Call it the sweetness paradox. In grocery stores across America, foods that were once saturated with sugar now contain none��— yet they taste just as sweet. ��

The secret is an assortment of additives that replicate sugar’s sweetness, but not its calorie count. Broadly classified as non-sugar sweeteners (NSS), these additives are creeping into everything from diet sodas (aspartame) to no-sugar-added fruit cups (sorbitol, sucralose, acesulfame potassium).

The rise of NSS has made it easier for conscious consumers to reduce their sugar intake, but these products may present their own health risks. in the journal JAMA Pediatrics, , a 91̽��clinical professor of health systems and population health and executive director of , and a team of co-authors argue for better and more comprehensive data on the proliferation and possible health effects of non-sugar sweeteners. They also call for reducing children’s exposure to NSS by restricting their use in kids’ food and beverages.

“The growing presence of (non-sugar sweeteners) in the food supply, combined with mounting concerns about their use… suggest that caution in adding them to foods and beverages is needed,” Krieger and his colleagues wrote.��

91̽��News sat down with Krieger to discuss what we know — and what we need to know — about these ever-present products.��

NSS have been getting a lot of attention lately, from their possible health effects to their impact on our overall diets despite having been used for decades. What’s the debate surrounding these products, and why are they drawing so much attention now?��

James Krieger: There’s been a longstanding controversy over the safety and efficacy of non-sugar sweetened products. The debate has just been lifted up recently because of a couple of things. Last year, the World Health Organization recommended that NSS not be used to achieve weight control or reduce the risk of non-communicable diseases, which means chronic diseases like diabetes or heart disease. That created quite a stir. The food industry, particularly those who rely on these products, reacted negatively to the WHO report, while many public health officials and advocates said this is a great and long- overdue statement.��

There’s also growing use of these products in the food system, particularly as more consumers are looking for and demanding products with less sugar in them. This is because there is widespread awareness of the negative health consequences of too much sugar consumption. Industry is substituting NSS for sugar. They don’t want to change the overall sweetness of their product, because they know really well that sweet foods attract consumers. Instead, they’re maintaining sweetness by substituting NSS for sugar.��

Just how much of these products is the average American eating?����

JK: There’s not great data on consumption of NSS, and that’s a real gap in the knowledge right now. There’s better evidence on consumption of sugars, and that is going down.����

The challenge is that the food industry is not very transparent about how much non-sugar sweeteners are in their products. They have to list sweeteners on the ingredients list, but they don’t have to list the amount. So we know in more of a binary yes/no fashion, are people eating products with non-sugar sweeteners? And the trend line of that looks like it’s going up. For example, from the Environmental Working Group found that the number of food and beverage products containing non-sugar sweeteners increased three- to five-fold between 2013 and 2022.��

We need a lot more research and better data to know what the exposures to these products are. We don’t really know how much people are consuming right now.��

On a quick trip through the grocery store, one might come across a dozen different non-sugar sweeteners. There’s the classics, aspartame and sucralose, the sugar alcohols like erythritol and xylitol, and the “natural” NSS like stevia and monk fruit extract. Do different sweeteners interact with our bodies differently? Do some carry greater potential health risks than others?������

JK: It’s not clear. Most of the studies, particularly the long-term studies, have looked at these products as a group. But each one has a distinct pharmacologic and toxicologic profile. Some of the older NSS have been directly assessed by the FDA, but those assessments are very dated now. The way the newer NSS get into the food supply now is that industry just needs to send in a statement to the FDA saying that, in their estimation, these are safe.����

Now that said, there are some specifics. Some credible researchers and agencies within the WHO have raised concerns that aspartame may be linked to cancer. Others disagree. It’s clear that saccharine is probably a carcinogen, and it’s not used much now. A recent study that came out on erythritol looked at its association with cardiovascular disease, that is death or non-fatal heart attacks or strokes, and found they were increased. The researchers found a possible mechanism for that, linking non-sugar sweeteners to platelet clumping and blood clotting in vitro, which could explain that link, because these can block blood flow and cause heart attacks and strokes. So there’s a plausible mechanism that it could do that.��

My guess is that it’s probably going to be a class effect — they’ll all have kind of the same effect. And the reason I suspect that is because the common mechanism they all work by is they all bind to sweet receptors, and those aren’t just in your mouth, they’re also in organs and blood vessels, everywhere in the body. All of these products bind to those sweet receptors, no matter where they are. And then they might have effects ranging from insulin sensitivity, glucose metabolism, to vascular reactivity, platelet activation and so on.

