consumer attitudes, nutrition knowledge and...
TRANSCRIPT
Faculty of Bioscience Engineering
Academic year 2011 – 2012
Consumer attitudes, nutrition knowledge and use of
nutrition information on food labels of soft drinks among
Belgian adults
RENATHA PACIFIC
Promoter: Prof. dr. ir. Wim Verbeke
Co-promoter: Dr. ir. Christine Hoefkens
Tutor: Ir. Ellen Van Loo
Master dissertation submitted in partial fulfillment of the requirements for the
degree of Master of Science in Human Nutrition and Rural Development,
Main subject: Human Nutrition
i
COPYRIGHT
“All rights reserved. Permission from the author and the promoters is granted to use this
Master’s Dissertation for consulting purposes and copying of parts for personal use. However,
any use fall under the limitations of copyright regulations, particularly the stringent obligation
to explicitly mention the source when using parts out of this Master’s dissertation”
Ghent University, 24
th August, 2012
Promoter Co-promoter
Signature Signature
Prof. dr. ir. Wim Verbeke Dr. ir. Christine Hoefkens
Email- [email protected] Email- [email protected]
Tutor: ir. Ellen Van Loo
Author
Renatha Pacific
Email- [email protected]
ii
ABSTRACT
Introduction: Health problems have been increasing as a result of excessive soft drink
consumption over the past 3 decades in western countries. Increased sweet taste preference,
advanced technology and reasonably cheap prices of soft drinks are contributing factors for this
increased consumption. Yet to our understanding it is not well established what are Belgian
adults’ nutrition knowledge and attitude towards soft drink consumption, their level of, and
whether and how they use nutrition information on soft drink labels and accept policy measures
regarding reduction of soft drink consumption.
Objective: This study aimed at assessing Belgian consumers’ attitude, nutrition knowledge, use
of nutrition information on soft drink labels and their acceptance of policy measures set by the
government in an effort to reduce soft drinks consumption.
Methodology: A cross-sectional online survey was carried out among Belgian adults through
an existing consumer panel for adults during the period of February to March 2012. A total of
507 subjects aged between 17-85 years were involved in this study. A comprehensive structured
questionnaire was developed for data collection. Data involved descriptive statistics (frequency
distribution), data reduction (cronbach’s alpha test, factor analysis), data segmentation (cluster
analysis) and bivariate statistics (correlations, chi-square tests, independent t-tests, Kruskal
Wallis, Mann-Whitney and one factor ANOVA).
Results: General consumption of soft drinks among Belgian adults was low, on average to
around once a week. Age, BMI and occupation were found to associate with consumption of
soft drinks in this study (P<0.05). Objective nutrition knowledge was higher in heavy light soft
drink consumers and in adults (30-50 years and 17-30 years) (P<0.05). Subjective nutrition
knowledge did not associate with many variables. A more positive attitude towards soft drinks
consumption was found in heavy users of both light and regular soft drinks, also in obese people
and young adults (17-30 years) compared to other groups (all P-values <0.05). Use of nutrition
information was high in the age group of between 30-50 years and heavy light users. Policies
aiming at information provision were more accepted than policies aiming at limiting availability
of soft drinks. Adults, retired, non users of soft drinks and highly educated people were more
supportive to policies. Finally attitude towards sweeteners used in soft drinks were found to be
rather low.
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Conclusion: Provision of adequate information especially informative policy measures about
soft drinks will be useful in raising awareness and nutrition knowledge of adult’s soft drink
consumers. Further nutrition interventions should focus on young adults (17-30years) who were
found to be high consumers of soft drinks with a more positive attitude and low acceptance of
policy measures. Adults in collaboration with educators and health professionals should play a
significant role to influence behavioral change in younger age. Furthermore addressing
environmental cues related to soft drinks consumption is necessary.
iv
ACKNOWLEDGEMENT
First and foremost, I’m so grateful to almighty God who showed me the right way to walk in
my life.
Special thanks to Prof. dr.ir. W. Verbeke and his research team for accepting me as their student
and guiding me throughout the thesis work, without them this work would not have been
completed.
My sincere thanks are devoted to dr.ir Christine Hoefkens for her tireless assistance, guidance,
discussions and constructive ideas, you are truly inspired Christine, I just cannot find suitable
words to express what I mean, but you have been the best coach to me through which I gained
experience and skills. Cannot also forget to mention ir. Ellen Van Loo for her supporting ideas
and comments on this work. May almighty God bless you all abundantly?
Many thanks to my sponsors VLIR-OUS for their financial support and trust on me, without
them I wouldn’t have managed to follow MSc. Program at Ghent University.
Deep gratitude to my lovely husband Yohane P. Mwampashi for his encouragement, love and
moral support in all situations I faced during my studies. Above all for his tolerance and
carrying multiple tasks of family and his own career during the whole period of my studies.
Thank you very much for listening and understanding.
Special thanks are also devoted to my beloved mother, Antusa Valery who laid down the
foundation of my education with a lot of sacrifices. For sure I cannot pay you ‘mom’ but God
knows how deeply I appreciate what you have done to me throughout my life.
Moreover I would like to thank my children, Dayana, Jackline and Herieth for their tolerance
and patience during the whole period of my absence. Also to my brother Peter Pacific for his
encouragement and advice.
