“Juice” Drinks and FDA Regulations: Opportunities to Increase Transparency and Support Public Health

RESEARCH AND PRACTICE

Children’s Fruit “Juice” Drinks and FDA Regulations: Opportunities to Increase Transparency and Support Public Health

Jennifer L. Pomeranz, JD, MPH, and Jennifer L. Harris, PhD, MBA

Objectives. To compare children’s drink products that contain or purport to contain indicate that the majority of parents believe juice and evaluate labels in light of US Food and Drug Administration (FDA) regulations. that nonnutritive sweeteners are not safe 10–12 Methods. In 2019, we analyzed federal law for drinks that contain or purport to for children. Yet, 21 out of 28 of the ’ contain juice by using LexisNexis and FDA’s Web site, identified top-selling children’s top-selling sweetened children s fruit drinks fl “juice” drinks in fruit punch flavors, gathered labels in store and online, and extracted and avored waters contained nonnutritive 8 ’ data from the principal display and information panels. sweeteners. Moreover, in studies of parents perceptions, they rated sugar-sweetened fruit Results. FDA regulations permit a wide range of names, claims, and fruit vignettes on drinks and flavored waters as significantly drinks that contain or purport to contain juice, reflecting the product’s flavor and not healthier and less likely to cause disease than necessarily its ingredients. We identified 39 brands of children’s drinks, including 100% regular and diet sodas.10,13 fl juice (n = 7), diluted juices (n = 11), juice drinks (n = 8), fruit- avored drinks (n = 8), and To increase transparency for drink labels, fl avored waters (n = 5), with nonuniform statements of identity; vitamin C and low-sugar the US Food and Drug Administration (FDA) claims; and fruit vignettes representing 19 fruits. Many products contained added sugar issued regulations in 1993 to establish name and nonnutritive sweeteners but little to no juice. and labeling requirements for juices and Conclusions. Principal display panels rendered it difficult to differentiate among beverages that purport to contain juice product types, identify those with added sweeteners, and distinguish healthier products. through advertising or labeling, such as by Revised labeling regulations are warranted to support public health. (Am J Public Health. depicting fruit or having fruit flavors.14 Published online ahead of print April 16, 2020: e1–e10. doi:10.2105/AJPH.2020.305621) However, these requirements do not appear to be adequate.15,16 When faced with lawsuits on food labels, courts regularly observe that potentially confusing labels are valid under “ ecause of their contribution to obesity juice through age 18 years.6,7 Yet, US sales FDA regulations, noting, for instance: a ‘ fl ’ Band other chronic diseases, sweetened of children’s drinks, defined as drinks that product may be labeled as fruit- avored or ‘ fl ’ companies marketed as intended for children, naturally avored, even if it does not contain drinks are the primary target of food and – 8 ”15(p1102 1103) nutrition policies aimed at improving public totaled $2.2 billion in 2018, with fruit- fruit or natural ingredients. – health.1 4 Yet, sugary drinks are responsible flavored and juice drinks the most common In an attempt to address concerns over for more than one half of US children’s total sugar-sweetened beverages consumed.9 confusing labels, in 2016 the FDA issued a “ added sugar intake (which is approximately Previous research found that of the 34 report explaining why consumers probably ” “ ” “ 300 calories per day).5 top-selling brands of sweetened children’s think their lemon drink from a package ” In September 2019, the American Heart drinks in the United States in 2018, 65% picturing fresh lemons was made with Association, American Academy of Pediat- contained added sugars, 74% contained lemons or lemon juice, but it does not nec- rics, Academy of Nutrition and Dietetics, and nonnutritive sweeteners, and 38% contained essarily contain either, and rather may be 8 American Academy of Pediatric Dentists both types of sweeteners. However, care- flavored with natural or artificial lemon fla- 16 issued a consensus statement on healthy givers may not understand that these drinks voring. The report recommends that con- beverage consumption for children up to age contain added sugar or nonnutritive sweet- sumers should not rely on product names, 8 5 years, recommending no drinks with added eners. Surveys and qualitative research pictures on the packaging, or the taste of foods sugars or nonnutritive sweeteners and limited juice (up to 0.5 cups/day starting at 1 year and ABOUT THE AUTHORS 3 Jennifer L. Pomeranz is with the School of Global Public Health, New York University, New York. Jennifer L. Harris is with 0.75 cups/day at 4 years). Additional leading the Rudd Center for Food Policy & Obesity, University of Connecticut, Hartford. health and nutrition experts recommend that Correspondence should be sent to Jennifer L. Pomeranz, Department of Public Health Policy and Management, School of Global children up to age 13 years avoid all beverages Public Health, New York University, 715 Broadway, 10th Floor, New York, NY 10003 (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. containing added sugars or nonnutritive This article was accepted February 5, 2020. sweeteners and no more than 6 to 8 ounces of doi: 10.2105/AJPH.2020.305621

