inappropriate due to substantial
will create forest plots and I2 calculations using Review Manager clinical heterogeneity, we will summarise the findings of the in-
5.3. cluded studies narratively. The narrative summary will be under-
taken according to intervention type and comparison; within each
intervention type and comparison, the structure will be informed
Assessment of reporting biases by our logic model reporting on all major components (e.g. pop-
If more than 10 studies within the same intervention category and ulation, outcomes, context, implementation). We will use harvest
assessing comparable outcomes in the same population group are plots for a graphical representation of results. The harvest plot has
included, we will use funnel plots to assess the risk of reporting been developed to convey the findings of sets of studies of complex
bias, and perform statistical tests of asymmetry, including Begg’s interventions in a clear and transparent way, especially when meta-
and Egger’s tests (Sterne 2008). analysis is not appropriate (Crowther 2011; Ogilvie 2008). The
harvest plot is a matrix on which the distribution of evidence is
plotted using bars of different heights and shadings, each of which
Data synthesis stands for an outcome reported by one specific study (see Figure
We will attempt to pool all studies within a given intervention 6). The direction of an effect is indicated by the location of the bars
category (as defined by the NOURISHING framework) assessing on the matrix. Black bars stand for objective outcome measures,
the same outcome (e.g. SSB consumption or BMI change) in the and shaded bars stand for subjective, self-reported or self-assessed
same population group (e.g. individuals below or above 18 years outcome measures. The height of the bar indicates the suitability
of age) by conducting a meta-analysis using Review Manager 5.3. of study design, and the numbers stand for further methodolog-
If so, we will run separate meta-analyses for (i) RCTs, NRCTs and ical criteria (in this case a maximum of six) met by that study
cluster-RCTs, provided these have been adjusted for clustering, (ii) (Crowther 2011; Ogilvie 2008). We will develop one harvest plot
ITS and RMS, and (iii) CBA studies. Due to the expected large for each of the seven pre-specified intervention categories, using
heterogeneity in intervention delivery, setting and study popula- the rows for different outcome categories, as illustrated in Figure
tion we will use the random-effects model. 6.
Figure 6. Example of a harvest plot. Adapted from Ogilvie 2008.
lation to allocation concealment, baseline differences and incom-
Subgroup analysis and investigation of heterogeneity
plete outcome data. We will consider conducting an intra-cluster
We will consider performing separate meta-analyses, or creating correlation value sensitivity analysis for cluster trials.
separate harvest plots, for studies assessing interventions imple-
mented:
• at the policy or at the setting level; Quality of evidence
• with or without behavioural co-interventions; We will use the Grading of Recommendations Assessment, De-
• targeted at SSB, sugar-sweetened milk, beverages with NNS velopment and Evaluation (GRADE) system for grading the body
or at beverages without added sweeteners; of evidence for all critical and important outcomes (as defined
• implemented in high-, middle- or low-income countries; with the help of our Review Advisory Group). In the context of
• targeted at the general population or at disadvantaged GRADE, the quality of a body of evidence is understood as the
populations. extent to which one can be confident that an estimate of an effect
is close to the true effect (Guyatt 2008; Schünemann 2008). The
assessment will be summarised with a ’Summary of findings’ table
Sensitivity analysis created with the GRADEpro software.
We will examine how the time frame of the outcome measure- Within the GRADE approach, the quality of a body of evidence
ment, the unit of analysis, the risk of bias and the existence of is assessed based on the design of the underlying studies (where
relevant conflicts of interest affect results by conducting separate RCTs start off as high quality and all other study designs start off
meta-analyses or by creating separate harvest plots. This will in- as low quality), and on a number of factors which can decrease or
clude three separate meta-analyses or harvests plots that in turn increase the quality of evidence irrespective of study design. The
omit data from studies with a high or unclear risk of bias in re- four possible quality ratings are shown in table 3.
Table 3: Levels of the quality of evidence in the GRADE approach
Quality rating Description
High quality Further research is very unlikely to change the confidence in the
estimate of effect
Moderate quality Further research is likely to have an important impact on the

confidence in the estimate of effect and may change the estimate
Low quality Further research is very likely to have an important impact on the
confidence in the estimate of effect and is likely to change the
estimate
Very low quality Any estimate of effect is uncertain.
There are five factors that can lead to a downgrading of the level
of evidence. If one of these factors is found to exist, it is classified • Indirectness of evidence (indirect population, intervention,
either as serious (downgrading by one level) or as very serious control, outcomes)
(downgrading by two levels): • Unexplained heterogeneity or inconsistency of results
• Risk of bias of individual studies (limitations in the design (including problems with subgroup analyses)
and implementation of available studies suggesting high • Imprecision of results (wide confidence intervals)
likelihood of bias) • High probability of publication bias
There are three factors increasing the quality of evidence, each of Hofman (University of Witwatersrand, South Africa), Artur Fur-
which can lead to an upgrading of the level of quality by one level: tado (European Commission), Mark Lawrence (Deakin Univer-
• Large magnitude of effect sity, Australia), Cintia Lombardi (Pan American Health Organiza-
• All plausible confounding would reduce a demonstrated tion), Rebecca Muckelbauer (Charité Universitätsmedizin Berlin,
effect or suggest a spurious effect when results show no effect. Germany), Modi Mwatsama (UK Health Forum, United King-
• Dose-response gradient dom), Sohyun Park (U.S. Centers for Disease Control and Preven-
tion, United States), Ludovic Reveiz (Pan American Health Or-
ganization), and Marc Suhrcke (University of York, United King-
dom).
ACKNOWLEDGEMENTS
We would like to acknowledge the substantial and generous con- Moreover, we would like to acknowledge the helpful contributions
tributions made by the members of our Review Advisory Group, by Lorainne Tudor Car (methodologist), Reza Yousefi Nooraie
who have helped to inform the background section and the param- (statistics advisor) and Patrick Condron (search specialist) as well
eters of the planned review. The members of the Review Advisory as the support provided by the Cochrane Public Health editorial
Group were María Eugenia Bonilla-Chacín (World Bank), Karen team.
REFERENCES
Additional references beverage consumption and dental caries in Australian