Last but not least, many thanks to all friends, relatives, classmates and all who supported and
helped me in one way or another during the entire course of my studies.
Ghent, August 24th
, 2012
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DEDICATION
This work is dedicated to my husband Yohane P. Mwampashi and to my children Dayana,
Jackline and Herieth, for your tolerance, patience and encouragement.
To my mother, Antusa Valery, for giving up a lot of your own life and belongings for me to
reach where I’m today. May God grant you long life so that you deeply enjoy the fruits of what
you sow.
and
To my late father Pacific P. Mchongi who also played a special role in our life, but he left us so
early, although you have gone to eternal life daddy, you are still locked up in our hearts.
May the Almighty God rest your soul in heavenly peace.
Amen!
vi
TABLE OF CONTENTS
COPYRIGHT ............................................................................................................................................... i
ABSTRACT ................................................................................................................................................ ii
ACKNOWLEDGEMENT ......................................................................................................................... iv
DEDICATION ............................................................................................................................................ v
TABLE OF CONTENTS ........................................................................................................................... vi
LIST OF FIGURES .................................................................................................................................. viii
LIST OF TABLES ..................................................................................................................................... ix
LIST OF ACRONYMS ............................................................................................................................... x
CHAPTER 1: INTRODUCTION ............................................................................................................... 1
1.1. Background information................................................................................................................... 1
1.2. Problem statement ............................................................................................................................ 2
1.3. Objectives of the study ..................................................................................................................... 3
1.3.1. General Objective ...................................................................................................................... 3
1.3.2. Specific objectives ..................................................................................................................... 3
1.4. Research questions ........................................................................................................................... 4
CHAPTER 2: LITERATURE REVIEW .................................................................................................... 5
2.1. Definition of soft drinks ................................................................................................................... 5
2.2. Classification of sweeteners used in soft drinks ............................................................................... 6
2.3. Socio-demographic and attitudinal characteristics of regular and light soft drinks consumers ....... 7
2.4. Consumption of soft drinks in Europe ........................................................................................... 10
2.5. Effects of regular and light soft drink consumption on health ....................................................... 11
2.6. Nutrition knowledge and use of nutrition information on food labels ........................................... 12
2.7. Association between socio-demographic characteristics and use of information to reduce soft
drink consumption ................................................................................................................................. 14
2.8. Initiatives focusing on reducing soft drinks consumption .............................................................. 16
CHAPTER 3: METHODOLOGY............................................................................................................. 19
3.1. Study population ............................................................................................................................ 19
3.2. Measures......................................................................................................................................... 22
3.2.1. Questionnaire on consumption patterns .................................................................................. 22
3.2.2. Subjective nutrition knowledge regarding soft drinks ............................................................. 23
vii
3.2.3. Objective nutrition knowledge regarding soft drinks .............................................................. 24
3.2.4. Questions on policy measures to reduce soft drink consumption and information use ........... 24
3.2.5. Questions on attitudes and consumption habits ....................................................................... 25
3.2.6. Question regarding consumers’ opinions on sweeteners ......................................................... 25
3.2.7. Questions on personal characteristics ...................................................................................... 26
3.3. Data analysis .................................................................................................................................. 26
3.3.1. Descriptive statistics ................................................................................................................ 26
3.3.2. Checking for assumptions ....................................................................................................... 27
3.3.3. Univariate statistics ................................................................................................................. 27
3.4. Limitation of the study ................................................................................................................... 27
CHAPTER 4: RESULTS AND DISCUSSION ........................................................................................ 29
4.1. Consumption characteristics of regular and light soft drink users ................................................. 29
4.1.1. Frequency of consumption ...................................................................................................... 29
4.1.2. Locations for soft drinks purchases ......................................................................................... 29
4.1.3. Soft drinks used as alternative and occasions for consumption .............................................. 30
4.2. Socio-demographic differences among soft drinks users ............................................................... 32
4.3. Objective and subjective nutrition knowledge ............................................................................... 35
4.3.1. Objective nutrition knowledge ................................................................................................ 35
4.3.2. Subjective nutrition knowledge ............................................................................................... 37
4.4. Attitude of participants towards soft drink consumption ............................................................... 39
4.4.1. General attitude towards consumption of soft drinks .............................................................. 39
4.4.2. Attitude towards consumption of regular soft drinks .............................................................. 39
4.4.3. Attitude towards consumption of light soft drinks .................................................................. 40