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or beverages but rather must inspect the in- visited the brands’ Web sites to identify based on the current state of products and FDA gredient list if one “cares if the food actually products marketed as specifically for chil- regulations. includes a certain ingredient.”16 Thus, even dren.8 From that list, we selected all brands of the FDA concedes that its labeling require- children’s drinks that contained or purported ments for front of packages (called the prin- to contain juice. Food and Drug Administration cipal display panel [PDP]) do not clearly To compare seemingly similar products Regulations convey product and ingredient information across brands and categories, we identified Congress granted the FDA broad authority to consumers. “fruit punch”–flavored products. If a brand to regulate food and beverage labeling.24 The Given the wide range of drinks marketed did not have a specific “fruit punch” flavor, FDA issued specific regulations for beverages to and consumed by children that contain or we included the closest flavor (e.g., tropical that contain or purport to contain juice.14 A purport to contain juice,8 it is important that punch) but excluded berry or vegetable beverage purports to contain fruit juice if the caregivers are able to differentiate among punches as the marketing and types of juice product’s advertising or labeling bears the product types and identify drinks that are and flavorings in these products were sub- name or pictorial representation of fruit or recommended for children. However, there stantially different. We excluded products fruit juice, or the product’s “color and flavor” is a gap in the research on whether FDA not sold in individual fruit-punch–flavored gives the beverage the “appearance and taste” regulations and the resulting names and packaging (e.g., flavor variety packs), as well as of containing fruit juice.17 statements on the PDP for these beverages carbonated products because they did not FDA regulations require the PDP to dis- enable consumers to identify healthier purport to contain juice. For flavored waters, play a statement of identity as “one of its products. To fill this gap, we researched because there were so few brands in this principal features,” which means it should be current labeling regulations and examined category, we randomly chose 1 flavor if fruit in bold type and in a size reasonably related to the labels and ingredients of the top-selling punch did not exist to include all brands. the most prominent text on the PDP.23 For children’s drinks that contain or purport to drinks that contain less than 100% juice, if contain juice. We identified opportunities for the name of the product includes the word the FDA to revise its regulations to ensure Labels “juice,” the statement of identity must also transparency and suggested avenues for future To analyze labels of the products iden- include a term such as “beverage,”“cocktail,” fi research and policy evaluation to support ti ed, researchers visited 2 Connecticut “diluted,” or “drink.”18 Regulations do not public health. supermarkets in March 2019 and took pho- differentiate between juice that is diluted tographs of the products. For products not (i.e., blend of juice and water without added available locally, researchers purchased them sweeteners) and drinks that contain juice with online or gathered product images from added sugars or nonnutritive sweeteners. ’ METHODS manufacturers Web sites. For labels that were Therefore, their statements of identity are not This research was conducted in 2019 and unavailable through these methods, in July to required to be distinguishable. fi consisted of 3 parts. September 2019, we identi ed and compared The statement of identity must also reflect ’ the products labels from at least 2 separate flavoring. Manufacturers must determine the online sellers (Walmart, Instacart, Target, or product’s “characterizing” flavor, which Food and Drug Administration Amazon) to ensure the identical information ’ Regulations represents the product s taste, and whether was displayed and retrieved those data. Data any juice added matches that flavor.19 If the To identify the law and gaps in the law extracted from the PDP included the brand, drink contains an insufficient amount of an related to the products at issue in this study, fl avor, statement of identity (a common ingredient to independently characterize the using LexisNexis and FDA’s Web site, 1 or usual name or appropriately descriptive food, the name on the label must include author (J. L. P.) analyzed the FDA’s authority term for the product), statements related to “flavored” or “naturally flavored.”19 If none and all existing federal labeling requirements sweeteners and vitamins or minerals, and of the natural flavor is derived from the for drinks containing or purporting to contain images of fruit. Data extracted from the nu- product whose flavor is the characterizing juice, including the US Code, FDA regula- trition information panel included the per- flavor or it is only artificially flavored, the label tions, case law referring to the statutes and cent juice declaration and ingredient list must state “artificially flavored.”19,25 FDA regulations identified, and the FDA’s re- (Appendix A, extraction document, available regulations allow the term “fruit punch” sponses to comments on its 1993 rulemaking as a supplement to the online version of this when there are 3 or more distinguishable for these products. article at http://www.ajph.org). characterizing flavors or a blend of flavors with no primary recognizable flavor.19 Selection of Products The name of juice blends need not include We identified the children’s drinks for the predominant juice but rather may reflect analysis in this study by utilizing previous RESULTS the flavor of the product (e.g., “raspberry and research that relied on a market research firm’s The box on page e3 provides the defini- cranberry flavored juice drink” may be ap- (IRI’s) national sales data for brands with at tions used in this article, including product propriate even if the predominant juice is least $10 million in sales in 2018.8 Researchers categories and ingredient and labeling terms apple).18 Fruit vignettes, or images, also need