There’s really pretty good evidence from long-term epidemiological diet studies that link exposure to non-sugar sweeteners to Type II diabetes, to weight gain, to heart disease. Those certainly are three big public health problems right now. That’s what has gotten me concerned about these and why I think we need to be taking a more active, aggressive approach toward limiting people’s exposure to them.��

You write in the article that it’s especially important to understand kids’ exposure to non-sugar sweeteners. Why is that?����

JK: In general, for any kind of environmental exposure, kids are more vulnerable because they’re going through these developmental windows when their bodies are more sensitive to the effects. Exposure early in life, can actually set up lifelong metabolic and physiological changes. So avoiding early exposure to substances associated with unhealthy biological processes is��a really good opportunity to set kids on a trajectory to a healthy life as opposed to problems.����

Also, taste preferences get set early in life. There’s evidence that kids who are exposed to more sweetness will develop a lifelong preference for sweetness, and that sets them up to either consume more sugar or non-sugar sweeteners. And children don’t make choices for themselves. They’re more vulnerable, so we have to do more to protect them from any kind of thing that’s going to jeopardize their health.��

That leads me to another thing that’s a little scary. The USDA released preliminary guidelines about the amount of added sugar that can be served in school foods and meals. The guidelines say that by 2027, no more than 10% of the calories in school food can come from added sugars, which is consistent with the US dietary guidelines. That’s great, but then I worry that the food industry will put more NSS in the foods available at schools, and kids’ exposure will go up.����

You highlight other countries, most notably Chile, that require food manufacturers to be transparent about the type and amount of NSS in their products. Do you see that as an effective strategy in the U.S.?��

JK: Chile is one of the few countries that requires the amount of non-sugar sweetener to be put on labels of their food products. I think that’s a great idea, and I would love to see that happen in the U.S.��

Another approach, short of putting the actual quantitative amounts on nutrition labels, is putting labels indicating the presence of NSS on the front of packages, which is what Mexico, Colombia and Argentina have done. Many countries, predominantly in Latin America, have put front-of-package labels warning about added sugars, salt and saturated fat, which are three ingredients of public health concern. Mexico, Colombia and Argentina have added a fourth, warning that the products contain these non-sugar sweeteners and that children should avoid them. That’s probably not going to happen in the U.S. anytime soon given industry opposition and slow action by the FDA.��

There’s more potential for either FDA or USDA to require more transparency by the food industry. I could see them saying that manufacturers must disclose how much and what types of non-sugar sweeteners are in their products to a database that could be made available to researchers. It could also help if federal agencies or nutrition groups and nonprofits take this data and package it in a way to make it accessible to consumers who want to know how much of this stuff is in there. It could increase the public’s ability to access that information, and those who are really motivated might make choices about what to buy or not buy.��

And finally, let’s protect children. There’s no place for NSS in foods commonly consumed by or marketed to kids. Until we have reliable data that NSS are safe for children, let’s do all we can to make sure they do not consume them.��

For more information, contact Krieger at jwkrieg@uw.edu.

When schools closed during the first year of the pandemic, an immediate and potentially devastating problem surfaced: How would millions of children in struggling families get the school meals many of them depended on?

The U.S. Congress responded by authorizing the Department of Agriculture to roll out two major programs. It launched the “grab and go school meals,” which helped schools provide prepared meals for off-site consumption and distributed funding for the state-operated Pandemic EBT (P-EBT) program, which gave parents debit cards so they could purchase groceries from food retailers.