4.5. Use of nutrition information on food and soft drinks ..................................................................... 43
4.6. Acceptance of policy measures to reduce soft drink consumption ................................................ 45
4.7. Consumers attitudes towards sweeteners used in soft drinks ......................................................... 49
CHAPTER 5: CONCLUSION AND RECOMMENDATIONS ............................................................... 51
5.1. Conclusion ...................................................................................................................................... 51
5.2. Recommendations .......................................................................................................................... 52
REFERENCES .......................................................................................................................................... 54
viii
LIST OF FIGURES
Figure 1. Theory of planned behaviour...............................................................................9
Figure 2. Percentage of participants on dieting ..................................................................21
Figure 3. Percentages of participants and family members with health related problems...21
Figure 4. Percentages of consumer’s acceptance on policy measures ................................48
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LIST OF TABLES
Table 1. Selected soft drinks, their description and examples...............................................6
Table 2. Sugar and energy contents of selected carbonated sugar sweetened soft drinks......7
Table 3. Description of the final sample..............................................................................20
Table 4. Initial cluster centers……………………………………………………………..23
Table 5. Consumption characteristics of soft drink user groups..........................................31
Table 6. Socio-demographic differences among soft drink users .......................................34
Table 7. Objective nutrition knowledge about soft drinks of participants in relation
to selected variables.............................................................................................................36
Table 8. Subjective nutrition knowledge about soft drinks of participants
in relation to selected variables...........................................................................................38
Table 9. Attitude towards soft drink consumption...............................................................41
Table 10. Use of nutrition information on food and soft drinks labels................................44
Table 11. Policy acceptance of the respondents against the tested variables......................47
Table 12. Consumers’ attitudes towards sweeteners used in soft drinks.............................50
x
LIST OF ACRONYMS
ADI Acceptable Daily Intake
ANOVA Analysis of Variance
BMI Body Mass Index
CIAA
EAS
EC
Confederation of the Food and Drink Industries
European Advisory Services
European Commission
EU European Union
HFCS High Fructose Corn Syrup
GDA Guideline Daily Amounts
NFP Nutrition Facts Panel
Q-Q-Plots
SDs
Quantile-Quantile Plots
Standard Deviations
SSB Sugar Sweetened Beverages
SPSS Statistical Package for Social Science
TPB Theory of Planned Behaviour
TV Television
USA United States of America
WHO World Health Organization
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CHAPTER 1: INTRODUCTION
This chapter presents background information of the study, the problem statement, overall and
specific objectives and research questions.
1.1. Background information
Diet-related diseases such as cardiovascular diseases, obesity, type II diabetes and cancer are
now diagnosed across the world and have a significant effect on public health. One of the
critical components in the shift of diets is the increased intake of soft drinks and sugary fruit
drinks (Popkin and Nielsen, 2003). High consumption of sugar sweetened beverages, especially
carbonated soft drinks, increases the risk of overweight, obesity (Malik et al., 2006), heart
diseases as well as tooth decay (Roos and Donly, 2002). They contain high amounts of energy
due to high sugar contents in the form of fluid which often do not give satiety in the same way
as solid foods do (Brownell et al., 2009; Elfhag et al., 2007; Malik et al., 2006). Obesity and
overweight in the European region especially to school children was estimated to be 31.8% by
the year 2006 and predicted to increase to 38.2% by the year 2010 (Fussenegger et al., 2007). In
the United States of America, one third of the adults are obese which is linked to the
consumption of sugar sweetened beverages. Energy intake from the consumption of soft drinks
increased by 135% from 1977 to 2001, thus doubling the prevalence of obese adults (Bleich et
al., 2009).
The carbonated soft drink market in Belgium represented a compound growth rate per annum of
2% between the year 2007 and 2011 (Market line, 2012). It was estimated that on average, the
intake of carbonated beverages in Europe was around one can per day, while for Dutch boys it
was estimated to be two cans per day (Renwick and Nordmann, 2007) and the total volume of
consumption in Western and Eastern Europe rose by 12.7% and 23% respectively in 2007
(Hawkes, 2010).
Soft drinks have become the largest beverage sector worldwide and they are slowly overtaking
the hot drinks sector. Since the introduction of soft drinks in the market in 1830, it is difficult to
ignore their existence. Instead, they are among the popular products today (Lazim and Hasliza,
2011). The consumption and popularity of soft drinks has been increasing steadily due to
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increased strong preference to palatable sweet taste, at a reasonably low price (Sartor et al.,
2011). In addition the presence of advanced production technologies contribute to this
popularity (Lazim and Hasliza, 2011).
Nutritional information on food labels is believed to help consumers make informed food
choices. Although consumers may be interested in nutrition labelling, it does not mean that they
will use the information (Hoefkens et al., 2011). Some other aspects such as taste, price and
some nutrients like fat, energy, salt and sugar have been reported to draw more interest from
consumers (Hoefkens et al., 2011). The present study examined if consumers have nutrition
knowledge about soft drinks and how often they use the nutrition information given on food
labels of light and regular soft drinks. It also assessed the attitude of Belgian adults towards
consumption of regular or sugar sweetened and light or diet soft drinks. The study also aimed at
finding relations between the consumption of soft drinks and demographic characteristics such
as gender, BMI, education, income, family composition and occupation. Last but not least the
study examined consumer acceptance of policies put by the government to reduce soft drink
consumption and consumers’ opinion on sweeteners used in soft drinks.
1.2. Problem statement
Nowadays there are tremendous varieties of foods in European markets including high energy
giving foods and drinks that are considered to be the cause of energy intakes above the
individual requirements. If the energy intake is higher than expenditure, over a longer period of
time an individual gains weight and becomes overweight or obese (Ocke et al., 2009). A
previous study in Belgium showed that the consumption amounts of energy-dense nutrient-poor
foods (mostly soft drinks, alcohol and snacks) were excessively (about 481g/d) deviating from
Belgian dietary guidelines (Vandevijvere et al., 2008). This contributes to excessive weight
gains which are a risk factor to overweight, obesity and diabetes. A number of studies showed
that the consumption of regular (sugar sweetened) soft drinks was linked with a higher
prevalence of health problems like childhood obesity and overweight, lower bone mineral
density and incidence of multiple metabolic risk factors (Cuco et al., 2003; Dhingra, et al.,
2007; Gartland et al., 2003; James et al., 2004; Ludwig et al., 2001; Schulze et al., 2004).