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DEFINITIONS RELATED TO THE STATE OF REGULATIONS AND PRODUCTS: UNITED STATES, 2019

Term Definition Product categories 100% juice Juice expressed from a fruit or vegetable and no parts water, or a single-strength juice made from concentrate and water, or a blend of more than 1 single-strength juice. 100% juice may have added ingredients that do not add volume significant enough to diminish the juice’s soluble solid content, such as sweeteners, preservatives, and vitamins; if added, this must be disclosed in or next to the statement of identity.14,17 Diluted juice Single-strength juice or multiple juices blended with water but with no added sweeteners.18 The product does not need to identify itself as diluted; the ingredient list and percent juice disclosed on the information panel are intended to notify consumers of the parts per juice and water. For example, 50% juice would mean 1 part juice and 1 part water.14 Flavored water Drink with water in the statement of identity and with added flavors and that may or may not contain nutritive sweeteners, nonnutritive sweeteners, or juice. Fruit-flavored drink Drink with natural or artificial flavors intended to portray the taste of a fruit or multiple fruits and that contains added sugar, nonnutritive sweetener, or both, and £ 2% juice (generally £ 2% juice is added as flavoring).14 Juice drink Beverage that contains more than 2% juice and less than 100% juice as an ingredient and added sugar, nonnutritive sweetener, or both. If the word “juice” is used to describe the product, it must also include a qualifying term such as “beverage,”“cocktail,” or “drink.”18 Ingredient and labeling terms Added sugars Sweeteners added to foods and beverages that contain calories, including sugar, sugar cane, honey, and high-fructose corn syrup. Artificial flavor Substance that functions to impart flavor that is not derived from a spice, fruit, fruit juice, vegetable, vegetable juice, edible plant, meat, fish, poultry, eggs, dairy, or fermentation products.19 Natural flavor Substance that contains the flavoring constituents derived from a spice, fruit, fruit juice, vegetable, vegetable juice, edible plant, meat, fish, poultry, eggs, dairy, or fermentation products, whose significant function is flavoring rather than nutritional.19 Nonnutritive sweeteners Sweeteners added to foods and beverages that do not contain calories, including sucralose, acesulfame potassium, neotame, and stevia, which are found in beverages. Some beverage manufacturers declare stevia a natural sweetener because it comes from a plant. Nonnutritive sweeteners are not considered flavors but may be considered flavor enhancers.20 The Food and Drug Administration also calls these high-intensity sweeteners21; yet, certain regulations refer to foods sweetened with them as “artificially sweetened.”22 Purport to contain juice A food or drink purports to contain an ingredient if it “conveys, implies, or professes outwardly that it contains that ingredient” or if the food or drink “has the appearance of being, intending, or claiming to contain that ingredient.”14(p2897) A beverage purports to contain fruit or vegetable juice if “the product’s advertising, label, or labeling bears the name of, or variation on the name of, or makes any other direct or indirect representation with respect to, any fruit or vegetable juice, or the label or labeling bears any vignette (i.e., depiction of a fruit or vegetable) or other pictorial representation of any fruit or vegetable, or the product contains color and flavor that gives the beverage the appearance and taste of containing a fruit or vegetable juice.”17 Principal display panel The part of a label that is most likely to be displayed, presented, shown, or examined under customary conditions of display for retail sale. This is commonly referred to as the front of the package. Statement of identity Statement on packaged food and beverage that is (1) a name specified in or required by federal law, (2) the common or usual name of the food that describes the basic nature of the food or its characterizing properties or ingredients, or (3) an appropriately descriptive term.23 The statement of identity must be 1 of the “principal features” on the principal display panel.23

not include all the fruit juices present in the drinks that contain less than 100% juice or which must include statements on the PDP drink.14 The FDA explained that fruit vi- no juice, such a statement is not required. such as “Sweetened with nutritive sweet- gnettes should indicate that the product Notably,theFDAdoesrequirethelabels ener(s) and nonnutritive sweetener(s).”27 contains that fruit’s juice or natural or artificial for products other than 100% juice to Based on these regulations, soft drink flavor.14 disclose added sweeteners on the PDP. companies label soda with nonnutritive For products that are 100% juice, if For example, the FDA established sweeteners as “diet,” with courts stating, “a non-juice ingredients are added such as standards of identity for “canned fruit reasonable consumer would understand” sweeteners or vitamins, the label must cocktail”26 and a separate naming require- that diet soda “contains artificial sweet- include a disclosure identifying the ment for “artificially sweetened canned eners.”28 We found no similar regulations product is “with added . . .” near the fruit cocktail.”22 The FDA also issued or standardized terms for drinks that purport 100% juice statement.17 Conversely, for regulations for “special dietary food,” to contain juice with nonnutritive