children. American Journal of Public Health 2013;103(3):
AAP 2015
494–500.
American Academy of Pediatrics. Snacks, sweetened
beverages, added sugars, and schools. Pediatrics 2015;135 Armstrong 2008
(3):575–3. Armstrong R, Waters E, Doyle J. Reviews in public health
AHRQ 2015 and health promotion. In: Higgins JPT, Green S editor(s).
Agency for Healthcare Research and Quality. Abstrackr: Cochrane Handbook for Systematic Reviews of Interventions.
software for semi-automatic citation screening. http: West Sussex: John Wiley & Sons Ltd, 2008:593–606.
//effectivehealthcare.ahrq.gov/index.cfm/search-for-
Avery 2015
guides-reviews-and-reports/?productid=985&pageaction=
Avery A, Bostock L, McCullough F. A systematic
displayproduct (accessed 1 October 2015).
review investigating interventions that can help reduce
Ajzen 2011 consumption of sugar-sweetened beverages in children
Ajzen I. The theory of planned behaviour: reactions and leading to changes in body fatness. Journal of Human
reflections. Psychology & Health 2011;26(9):1113–27. Nutrition and Dietetics 2015;28:52–64.
American Beverage Association 2010
Bae 2012
American Beverage Association. Alliance
Bae SG, Kim JY, Kim KY, Park SW, Bae J, Lee WK.
school beverage guidelines: final progress
Changes in dietary behavior among adolescents and their
report. http://www.ameribev.org/files/
association with government nutrition policies in Korea,
240˙School%20Beverage%20Guidelines%20Final%20Progress%20Report.pdf
2005-2009. Journal of Preventive Medicine & Public Health
(accessed 1 November 2015). American Beverage
2012;45(1):47–59.
Association, 2010.
Andreyeva 2010 Bandura 2001
Andreyeva T, Long MW, Brownell KD. The impact of food Bandura A. Social cognitive theory: an agentic perspective.
prices on consumption: a systematic review of research on Annual Review of Psychology 2001;52:1–26.
the price elasticity of demand for food. American Journal of
Public Health 2010;100(2):216–22. Basu 2013
Basu S, McKee M, Galea G, Stuckler D. Relationship of
Andreyeva 2011
soft drink consumption to global overweight, obesity, and
Andreyeva T, Kelly IR, Harris JL. Exposure to food
diabetes: a cross-national analysis of 75 countries. American
advertising on television: associations with children’s fast
Journal of Public Health 2013;103(11):2071–7.
food and soft drink consumption and obesity. Economics &
Human Biology 2011;9(3):221–33. Bellisle 2015
Armfield 2013 Bellisle F. Intense sweeteners, appetite for the sweet taste,
Armfield JM, Spencer AJ, Roberts-Thomson KF, Plastow K. and relationship to weight management. Current Obesity
Water fluoridation and the association of sugar-sweetened Reports 2015;4(1):106–10.
Bergen 2006 beverages reduces the obesity rate: a meta-analysis. BMC
Bergen D, Yeh MC. Effects of energy-content labels and Public Health 2013;13:1072.
motivational posters on sales of sugar-sweetened beverages: Cassady 2012
stimulating sales of diet drinks among adults study. Journal Cassady BA, Considine RV, Mattes RD. Beverage
of the American Dietetic Association 2006;106(11):1866–9. consumption, appetite, and energy intake: what did you
Bernabé 2014 expect?. American Journal of Clinical Nutrition 2012;95(3):
Bernabé E, Vehkalahti MM, Sheiham A, Aromaa A, 587–93.
Suominen AL. Sugar-sweetened beverages and dental caries CDC 2015
in adults: A 4-year prospective study. Journal of Dentistry Division of Cancer Prevention and Control, Centers for
2014;42(8):952–8. Disease Control and Prevention. Social ecological model.
Bes-Rastrollo 2013 http://www.cdc.gov/cancer/crccp/sem.htm (accessed 1
Bes-Rastrollo M, Schulze MB, Ruiz-Canela M, Martinez- October 2015).
Gonzalez MA. Financial conflicts of Interest and reporting Cheungpasitporn 2014
bias regarding the association between sugar-sweetened Cheungpasitporn W, Thongprayoon C, O’Corragain
beverages and weight gain: a systematic review of systematic OA, Edmonds PJ, Kittanamongkolchai W, Erickson SB.
reviews. PLoS Medicine 2013;10(12):e1001578. Associations of sugar-sweetened and artificially sweetened
Bleich 2014 soda with chronic kidney disease: a systematic review and
Bleich SN, Barry CL, Gary-Webb TL, Herring BJ. Reducing meta-analysis. Nephrology (Carlton) 2014;19(12):791–7.
sugar-sweetened beverage consumption by providing caloric Cochrane 2011
information: how Black adolescents alter their purchases The Cochrane Public Health Group. Guide for developing
and whether the effects persist. American Journal of Public a Cochrane protocol. http://ph.cochrane.org/resources-
Health 2014;104(12):2417–24. and-guidance (accessed 1 November 2015).
Bleich 2015
Cochrane 2015a
Bleich SN, Wolfson JA. Trends in SSBs and snack
Cochrane Public Health. Nutrition, food supply and access
consumption among children by age, body weight, and
reviews. http://ph.cochrane.org/nutrition-food-supply-and-
race/ethnicity. Obesity (Silver Spring) 2015;23(5):1039–46.
access-reviews (accessed 1 October 2015).
Block 2010
Cochrane 2015b
Block JP, Chandra A, McManus KD, Willett WC. Point-
Cochrane Informatics and Knowledge Management
of-purchase price and education intervention to reduce
Department. Covidence. http://tech.cochrane.org/our-
consumption of sugary soft drinks. American Journal of
work/cochrane-author-support-tool/covidence (accessed 1
Public Health 2010;100(8):1427–33.
October 2015).
Blum 2008
Cochrane 2015c
Blum JE, Davee AM, Beaudoin CM, Jenkins PL, Kaley
Cochrane Dementia, Cognitive Improvement.
LA, Wigand DA. Reduced availability of sugar-sweetened
Non-pharmacological interventions. http://
beverages and diet soda has a limited impact on beverage
dementia.cochrane.org/non-pharma (accessed 1 October
consumption patterns in Maine high school youth. Journal
2015).
of Nutrition Education and Behavior 2008;40(6):341–7.
Cochrane Campbell Methods Group 2011
Boyle 2014
Ueffing E, Tugwell P, Welch V, Petticrew M, Kristjansson E
Boyle P, Koechlin A, Autier P. Sweetened carbonated
for the Campbell and Cochrane Equity Methods Group.
beverage consumption and cancer risk: meta-analysis and
Equity checklist for systematic review authors. http://
review. European Journal of Cancer Prevention 2014;23(5):
equity.cochrane.org/sites/equity.cochrane.org/files/uploads/
481–90.
equitychecklist2011.pdf (accessed 1 October 2015).
Burls 2016
Burls A, Price AI, Cabello JB, Roberts NW. Drinking Cope 2009
extra water or other non-caloric beverages for promoting Cope MB, Allison DB. White hat bias: examples of
weight loss or preventing weight gain. Cochrane Database its presence in obesity research and a call for renewed
of Systematic Reviews 2016, Issue 5. [DOI: 10.1002/ commitment to faithfulness in research reporting.
14651858.CD012211] International Journal of Obesity 2009;34(1):84–8.
Byrne 2011 Covidence 2015
Byrne S, Niederdeppe J. Unintended consequences of Covidence. Covidence streamlines your systematic review
obesity prevention messages. In: Cawley J editor(s). The projects. https://www.covidence.org/ (accessed 1 October
Oxford Handbook of the Social Science of Obesity. Oxford: 2015).
Oxford University Press, 2011:752–71. Cradock 2011
Cabrera Escobar 2013 Cradock AL, McHugh A, Mont-Ferguson H, Grant L,
Cabrera Escobar MA, Veerman JL, Tollman SM, Bertram Barrett JL, Wang YC, et al. Effect of school district policy
MY, Hofman KJ. Evidence that a tax on sugar sweetened change on consumption of sugar-sweetened beverages
among high school students, Boston, Massachusetts, 2004- and food source. American Journal of Clinical Nutrition.
2006. Preventing Chronic Disease 2011;8(4):A74. 2014;100(3):901–7.
Crowther 2011 Ebbeling 2012
Crowther M, Avenell A, MacLennan G, Mowatt G. A Ebbeling CB, Feldman HA, Chomitz VR, Antonelli TA,
further use for the Harvest plot: a novel method for the Gortmaker SL, Osganian SK, et al. A randomized trial of
presentation of data synthesis. Research Synthesis Methods sugar-sweetened beverages and adolescent body weight.
2011;2(2):79–83. New England Journal of Medicine 2012;367(15):1407–16.
Cullen 2006 Elmagarmid 2014
Cullen KW, Watson K, Zakeri I, Ralston K. Exploring Elmagarmid A, Fedorowicz Z, Hammady H, Ilyas I, Khabsa
changes in middle-school student lunch consumption after M, Ouzzani M. Rayyan: a systematic reviews web app
local school food service policy modifications. Public Health for exploring and filtering searches for eligible studies for
Nutrition 2006;9(6):814–20. Cochrane Reviews. Evidence-Informed Public Health:
Cullen 2008 Opportunities and Challenges. Abstracts of the 22nd
Cullen KW, Watson K, Zakeri I. Improvements in middle Cochrane Colloquium; 2014 21-26 Sep. John Wiley &
school student dietary intake after implementation of the Sons, 2014.
Texas Public School Nutrition Policy. American Journal of Eneli 2014
Public Health 2008;98(1):111–7. Eneli IU, Oza-Frank R, Grover K, Miller R, Kelleher K.
Instituting a sugar-sweetened beverage ban: experience
Daniels 2010
from a children’s hospital. American Journal of Public Health
Daniels MC, Popkin BM. Impact of water intake on energy
2014;104(10):1822–5.
intake and weight status: a systematic review. Nutrition
Reviews 2010;68(9):505–21. EPOC 2013a
Effective Practice, Organisation of Care (EPOC). What
Davy 2008
study designs should be included in an EPOC review?
Davy BM, Dennis EA, Dengo AL, Wilson KL, Davy KP.
EPOC resources for review authors. Oslo: Norwegian
Water consumption reduces energy intake at a breakfast
Knowledge Centre for the Health Services. 2013. Online:
meal in obese older adults. Journal of the American Dietetic
http://epoc.cochrane.org/epoc-specific-resources-review-
Association 2008;108(7):1236–9.
authors (accessed 1 October 2015).
de Ruyter 2012
EPOC 2013b
de Ruyter JC, Olthof MR, Seidell JC, Katan MB. A trial of
Effective Practice, Organisation of Care (EPOC). How
sugar-free or sugar-sweetened beverages and body weight in
to prepare a risk of bias table for reviews that include
children. New England Journal of Medicine 2012;367(15):
more than one study design. EPOC resources for review
1397–406.
authors. Oslo: Norwegian Knowledge Centre for the
Demissie 2013 Health Services. 2013. Online: http://epoc.cochrane.org/
Demissie Z, Lowry R, Eaton DK, Park S, Kann L. Electronic epoc-specific-resources-review-authors (accessed 1 October
media and beverage intake among United States high school 2015).
students--2010. Journal of Nutrition Education and Behavior
EPOC 2015
2013;45(6):756–60.
Effective Practice, Organisation of Care (EPOC). Suggested
Denney-Wilson 2009 risk of bias criteria for EPOC reviews. EPOC resources for
Denney-Wilson E, Crawford D, Dobbins T, Hardy L, review authors. Oslo: Norwegian Knowledge Centre for the
Okely AD. Influences on consumption of soft drinks and Health Services 2015. Online: http://epoc.cochrane.org/
fast foods in adolescents. Asia Pacific Journal of Clinical epoc-specific-resources-review-authors (accessed 1 October
Nutrition 2009;18(3):447–52. 2015).
Dennis 2010 European Commission 2007
Dennis EA, Dengo AL, Comber DL, Flack KD, Savla J, European Commission. White paper on a strategy for
Davy KP, et al. Water consumption increases weight loss Europe on nutrition, overweight and obesity related
during a hypocaloric diet intervention in middle-aged and health issues. http://ec.europa.eu/health/ph˙determinants/
older adults. Obesity (Silver Spring) 2010;18(2):300–7. life˙style/nutrition/documents/nutrition˙wp˙en.pdf. EU
DGE 2015 Commission, (accessed 1 October 2015).
Deutsche Gesellschaft für Ernährung. What should Evans 2003
children drink? [Presseinformation: Was sollen Kinder Evans T, Brown H. Road traffic crashes: operationalizing
trinken?]. www.dge.de/presse/pm/was-sollen-kinder- equity in the context of health sector reform. International
trinken/. Deutsche Gesellschaft für Ernährung, (accessed 1 Journal of Injury Control and Safety Promotion 2003;10(1-
November 2015). 2):11–2.
Drewnowski 2014 Evans 2013
Drewnowski A, Rehm CD. Consumption of added sugars Evans EW, Hayes C, Palmer CA, Bermudez OI, Cohen SA,
among US children and adults by food purchase location Must A. Dietary intake and severe early childhood caries
in low-income, young children. Journal of the Academy of among older children and adolescents. Archives of Family
Nutrition and Dietetics 2013;113(8):1057–61. Medicine 2000;9(3):235–40.
Ezzati 2013 Gortmaker 2011
Ezzati M, Riboli E. Behavioral and dietary risk factors Gortmaker SL, Swinburn BA, Levy D, Carter R, Mabry
for noncommunicable diseases. New England Journal of PL, Finegood DT, et al. Changing the future of obesity:
Medicine 2013;369(10):954–64. science, policy, and action. Lancet 2011;378(9793):
FAO/WHO 2014 838–47. [0140–6736]
Food and Agriculture Organization of the United Nations. Green 2008
World Health Organization. Second International Green S, Higgins JPT. Preparing a Cochrane review. In:
Conference on Nutrition. Conference outcome document: Higgins JPT, Green S editor(s). Cochrane Handbook for
Rome Declaration on Nutrition. http://www.fao.org/3/a- Systematic Reviews of Interventions. West Sussex: John Wiley
ml542e.pdf (accessed 1 October 2015). & Sons Ltd, 2008:11–30.
Fernandes 2008 Greenwood 2014
Fernandes MM. The effect of soft drink availability in Greenwood DC, Threapleton DE, Evans CE, Cleghorn
elementary schools on consumption. Journal of the Academy CL, Nykjaer C, Woodhead C, et al. Association between
of Nutrition and Dietetics 2008;108(9):1445–52. sugar-sweetened and artificially sweetened soft drinks and
Fitch 2012 type 2 diabetes: systematic review and dose-response meta-
Fitch C, Keim KS. Position of the Academy of Nutrition analysis of prospective studies. British Journal of Nutrition
and Dietetics: use of nutritive and nonnutritive sweeteners. 2014;112(5):725–34.
Journal of the Academy of Nutrition and Dietetics 2012;112 Guyatt 2008
(5):739–58. Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter Y,
Flood 2006 Alonso-Coello P, et al. GRADE: an emerging consensus on
Flood JE, Roe LS, Rolls BJ. The effect of increased beverage rating quality of evidence and strength of recommendations.
portion size on energy intake at a meal. Journal of the BMJ 2008;336(7650):924–6.
American Dietetic Association 2006;106(12):1984-90;
Hanks 2014
discussion 1990-1. [0002–8223: (Print)]
Hanks AS, Just DR, Wansink B. Chocolate milk
Fowler 2008 consequences: a pilot study evaluating the consequences
Fowler SP, Williams K, Resendez RG, Hunt KJ, Hazuda of banning chocolate milk in school cafeterias. PLoS One
HP, Stern MP. Fueling the obesity epidemic? Artificially 2014;9(4):e91022.
sweetened beverage use and long-term weight gain. Obesity
(Silver Spring) 2008;16(8):1894–900. Hartstein 2008
Hartstein J, Cullen KW, Reynolds KD, Harrell J, Resnicow
French 2003
K, Kennel P. Impact of portion-size control for school a
French SA, Lin BH, Guthrie JF. National trends in soft
la carte items: changes in kilocalories and macronutrients
drink consumption among children and adolescents age 6
purchased by middle school students. Journal of the
to 17 years: prevalence, amounts, and sources, 1977/1978
American Dietetic Association 2008;108(1):140–4.
to 1994/1998. Journal of the American Dietetic Association
2003;103(10):1326–31. Hauner 2012
Hauner H, Bechthold A, Boeing H, Brönstrup A, Buyken
Fung 2013
A, Leschik-Bonnet E, et al. Evidence-based guideline of
Fung C, McIsaac JL, Kuhle S, Kirk SF, Veugelers PJ. The
the German Nutrition Society: carbohydrate intake and
impact of a population-level school food and nutrition
prevention of nutrition-related diseases. Annals of Nutrition
policy on dietary intake and body weights of Canadian
and Metabolism 2012;60 (Suppl 1):1–58.
children. Preventive Medicine 2013;57(6):934–40.
Galbraith-Emami 2013 Hennessy 2015
Galbraith-Emami S, Lobstein T. The impact of initiatives Hennessy M, Bleakley A, Piotrowski JT, Mallya G, Jordan
to limit the advertising of food and beverage products to A. Sugar-sweetened beverage consumption by adult
children: a systematic review. Obesity Reviews 2013;14(12): caregivers and their children: the role of drink features and
960–74. advertising exposure. Health Education & Behavior 2015;42
Giles 2012 (5):677–86.
Giles CM, Kenney EL, Gortmaker SL, Lee RM, Thayer JC, Hersey 2013
Mont-Ferguson H, et al. Increasing water availability during Hersey JC, Wohlgenant KC, Arsenault JE, Kosa KM, Muth
afterschool snack: evidence, strategies, and partnerships MK. Effects of front-of-package and shelf nutrition labeling
from a group randomized trial. American Journal of systems on consumers. Nutrition Reviews 2013;71(1):1–14.
Preventive Medicine 2012;43(3, Supplement 2):S136–42. Higgins 2008a
Gillman 2000 Higgins JPT, Altman DG, Sterne JA, on behalf of the
Gillman MW, Rifas-Shiman SL, Frazier AL, Rockett HR, Cochrane Statistical Methods Group and the Cochrane Bias
Camargo CA, Jr, et al. Family dinner and diet quality Methods Group. Assessing risk of bias in included studies.
In: Higgins JPT, Green S editor(s). Cochrane Handbook for Johnson 2002
Systematic Reviews of Interventions. West Sussex: John Wiley Johnson RK, Frary C, Wang MQ. The nutritional
& Sons Ltd, 2008:187–242. consequences of flavored-milk consumption by school-aged
Higgins 2008b children and adolescents in the United States. Journal of the
Higgins JPT, Deeks JJ, Altman DG on behalf of the American Dietetic Association 2002;102(6):853–6.
Cochrane Statistical Methods Group. Special topics in Johnson 2009
statistics. In: Higgins JPT, Green S editor(s). The Cochrane Johnson RK, Appel LJ, Brands M, Howard BV, Lefevre M,
Handbook for Systematic Reviews of Interventions. West Lustig RH, et al. Dietary sugars intake and cardiovascular
Sussex: John Wiley & Sons Ltd., 2008:481–530. health: a scientific statement from the American Heart
Association. Circulation 2009;120(11):1011–20.
Hoffmann 2014
Hoffmann TC, Glasziou PP, Boutron I, Milne R, Perera R, Jones 2014
Moher D, et al. Better reporting of interventions: template Jones NR, Conklin AI, Suhrcke M, Monsivais P. The
for intervention description and replication (TIDieR) growing price gap between more and less healthy foods:
checklist and guide. BMJ 2014;348:g1687. analysis of a novel longitudinal UK dataset. PLoS One
2014;9(10):e109343. [1932–6203: (Electronic)]
Hsiao 2013 Keast 2015
Hsiao A, Wang YC. Reducing sugar-sweetened beverage Keast RS, Swinburn BA, Sayompark D, Whitelock S,
consumption: evidence, policies, and economics. Current Riddell LJ. Caffeine increases sugar-sweetened beverage
Obesity Reports 2013;2(3):191–9. consumption in a free-living population: a randomised
Hu 2013 controlled trial. British Journal of Nutrition 2015;113(2):
Hu FB. Resolved: there is sufficient scientific evidence 366–71.
that decreasing sugar-sweetened beverage consumption will Kenney 2015
reduce the prevalence of obesity and obesity-related diseases. Kenney EL, Long MW, Cradock AL, Gortmaker SL.
Obesity Reviews 2013;14(8):606–19. Prevalence of inadequate hydration among US children and
disparities by gender and race/ethnicity: National Health
Huang 2014
and Nutrition Examination Survey, 2009-2012. American
Huang C, Huang J, Tian Y, Yang X, Gu D. Sugar sweetened
Journal of Public Health 2015;105(8):e113–8.
beverages consumption and risk of coronary heart disease: a
meta-analysis of prospective studies. Atherosclerosis 2014; Ker 2010
234(1):11–6. Ker K, Edwards PJ, Felix LM, Blackhall K, Roberts I.
Caffeine for the prevention of injuries and errors in shift
Hunter 2013
workers. Cochrane Database of Systematic Reviews 2010,
Hunter DJ, Reddy KS. Noncommunicable diseases. New
Issue 5. [DOI: 10.1002/14651858.CD008508]
England Journal of Medicine 2013;369(14):1336–43.
Kit 2013
IHME 2015 Kit BK, Fakhouri TH, Park S, Nielsen SJ, Ogden CL.
Institute for Health Metrics and Evaluation. GBD Trends in sugar-sweetened beverage consumption among
Compare. www.healthdata.org/data-visualization/gbd- youth and adults in the United States: 1999-2010.
compare. I, (accessed 15 May 2015). American Journal of Clinical Nutrition 2013;98(1):180–8.
Imamura 2015 Köpke 2015
Imamura F, O’Connor L, Ye Z, Mursu J, Hayashino Y, Köpke S, McCleery J. Systematic reviews of case
Bhupathiraju SN, et al. Consumption of sugar sweetened management: Too complex to manage?. Cochrane Database
beverages, artificially sweetened beverages, and fruit juice of Systematic Reviews 2015;1:ED000096. [DOI: 10.1002/
and incidence of type 2 diabetes: systematic review, meta- 14651858.ED000096]
analysis, and estimation of population attributable fraction. Lana 2014
BMJ 2015;351:h3576. Lana A, Rodriguez-Artalejo F, Lopez-Garcia E.