However most of these studies focused on the consumption of soft drinks by children and
adolescents. Studies focusing on adults are limited, that is why this study found the necessity to
3
investigate adult’s consumption behaviours regarding soft drinks. The study also will help to
identify Belgian adults who are heavy consumers of soft drinks. In so doing appropriate
preventive measures can be suggested to rescue them from adverse health effects resulting from
excessive soft drinks consumption. On the other hand, once established that adults have high
nutrition knowledge on consumption of regular and light soft drinks, then it is hypothesized
that, they will act as tools to guide and influence behavioural change to children and adolescents
towards consumption of regular soft drinks. Therefore lessen diet related problems and
promoting consumers’ health and well being.
Therefore this study focuses on adults and evaluates their attitude, nutrition knowledge, their
use of nutrition information on soft drinks, policy measures to reduce soft drink consumption
and their opinion regarding sweeteners use. The findings obtained from the study will also be
useful for food industries and companies to formulate new products and/or to modify existing
products of soft drinks based on consumers’ preference. The findings can also help to improve
nutritional labels and make the purchasing environment more convenient to consumers.
1.3. Objectives of the study
1.3.1. General Objective - the general objective of this study is the assessment of consumers’
attitudes and nutrition knowledge regarding soft drinks, policy acceptance, opinion regarding
sweeteners and use of nutrition information on food labels of regular and light soft drinks.
1.3.2. Specific objectives
i) To determine consumption characteristics of regular versus light soft drinks
ii) To examine the objective and subjective nutrition knowledge of consumers with
regard to soft drinks
iii) To assess consumers’ attitudes towards consumption of regular and light soft drinks
iv) To identify the use of nutrition information on soft drinks and public acceptance of
policy measures to reduce soft drinks consumption.
v) To assess consumers’ attitudes and/or opinions regarding sweeteners used in soft
drinks.
4
vi) To assess if there is an association between consumers’ attitudes towards
consumption of soft drinks and demographic characteristics including Body Mass
Index.
1.4. Research questions
The following research questions will be investigated in respect of the stated objectives of
the study.
i) What is the consumption frequency of soft drinks among Belgian adults?
ii) What is consumers’ subjective and objective knowledge with regard to soft drinks?
iii) What is the attitude of consumers towards consumption of soft drinks?
iv) Do respondents use nutrition information given on labels of soft drinks and what is
their acceptance of various government policies to reduce soft drink consumption?
v) Do consumers have different attitudes and/or opinions regarding sweeteners used in
soft drinks.
vi) Are the nutrition knowledge and attitudes regarding soft drinks and consumption of
soft drinks different among different demographic groups and between light and
regular soft drinks consumers?
5
CHAPTER 2: LITERATURE REVIEW
This chapter presents the review of the literature which is organized based on the objectives of
the study and research questions. The chapter discusses the following items: (i) Definition of
soft drinks (ii) Classification of sweeteners used in soft drinks (iii) Socio-demographic and
attitudinal characteristics of regular and light soft drinks consumers (iv) Consumption of soft
drinks in Europe (v) Effects of regular and light soft drinks consumption on health (vi) Nutrition
knowledge and use of nutrition information on food labels (vii) Association between socio-
demographic characteristics and information use to reduce soft drink consumption (viii)
Initiatives focusing on reducing soft drinks consumption and consumers’ opinions. This chapter
ends up with research hypotheses.
2.1. Definition of soft drinks
There are several definitions for soft drinks. Generally soft drinks are non-alcoholic beverages
containing basically water, a flavouring agent and a sweetener (Hu and Malik, 2010). Soft
drinks are composed of 100% carbohydrates, with no protein and fats (low in cholesterol and
saturated fats). They also have phosphoric and/or citric acids, flavouring agents and carbonated
water. A major ingredient in soft drinks is sugar and often high amounts of caffeine. On average
one can of soda (355ml) has about 40g of sugar which corresponds to 10 teaspoons. Soda is
named based on the use of bicarbonate of soda from which carbonation is produced (Nathe et
al., 2005). According to USA data one can of soda per serving gives 150Kcal and 40-50g of
sugar in the form of high-fructose corn syrup (Malik, et al., 2006). Sugar sweetened soft drinks
can be defined as carbonated or non carbonated water based beverages that contain sugar (Van
der Horst, et al., 2007) or natural sweeteners like table sugar (sucrose), high fructose corn syrup
and concentrates of fruit juice (Brownell, et al., 2009). Examples of sugar sweetened beverages
are: carbonated beverages, fruit drinks, iced tea, lemonade, red bull, sunny delight orange
flavour, sport drinks, energy drinks, sweetened coffee and tea (Hu and Malik, 2010). This study
will focus on carbonated soft drinks such as soda varieties (Coca-cola, Pepsi, Sprite, Fanta e.t.c)
both light and sugar sweetened beverages. Regular (drinks with added sugars) and light soft
drinks (drinks with no sugar) are terms which will be used in this study.