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sweeteners. We also found no regulations or sucralose and acesulfame potassium; n = 3), contained juice, and those that contained specifically defining or regulating drinks or both high-fructose corn syrup and non- juice did not always contain juice from the purporting to be water beverages that nutritive sweeteners (n = 3). Nonnutritive fruits depicted (n = 10). For the products that contain added sugar, nonnutritive sweet- sweeteners were identified from the ingre- did contain juice, apple was the primary juice ener, or both. dient list and not indicated on the PDP except present (n = 26), although apple was not al- Vitamin and mineral statements for 1 product was named “Light.” Juice drinks ways one of the fruits in the vignette (n = 6). the products in this study must align with had a range of statements of identity—many Some of the statements of identity were FDA regulations for all packaged food of which were similar to diluted juices— difficult to notice or read because of the same products.20 During the 1993 rulemaking, including the terms juice drink, fruit drink, color text as background color, location on the FDA determined that for drinks that juice cocktail, blend, from concentrate, nat- the package, small text size, or thin all-cap were not 100% juice, a declaration stating urally flavored, and artificially flavored. lettering (Appendix B, examples). that the product is 100% pure or natural The fruit-flavored drinks contained 0% would have “great potential to mislead,” but to 2% juice and high-fructose corn syrup that “100% vitamin C” statements would not alone (n = 1), nonnutritive sweeteners alone be similarly misleading.14 Also during the (n = 2), or both high-fructose corn syrup and DISCUSSION 1993 rulemaking, commenters urged the nonnutritive sweeteners (n = 5). Statements Clear and transparent labeling is essential to FDA to require disclosure of juice per- of identity for fruit-flavored drinks were more provide information to consumers and sup- centages on the PDP instead of on the in- uniform, including artificially flavored fruit port caretakers’ efforts to ensure healthy diets formation panel.14 However, the FDA did drink, artificially flavored drink, and naturally for young children. Yet, we identified nu- (and still does) not have the authority to and artificially fruit-flavored drink, with 1 merous labeling practices that obscure the require this because Congress mandated the exception: a Kool-Aid product was called true nature of drinks purporting to contain location.29 “soft drink,” although the ingredients were juice and would make it difficult for con- almost identical to other fruit-flavored drinks. sumers to identify healthier products. La- The majority of juice drinks and fruit- beling practices appear to be designed to blur Beverage Products and Labels flavored drinks had low or no sugar claims and the distinction between drinks recommended We identified 39 brands of the following claims about vitamin C (most commonly for children and those containing added sugar children’s drinks in fruit-punch or similar “100% vitamin C”). or nonnutritive sweeteners.10,30 Nonetheless, flavors: 7 brands of 100% juice, 11 diluted The flavored water brands had the fol- many such practices aligned with FDA juices, 8 juice drinks (drinks that contain lowing statements of identity: naturally fla- regulations. < 100% juice and > 2% juice with added sugar, vored water beverage (n = 2), flavored water First, certain words had no inherent meaning nonnutritive sweetener, or both), 8 fruit- beverage (n = 2), and naturally flavored water for the products evaluated because they were flavored drinks (drinks with natural or arti- drink (n = 1). Although flavored waters had found on the labels of a wide range of products ficial flavors intended to portray the taste of different statements of identities than juice with varying ingredients: water, beverage, fruit and that contain added sugar, nonnu- drinks and fruit-flavored drinks, they had drink, naturally flavored, fruit-flavored, fruit tritive sweetener, or both, and £ 2% juice), almost identical ingredients with 10% juice punch. Yet, manufacturers’ use of these terms and 5 flavored water drinks. Table 1 presents and cane sugar (n = 1), 0% juice and added was consistent with FDA regulations. the findings for each product. All products sugars and nonnutritive sweeteners (n = 3), or Second, statements of identity for these disclosed the percent juice (including 0%) on 0% juice and nonnutritive sweeteners (n = 1). products were unclear. Many of them did not the information panel confirming that man- One flavored water that displayed a “No abide by FDA requirements to be a principal ufacturers consider these products to be drinks artificial sweeteners” claim contained stevia feature of the PDP and rather were difficult to that contain or purport to contain juice. extract, which is a nonnutritive sweetener notice or read because of placement on the Table 2 summarizes the findings by prod- manufacturers consider not artificial because package, or font size or color.23 At the same uct category. All 100% juices and diluted it is derived from a plant. Water was the first time, the words used for the statements of juices had apple juice concentrate as the ingredient in all juice drinks, fruit-flavored identity did abide by FDA regulations, yet first ingredient, and none contained added drinks, and flavored waters. they provided little practical information and sweeteners. Diluted juices varied in juice With 1 exception, all products in all cat- may increase consumer confusion if read. content ranging from 38% to 72% and had egories pictured fruit on the PDP (Table 1; Products across categories with or without different statements of identity, which in- Appendix B, available as a supplement to added sweeteners had statements of identity cluded the terms juice beverage, juice drink, the online version of this article at http:// that did not enable comparisons within or blend, from concentrate, naturally flavored, www.ajph.org). Even though the flavor across categories or brands, nor did they and flavored drink. names were generally consistent (e.g., fruit enable identification of healthier products. Juice drinks contained a smaller amount of punch, tropical punch) there were 19 dif- For example, the ingredients of flavored juice (5% to 20%) and added sweeteners, ferent types of fruit (including coconut) waters were almost indistinguishable from including added sugar cane or sugar alone depicted on the PDP across products. How- those of juice drinks and fruit-flavored drinks, (n = 2), nonnutritive sweeteners alone (stevia ever, not all products with fruit vignettes yet their names and statements of identity