INFORMAS 2015 Consumption of sugar-sweetened beverages is positively
University of Auckland. International Network for Food related to insulin resistance and higher plasma leptin
and Obesity / non-communicable diseases Research, concentrations in men and nonoverweight women. Journal
Monitoring and Action Support (INFORMAS). https:// of Nutrition 2014;144(7):1099–105.
www.fmhs.auckland.ac.nz/en/soph/global-health/projects/ Lana 2015
informas.html (accessed 1 October 2015). Lana A, Lopez-Garcia E, Rodriguez-Artalejo F.
Jayalath 2015 Consumption of soft drinks and health-related quality of
Jayalath VH, de Souza RJ, Ha V, Mirrahimi A, Blanco- life in the adult population. European Journal of Clinical
Mejia S, Di Buono M, et al. Sugar-sweetened beverage Nutrition 2015;69(11):1226–32.
consumption and incident hypertension: a systematic Laurence 2007
review and meta-analysis of prospective cohorts. American Laurence S, Peterken R, Burns C. Fresh Kids: the efficacy
Journal of Clinical Nutrition 2015;102(4):914–21. of a Health Promoting Schools approach to increasing
consumption of fruit and water in Australia. Health Malik 2015
Promotion International 2007;22(3):218–26. Malik VS, Hu FB. Fructose and cardiometabolic health:
what the evidence from sugar-sweetened beverages tells us.
Levy 2011
Levy DT, Friend KB, Wang YC. A review of the literature Journal of the American College of Cardiology 2015;66(14):
1615–24.
on policies directed at the youth consumption of sugar
sweetened beverages. Advances in Nutrition 2011;2(2): Massougbodji 2014
182S–200S. Massougbodji J, Le Bodo Y, Fratu R, De Wals P. Reviews
Liira 2014 examining sugar-sweetened beverages and body weight:
Liira J, Verbeek JH, Costa G, Driscoll TR, Sallinen correlates of their quality and conclusions. American Journal
M, Isotalo LK, et al. Pharmacological interventions for of Clinical Nutrition 2014;99(5):1096–104.
sleepiness and sleep disturbances caused by shift work. Mazarello Paes 2015
Cochrane Database of Systematic Reviews 2014, Issue 8. Mazarello Paes V, Hesketh K, O’Malley C, Moore H,
[DOI: 10.1002/14651858.CD009776] Summerbell C, Griffin S, et al. Determinants of sugar-
Lim 2012 sweetened beverage consumption in young children: a
Lim SS, Vos T, Flaxman AD, Danaei G, Shibuya K, Adair- systematic review. Obesity Reviews 2015;16(11):903-913.
Rohani H, et al. A comparative risk assessment of burden Mello 2008
of disease and injury attributable to 67 risk factors and Mello MM, Pomeranz J, Moran P. The interplay of public
risk factor clusters in 21 regions, 1990-2010: a systematic health law and industry self-regulation: the case of sugar-
analysis for the Global Burden of Disease Study 2010. sweetened beverage sales in schools. American Journal of
Lancet 2012;380(9859):2224–60. Public Health 2008;98(4):595–604.
Ludwig 2002 Miller 2014
Ludwig DS. The glycemic index: physiological mechanisms Miller PE, Perez V. Low-calorie sweeteners and body weight
relating to obesity, diabetes, and cardiovascular disease. and composition: a meta-analysis of randomized controlled
JAMA 2002;287(18):2414–23. trials and prospective cohort studies. American Journal of
MacLean 2009 Clinical Nutrition 2014;100(3):765–77.
MacLean L, Edwards N, Garrard M, Sims-Jones N, Clinton Moise 2011
K, Ashley L. Obesity, stigma and public health planning. Moise N, Cifuentes E, Orozco E, Willett W. Limiting the
Health Promotion International 2009;24(1):88–93. consumption of sugar sweetened beverages in Mexico’s
Maersk 2012 obesogenic environment: a qualitative policy review and
Maersk M, Belza A, Holst JJ, Fenger-Gron M, Pedersen SB, stakeholder analysis. Journal of Public Health Policy 2011;32
Astrup A, et al. Satiety scores and satiety hormone response (4):458–75.
after sucrose-sweetened soft drink compared with isocaloric Moodley 2015
semi-skimmed milk and with non-caloric soft drink: a Moodley G, Christofides N, Norris SA, Achia T, Hofman
controlled trial. European Journal of Clinical Nutrition. KJ. Obesogenic environments: access to and advertising of
2012/01/19 2012; Vol. 66, issue 4:523–9. sugar-sweetened beverages in Soweto, South Africa, 2013.
Malik 2010 Preventing Chronic Disease 2015;12:E186. [1545–1151:
Malik VS, Popkin BM, Bray GA, Despres JP, Hu FB. Sugar- (Electronic)]
sweetened beverages, obesity, type 2 diabetes mellitus, and Muckelbauer 2009
cardiovascular disease risk. Circulation 2010;121(11): Muckelbauer R, Libuda L, Clausen K, Toschke AM, Reinehr
1356–64. T, Kersting M. Promotion and provision of drinking
Malik 2010a water in schools for overweight prevention: randomized,
Malik VS, Popkin BM, Bray GA, Despres JP, Willett WC, controlled cluster trial. Pediatrics 2009;123(4):e661–7.
Hu FB. Sugar-sweetened beverages and risk of metabolic Muckelbauer 2013
syndrome and type 2 diabetes: a meta-analysis. Diabetes Muckelbauer R, Sarganas G, Gruneis A, Muller-Nordhorn
Care 2010;33(11):2477–83. J. Association between water consumption and body weight
Malik 2013 outcomes: a systematic review. American Journal of Clinical
Malik VS, Pan A, Willett WC, Hu FB. Sugar-sweetened Nutrition 2013;98(2):282–99.
beverages and weight gain in children and adults: a Negoianu 2008
systematic review and meta-analysis. American Journal of Negoianu D, Goldfarb S. Just add water. Journal of the
Clinical Nutrition 2013;98(4):1084–102. American Society of Nephrology. 2008/04/04 2008; Vol.
Malik 2014 19, issue 6:1041–3.
Malik AH, Akram Y, Shetty S, Malik SS, Yanchou Njike Nestle 2015
V. Impact of sugar-sweetened beverages on blood pressure. Nestle M. Sodas. Soda Politics. Oxford: Oxford University
American Journal of Cardiology 2014;113(9):1574–80. Press, 2015:11–22.
Nielsen 2004 Pfadenhauer 2016
Nielsen SJ, Popkin BM. Changes in beverage intake between Pfadenhauer L, Rohwer A, Burns J, Booth A, Lysdahl KB,
1977 and 2001. American Journal of Preventive Medicine Hofmann B, et al. Guidance for the assessment of context
2004;27(3):205–10. and implementation in Health Technology Assessments
O’Neill 2014 (HTA) and systematic reviews of complex interventions:
O’Neill J, Tabish H, Welch V, Petticrew M, Pottie K, Clarke the Context and Implementation of Complex Interventions
M, et al. Applying an equity lens to interventions: using (CICI) framework. www.integrate-hta.eu/downloads/
PROGRESS ensures consideration of socially stratifying 2016.
factors to illuminate inequities in health. Journal of Clinical Pomeranz 2012
Epidemiology 2014;67(1):56–64. Pomeranz JL. Advanced policy options to regulate sugar-
sweetened beverages to support public health. Journal of
Ogden 2011 Public Health Policy 2012;33(1):75–88.
Ogden CL, Kit BK, Carroll MD, Park S. Consumption of
Poppitt 2015
sugar drinks in the United States, 2005-2008. National
Poppitt SD. Beverage consumption: are alcoholic and
Center for Health Statistics Data Brief. Hyattsville, MD:
sugary drinks tipping the balance towards overweight and
National Center for Health Statistics, No. 71, August 2011.
obesity?. Nutrients 2015;7(8):6700–18.
Ogilvie 2008 Powell 2014
Ogilvie D, Fayter D, Petticrew M, Sowden A, Thomas Powell LM, Wada R, Persky JJ, Chaloupka FJ. Employment
S, Whitehead M, et al. The harvest plot: A method for impact of sugar-sweetened beverage taxes. American Journal
synthesising evidence about the differential effects of of Public Health 2014;104(4):672–7.
interventions. BMC Medical Research Methodology 2008;8
(1):8. PROSPERO 2014a
Abdel-Rahman A, Adair P, Pine C, Jomaa L, Elliott M.
Oldroyd 2008 Effectiveness of behavioral interventions to reduce the
Oldroyd J, Burns C, Lucas P, Haikerwal A, Waters E. The intake of sugar sweetened beverages among children and
effectiveness of nutrition interventions on dietary outcomes adolescents: a systematic review. International prospective
by relative social disadvantage: a systematic review. Journal register of systematic reviews 2014:CRD42014004432.
of Epidemiology & Community Health 2008;62(7):573–9. http://www.crd.york.ac.uk/prospero/display˙record.asp?
Onufrak 2014 ID=CRD42014004432 (accessed 1 October 2015).
Onufrak SJ, Park S, Sharkey JR, Sherry B. The relationship PROSPERO 2014b
of perceptions of tap water safety with intake of sugar- Vargas Garcia E, Evans C, Cade J. Impact of interventions
sweetened beverages and plain water among US adults. to reduce sugar-sweetened beverage intake or increase water
Public Health Nutrition 2014;17(1):179–85. intake in children and adults: a systematic review and meta-
Park 2014 analysis. International prospective register of systematic
Park S, Onufrak S, Sherry B, Blanck HM. The relationship reviews PROSPERO 2014:CRD42014013436. http://
between health-related knowledge and sugar-sweetened www.crd.york.ac.uk/PROSPERO/display˙record.asp?ID=
beverage intake among US adults. Journal of the Academy of CRD42014013436 (accessed 1 October 2015).
Nutrition and Dietetics 2014;114(7):1059–66. Public Health England 2015
Public Health England. Sugar reduction. The
Park 2015
evidence for action. https://www.gov.uk/government/
Park S, Lin M, Onufrak S, Li R. Association of sugar-
uploads/system/uploads/attachment˙data/file/470179/
sweetened beverage intake during infancy with dental caries
Sugar˙reduction˙The˙evidence˙for˙action.pdf (accessed 1
in 6-year-olds. Clinical Nutrition Research 2015;4(1):9–17.
November 2015).
Park 2015a Quann 2013
Park S, Li R, Birch L. Mothers’ child-feeding practices are Quann EE, Adams D. Impact on milk consumption
associated with children’s sugar-sweetened beverage intake. and nutrient intakes from eliminating flavored milk in
Journal of Nutrition 2015;145(4):806–12. elementary schools. Nutrition Today 2013;48(3):127–34.
Patel 2010 Raben 2011
Patel AI, Cabana MD. Encouraging healthy beverage intake Raben A, Moller BK, Flint A, Vasilaris TH, Christina Moller
in child care and school settings. Current Opinion in A, Juul Holst J, et al. Increased postprandial glycaemia,
Pediatrics 2010;22(6):779–84. insulinemia, and lipidemia after 10 weeks’ sucrose-rich diet
Pfadenhauer 2015 compared to an artificially sweetened diet: a randomised
Pfadenhauer LM, Mozygemba K, Gerhardus A, Hofmann controlled trial. Food & Nutrition Research 2011;55:1.
B, Booth A, Lysdahl KB, et al. Context and implementation: Ramos Salas 2015
A concept analysis towards conceptual maturity. Zeitschrift Ramos Salas X. The ineffectiveness and unintended
für Evidenz, Fortbildung und Qualität im Gesundheitswesen consequences of the public health war on obesity. Canadian
2015;109(2):103–14. Journal of Public Health 2015;106(2):e79–81.
Rathbone 2015 Stern 2014
Rathbone J, Hoffmann T, Glasziou P. Faster title and Stern D, Piernas C, Barquera S, Rivera JA, Popkin BM.
abstract screening? Evaluating Abstrackr, a semi-automated Caloric beverages were major sources of energy among
online screening program for systematic reviewers. children and adults in Mexico, 1999-2012. Journal of
Systematic Reviews 2015;4:80. Nutrition 2014;144(6):949–56.
Rayner 2013 Sterne 2008
Rayner M, Wood A, Lawrence M, Mhurchu CN, Albert J, Jonathan AC Sterne, Matthias Egger and David Moher on
Barquera S, et al. Monitoring the health-related labelling of behalf of the Cochrane Bias Methods Group. Addressing
foods and non-alcoholic beverages in retail settings. Obesity reporting biases. In: Higgins JPT, Green S editor(s).
Reviews 2013;14(S1):70–81. [1467–789X] Cochrane Handbook for Systematic Reviews of Interventions.
Reeves 2008 West Sussex: John Wiley & Sons Ltd, 2008.
Reeves BC, Deeks JJ, Higgins JP, Wells GA, on behalf of Stice 2013
the Cochrane Non-Randomised Studies Methods Group. Stice E, Burger KS, Yokum S. Relative ability of fat and
Including non-randomized studies. In: Higgins JPT, Green sugar tastes to activate reward, gustatory, and somatosensory
S editor(s). Cochrane Handbook for Systematic Reviews of regions. American Journal of Clinical Nutrition 2013;98(6):
Interventions. West Sussex: John Wiley & Sons Ltd, 2008: 1377–84. [1938–3207: (Electronic)]
391–432. Sturm 2015
Roberto 2015 Sturm R, Hattori A. Diet and obesity in Los Angeles County
Roberto CA, Swinburn B, Hawkes C, Huang TTK, Costa 2007-2012: is there a measurable effect of the 2008 “Fast-
SA, Ashe M, et al. Patchy progress on obesity prevention: Food Ban”?. Social Science & Medicine 2015;133:205–11.
emerging examples, entrenched barriers, and new thinking. Swartz 2011
Lancet 2015;385(9985):2400–9. Swartz JJ, Braxton D, Viera AJ. Calorie menu labeling on
Sacks 2009 quick-service restaurant menus: an updated systematic
Sacks G, Swinburn B, Lawrence M. Obesity Policy Action review of the literature. International Journal of Behavioral
framework and analysis grids for a comprehensive policy Nutrition and Physical Activity 2011;8:135.
approach to reducing obesity. Obesity Reviews 2009;10(1): Swinburn 1999
76–86. [1467–789X: (Electronic)] Swinburn B, Egger G, Raza F. Dissecting obesogenic
Schünemann 2008 environments: the development and application of a
Schünemann HJ, Oxman AD, Higgins JP, Vist GE, framework for identifying and prioritizing environmental
Glasziou P, Guyatt GH, on behalf of the Cochrane interventions for obesity. Preventive Medicine 1999;29(6 Pt
Applicability and Recommendations Methods Group and 1):563–70.
the Cochrane Statistical Methods Group. Presenting results Swinburn 2011
and ‘Summary of findings’ tables. In: Higgins JPT, Green Swinburn BA, Sacks G, Hall KD, McPherson K, Finegood
S editor(s). Cochrane Handbook for Systematic Reviews of DT, Moodie ML, et al. The global obesity pandemic:
Interventions. West Sussex: John Wiley & Sons Ltd, 2008: shaped by global drivers and local environments. Lancet
335–58. 2011;378(9793):804–14.
Seymour 2004 Tipton 2015
Seymour JD, Lazarus Yaroch A, Serdula M, Blanck HM, Tipton JA. Reducing sugar-sweetened beverage intake
Khan LK. Impact of nutrition environmental interventions among students: school-based programs and policies that
on point-of-purchase behavior in adults: a review. Preventive work. NASN School Nurse 2015;31(2):102–10.
Medicine 2004;39(S2):S108–36. Tugendhaft 2015
Sichieri 2009 Tugendhaft A, Manyema M, Veerman LJ, Chola L,
Sichieri R, Paula Trotte A, de Souza RA, Veiga GV. School Labadarios D, Hofman KJ. Cost of inaction on sugar-
randomised trial on prevention of excessive weight gain by sweetened beverage consumption: implications for obesity
discouraging students from drinking sodas. Public Health in South Africa. Public Health Nutrition Published online
Nutrition 2009;12(02):197–202. 22 October 2015, doi:10.1017/S1368980015003006;
Singh 2015 Epub ahead of print:1–9. [DOI: http://dx.doi.org/
Singh GM, Micha R, Khatibzadeh S, Shi P, Lim S, Andrews 10.1017/S1368980015003006]
KG, et al. Global, regional, and national consumption Tugwell 2010
of sugar-sweetened beverages, fruit juices, and milk: a Tugwell P, Petticrew M, Kristjansson E, Welch V, Ueffing
systematic assessment of beverage intake in 187 countries. E, Waters E, et al. Assessing equity in systematic reviews:
PLoS One 2015;10(8):e0124845. realising the recommendations of the Commission on Social
Steenhuis 2009 Determinants of Health. BMJ 2010;341:c4739.
Steenhuis I, Vermeer W. Portion size: review and framework USDA 2015
for interventions. International Journal of Behavioral U.S. Department of Health and Human Services, U.S.
Nutrition and Physical Activity 2009;6(1):58. Department of Agriculture. Scientific Report of the 2015
Dietary Guidelines Advisory Committee. http://health.gov/ behavior: a review of randomized, controlled trials.
dietaryguidelines/2015-scientific-report/. Washington, Nutrition Reviews 2006;64(12):518–31.
D.C.: U.S. Department of Health and Human Services, Wang 2015
U.S. Department of Agriculture. Wang M, Yu M, Fang L, Hu RY. Association between sugar-
USDA 2015a sweetened beverages and type 2 diabetes: A meta-analysis.
U.S. Department of Health and Human Services and U.S. Journal of Diabetes Investigation 2015;6(3):360–6.
Department of Agriculture. 2015 - 2020 Dietary Guidelines Warren 2009
for Americans. http://health.gov/dietaryguidelines/2015/ Warren JJ, Weber-Gasparoni K, Marshall TA, Drake DR,
. 8. Washington D.C.: U.S. Department of Health and Dehkordi-Vakil F, Dawson DV, et al. A longitudinal study
Human Services and U.S. Department of Agriculture, of dental caries risk among very young low SES children.
(accessed 1 June 2016). Community Dentistry and Oral Epidemiology 2009;37(2):
van de Gaar 2014 116–22.
van de Gaar V, Jansen W, van Grieken A, Borsboom G, WCRFI 2015
Kremers S, Raat H. Effects of an intervention aimed at World Cancer Research Fund International.
reducing the intake of sugar-sweetened beverages in primary NOURISHING framework. www.wcrf.org/int/policy/
school children: a controlled trial. International Journal of nourishing-framework (accessed 1 October 2015).
Behavioral Nutrition and Physical Activity 2014;11(1):98. WHO 2013
World Health Organization. Global Action Plan for the
Van Walleghen 2007
Prevention and Control of Noncommunicable Diseases.
Van Walleghen EL, Orr JS, Gentile CL, Davy BM. Pre-meal
www.who.int/nmh/events/ncd˙action˙plan/en/. WHO,
water consumption reduces meal energy intake in older but
(accessed 1 October 2015).
not younger subjects. Obesity (Silver Spring) 2007;15(1):
93–9. WHO 2015
World Health Organization. Sugars intake for adults and
Vargas-Garcia 2015
children. www.who.int/nutrition/publications/guidelines/
Vargas-Garcia EJ, El Evans C, Cade JE. Impact of
sugars˙intake/en/. World Health Organization, (accessd 1
interventions to reduce sugar-sweetened beverage intake in
November 2015).
children and adults: a protocol for a systematic review and
meta-analysis. Systematic Reviews 2015;4(1):17. WHO-EURO 2014
World Health Organization Regional Office for Europe.
Vartanian 2007 European Food and Nutrition Action Plan 2015-2020.
Vartanian LR, Schwartz MB, Brownell KD. Effects of soft http://www.euro.who.int/˙˙data/assets/pdf˙file/0008/
drink consumption on nutrition and health: a systematic 253727/64wd14e˙FoodNutAP˙140426.pdf. Copenhagen:
review and meta-analysis. American Journal of Public Health WHO, (accessed 1 November 2015).
2007;97(4):667–75.
Wiecha 2006
Vereecken 2009 Wiecha JL, Finkelstein D, Troped PJ, Fragala M, Peterson
Vereecken C, Legiest E, De Bourdeaudhuij I, Maes L. KE. School vending machine use and fast-food restaurant
Associations between general parenting styles and specific use are associated with sugar-sweetened beverage intake in
food-related parenting practices and children’s food youth. Journal of the American Dietetic Association 2006;106
consumption. American Journal of Health Promotion 2009; (10):1624–30.
23(4):233–40.
Wolf 2008
Verloigne 2012 Wolf A, Bray GA, Popkin BM. A short history of beverages
Verloigne M, Van Lippevelde W, Maes L, Brug J, De and how our body treats them. Obesity Reviews 2008;9(2):
Bourdeaudhuij I. Family- and school-based correlates 151–64.
of energy balance-related behaviours in 10-12-year-old Woodward-Lopez 2010
children: a systematic review within the ENERGY Woodward-Lopez G, Gosliner W, Samuels SE, Craypo L,
(EuropeaN Energy balance Research to prevent excessive Kao J, Crawford PB. Lessons learned from evaluations of
weight Gain among Youth) project. Public Health Nutrition California’s statewide school nutrition standards. American
2012;15(8):1380–95. Journal of Public Health 2010;100(11):2137–45.
Visscher 2010 Xi 2015
Visscher TL, van Hal WC, Blokdijk L, Seidell JC, Renders Xi B, Huang Y, Reilly KH, Li S, Zheng R, Barrio-Lopez MT,
CM, Bemelmans WJ. Feasibility and impact of placing et al. Sugar-sweetened beverages and risk of hypertension
water coolers on sales of sugar-sweetened beverages in Dutch and CVD: a dose-response meta-analysis. British Journal of
secondary school canteens. Obesity Facts 2010;3(2):109–15. Nutrition 2015;113(5):709–17.
Wall 2006 Zhang 2010
Wall J, Mhurchu CN, Blakely T, Rodgers A, Wilton J. Zhang X, Albanes D, Beeson WL, van den Brandt PA,
Effectiveness of monetary incentives in modifying dietary Buring JE, Flood A, et al. Risk of colon cancer and coffee,
tea, and sugar-sweetened soft drink intake: pooled analysis
of prospective cohort studies. Journal of the National Cancer
Institute 2010;102(11):771–83.
Zheng 2015
Zheng M, Allman-Farinelli M, Heitmann BL, Rangan
A. Substitution of sugar-sweetened beverages with other
beverage alternatives: a review of long-term health
outcomes. Journal of the Academy of Nutrition and Dietetics
2015;115(5):767–79.
∗
Indicates the major publication for the study
APPENDICES
Appendix 1. Review Advisory Group

