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The Effect of a Sugar-Sweetened Beverage Portion Cap on Food and Beverages Purchased, Calories Consumed and Consumer Perception

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The Effect of a Sugar-Sweetened Beverage Portion Cap on Food and Beverages Purchased, Calories Consumed and Consumer Perception Evaluating a Public Health Policy: The Effect of a Sugar-Sweetened Beverage Portion Cap on Food and Beverages Purchased, Calories Consumed and Consumer Perception By Sheri Volger M.S., R.D.N. A Dissertation Submitted In Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy in Health Sciences Department of Interdisciplinary Studies Rutgers, The State University of New Jersey School of Health Professions August 2020 2 Final Dissertation Defense Approval Form Evaluating a Public Health Policy: The Effect of a Sugar-Sweetened Beverage Portion Cap on Food and Beverages Purchased, Calories Consumed and Consumer Perception By Sheri Volger M.S., R.D.N Dissertation Committee: Pamela Rothpletz-Puglia EdD, RDN James Scott Parrott, PhD Christina A. Roberto, PhD Approved by the Dissertation Committee __________________________ Date: ___________ __________________________ Date: ___________ __________________________ Date: ___________ __________________________ Date: ___________ __________________________ Date: ___________ 3 ABSTRACT Evaluating a Public Health Policy: The Effect of a Sugar- Sweetened Beverage Portion Cap on Food and Beverages Purchased, Calories Consumed and Consumer Perception Sheri Volger, M.S., RDN. Rutgers, the State University of New Jersey August 2020 Dissertation Chair: Dr. Pamela Rothpletz-Puglia BACKGROUND: Policy makers have proposed implementing sugar- sweetened beverage (SSB) portion size cap policies as a public health initiative to curb SSB consumption and prevent obesity. Such a policy would eliminate larger portion-sizes of SSB and render the smaller-sized portion as the healthier, default option. This study evaluated the effects of an SSB portion-size cap on food and beverages purchased, consumed and caloric intake in three projects. METHODS: First, a systematic scoping review of obesity prevention efforts in young children described obesity prevention efforts in the United States. Next, a cross-sectional survey study examined the association between a 16 ounces (oz) SSB portion-size cap at the Barclays Center and SSBs oz and food calories purchased and consumed compared to Madison Square Garden, an arena with no SSB portion restrictions. The final study examined the impact of the SSB portion-size limit and offering free SSB refills on food, beverage and SSB calories purchased and consumed during a randomized controlled simulated restaurant dining experience. RESULTS: The scoping review found a limited number of community and societal public health obesity policy initiatives targeting young children. Study two found the portion-size cap was associated with Barclays customers’ purchasing 2.24 fewer beverage oz (95% confidence interval [CI]= 4.19, .29, p=.024) and purchasing and consuming 11.03 (95% CI= 17.21, 4.86, p<.001) and 12.10 (95% CI= 18.42, 5.78, p<.001) fewer SSB oz, after adjusting for sex, age, BMI, ethnicity, race, marital status, education, and income without 4 impacting food calories and arena-event experience. Study three did not find any association between an SSB portion-size restriction and food, beverage and SSB calories consumed during the simulated restaurant dinner meal but found that offering free SSB refills along with a 16 oz portion-sized SSB was associated with ordering a greater number of SSB compared with the current restaurant portion, purchase refill condition (0.66 vs. 0.40, p=.048). CONCLUSION: This study provides preliminary real-world evidence of the effectiveness of an SSB portion-size cap in sporting arenas and suggests that SSB portion cap policies may be an effective public health strategy to reduce SSB consumption but may be limited by promotions such as free-refills. 5 Acknowledgement First and foremost, I would like to express my deepest gratitude to my dissertation committee: Dr. Pamela Rothpletz-Puglia, Dr. Scott James Parrott and Dr. Christina A. Roberto. Our many meetings and lively discussions inspired this dissertation research and helped me develop new ideas and creative solutions. A special thank you to my Dissertation Chair and my Academic Advisor Dr. Pamela Rothpletz-Puglia who for the past six years provided me with strong encouragement, unwavering support, and valuable scientific guidance while she led me through my doctoral journey. Without the statistical guidance and great knowledge of Dr. Scott James Parrott, along with his unique sense of humor, the success of this dissertation would not have been possible. Many, many thanks to Dr. Christina A. Roberto for joining my dissertation committee at Rutgers and for generously providing access to her sugar-sweetened beverage research projects —Dr. Roberto’s compassionate assistance and scientific expertise cannot be overestimated. It has been a privilege to have had the opportunity to work with and learn from this amazing group of researchers. I would also like to acknowledge the numerous individuals who inspired me to begin this journey. I would like to extend my sincere thanks to Dr. Robert Denmark whose research class persuaded me to apply to the doctoral program, and for his continuous encouragement and helpful advice. Special thanks to my role models and mentors Dr. Philippe Szapary, Dr. Thomas A. Wadden and Dr. Marion Vetter, whose passion for research inspired me to pursue this degree. I also wish to thank Dr. Melissa Marko for her wealth of practical suggestions and motivational support. Thank you to the many researchers who took the time to conduct these sugar-sweetened beverage research studies and the thousands of study participants who completed surveys and attended pseudo-focus groups and test dinner meals. Although we have never met, I will forever be grateful for your hard work and dedication to food policy research. Finally, I would not have been able to complete this tremendous undertaking without the endless support and loving encouragement from my family and friends. To everyone, and for all of this, I will forever be grateful. 6 Table of Contents Chapter 1. Introduction and Background .................................................... 9 Context and Background of the problem .............................................. 9 Research Aims, Questions, Hypothesis ..................................... 17 Project 1: Scoping Review of Obesity Prevention Efforts ................... 18 Project 2: Real-world SSB Limit Policy Study ..................................... 19 Project 3: SSB Portion Limit Dining Lab RCT ..................................... 20 Study Manuscripts .......................................................................... 23 Relationship of the manuscripts to overall dissertation project ........... 26 Chapter 2. Theory and Literature Review................................................. 28 Introduction ...................................................................................... 28 SSB Policy Initiatives .......................................................................... 28 Theoretical Framework ....................................................................... 40 Literature Review................................................................................ 47 Methodology ....................................................................................... 47 Search Results ................................................................................... 49 Discussion and Conclusion ................................................................ 66 Relevance of Theory and Literature Review ....................................... 69 Chapter 3. Methods .................................................................................... 71 Project 1: Scoping Review of Obesity Prevention .............................. 71 Project 2: Real-world SSB Limit Policy Study ..................................... 72 Project 3: SSB Portion Limit Dining Lab RCT ..................................... 86 Chapter 4. Manuscript 1.............................................................................. 96 Abstract .............................................................................................. 97 Introduction ......................................................................................... 98 Methods ............................................................................................ 100 Results ............................................................................................. 103 Discussion ........................................................................................ 112 Conclusions ...................................................................................... 117 References: ...................................................................................... 119 7 Tables ............................................................................................... 125 Figures ............................................................................................. 141 Supporting information ..................................................................... 143 Chapter 5. Manuscript 2............................................................................ 145 Abstract ............................................................................................ 145 Methods ............................................................................................ 149 Results ............................................................................................. 155 Discussion .......................................................................................
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