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TABLE 1—Labels of “Fruit Punch” (or Similarly Flavored) Drinks Marketed to Children That Contain Juice or Purport to Contain Juice: United States, 2019

Product Juice/Sweeteners Principal Display Panel Statement About Pictured Fruit(s) > 2% Juice, Added Nonnutritive Sweeteners and Vitamins/ Ingredient as Juice or Brand/Subbrand Flavor Statement of Identity % Sugar Sweetener Minerals Fruit Picturesa Concentrate 100% juiceb Apple & Eve/ Elmo’s Punch 100% juice blend of 5 juices 100 No No No sugar added Apple, pear, All Sesame Street from concentrate with 100% vitamin C pineapple, cherryc other added ingredients Capri Sun/100% Fruit punch Flavored 100% juice blend 100 No No No added sugar Grape, cherry, applec All Juice from concentrate with No high-fructose corn added ingredient and syrup other natural flavor Good 2 Grow/ Fruit punch 100% apple pear grape juice 100 No No No sugar added Pear, grape, applec All 100% Juice from concentrate with Excellent source of natural fruit punch flavor vitamin C Juicy Juice Fruit punch 100% juice flavored juice 100 No No No added sugar Pear, apple, grapesc All blend from concentrate 120% vitamin C daily with other natural flavors value per serving and added ingredients Langers Disney Fruit punch 100% juice a blend of 3 100 No No 120% vitamin C Apple, orange, All juices from concentrate With added vitamin C pineapplec with natural flavors and added ingredients Minute Maid Fruit punch 100% juice blend of 4 juices 100 No No Good source calcium Apple, pineapple, Apple, grape 100% Juice from concentrate with No sugar added grapec added ingredients 100% vitamin C Mott’s Fruit punch 100% juice 100 No No No sugar added Grapes, apple, All 100% daily value vitamin orange, cherriesc C per juice box Diluted juices Apple & Eve/ Fruit punch Naturally flavored juice 66 No No No sugar added Apple, cherry, carrot, All Fruitables beverage from pineapplec concentrate Apple & Eve Fruit punch burst Juice drink from 40 No No 50% less sugar Apple, cherry, All Organic concentrate 100% vitamin C strawberryc Quenchers No sugar added Capri Sun Organic Fruit punch Juice drink blend from 56 No No No added sugar Orange, apple, All concentrate No high-fructose corn grapec syrup Good to Grow Tropical fruit Apple, carrot, and beet juice 72 No No No sugar added Pineapple, mango, None Fruit & Veggie medley beverage from peachc Blend concentrate with natural tropical fruit flavors Honest Kids Super fruit punch Organic juice drink from 38 No No Sweetened only with fruit Watermelon, grape, All concentrate juice apple, strawberryc 100% vitamin C Juicy Juice Punch splash Flavored organic juice 60 No No 35% less sugar than the Grapes, applesc All Fruitifuls beverage blend from leading juice concentrate with other 100% daily vitamin C natural flavors