A Review Advisory Group (RAG) was formed, as recommended by Cochrane policies (Green 2008, Cochrane 2011). RAG members
are policy advisors, researchers, and civil society representatives with extensive and diverse experience in a number of relevant fields.
The protocol draft was sent to all RAG members, who provided feedback to ensure the review will meet its intended goal of assessing
the effectiveness of sugar-sweetened beverage (SSB) interventions in a systematic and comprehensive way and that the review will
appropriately inform policy. The members of our RAG are listed in table 4.
Table 4: Members of the Review Advisory Group
Government and International Organizations
Dr. María Eugenia Bonilla-Chacín World Bank, Health, Nutrition and Population Global Practice
Mr. Artur Furtado European Commission, Directorate General for Health and Food Safety, Di-
rectorate for Public Health, Health Determinants Unit
Dr. Cintia Lombardi Pan American Health Organization/World Health Organization Regional Of-
fice for the Americas, Department of Noncommunicable Diseases and Mental
Health
Dr. Sohyun Park US Centers for Disease Control and Prevention, Division of Nutrition, Phys-
ical Activity, and Obesity
Dr. Ludovic Reveiz Pan American Health Organization/World Health Organization Regional Of-
fice for the Americas, Department of Knowledge Translation and Evidence
Knowledge Management, Bioethics and Research Office
Academia
Prof. Karen Hofman South Africa Medical Research Council Wits/Agincourt unit, PRICELESS SA,
University of Witwatersrand School of Public Health, Johannesburg, South
Africa
(Continued)
Prof. Mark Lawrence Deakin University, School of Exercise and Nutrition Sciences, Burwood, Aus-
tralia
Dr. Rebecca Muckelbauer Charité - Universitätsmedizin Berlin, Institute for Public Health, Berlin, Ger-
many
Prof. Marc Suhrcke University of York, Centre for Health Economics, United Kingdom
Civil society
Ms. Modi Mwatsama UK Health Forum, London, United Kingdom
Appendix 2. List of abbreviations
Table 5: List of Abbreviations
BMI Body mass index
CBA Controlled before-after study
CDC U.S. Centers for Disease Control and Prevention
CI Certainty interval
CICI Context and Implementation of Complex Interventions
CONSORT Consolidated Standards Of Reporting Trials
EPOC Cochrane Effective Practice and Organization of Care
EQUATOR Enhancing the Quality and Transparency of Health Research
GI Glycaemic index
GL Glycaemic load
GRADE Grading of Recommendations Assessment, Development and Evaluation
ITS Interrupted-time-series study
NNS Non-nutritive sweetener
NRCT Non-randomised controlled trial
(Continued)
RCT Randomised controlled trial
RMS Repeated measures study
RR Risk ratio
SES Socio-economic status
SSB Sugar-sweetened beverage
TIDieR Template for Intervention Description and Replication
UBA Uncontrolled before-after study
USDA U.S. Department of Agriculture
WHO World Health Organization
Appendix 3. Glossary of key terms
Table 6: Glossary of Key Terms
Term Definition
Sugar-sweetened beverages (SSB) For the purpose of this review, SSB are defined as non-alcoholic,
non-dairy beverages with added caloric sweeteners. This defini-
tion includes, but is not limited to, carbonated and/or caffeinated
soft drinks (sodas), fruit juices with less than 100% fruit con-
tent and added sugar, sugar-sweetened energy and sports drinks,
sugar-sweetened vitamin waters and flavoured waters, and sugar-
sweetened coffee and tea. This includes both ready-to-use SSB
and SSB prepared from syrups, concentrates or powder. SSB may
contain non-nutritive sweeteners (NNS) in addition to caloric
sweeteners. Beverages containing coffee and added sugars that are
primarily milk-based, such as latte macchiato or cappuccino, are
not included in this definition, but will be considered within the
category of sugar-sweetened milk
Sugar-sweetened milk Milk and milk-based beverages with added caloric sweeteners.
NNS may or may not be present in addition to caloric sweeteners.
For the purpose of this review, and following the Scientific Report
of the 2015 U.S. Dietary Guidelines Advisory Committee as well
as the Dietary Guidelines for Americans 2015-2020, we consider
fortified soy beverages, but not almond or other plant-based “milk-
type” products as substitute for milk. This definition includes
(Continued)
beverages containing coffee and added sugars that are primarily