6
Table 1. Selected soft drinks, their description and examples.
Type of soft drink Description Examples
Fruit juice Contains 100% pure fruit juice +
minerals and vitamins
Apple juice, grape juice, orange juice, peach
juice
Carbonated drinks Any effervescent soft drinks aerated
with carbon dioxide
Sodas such as; Coke, Sprite and Pepsi
Fruit drink Fruit flavoured drinks, not actual fruit
juice, basically contains sugar and water
Fruit blend, punches fruit nectars with
beverage added sugar, apple drink, orange
drink
Sugar sweetened
soft drinks
Carbonated or non-carbonated drink
containing sugar, natural sweetener or
High Fructose Corn Syrup (HFCS) and
concentrates of fruits
Sweetened sodas, Iced tea, lemonade, red
bull, sunny delight orange flavour, sport
drinks, energy drinks, sweetened coffee and
tea
Light soft drinks Carbonated or non-carbonated drink
with no sugar and calories, but with
artificial sweetener
Light sodas, coffee, tea
Sources: http://www.californiaprojectlean.org, Hu and Malik (2010)
2.2. Classification of sweeteners used in soft drinks
Sweeteners can be classified into two basic classes: (1) those providing energy, referred as bulk
or caloric sweeteners (Hu and Malik, 2010), which are mainly used in regular/sugar sweetened
soft drinks and (2) non energy sweeteners, referred as intense or artificial sweeteners, which are
used in light/diet soft drinks. Caloric/bulk sweeteners include High Fructose Corn Syrup
(HFCS), sucrose/table sugar and fruit juice concentrates (Hu and Malik, 2010). HFCS is a major
sweetener used in USA (Popkin and Nielsen, 2003). Intense sweeteners that are authorised in
soft drinks in the European Union are saccharin, cyclamate, acesulfame K, aspartame,
neohesperidin, thaumatic. However, the European Commission (EC) has proposed the use of
reduced concentrations of cyclamates in soft drinks (Arcella et al., 2004). Intense sweeteners
are believed to be safe for health although they have a bitter after taste, for example saccharin
(Grenby, 1991). There is evidence in literature to support the use of intense or artificial
sweeteners instead of bulk or caloric sweeteners, these includes studies by (Arcella et al., 2004)
7
who reported less risk with high intake of intense sweeteners. Hendrickson et al., 2011; Husøy
et al., 2008 and Nahon et al., 1996), reported significance role in substituting sucrose with
intense sweeteners such as aspartame. More details on health impacts are presented under
section 2.5.
Table 2. Sugar and energy contents of some selected carbonated sugar sweetened/regular
soft drinks
Soft drink Sugar content in grams per 12oz
(355ml)
Energy content (Kcal)
Coca-Cola 39 140
Pepsi 41 150
Seven up 39 150
Sprite 38 140
Fanta orange 44 160
Fanta grape, pineapple and
strawberry flavoured
48 180
Sources; http://www.dentistryiq.com, and http://www.livestrong.com
2.3. Socio-demographic and attitudinal characteristics of regular and light soft drinks
consumers
General food consumption behaviour is influenced by consumers’ attitudes towards food and
nutrition (Pieniak et al., 2010). Consumer attitudes can be explained as one’s general evaluation
of a certain product or brand based on his/her assessment of specific characteristics of the
product (Dube et al., 2003). Attitude has components like affective (feelings, sensations,
emotions) which to a food product may entail enjoyment to share food with others or attractive
childhood memories of a particular food. Cognitive involves positive and negative
attributes/characteristics someone attaches to food product (e.g. nutrition value, health effects or
conveniences) which together form attitude towards a product (Dube et al., 2003). Both
cognitive and affective attitudes motivate purchase and consumption of a certain food
(behaviour) (Honkanen et al., (2006).
8
Sweet taste perception of food including soft drinks influences food selection (Sartor et al.,
2011). This perception differ among individuals, others may find a food of given sugar
concentration as extremely sweet while others may identify the same food as not sweet at all
(Renwick and Nordmann, 2007). This author suggested that, the reduction of sweetness in soft
drinks would be important but not useful because consumers will go for products that satisfy
their taste.
It is also reported that about 90% of American adults consumed low energy foods and drinks
regularly because they had positive attitudes to those products, majority of these consumers
were better educated women with higher income (Nabors, 1999). Moreover consumers of diet
soda were more concerned about weight related issues compared to consumers of regular sodas
(Tuorila et al., 1990).
Obese individuals are believed to have high preferences or implicit attitudes towards high
consumption of soft drinks compared to non-obese counterparts. This was revealed by Sartor et
al. (2011) who found that stronger and automatic attraction to sweet taste was observed in obese
people after a one month supplementation of soft drinks, thus genetic and environmental factors
predict taste preference. The author also found that young men had higher liking to sweet taste
compared to women of the same age. He added that, long term exposure to soft drinks
consumption may increase sweet taste threshold in both children and adults. Leptin (hormone
responsible for influencing satiety) levels in human affect sweet taste perception due to central
leptin resistance (Sartor et al., 2011) and poor satiety impact which triggers overconsumption of
high energy dense foods by obese people (Ahrens et al., 2006).