A new study led by the Harvard and 91̽�� schools of public health found that the programs reached more than 30 million children and either directly provided meals or, through the P-EBT program, cash for nearly 1.5 billion meals a month in 2020.

In the new study , the researchers found:

• The P-EBT program reached 26.9 million of the 30 million children whose families qualified because of low income at a cost of $6.46 per meal, providing access to 1.1 billion meals a month.
• The grab-and-go program reached 8 million children not eligible for P-EBT at a cost of $8.07 per meal, providing 429 million meals a month.

“When schools had to close across the country during the spring of 2020 due to COVID-19, kids all of a sudden lost access to school lunches and breakfasts. From a public health and nutrition security��perspective, this was an urgent concern, given that these meals are critical for students at risk of food insecurity and are also an essential source of nutrition for millions of children,” said , study lead author and assistant professor of public health nutrition at Harvard.

Kenney said when these programs began, no one really knew how effectively they would reach kids who needed them and at what cost per meal. So the researchers set out to try to answer how these two major policy responses to the loss of regular school meal access worked.

“This study suggests that, in many states, P-EBT can reach the most eligible children at relatively low cost to the government, while a meal distribution model such as grab-and-go school meals can also ensure families directly receive meals and reach children beyond those who are P-EBT-eligible,” said , senior author and clinical professor of health systems and population health in the 91̽��School of Public Health.

Now, Krieger said, extensions of these two key projects are being debated in Congress. On July 27, the House Education and Labor Committee sent its 2022 Child Nutrition Reauthorization bill (H.R. 8450), the ““ to the House floor.

In the following Q&A, Krieger and Kenney discuss what their findings mean for this or similar policy.

What would the new “kids act” do?

Krieger: The act proposes a comprehensive, science-driven reauthorization of federal child nutrition programs that meets the needs of children and families. It includes many familiar and essential programs, such as school meals and the WIC program. It would address food insecurity among children during the summer, when schools are closed, by significantly expanding access to summer meals and creating a nationwide Summer-EBT program. The Summer-EBT program would operate similarly to P-EBT in many ways and provide $75 per month per household on an electronic debit card. It supports school efforts to increase access to summer meals using methods that worked in the grab-and-go school meals program during COVID school closures.

Based on your findings, what should Congress do for kids?

Krieger: Our study offers evidence that these components of the proposed act — an EBT program to distribute the value of school meals, similar to the proposed summer-EBT program, combined with expanded distribution of meals in the community, similar to the expanded summer meals program— were effective in feeding millions of children when schools were closed due to COVID and suggests that they will also likely be effective in delivering food to children during school summer recess. Including both programs in the act would help to assure food access when schools are closed during summer breaks.

Kenney: An important takeaway from our study that may be relevant for the conversation about the Healthy Meals, Healthy Kids Act is that these should be considered together, as a two-pronged strategy. The two approaches complement one another: P-EBT can help make sure that at least the cash value of those missed meals can get out to low-income families efficiently, and grab-and-go meals can ensure that families who may be struggling but may not have a low-enough income to qualify for P-EBT can still get meals. They can also ensure that families who may have more difficulty preparing food — like families experiencing homelessness or with limited kitchen facilities, or even just with limited time — can access nutritionally adequate meals.

What else should Congress consider?

Krieger: The federal government should be investigating strategies for optimizing the cost-effectiveness of grab-and-go school meals. It should also expand the P-EBT program or its equivalent to cover 60 meals per month instead of 40 to match the grab-and-go school meals benefit level. And, it should work to optimize the nutritional quality of the foods provided.

Co-authors include Lina Pinero Walkinshaw and Jessica Jones-Smith, 91̽��Department of Health Systems and Population Health; Ye Shen and Sara Bleich, Harvard T.H. Chan School of Public Health; and Sheila E. Fleischhacker of the Georgetown University Law Center. This research was funded by the Robert Wood Johnson Foundation.

###

For more information, contact Kenney at ekenney@hsph.harvard.edu or Krieger at jkrieger@hfamerica.org.