milk-based, such as latte macchiato or cappuccino, but excludes
coffee, tea or other beverages with trivial amounts of milk
Low-calorie alternatives to SSB Non-alcoholic beverages without added caloric sweeteners. These
may be beverages without any added sweeteners, or beverages
sweetened exclusively with NNS (see below)
Beverages without added sweeteners Any non-alcoholic beverage without any added sweeteners. This
includes drinking water, unsweetened tea and coffee, and low-fat
or fat-free unsweetened milk (including fortified soy beverages)
, among others. For the purpose of this review, full-fat milk and
100% fruit juice are not included, while beverages prepared by
adding 100% fruit juice to carbonated or uncarbonated water
without adding additional caloric sweeteners are included
Beverages sweetened exclusively with non-nutritive sweeteners Any non-alcoholic beverage exclusively sweetened with NNS.
This may include low-fat or fat-free milk sweetened exclusively
with NNS. Beverages containing both caloric sweeteners and NNS
will be considered as reformulated SSB
Reformulation In the context of SSB, reformulation generally involves the partial

substitution of caloric sweeteners with NNS, resulting in SSB
with a reduced energy content. As long as caloric sweeteners are
added in addition to NNS, the beverage will be considered a SSB.
Reformulation may also involve a reduction in the amount of
caloric sweetener without the addition of NNS, or other recipe
changes
Non-nutritive sweeteners (NNS) NNS, also referred to as low-calorie, low-energy or artificial sweet-
eners, are chemically diverse compounds with no or minimal
caloric content and a sweet taste of varying intensity
Appendix 4. The NOURISHING framework used for the classification of intervention areas
Adapted and reprinted with permission from the World Cancer Research Fund International (WCRFI 2015). In our scoping literature
search we searched for intervention studies reporting intervention effects on SSB consumption levels, excluding studies on taxation
and behavioural interventions without environmental components.
Table 7: The NOURISHING Framework
INTERVENTION AREA EXAMPLES FOR POTENTIAL IN- INTERVENTION STUDIES TARGET-