Tak et al. (2011) in his study with adolescents found a positive association between home
environmental factors (such as availability, accessibility, parental modelling and rules), theory
of planned behaviour, habit strength and consumption behaviour of soft drinks among
adolescents. Intention and habit strength mediated the strength of association between home
environmental factors and soft drinks consumption. Parental rules were found to influence
adolescents’ dietary behaviour. Also habit strength associated positively with adolescents’
television viewing and soft drinks consumption (De Bruijn and Van den Putte, 2009).A higher
intention to consume soft drinks also occurs when adolescents become more exposed to soft
drinks, this is the same to children and adults as postulated by Sartor et al. (2011). A related
study by Van der Horst et al. (2008) found a positive link between soft drinks consumption and
9
attitude, subjective norm, intentions, parental and peer modelling among adolescents. Young
females liked diet soft drinks as they contain less energy, but males were found to be sugar
drink users because they were attracted by the sweetness of sugar and not by the energy content
they would obtain or not from sugar (Freeman and Booth, 2010). This result is in line with the
study by Ollikainen and Kultanen (1985) who observed that females had more negative attitude
to sweetness in soft drinks while males had more positive attitude. Tak et al. (2011) used the
theory of planned behaviour (TPB) to explain how soft drink consumption is influenced by
behaviour (Figure 1). According to this theory (Ajzen, 1991) behaviour is predicted by intention
and intention is determined by three components; (1) Person’s attitude in performing a certain
behaviour. (2) Subjective norm which is influenced by social pressure or environment
surrounding a person who is performing a certain behaviour, this includes people who may
approve or disapprove the behaviour and (3) Perceived behavioural control which is the
people’s belief in their ability to control behaviour. Furthermore behavioural beliefs and
evaluation influence attitude. Normative beliefs and motivation influences subjective norm.
Control and perceived power influences perceived behavioural control (Zoellner et al., 2012).
Figure 1. Theory of planned behaviour, a model adapted from Ajzen, I. (1991)
Subjective norm
Perceived
behavioural control
Intention Actual behaviour
Attitudes towards
behaviour
10
2.4. Consumption of soft drinks in Europe
Consumption of soft drinks has increased in western countries over the past 3 decades (Sartor et
al. 2011). Some studies revealed association between soft drink consumption, weight gain and
television viewing these includes; Juan et al. (2011) who reported high food and drink
consumption during television viewing among adolescents in Belgium, Greece, Hungary and
Spain and showed boys had a higher consumption than girls. Van den Bulck and Van Mierlo,
2004; Vereecken and Maes, 2006; Weicha et al., 2006; Verzeletti et al. 2009) found association
between television viewing, consumption of energy dense foods and weight gain, this results
from long exposure to television viewing and misleading messages of food advertisements.
Apart from TV watching soft drinks consumption among adolescents is also associated with
food-related life styles and parental/family rules (Van der Horst et al., 2007 and Verzeletti et
al., 2009). Interventions to reduce/limit soft drinks intake in adolescents will be effective if
television viewing is limited and parents are involved (Verzeletti et al. 2009). Vandevijvere et
al. (2008) reported high intakes of soft drinks by Belgian adolescents ranging from 15-18 years
where the consumption decreased as age increased except alcohol intake which was highest in
older people. A study among schoolchildren within 20 European countries found that, one third
to half of the children (30-48%) drank coke or other soft drinks more than once a day.
Consumptions were high in Israel, Northern Ireland, Scotland, the Slovak Republic and
Flemish-speaking Belgium. Soft drinks consumption was not common in Finland, Sweden,
Norway, Denmark, Latvia and Estonia. Boys drank soft drinks and ate sweets slightly more
often than girls (Kuusela, et al., 1999). Dutch adolescents increased consumption of sugar
sweetened carbonated and non-carbonated soft drinks between the years 1987 and 1998 by
50.2% for boys and by 32.5% for girls (Van der Horst et al., 2007). Referring to Kvaavik, et al.
(2004), the intake of sugar-sweetened carbonated soft drinks from adolescence to early
adulthood (15 to 25 years) and from early adulthood to later adulthood (25 to 33 years) was
moderate to high, while the intake from adolescence to later adulthood was low among
Norwegian adolescents and adults. Brownell et al. (2009) reported high daily consumption of
sugar sweetened beverages in USA in both adults and children to about 175kcal and 172 Kcal
respectively (from data of 2005-2006) leading to increased energy intake from 50 Kcal in 1965
to above 200 Kcal in 2002 (Ventura et al., 2010).
11
2.5. Effects of regular and light soft drink consumption on health
Soft drinks contain high amounts of energy and the ability of the body to compensate energy
from carbohydrate consumed in fluid form is less clear than from carbohydrates consumed in
solid form. This means that sugar in soluble form may fail to trigger satiety in the same way
than solid foods do (Wolff and Dansinger, 2008), thus puts consumers at greater risk of
overweight and obesity (Gibson and Neate, 2007; Malik et al., 2006; Vartanian et al., 2007).