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TABLE 1—Continued

Product Juice/Sweeteners Principal Display Panel Statement About Pictured Fruit(s) > 2% Juice, Added Nonnutritive Sweeteners and Vitamins/ Ingredient as Juice or Brand/Subbrand Flavor Statement of Identity % Sugar Sweetener Minerals Fruit Picturesa Concentrate Juicy Juice Fruit punch Flavored organic juice 44 No No 50% less sugar than the Raspberry, cherry, Cherry Splashers beverage blend from leading juice blackberryc concentrate with other No high-fructose corn natural flavors syrup No artificial sweeteners Mott’s For Tots Fruit punch Juice drink 53 No No 40% less sugar (than 100% Grapes, apple, All apple juice) cherriesc With added vitamins A, C, E Old Orchard for Fruit punch Reduced-sugar juice drink 50 No No 50% less sugar than 100% Grape, pear, All Kids from concentrate apple juice pineapple, cherryc 100% daily value vitamin C R.W. Knudsen Organic fruit punch Flavored beverage from 7 50 No No No Pineapple, grape, All Family Sensible juice concentrates apple, orangec Sippers Tropicana Kids Fruit punch Flavored drink with other 45 No No No Apple, carrot, grape, All natural flavors strawberry, black currantc Juice drinks Apple & Eve/On Fruit punch Fruit punch juice cocktail 20 Cane sugar No No high-fructose corn Orange, cherries, Cherries, pineapple the Go from concentrate syrup pineapplec 100% vitamin C Capri Sun/Juice Fruit punch Fruit punch flavored juice 10 Sugar No 35% less sugar than Apple, orange, Apple, orange, Drink drink blend leading regular juice pineapple, grape, pineapple, grape drinks cherry No high-fructose corn syrup Good to Grow Fruit fusion Fruit punch flavored juice 18 No Stevia extract No sugar added Orange, cherry, None beverage with other 75% less sugar versus our pineapplec natural flavors and 100% juice organic apple juice from concentrate Hawaiian Punch Fruit juicy red Natural and artificial fruit 5 High- Sucralose 100% vitamin C Orange, apple, None flavored juice drink fructose pineapple, papaya, corn guava, apricot, syrup passion fruitc Hi-C Flashin’ fruit punch Naturally and artificially 5 High- Sucralose, 50% less sugar than Orange, pineapple All flavored fruit drink fructose acesulfame regular Hi-Cd corn potassium 100% vitamin C syrup Light Hawaiian Fruit juicy red Natural and artificial fruit 5 No Sucralose, Excellent source of Orange, apple, None Punch flavored juice drink acesulfame vitamin C pineapple, papaya, potassium guava, apricot, passion fruitc

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TABLE 1—Continued

Product Juice/Sweeteners Principal Display Panel Statement About Pictured Fruit(s) > 2% Juice, Added Nonnutritive Sweeteners and Vitamins/ Ingredient as Juice or Brand/Subbrand Flavor Statement of Identity % Sugar Sweetener Minerals Fruit Picturesa Concentrate Minute Maid Fruit punch A 5% juice blend of grape 5 High- Sucralose No Grape, pineapple, Grape, pineapple pineapple pear apple fructose pear, apple juices from concentrate corn syrup Robinson’s Fruit Fruit punch Naturally flavored juice 10 No Sucralose, No sugar added Cherry, orange, Apple Shoot drink from concentrate acesulfame apple, grape, black potassium currantc Fruit-flavored drinks Fruit Rush Fruit punch Artificially flavored fruit < 1 High- Sucralose, No Cherry, pineapple, None drink fructose acesulfame orange, cherryc corn potassium syrup Kool-Aid Multi Tropical punch Artificially flavored drinke 0 High- No 100% daily value Orange, lime, lemon, None Serve fructose vitamin C grape, cherry corn syrup Kool-Aid/Bursts Tropical punch Soft drink 0 High- Sucralose 75% less sugar than Cherry, lime, grape None fructose leading regular sodas corn syrup Kool-Aid/ Tropical punch Artificially flavored drink 0 High- Sucralose 55% less sugar than Grape, lemon, None Jammers fructose leading regular sodas cherry, orange, corn 100% daily value of lime syrup vitamin C Kool-Aid/Zero Tropical punch Zero-calorie artificially 0 No Sucralose, Zero sugar Grape, lemon, None Sugar Jammers flavored drink acesulfame 100% daily value of cherry, orange, potassium vitamin C lime Little Hug Fruit punch Naturally and artificially 0 High- Sucralose, 75% less sugar than other Oranges, cherries None fruit flavored drink fructose acesulfame leading fruit-flavored corn potassium drinks syrup 2 grams per pouch Mondo Squeezers Primo punch Artificially flavored drink 0 No Sucralose, No high-fructose corn Lime, grape, None acesulfame syrup pineapple, potassium strawberry, cherry, orange Sunny D Fruit punch Artificially flavored fruit 2 High- Sucralose 100% daily value of Cherry, orange, Apple punch fructose vitamins C, B6, and B12 peach, applec corn syrup Flavored waters Apple & Eve/ Fruit punch frenzy Naturally flavored water 10 Cane sugar No No artificial sweeteners Apple, orange, All Water Fruits beverage coconut, cherryc Capri Sun/Roarin’ Fruit punch wave Flavored water beverage 0 Sugar Stevia extract 50% less sugar than the Cherries, orange, None Waters natural flavor with average leading fruit apple other natural juices flavor