TERVENTIONS ING SSB OR LOW-CALORIE ALTER-
NATIVES TO SSB
FOOD ENVIRONMENT
(Continued)
Nutrition label standards and regula- e.g. Nutrient lists on food packages; clearly Energy-content labels at SSB vending ma-
tions on the use of claims and implied visible ‘interpretive’ and calorie labels; chines (Bergen 2006) and in neighbour-
claims on foods menu, shelf labels; rules on nutrient and hood stores (Bleich 2014).
health claims
Offer healthy foods and set standards in e.g. Fruit and vegetable programmes; stan- Interventions to improve the availability
public institutions and other specific set- dards in education, work, health facilities; and convenience of drinking water and
tings award schemes; choice architecture other low-calorie beverages in schools (
Giles 2012, Muckelbauer 2009, van de
Gaar 2014, Visscher 2010, Laurence 2007)
.
Interventions limiting access to SSB in in-
dividual schools (Blum 2008, Cullen 2006)
and at workplaces (Eneli 2014), includ-
ing restrictions to sugar-sweetened milk
(Hanks 2014, Quann 2013).
National and sub-national school nutrition
policies limiting access to SSB, and im-
proving access to low-calorie alternatives to
SSB (Woodward-Lopez 2010, Fung 2013,
Cullen 2008, Cradock 2011, Bae 2012).
Industry self-regulation limiting sales of
SSB at schools (American Beverage
Association 2010).
Use economic tools e.g. Targeted subsidies; price promotions Price changes to SSB and alternatives to
to address food affordability and pur- at point of sale; unit pricing; health-related SSB in work site cafeterias (Block 2010).
chase incentives food taxes Taxation of SSB (not covered by this re-
view, for an existing systematic review see
Cabrera Escobar 2013).
Restrict food advertising and other e.g. Restrict advertising to children that No intervention studies reporting effects
forms of commercial promotion promotes unhealthy diets in all forms of on SSB consumption identified in our
media; sales promotions; packaging; spon- scoping literature search. For a review of in-
sorship tervention effects on advertisement expo-
sure see (Galbraith-Emami 2013).
Improve the nutritional quality of the e.g. Reformulation to reduce salt and fats; Unit size changes to SSB and low-calorie
whole food supply elimination of transfats; reduce energy den- alternatives to SSB implemented at school
sity of processed foods; portion size limits cafeterias (Hartstein 2008).
Interventions altering the caffeine content
of SSB (Keast 2015).
Set incentives and rules to create a e.g. Incentives for shops to locate in under- Urban planning policies limiting new fast
healthy retail and food service environ- served areas; planning restrictions on food food restaurants serving SSB (Sturm 2015)
ment outlets; in-store promotions .
FOOD SYSTEM
(Continued)
Harness the food supply chain and ac- e.g. Supply-chain incentives for produc- No intervention studies identified in our
tions across sectors to ensure coherence tion; public procurement through ‘short’ scoping literature search
with health chains; health-in-all policies; governance
structures for multi-sectoral engagement
BEHAVIOUR CHANGE COMMUNICATION
Inform people about food and nutrition e.g. Education about food-based dietary Education and awareness-raising on the
through public awareness guidelines, mass media, social marketing; health effects of different beverage choices
community and public information cam- delivered at schools (Muckelbauer 2009,
paigns van de Gaar 2014, Fung 2013, Laurence
2007) and work sites (Block 2010).
Motivational posters at beverage vending
machines (Bergen 2006).
Nutrition advice and counselling in e.g. Nutrition advice for at-risk individu- No intervention studies identified in our
health care settings als; telephone advice and support; clinical scoping literature search
guidelines for health professionals on effec-
tive interventions for nutrition
Give nutrition education and skills e.g. Nutrition, cooking/food production Skills development activities at schools (
skills on education curricula; workplace Laurence 2007).
health schemes; health literacy programmes
Appendix 5. The EPOC algorithm used for the classification of study designs
Figure 7
Figure 7. Algorithm for the classification of study designs. Reproduced with permission from EPOC 2013a.
Appendix 6. Search strategy for MEDLINE, Embase and CENTRAL
Search Strategy for MEDLINE, Embase and CENTRAL
MEDLINE Search Strategy
The search syntax has been developed for use with the Ovid search interface. The numbers of results provided below are from a test
run conducted on March 13, 2016 in the database Ovid MEDLINE(R) 1946 to March Week 1 2016.
Beverage search set (containing terms related to SSB and low-calorie alternatives to SSB, as well as to nutritive and non-
nutritive sweeteners)
# Search terms Results
1 Carbonated Beverages/ 2165
2 Drinking Water/ 3876
3 Carbonated Water/ 32
4 Energy Drinks/ 348
5 (SSB or SSBs or sugar-sweetened beverage 122

or sugar-sweetened beverages or lemonade
or lemonades or softdrink or softdrinks).kf
6 (SSB or SSBs or cola or lemonade* or 39551

drinking water).ti,ab.
7 ((sugar or sugar-sweetened or sugarsweet- 10198

ened or sugary or carbonated or caffein* or
fizzy or diet* or cal or calorie or caloric or
energy or soft or sport* or sweet* or fruc-
tose* or sucrose* or corn syrup or HFCS)
adj2 (drink* or beverage* or soda or milk)
).ti,ab
8 ((tea or coffee or milk or dairy or water or 3923

soda) adj2 (flavour* or flavor* or ice* or
sugar* or sweet*)).ti,ab
9 (soda adj10 (consumption or intake or sales 486

or drink* or beverage* or sugar* or sweet*)
).ti,ab
10 ((water or soda) adj2 (fountain* or cooler* 2052

or dispenser* or chiller* or bottled or vend-
ing or filter*)).ti,ab
(Continued)
11 Dietary Sucrose/ 3285
12 exp Agents, sweetening/ and (beverage* or 4008

drink* or soda*).ti,ab
13 or/1-12 58862
Intervention search set (containing terms related to intervention types, intervention areas and study designs)
14 Nutrition Policy/ 7081
15 exp School Health Services/ 20048
16 exp Occupational Medicine/ 22990
17 Food Labeling/ 2665
18 Product labelling/ 1993
19 Consumer Health Information/ 2362
20 Health Literacy/ 2514
21 Portion Size/ 153
22 Serving Size/ 14
23 Food Dispensers, Automatic/ 271
24 exp Nutritive Value/ 11901
25 (intervention* or policy or policies or 1260410

prevention or preventive or school* or
lifestyle* or (community adj1 (project or
involvement))).ti,ab
26 (labelling or labeling or affordability or in- 180410

centive* or advertisment* or advertising or
marketing or (water adj2 (availability or
provision))).ti,ab
27 exp Clinical Studies/ 289622
(Continued)
28 (randomised controlled trial or controlled 623067

clinical trial or multicenter study or prag-
matic clinical trial).pt
29 (random* or RCT* or controlled trial* or 931693

controlled stud* or controlled design or in-
terrupted time series or “before and after”
or “before-and-after” or pretest posttest or
pretest-posttest).ti,ab
30 or/14-29 2634083
Outcome search set (containing terms related to intervention outcomes)
31 ((consumption or intake) adj2 (water or 9711

soda or lemonade or SSB or SSBs or sugar-
sweetened beverage*)).ti,ab
32 Drinking/ 12885
33 exp Overweight/ 162143
34 exp Body Weight Change/ 55481
35 Nutritional Status/ 33731
36 exp Energy Intake/ 38022
37 Food Preferences/ 10865
38 exp Diabetes Mellitus/ 342935
39 (weight* or bodyfat or obes* or overweight* 1638858

or adiposity or BMI or zBMI or body mass
index or skinfold thickness or diabetes or
prediabetes or hyperglyc?emia or glucose
tolerance or insulin resistance or HBA1c
or cardiovascular or hypertension or hy-
perlipidemia or dyslipidemia or hyperuric?
emia or caries or dental decay or dental ero-
sion or ((fat or fatness) adj1 (body or vis-
ceral or skin or abdominal))).ti,ab
(Continued)
40 or/31-39 1818089
Search set to exclude animal studies and non-eligible study designs
41 exp Animals/ not humans/ 4203554
42 exp Veterinary Medicine/ 22778
43 exp Animal Experimentation/ 7815
44 (editorial or case reports or in vitro).pt. 2139588
45 or/42-45 6319854
Joint search sets
46 13 and 30 and 40 5427
47 46 not 45 4244
Embase Search Strategy

The search syntax has been developed for use with the Ovid search interface. The numbers of results provided below are from a test
run conducted on March 13, 2016 in the database Ovid Embase 1974 to 2016 Week 11.
1 carbonated beverage/ 2551
2 carbonated water/ 52
3 drinking water/ 35466
4 energy drink/ 943
(Continued)
5 sports drink/ 450

or lemonades or softdrink or softdrinks).
kw


ened or sugary carbonated or caffein* or
).ti,ab


).ti,ab

12 ((corn syrup or nonutritive sweetener or 191

nutritive sweetener) and (beverage* or
drink* or soda*)).ti,ab
13 or/1-12 86540
14 portion size/ 1093
15 nutritional health/ 5287
16 nutrition education/ 3038
(Continued)
17 cariogenic diet/ 1045
18 glycemic load/ 1010
19 glycemic index/ 3537
20 exp school health service/ 19652
21 (intervention* or policy or policies or 1825232

prevention or preventive or school* or
lifestyle* or (community adj1 (project or
involvement))).ti,ab

centive* or advertisment* or advertising or
marketing or (water adj2 (availability or
provision))).ti,ab