Sugar-sweetened beverages are a known contributor to several health issues, including poor diet quality, weight gain and diabetes. While several studies have shown that taxing sweetened beverages significantly reduces purchasing, questions have been raised about whether the taxes place a greater economic burden on lower-income households.

New research from the 91̽��, , addressed the issue by examining the economic equity impacts of sweetened beverage taxes in three cities: Seattle, San Francisco and Philadelphia.

“Sugar-sweetened beverages are the new tobacco,” said , senior author and clinical professor of health systems and population health in the 91̽��School of Public Health. “Public health researchers and others have been working for some time to reduce sales of these beverages. Taxes worked well to reduce tobacco purchases, and they’ve been applied and appear to work equally well in sugary drinks.”

The study showed the tax paid by households accounted for a larger proportion of income for lower-income households, but still only 0.01% to 0.05%. The annual per capita dollar amount that households paid toward the tax, between $5.50 and $31, didn’t differ by income level.

The researchers also found that sweetened beverage taxes redistributed dollars from higher- to lower-income households. More dollars went toward funding programs that benefit lower-income communities than those households paid in taxes. The annual net benefit to lower-income communities ranged from $5.3 to $16.4 million per year across the three U.S. cities.

“Cities have prioritized funding programs that benefit lower-income populations, which makes sweetened beverage tax policies more economically equitable,” Krieger said.

For example, revenue raised by has been used to fund programs and services that increase access to healthy food and support child health and learning in early childhood. In 2020, sweetened beverage tax revenue was also used to provide support to communities disproportionately impacted by the COVID-19 pandemic.

The researchers studied the volume of beverage purchases made in stores by 1,141 households in the three U.S. cities to estimate taxes paid by households during the first year after tax implementation. They then used city population data to calculate the per capita amount of sweetened beverage tax paid by income level.

The authors also reviewed public documents and contacted city representatives to find the dollar amount of annual tax revenue and the amount invested in programs serving lower-income communities.

“There aren’t a lot of studies right now that look at actual household purchases of these taxed beverages,” said co-lead author , 91̽��associate teaching professor of economics. “They mostly look at retail-level data. But you don’t know what people are doing at a household level. They could be going to another city to buy their sweetened beverages and bringing them back to Seattle. This study catches all of that. We’re just looking at households that live in these cities and the totality of everything they report having purchased.”

The study shows that sweetened beverage taxes “can be an economically progressive policy,” Krieger said. Seven local jurisdictions in the United States, the Navajo Nation and at least 45 other nations have implemented sweetened beverage taxes.

“These taxes selectively and specifically benefit people with lower incomes to a greater extent than people with higher incomes, because the money that’s raised by taxes goes toward programs serving lower-income communities,” Krieger said. “That’s from the economic point of view.

“The taxes also benefit people with lower incomes because they drive down consumption more and sales more for that population. People will consume less of an unhealthy product and they’ll be healthier because of that. It’s a win for health, it’s a win for the pocketbook and it’s a win for their communities.”

, 91̽��associate professor of health systems and population health and of epidemiology, was a corresponding author and co-principal investigator.

Other co-authors from the 91̽��were , clinical instructor of health systems and population health; , senior research scientist in the Center for Studies in Demography and Ecology, , affiliate associate professor of urban design and planning; and , who recently graduated with a master’s degree in epidemiology. , associate professor at the University of Pennsylvania Perelman School of Medicine, was also a co-author.

The study was funded by the Robert Wood Johnson Foundation’s with partial support from an NICHD grant to the at the 91̽��.

For more information, contact James Krieger at jkrieger@hfamerica.org and Melissa Knox at knoxm@uw.edu.

Correction on 7/13: A previous version of this story said that the annual net benefit to lower-income communities ranged from $5.3 to $19.1 million per year across the three U.S. cities. The latter number is actually $16.4 million.

The UW-led study set out to assess the effect of culturally tailored countermarketing messages on drink choices, similar to stark anti-smoking campaigns, and involved more than 1,600 Latinx parents who participated by joining Facebook groups. Study authors focused on this demographic because Latinx children have a , and the beverage industry , said Dr. , lead author and clinical professor of health systems and population health in the 91̽��School of Public Health.