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TABLE 1—Continued

Note. NA = not applicable. aAs shown from left to right or by prominence. bFor 100% juices, we included 1 subbrand from each brand because the ingredient and nutrition content of 100% juice products did not vary substantially.8 cFor these products, the first juice present in the ingredient list is apple. dThe full statement on packages of this product states “50% less sugar fewer calories than regular Hi-C,” but Coca-Cola no longer makes a version of Hi-C that is 50% more sugar or calories than this type. See Coca-Cola Product Facts, Hi-C, available at: https://www.coca-colaproductfacts.com/en/products/hi-c/poppin- pink-lemonade/6-oz. eThe words “artificially flavored” are separated from “drink.” indicated that they were different, corn syrup” and every product type displayed Research into the most appropriate labeling potentially creating an impression of low- and no-sugar claims. Similarly, a “No term (e.g., zero calorie or diet sweeteners) is healthfulness for products with “water” in artificial sweeteners” claim found on products necessary.21 the name.10 containing stevia extract may lead consumers Transparent product labeling could also Third, 38 of the 39 products in this study to believe they contain no nonnutritive help consumers identify healthier products had fruit vignettes on their labels. Although sweeteners. Consumers who do read the and may encourage manufacturers to produce fruit punch was the characterizing flavor, information panel would need knowledge of a wider range of them. Diluted juices (100% many products lacked fruit juice, juice from nonnutritive sweetener chemical names to juice and water with no added sweeteners) the fruit pictured, or multiple fruit juices, identify their inclusion. have less juice and total sugar than do 100% which the term “fruit punch” may signify to This study highlighted a need for future juice8 and align with expert recommenda- some consumers. For all product categories regulatory action and further research. FDA tions.3,6 Yet, their statements of identity and in this study, FDA regulations permit the has the authority to revise a wide range labeling claims were similar to those of juice naming and use of fruit vignettes that reflect of labeling requirements, including stan- drinks, making it difficult to distinguish them the drink’s flavor regardless of the product’s dardizing the common and usual names for from products with added sugar, nonnutritive ingredients. For products that did contain products, differentiating between ingredi- sweeteners, or both. FDA should update its juice, apple juice was the primary juice. It is ent versus flavor disclosures, and directly regulations to ensure that these products are unclear whether consumers understand that addressing misleading labels.31 Statements of identifiable as a blend of juice and water fruit flavors, names, and images do not nec- identity should be visible, uniform within without added sweeteners. essarily reflect fruit or juice as an ingredient. product categories, and meaningfully convey Future research is needed to identify Fourth, 100% juice is the only product in information to assist consumers to make consumers’ perception of labeling terms and this analysis required to include statements on comparisons within and across product cat- statements, including whether consumers can the PDP related to added sweeteners, and egories. Standardized PDP labeling of added differentiate among product types, distinguish none of them included sweeteners. For other sweeteners for all beverages is also necessary so between flavor and ingredient statements, and products, it would not be possible to identify consumers can identify drinks with added determine whether names (such as water), which contained added sugars or nonnutri- sugars or nonnutritive sweeteners. Nonnu- fruit images, and statements on the PDP affect tive sweeteners from the PDP alone. Such tritive sweetener disclosures are especially perceptions of healthfulness, including transparency exists for regular and diet soda, warranted now that the Nutrition Facts label whether vitamin statements, such as 100% but not for similarly unhealthy drinks directly is required to disclose added sugars, which vitamin C, mislead consumers to believe marketed for children. Products containing may encourage manufacturers to replace these are derived from fruit rather than sugar or sugar cane touted “no high fructose added sugars with nonnutritive sweeteners. fortification across all product types. These

e8 Research and Practice Peer Reviewed Pomeranz and Harris AJPH Published online ahead of print April 16, 2020 RESEARCH AND PRACTICE

TABLE 2—Summary of Drink Labels by Category of “Fruit Punch” (or Similarly Flavored) Drinks Marketed to Children That Contain Juice or Purport to Contain Juice: United States, 2019