24 or/14-23 3140331

26 drinking/ 18428
27 exp obesity/ 359492
28 weight gain/ 76493
29 weight change/ 8918
30 weight control/ 4607
31 weight reduction/ 121984
(Continued)
32 caloric intake/ 45324
33 food preference/ 10857
34 diabetes mellitus/ 433109
35 impaired glucose tolerance/ 21761

or adiposity or BMI or zBMI or body mass
index or skinfold thickness or diabetes or
prediabetes or hyperglyc?emia or insulin
resistance or glucose tolerance or HBA1c
or cardiovascular or hypertension or hy-
perlipidemia or dyslipidemia or hyperuric?
emia or caries or dental decay or dental ero-
sion or ((fat or fatness) adj1 (body or vis-
ceral or skin or abdominal))).ti,ab
37 or/25-36 2675008
Joint search sets
38 13 and 24 and 37 6792
Search set to exclude animal studies and non-eligible study designs
39 limit 38 to human 4756
40 limit 39 to (article or conference abstract 4249

or conference paper or report)
CENTRAL (Cochrane Central Register of Controlled Trials) Search Strategy

The search syntax has been developed for use with the Ovid search interface. It uses both the controlled vocabulary of MEDLINE (the
Medical Subject Headings, or MeSH terms) and the controlled vocabulary of EMBASE (the EMTREE thesaurus). The numbers of
results provided below are from a test run conducted on March 13, 2016.
1 Carbonated Beverages/ 127
2 Drinking Water/ 44
3 Carbonated Water/ 3
4 Energy Drinks/ 37

or lemonades or softdrink or softdrinks or
carbonated beverage or carbonated water
or drinking water or energy drink or sports
drink).kw


ened or sugary carbonated or caffein* or
).ti,ab


).ti,ab

11 Dietary Sucrose/ 247
12 exp Agents, sweetening/ and (beverage* or 421

drink* or soda*).ti,ab
13 or/1-12 2743
14 Nutrition Policy/ 228
15 exp School Health Services/ 1056
16 exp Occupational Medicine/ 63
17 Food Labeling/ 63
18 Product labelling/ 38
19 Consumer Health Information/ 86
20 Health Literacy/ 160
21 Portion Size/ 24
22 Serving Size/ 4
23 Food Dispensers, Automatic/ 6
24 exp Nutritive Value/ 762
25 (portion size or nutritional health or nu- 595

trition education or cariogenic diet or
glycemic load or glycemic index or school
health service).kw

centive* or advertisment* or advertising*
or marketing or (water adj2 (availability or
provision))).ti,ab

centive* or advertisment* or advertising* or
marketing).ti,ab
28 (randomised controlled trial or controlled 477749

clinical trial or multicenter study).pt

(Continued)
30 or/14-29 660229

32 Drinking/ 463
33 exp Overweight/ 8933
34 exp Body Weight Change/ 5343
35 Nutritional Status/ 1694
36 exp Energy Intake/ 4071
37 Food Preferences/ 567
38 exp Diabetes Mellitus/ 16322
39 (drinking or obesity or weight gain or 15922

weight change or weight control or weight
reduction or caloric intake or food prefer-
ence or diabetes mellitus or impaired glu-
cose tolerance).kw

or adiposity or BMI or zBMI or body
mass index or skinfold thickness or diabetes
or prediabetes or hyperglycemia or insulin
resistance or HBA1c or cardiovascular or
hypertension or hyperlipidemia or hyper-
uricemia or caries or dental decay or den-
tal erosion or ((fat or fatness) adj1 (body or
visceral or skin or abdominal))).ti,ab
41 or/31-40 136188
Joint search sets
42 13 and 30 and 41 1240
Appendix 7. Data extraction form

An electronic data extraction form has been developed based on the following items. We will consider using Covidence for online data
extraction. Exact references, such as page or paragraph numbers, will be documented.
General Information:
• Study ID
• Study title
• Supporting documents
• Date of extraction
• Extractor
• Publication type:
◦ Journal article (peer reviewed)
◦ Report (grey literature)
◦ Other
◦ If report or other type of publication, please provide details
• Copy of the funding, conflict of interest (coi) and/or acknowledgements section
• Funding source of study:
◦ Public
◦ Private (Industry)
◦ Private (Other)
◦ Other
• Potential conflict of interest from funding? (Yes, No, or Unclear; if yes or unclear, please specify)
• Other potential conflict of interest (COI)? (Yes, No, or Unclear; if yes or unclear, please specify)
• Has the study been registered? (Yes, No, or Unclear; if yes, please specify by providing the trial registry and the trial ID)
• Corresponding author and correspondence address
Study eligibility:
• Intervention:
◦ Are any of the intervention’s main components intended to, or potentially suitable to limit the health effects of SSB
consumption, or to increase the consumption of low-calorie alternatives to SSB? (Yes or No)
◦ Definition of SSB used in the study / type of SSB targeted by the intervention
◦ Definition of alternatives to SSB used in the study / type of alternative beverage targeted by the intervention:
◦ Is the intervention an environmental intervention, i.e. is it trying to permanently alter the environment in which
individuals make beverage choices? (Yes or No)
◦ Any further relevant comments regarding the eligibility of the intervention
◦ Does the intervention satisfy the inclusion criteria? (Yes or No)
• Level of implementation:
◦ What was the level of implementation of the intervention? (Policy or Setting-based intervention)
• Study design:
◦ What is the design of the study? (RCT, NRCT, CBA, ITS, UBA, or Other; if other, please specify)
◦ In case the study design is a NRCT, CBA or ITS, does it fulfil the EPOC criteria? (Yes, No, or Not applicable)
◦ Comment on adherence to EPOC criteria
◦ Does the study design satisfy the inclusion criteria? (Yes or No)
◦ Any further relevant comments regarding the eligibility of the study design
• Outcomes:
◦ Does the study assess any of the primary outcomes?
◦ Do the outcomes reported satisfy the inclusion criteria? (Yes or No)
◦ Any further relevant comments regarding the eligibility of the outcome measures
• Further exclusion criteria:
◦ Is any of the following exclusion criteria fulfilled?
⋄ The intervention is implemented in a laboratory
⋄ The intervention is implemented in a virtual setting
⋄ The follow-up period is less than three months (In this review, the follow-up period is defined as the time span
between the start of the intervention and the last outcome assessment)
⋄ There are less than 20 individuals in the intervention or control group
⋄ The study is a clinical trial on the physiological effects of SSB
◦ Is one or more of the above exclusion criteria fulfilled? (Yes or No)
◦ Any further relevant comments regarding the above mentioned exclusion criteria
• Summary of study eligibility:
◦ Regarding the study design, intervention, outcomes and further exclusion criteria, does the study meet all inclusion criteria?
(Yes or No)
◦ Any further relevant comments regarding the study eligibility, including uncertainties or concerns
Timing:
• Start of the study (i.e. the date of the baseline assessment)
• End of the study (i.e. the date of the last outcome assessment)
• Start of the intervention (i.e. the start date of the implementation of the first intervention component)
• End of the intervention(i.e. the date when the last intervention component was discontinued; in case the intervention was not
discontinued within the study period, enter the last reported date instead)
• Duration of the intervention (i.e. the time span from the start of the intervention to the end of the intervention)
• Total duration of the follow-up (i.e. the time span from the start of the intervention to the date of the last outcome assessment)
• Was there an additional follow-up period after the end of the intervention? (I.e., was the total follow-up period longer than the
duration of the intervention?) (Yes or No)
• If yes, duration of the additional follow-up after the end of the intervention
• Any other relevant information regarding intervention timing?
Study design:
• Unit of randomisation or control (allocation by individuals or clusters/groups)
• Unit of analysis
• Is the unit of randomisation or control the same as the unit of analysis? (Yes, No, or Unclear)
• If yes, was this taken into account in the analysis? (Yes, No, or Unclear)
• Details on unit of randomisation, control and analysis issues, and on the way how these were taken into account in the analysis
• Total number of persons in all intervention and control groups at baseline (or total number randomised for RCTs)
• Number of individuals in each intervention and control group (for cluster trials, include the number of individuals and the
number of clusters)
• Mode of analysis (Intention-to-treat, Per protocol, or Unclear =
• Please provide details on the mode of analysis(e.g. on attempts to impute missing data)
• Was a subgroup analysis done? (Yes or No; if yes, please provide details)
• Is any information on moderators or mediators of effectiveness discussed in the study? (Yes or No; if yes, please provide details)
• Was a power calculation done? (Yes or No; if yes, please provide details)
Participants:
• General Characteristics:
◦ General description of the participants(e.g. school children aged 7-12 in four schools in Chicago)
◦ Was the intervention targeted at specific age categories? (No, Children, Teenagers, Adults, or Other)
◦ Details on the age of the participants
◦ List of all inclusion and exclusion criteria for study participation (in case of cluster-randomised studies include details both
for clusters and for individuals within clusters)
• Recruitment:
◦ How were potential participants approached and invited to participate?
◦ Where were participants recruited from?
• Baseline assessment:
◦ How were baseline differences between study groups assessed?
◦ List any baseline differences found
◦ Was baseline body weight of participants higher than the average of their population? (Yes or No)
◦ Details on the baseline weight status of the participants
◦ Did participants have at baseline any existing medical conditions or physiological risk factors other than overweight or
obesity? (Yes or No)
◦ Details on the baseline health status of the participants (Yes or No)
◦ Was the baseline SSB consumption of participants higher than the average of their population?
◦ Details on the baseline SSB consumption of the participants
◦ Representativeness of the sample
• Equity considerations (PROGRESS-Plus framework):
◦ Place of residence
◦ Race or ethnicity
◦ Occupation
◦ Gender
◦ Religion
◦ Education
◦ Socio-economic status
◦ Social capital
◦ Any other information of potential relevance to equity considerations (e.g. disability)
• Any other relevant data regarding participant characteristics
Intervention and Comparison:
• How many groups were assessed in total?
• What was the comparison? (No intervention, Behavioural intervention only, Minimal intervention, or Other)
• Further comments on the comparison
In case there are several intervention groups, or if the comparison was a minimal, behavioural or alternative intervention, the following section
should be copy-pasted and used for each intervention or active control group.
Intervention:
• Description of the intervention (TIDieR framework):
◦ BRIEF NAME: The name or phrase that describes the intervention
◦ WHY: The rationale, theory, or goal of the elements essential to the intervention
◦ WHAT (Materials): The physical or informational materials used in the intervention
◦ WHAT (Procedures): The procedures, activities, and/or processes used in the intervention
◦ WHO PROVIDED: The expertise, background and training of intervention providers
◦ HOW: The modes of delivery of the intervention (e.g. face-to-face, or by internet or telephone)
◦ WHERE: The type(s) of location(s) where the intervention occurred
◦ WHEN and HOW MUCH: The schedule, duration, intensity or dose of the intervention
◦ TAILORING: Any personalisation, titration or adaption of the intervention to individual participants
◦ MODIFICATIONS: Modification of the intervention during the study
◦ HOW WELL (planned): Strategies for the assessment and maintenance of intervention adherence or fidelity
◦ HOW WELL (actual): Extent of the intervention adherence or fidelity
• Categorisation of the intervention:
◦ What type of intervention was performed? (not applicable for the intervention groups):
⋄ Labelling
⋄ Limits to the availability of SSB
⋄ Improved access to low-calorie alternatives to SSB
⋄ Pricing
⋄ Advertisement / marketing
⋄ Nutritional content / reformulation
⋄ Food system intervention
⋄ Other
⋄ If other, please specify
◦ What type of behavioural co-intervention (or control intervention) performed?
⋄ None
⋄ Behavioural co-intervention (information / awareness-raising)
⋄ Behavioural co-intervention (nutrition advice and counselling for at-risk individuals)
⋄ Behavioural co-intervention (skills-building)
⋄ Other
⋄ If other, please specify
In the following section, information on all primary and secondary outcomes will be extracted. It will be copy-pasted in case more than one
outcome is reported.
Outcomes:
• Select the outcome that was assessed:
◦ Primary outcomes:
⋄ Direct and indirect measures of SSB intake (e.g. the amount of SSB consumed or purchased in ml/day/person, energy
intake from SSB and total energy intake in kcal/day/person)
⋄ Diet-related anthropometric measures (e.g. BMI, waist circumference, waist-to-hip ratio, body weight change,
incidence and prevalence of overweight and obesity, body composition or total body fat)
⋄ Diet-related health outcomes other than body weight (e.g. incidence and prevalence of pre-diabetes and diabetes,
insulin resistance, blood lipids and blood pressure, incidence of dental caries and other indicators of oral health)
⋄ Any reported adverse outcomes or unintended consequence (e.g. compensatory behaviour, reduced fluid intake and
dehydration, reduced intake of essential nutrients, body image changes, unhealthy dietary practices, unhealthy weight control,
perceived reduction of freedom of choice and other forms of target group and stakeholder dissatisfaction, negative effects on
employment or other adverse economic consequences).
◦ Secondary outcomes:
⋄ Measure of financial and economic viability and sustainability (e.g. costs, cost-effectiveness, return on investment, and
staff time requirements)
⋄ Diet- and nutrition-related psychosocial variable (e.g. perceived dietary self-efficacy, general self-efficacy, health-related
and general and quality of life)
⋄ Measure for target group and stakeholder perceptions of the intervention (e.g. satisfaction with the intervention,
satisfaction with the way the intervention was implemented, support for the continuation of the intervention)
• Exact description of the outcome
• How the outcome was assessed
• By whom the outcome was assessed
• Has the assessment tool or measurement method been validated? (Yes, No, or Unclear)
• Details on the validation of the assessment tool or measurement method
• Has the assessment tool or measurement method been used as validated? (Yes, No, or Unclear)
• Details on whether the validation of the assessment tool or measurement method has been used as validates
• Is the assessment or measurement repeated on the same individuals or redrawn from the population for each time point? (Yes,
No, or Unclear)
• Description of the time points at which the outcome was measured
• Description of the time points at which the outcome was analysed
• Description of the statistical method applied
• Description of any methods used for adjustment
• Number of participants in group and attrition rate
• Reasons for attrition, if provided
• Baseline, Follow-up and Post-intervention means of the intervention group and the control or comparison (Including variance
measure and indication of whether measures are adjusted or not, and indication of significant differences were shown)
• Effect estimate, if given (e.g. odds ratio, risk ratio, regression coefficients)
• Narrative summary of results for this outcome
Adverse outcomes or unintended consequences:
• Does the study mention whether adverse outcomes or unintended consequences occurred? (This includes adverse or unintended
consequences on the broader context, such as employment effects)
◦ Yes (study states explicitly that there were no adverse outcomes)
◦ Yes (study states explicitly that there were adverse outcomes)
◦ No (study does not mention whether adverse outcomes were observed or not)
• Details on the statement of adverse outcomes or unintended consequences
• Does the study provide any information on how information on possible adverse outcomes was collected? (e.g. through a critical
incident reporting system, anonymous feedback options, explicit screening for adverse outcomes in the process evaluation, etc) (Yes, No, or
Unclear)
• Were any precautions made to avoid adverse outcomes or unintended consequences? (Yes, No, or Unclear)
• Any information on adverse outcomes or unintended consequences not captured above
Attribution of outcomes:
• Does the study provide information on the possibility of attributing specific outcomes to specific intervention components? (e.g.
whether some intervention components were more effective than others)
◦ Yes (Attribution is possible)
◦ Yes (Attribution is not possible)
◦ No (No information provided)
• Details on attribution of outcomes
Context and implementation (CICI framework)