“The negative health effects associated with the consumption of sugary drinks — such as tooth decay or, later in life, diabetes — are disproportionately affecting this community,” Krieger said. “We want these and other kids to be able to avoid developing strong taste preferences for a product that’s ultimately going to harm them.”

To design their study, , researchers consulted focus groups involving dozens of Latinx parents from across the country to get their perceptions of how marketing works, how they think about what they are buying for their children, as well as how to culturally tailor messages that would resonate in their community.

“They know that targeted marketing happens all the time in the digital era, but what really got them was the fact that they were given deceptive information that they felt was leading them to make unhealthy choices on behalf of their kids,” Krieger said.

That industry marketing, Krieger added, led parents to believe fruit drinks are healthy beverages by creating a “halo of health” around the product. Ads, labels, and even online games and cartoons often contain claims about nutrients such as vitamin C and images of healthy kids drinking their products while participating in sports.

With information from those focus groups and the aid of a Latinx marketing firm, the researchers created countermarketing graphics and messages in Spanish and English designed to elicit outrage, fear of the harmful effects on children and other negative emotions. The messages called out specific brands and images, along with describing the adverse effects of these products.

“We looked at anti-tobacco messages and the words and types of images they used,” Krieger said. “We wanted messages that would appeal to folks on an emotional level as well as a cognitive one, because that’s what research shows drives people to make choices.”

The researchers then enrolled 1,628 Latinx parents — predominantly female and from lower-income households — to participate in Facebook groups for six weeks to study the impact of countermessages on those parents’ beverage choices and fruit drink perceptions.

Sample messages

Message text: Your body turns sugar you drink into fat which can result in diabetes.

Message text: WARNING: Calling it natural does not make it good for your kids.

Message text: Activate your kid’s health by giving them thirst quenching water instead of sugary fruit drinks. The choice is clear.

The study divided parents into three groups. The two “intervention” groups were those who received fruit drink countermessages only, and those receiving a combination of countermessages plus water promotion messages. The third group, the control group, saw safety messages about car seats. Using a simulated online store that offered fruit drinks, soda, water, milk or 100% fruit juice, parents from all three groups chose a drink for their kids and received money they could use to buy the drink in a real store.

The researchers found that parents who saw countermarketing messages alone or combined with pro-water messages were less likely to buy a fruit drink and more likely to buy water. Specifically, parents in the fruit-drink countermarketing group decreased their virtual purchases of these drinks by 31% compared to the control group, and by 43% by the group receiving the combined messages. Parents in the combination group did choose water more often than the first group.

Based on those choices, the authors estimated that children in the combination group consumed 22% less added sugar than the average for children two- to five-years-old. In exit surveys, the authors wrote, the parents in both intervention groups were also “significantly” less likely to trust fruit drink brands.

The researchers said the study is the first to “demonstrate the efficacy of countermessages delivered solely via social media as well as the first to specifically target sweetened beverage consumption among young children.” As a result of this study, the researchers have also created for use by anyone to campaign against fruit drink purchases for children.

As executive director of and with an extensive background in the development and evaluation of community-based chronic disease prevention programs, including a stint with Public Health-Seattle & King County, Krieger hopes the study will be used widely to curb consumption of sugary fruit drinks.

“For me, there’s no point in doing a study if it is not going to be applied to changing things in the world, so we’ve formed an advisory group and created the toolkit and a plan to reach out to national organizations and encourage them to use the messages,” Krieger said.

Co-authors include Taehoon Kwon, who worked on the study while a 91̽��graduate student in economics; Rudy Ruiz, of Interlex, a multicultural advocacy marketing agency��in San Antonio; , a clinical instructor in the 91̽��School of Public Health; and Jiali Yan and Christina Roberto at the University of Pennsylvania. This research was funded by the Healthy Eating Research Program of the Robert Wood Johnson Foundation; and the Arcora Foundation, the foundation of Delta Dental of Washington.

###

For more information, contact Dr. Krieger at jwkrieg@uw.edu.