Product Category Juice Most Common Statements Contain > 0% Apple is First Juice (No. of Products Statements of Identity Percent Nonnutritive Related to Sweeteners and Juice, No. (%) of Ingredient, No. (% of Evaluated) (Key Words) Range Added Sugars Sweeteners Vitamins or Minerals Products Products Containing Juice) 100% juice (7) 100% juice; 100% juice 100 None None No sugar added 7 (100) 7 (100) blend from concentrate 100% vitamin C Diluted juice (11) Juice drink; juice beverage; 38–72 None None No sugar added 11 (100) 11 (100) blend; naturally flavored; No high-fructose corn from concentrate syrup Less sugar than [other] juice 100% vitamin C Juice drinks (8) Juice drink; fruit drink; 5–20 Cane sugar; sugar; Stevia extract; No sugar added 8 (100) 5 (63) juice cocktail; naturally high-fructose sucralose; No high-fructose corn flavored; artificially corn syrup acesulfame syrup flavored; blend; from potassium Less sugar than [other concentrate drinks] 100% vitamin C Fruit-flavored Artificially flavored fruit 0–2 High-fructose Sucralose; Less sugar than [other 2 (25) 2 (100) drinks (8) drink; artificially flavored corn syrup acesulfame drinks] drink; naturally and potassium 100% vitamin C artificially fruit-flavored drink Flavored waters (5) Naturally flavored water 0–10 Cane sugar; sugar; Stevia extract; No artificial sweeteners 1 (20) 1 (100) beverage; flavored water high-fructose sucralose; Zero or low sugar claims beverage; naturally corn syrup acesulfame flavored water drink potassium questions are especially important in the companies did not pass the tax through to widevariationiningredientsandnutritional context of fruit-flavored products because consumers on flavored water or fruit drinks quality. the characterizing flavors and images are to the same extent as they did with regular associated with health and nutrition.30,32 soda in France1 and Berkeley, California,34 Future regulations should align with these and that consumption of sweetened fruit Conclusions study results. drinks did not change after implementation Health and nutrition experts recommend This study also highlighted the need to of the Berkeley35 and Philadelphia, Penn- that children do not consume drinks with examine additional policies that are relevant sylvania,1 taxes. Additional research and added sugar or nonnutritive sweeteners, yet to the products evaluated. For example, policy evaluation are necessary to determine drinks containing both represent a major most sugary beverage taxes implemented in how different taxing strategies affect pur- portion of beverages consumed by children. US cities and international countries apply chase and consumption of various products Caregivers may reasonably rely on the state- to the drinks identified with added sugars.1 including those evaluated in this study that ments and images on the PDP when deciding Fewer taxes apply to products with non- may seem healthy but are primarily com- whether a drink is healthful for children. nutritive sweeteners; evidence from the posed of water, added sweeteners, and apple However, this study found that labeling United Kingdom showed that consumption juice. practices for drinks across product categories of these drinks increased when only sugar- were virtually indistinguishable, making it sweetened beverages were taxed.33 Some impossible for caregivers to identify the pri- taxesdonotapplytodrinksthatcontain Limitations mary ingredients in these products without both juice and added sugar; such an ex- Limitations of this study include that carefully inspecting the nutrition facts panel clusion may warrant further investigation as we did not examine labels for every drink in and ingredient list on the back of the package. the majority of children’sdrinkscontain the market. However, focusing on fruit- The FDA should revise its regulations toensure both.9 Notably, studies that evaluated the punch–flavored products allowed us to the labels for drinks containing or purporting impact of sugar-sweetened beverage taxes compare labeling for seemingly similar to contain juice are clear and not misleading to across beverage categories found that drinks across product types, and we found support children’shealth.

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CONTRIBUTORS 10. Munsell CR, Harris JL, Sarda V, Schwartz MB. 35. Falbe J, Thompson HR, Becker CM, Rojas N, Both authors conceptualized the article and led or con- Parents’ beliefs about the healthfulness of sugary drink McCulloch CE, Madsen KA. Impact of the Berkeley ducted research for the article. J. L. Pomeranz wrote the options: opportunities to address misperceptions. Public excise tax on sugar-sweetened beverage consumption. first draft of the article. J. L. Harris contributed to all Health Nutr. 2016;19(1):46–54. Am J Public Health. 2016;106(10):1865–1871. versions of the article. 11. Smith MA, Wells MH, Scarbecz M, Vinall CV, Woods MA. Parents’ preferences and perceptions ACKNOWLEDGMENTS of their children’s consumption of sugar and non- This work was supported by a grant from the Robert nutritive sugar substitutes. Pediatr Dent. 2019;41(2): Wood Johnson Foundation, Princeton, NJ. 119–128. The authors would like to thank Abby Katz and Haley 12. Sylvetsky AC, Greenberg M, Zhao X, Rother KI. Gershman for their assistance in collecting and organizing What parents think about giving nonnutritive sweeteners the data for analysis. to their children: a pilot study. Int J Pediatr. 2014;2014: Note. The views expressed here do not necessarily 819872. reflect the views of the Robert Wood Johnson Foundation. 13. Moran AJ, Roberto CA. Health warning labels correct parents’ misperceptions about sugary drink options. Am J – CONFLICTS OF INTEREST Prev Med. 2018;55(2):e19 e27. The authors have no conflicts of interest to declare. 14. 58 Federal Register 2897 (1993). 15. Lam v General Mills Inc, 859 F Supp 2d 1097 (ND Cal HUMAN PARTICIPANT PROTECTION 2012). Human participant protection was not needed because 16. Food and Drug Administration. What’s in a name? there were no human participants involved in this study. What every consumer should know about foods and flavors. September 26, 2016. Available at: https://www. 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