Context:
◦ Which geographical aspects could influence the intervention, its implementation, its population reach and its effectiveness?
◦ Which epidemiological aspects could influence the intervention, its implementation, its population reach and its
effectiveness?
◦ Which socio-cultural aspects could influence the intervention, its implementation, its population reach and its effectiveness?
◦ Which socio-economic aspects could influence the intervention, its implementation, its population reach and its
effectiveness?
◦ Which political aspects could influence the intervention, its implementation, its population reach and its effectiveness?
(This may include policies not assessed in the study but implemented in parallel or in close sequence).
◦ Which legal aspects could influence the intervention, it implementation, its population reach and its effectiveness?
◦ Which ethical aspects could influence the intervention, it implementation, its population reach and its effectiveness?
(Note: Setting aspects, which are also part of the CICI framework, are already captured by the TIDeR framework, and are therefore not
duplicated here.)
• Implementation:
◦ Which funding measures and mechanisms are applied and how do these mechanisms and processes enable or limit
implementation?
◦ In which policy field was the intervention implemented? (Education, Health care, Consumer protection, Food safety,
Media and marketing regulation, or Other)
◦ In which sector was the intervention implemented? (Public sector, Private not-for-profit, Private for profit, or Other)
◦ What was the mode of implementation? (Pilot trial by researchers, Voluntary action by private actors other than industry
(e.g. non-governmental organizations, philanthropy), Mandatory government regulation, Industry self-regulation, Public-private
partnership, or Other)
◦ Was resource-intensity or cost-effectiveness of the intervention discussed by the authors? Were resource-intensity and cost-
effectiveness considerations in the study development?
◦ Was sustainability discussed by the authors? (i.e. whether the intervention is likely to persist after the end of the study
period) Was sustainability a consideration in the study development?
◦ Was political viability and sustainability discussed by the authors? (i.e. the ease of political implementation, and the
likelihood that the intervention is reversed after the end of the study due to political reasons) Was political viability and sustainability
a consideration in the study development?
◦ Were barriers to implementation before and during the intervention discussed by the authors? Were barriers to
implementation a consideration in the study development?
◦ Was scalability discussed by the authors? (i.e. whether the intervention is suitable to be implemented on a larger scale) Was
scalability a consideration in the study development?
◦ Was generalisability discussed by the authors? (i.e. whether the intervention is suitable to be implemented in other contexts
with similar results) Was generalisability a consideration in the study development?
CONTRIBUTIONS OF AUTHORS
PvP drafted the protocol with support from JMS, JB, LKB, LMP, SP, CH, HH and ER. The search strategy was developed by PvP,
and the data extraction form by PvP and JB. JB, LKB, LMP, SP and ER provided methodological support at all stages of protocol
development.
DECLARATIONS OF INTEREST
CH is a member of the scientific advisory board of 4sigma, a consultancy working primarily for health insurance companies. She has
been involved in the preparation of a systematic review on Associations between single nucleotide polymorphisms and macronutrient
intake (PROSPERO: CRD42015025738), partly funded by an institutional grant from the consumer products company Amway
GmbH. CH is fully involved in all steps of this systematic review.
HH has received honoraria for membership on scientific advisory boards of Weight Watchers, NovoNordisk and Boehringer Ingelheim.
His institution has received grants from Riemser Pharma, Amway GmbH and Certmedica, a producer of slimming products. HH has
received honoraria for membership on scientific advisory boards of Nestle and Danone, providing advice on recommendations regarding
the nutritional content of breakfast meals and dairy products. Nestle and Danone produce, among others, both sugar-sweetened foods
and beverages and alternatives to sugar-sweetened foods and beverages.
All other authors have no conflicts of interest to declare.

Environmental Interventions To Reduce The Consumption of Sugar-Sweetened Beverages and Their Effects On Health (Protocol)

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Environmental Interventions To Reduce The Consumption of Sugar-Sweetened Beverages and Their Effects On Health (Protocol)

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Cochrane Database of Systematic Reviews

Environmental interventions to reduce the consumption of

Environmental interventions to reduce the consumption of

Editorial group: Cochrane Public Health Group.

BACKGROUND Among the various potential dietary risk factors sugar-sweetened

may be due to a concomitantly reduced intake of caloric bever-

Over the past decades, consumption of SSB has increased sub-

Behavioural interventions are often informed by theories of human

How a given intervention will work additionally depends on a

Public health and health promotion interventions can have unin-

Table 1: Primary and secondary outcomes

BRIEF NAME The name or phrase that describes the intervention

WHY The rationale, theory, or goal of the elements essential to the

WHAT (Materials) The physical or informational materials used in the intervention

WHO PROVIDED The expertise, background and training of intervention providers

HOW The modes of delivery of the intervention (e.g. face-to-face, or by

WHERE The type(s) of location(s) where the intervention occurred

TAILORING Any personalisation, titration or adaption of the intervention to

MODIFICATIONS Modification of the intervention during the study

HOW WELL (actual) Extent of the intervention adherence or fidelity

The effectiveness and the potential for unintended consequences

Measures of treatment effect Assessment of heterogeneity

Figure 6. Example of a harvest plot. Adapted from Ogilvie 2008.

Table 3: Levels of the quality of evidence in the GRADE approach

Quality rating Description

Moderate quality Further research is likely to have an important impact on the

Very low quality Any estimate of effect is uncertain.

Additional references beverage consumption and dental caries in Australian

Appendix 1. Review Advisory Group

Table 4: Members of the Review Advisory Group

Government and International Organizations

Ms. Modi Mwatsama UK Health Forum, London, United Kingdom

Appendix 2. List of abbreviations

Table 5: List of Abbreviations

BMI Body mass index

CBA Controlled before-after study

CDC U.S. Centers for Disease Control and Prevention

CICI Context and Implementation of Complex Interventions

CONSORT Consolidated Standards Of Reporting Trials

EPOC Cochrane Effective Practice and Organization of Care

EQUATOR Enhancing the Quality and Transparency of Health Research

GRADE Grading of Recommendations Assessment, Development and Evaluation

ITS Interrupted-time-series study

NNS Non-nutritive sweetener

NRCT Non-randomised controlled trial

RCT Randomised controlled trial

RMS Repeated measures study

SES Socio-economic status

SSB Sugar-sweetened beverage

TIDieR Template for Intervention Description and Replication

UBA Uncontrolled before-after study

USDA U.S. Department of Agriculture

WHO World Health Organization

Appendix 3. Glossary of key terms

Table 6: Glossary of Key Terms

beverages containing coffee and added sugars that are primarily

Reformulation In the context of SSB, reformulation generally involves the partial

Table 7: The NOURISHING Framework

INTERVENTION AREA EXAMPLES FOR POTENTIAL IN- INTERVENTION STUDIES TARGET-

BEHAVIOUR CHANGE COMMUNICATION

# Search terms Results

1 Carbonated Beverages/ 2165

2 Drinking Water/ 3876