Soft drinks can also affect the diet quality for example it may displace milk consumption, thus
reducing calcium intake from milk which is the main source of calcium, especially in children
(French et al., 2003; Harnack et al., 1999).
Consumption of sugar sweetened beverages (SSB) is associated with weight changes in all ages
although the mechanism may not be clearly understood (James and Kerr, 2005), especially for
those who take one or more drinks per day (Schulze et al., 2004). This is attributed to the excess
intake of energy and large amounts of rapidly absorbable sugars. However, there are little
effects on weight changes for those who decreased consumption of sugar sweetened beverages
(Husøy et al., 2008; Schulze et al., 2004). For example randomized control trial in children in
southwest England showed that there was an increase in overweight and obesity by 7.5% in the
control group who increased their consumption by 0.2 glasses while in the intervention group
overweight and obesity decreased by 0.2% after a decreased consumption of 0.6 glasses (James
et al., 2004). An increase in BMI was also reported by Ludwig et al. (2001) for every additional
serving of sugar sweetened beverage in USA school children. Positive association between
increased intake of sugar sweetened beverages (SSBs) and overweight and obesity was also
reported by Olsen and Heitmann, (2009), as well as Malik et al. (2006) and Hu and Malik,
(2010) through a systematic review of well done cohort studies and Forshee et al. (2008)
through meta analysis study. For adults who decreased intake of SSBs from more than one soft
drink per day to less than one per week had a decreased body weight (Bergen and Yeh, 2006).
Soft drinks consumption of more than one drink a day was linked to a higher prevalence of
multiple metabolic risk factors like obesity, impaired fasting glucose, high blood pressure, more
waist circumference and low density lipoprotein cholesterol (Dhingra, et al., 2007). Also
triglyceride deposition in the liver, insulin resistance and kidney stones (Ventura et al., 2010),
rise in serum uric acid levels (Choi, et al., 2008) due to high fructose intake from SSB. Fructose
12
is believed to cause an increase in uric acid levels leading to a condition called hyperuricemia
resulting to gout disease, an inflammatory arthritis in adult men, (Choi, et al., 2008). Also high
consumption of soft drinks is linked to the increase of coronary heart disease (Fung et al.,
2009), low mineral density in adolescent girls (Gartland et al., 2003) and an increased risk of
type 2 diabetes mellitus (Malik et al., 2010; Schulze et al. 2004)
Sweetened beverages are also reported to increase the risk for dental caries especially in
children. This is due to high sugar content of these beverages and other energy dense foods
which create a sugar-starch combination leading to increased possibility for acidification in the
oral environment (Cinar and Murtomaa, 2009). These drinks also have phosphoric and citric
acids contributing to acidic condition causing dental plague, (Roos and Donly, 2002).
Light or non-energy containing soft drinks are reported to have promising effects on body
weight and food consumption. A decrease in body weight was observed among USA
overweight adult women who increased their consumption of non-energy containing soft drinks
(Fung et al., 2009).
A study done in Norwegian children and adults revealed that, a shift from sugar sweetened
beverages to diet beverages reduced the energy intake to below the recommendation (10%) in
all groups. (Husøy et al., 2008). In addition the shift to diet drinks brings doubt in the fact that
diet soft drinks require a higher amount of benzoic acid as a preservative, Therefore, the intake
of benzoic acid above the acceptable daily intake (ADI) requires further investigation (Husøy et
al., 2008).
A recent review by Weed et al. (2011) on the association between soft drinks and health aspects
such as obesity, type two diabetes, coronary heart diseases and metabolic syndrome, found a
moderately low quality score of the reviews. This is because comprehensive reporting and
systematic methodologies to interpret evidence were underutilized except for very few reviews.
Therefore lack of basic methodologies put review conclusions onto personal subjective opinions
which may obstruct the reader to get a clear and accurate summary of the available evidence.
2.6. Nutrition knowledge and use of nutrition information on food labels
Nutrition knowledge is expected to have an impact on understanding and using of nutrition
information and decision making in general (Grunert et al., 2012). However it is important to
differentiate between subjective and objective knowledge. Subjective knowledge depends on
13
how a consumer attaches meaning to the given label information and what she/he believes to
understand (Grunert and Wills, 2007). Objective knowledge implies that the meaning
consumers attach to the information on nutrition labels for example is in line with the meaning
the sender intends to communicate about it (Grunert and Wills, 2007). Subjective and objective
knowledge lies in the fact that people do not perceive accurately how much or how little they
know (House et al., 2004). Fitzgerald et al. (2008) and Pieniak et al. (2010) argued that
sufficient levels of knowledge, both subjective and objective are required for people to use
reliable information to positively influence their healthier foods choices such as those low in fat
and sugar (Fitzgerald et al., 2008). Thus people with higher knowledge are more likely to use
food labels.
According to this study nutrition knowledge is expected to be an important factor to explain
consumers’ attitudes towards soft drinks, policy acceptance and their opinion regarding
sweeteners used in soft drinks.
Subjective knowledge was negatively associated with the amount of information obtained by
consumers during food purchase decision (House et al., 2004). This author reported significant
variations of levels of objective and subjective knowledge with age, income and education.
Older people with lower incomes and lower education tend to have low levels of both objective
and subjective knowledge. No relation was observed between subjective and objective
knowledge. Nutrition knowledge was found to be higher in females and people with higher
education (Grunert et al., 2012). However the existence of relation between socio-demographic
factors and nutrition knowledge is not indicated by most studies. (Grunert et al., 2012).
In the European context, there are some studies which explored the usefulness of nutritional
labelling information to consumers (Moser et al., 2009) but there is no current insights on how
nutrition information is used by consumers in the real-world shopping situations (Genannt et al.,
2010; Verbeke, 2008). This makes the formulation of new labelling policies and the evaluation
of existing policies more cumbersome (Genannt et al., 2010).
Objective measures showed that actual use of nutrition labelling during shopping may be lower
than what people report. Evidence suggests consumers can understand some of the terms and
become confused by other information given on nutrition labels (Cowburn and Stockley, 2004).
Consumers may also prefer on-pack nutrition information and make undesirable conclusions on
products that lack such nutrition information, but the extent to which they use on-pack nutrition
14
information is not well known (Cowburn and Stockley, 2004). Differences among individuals
on the use of labels may be contributed by personal characteristics like gender, education, age
nutrition and health awareness (Baltas, 2001), also healthy eating interests, nutrition knowledge
and social class (Grunert et al., 2010). Consumers seek for information that help them achieve
more pleasure from food, better diet, avoid allergens, knowing origin of food and necessary
conditions in which food has been produced and processed (Verbeke, 2008).
Cho and Yu (2007) revealed that, Kunsan (Korean) high school girls had generally low nutrition
knowledge and low use of food labels. Nutrition Facts Panel (NFP) are mainly used by almost
58% of American consumers during the first time of food/beverage purchase or when
comparing products with the same prices, however three quarters of these consumers find it
difficult to use NFP information (Wills et al., 2009).
The European Union established a nutrient profiling system to be implemented by food
industries, catering companies and retailing sector in German and Belgium. The Confederation
of the Food and Drink Industries (CIAA) of the EU promoted the use of voluntary nutrition
labelling system based on Guideline Daily Amounts (GDA). The system aimed at providing
energy and macronutrient intake levels people are required to take per day for a healthy diet
(Moeser et al., 2009)
Grunert et al. (2010) reported that, about 16.8% of European buyers read the nutrition
information on the food label and the probability of reading nutrition information on soft drinks
reported to be low.
2.7. Association between socio-demographic characteristics and use of information to
reduce soft drink consumption
Nutrition labelling especially of pre-packed food products is an essential component among the
strategies to reduce obesity and other communicable diseases. Although health benefits are not
caused by nutrition labelling alone, improving the available information could ultimately
increase consumers understanding and help them to make healthy food choices (European
Advisory Services, 2004). World Health Organization (WHO) has adopted a marketing and
nutrition labelling policy in 2004 to lessen the burden of chronic diseases associated with
unhealthy foods. When health friendly logos (illustrations/symbols designed to label healthier
foods) are used in labelling healthy foods, it can promote consumption of these foods (Cinar and
15
Murtomaa, 2009; Moser et al., 2010; Wills et al., 2009) and thus promoting public health (Ali
and Kapoor, 2009).
A study by Fitzgerald et al. (2008) revealed that diabetic patients use food labels to look at
sugar information on the label and prefer artificially sweetened foods over regular sugar
sweetened foods. Finke and Weaver (2003) reported that labelling was an effective means of
assisting consumers to moderate their intake of sugars as there is a significant association
between frequent use of sugar information on food label and reduced consumption of added
sugar density. Vermeer et al. (2010) investigated the effect of labelling portion sizes of soft
drinks and its consumption. The results revealed that consumers preferred soft drinks with small
portion sizes. They concluded that portion size labelling helps consumers to select small sizes of
soft drinks, monitor the amount of intake and reduce their consumption per single sitting
(Vermeer et al., 2010).
It is indicated that female consumers use more labels than male counter parts and old people
limit their use of information about a certain product before making purchasing decision and
they less often look at food labels (Baltas, 2001).
Elfhag et al. (2007) and Zoellner et al., (2012) reported findings that consumption of soft
drinks, especially sugar sweetened is lower in adult women with higher education and higher in
men, young age and low education. Also consumption of soft drinks was lower among pupils
of higher parental occupation status compared to pupils of lower parental occupation status in
Northern, Southern and Western Europe (Vereecken et al., 2005). Increase in income per capita
and fraction of people residing in urban areas led to increased consumption of sugary foods
including soft drinks (Popkin and Nielsen, 2003). Furthermore intake of light soft drinks was
preferred with persons with higher body weights because they avoid intake of excess energy.
Forshee and Storey (2003) found that, age, gender and race play an important role in the amount
and type of beverages consumed by children and adolescents in USA. Older teens are said to
drink more of carbonated beverages, fruit drinks and juices, but boys drink more beverages than
girls. Also white adolescents’ boys consume heavily more beverages compared to African-
American boys.
16
2.8. Initiatives focusing on reducing soft drinks consumption
As pointed earlier that, consumption of soft drinks especially sugar sweetened beverages may
pose devastating impact on consumers health as they are believed to contribute for the growing
prevalence of overweight, obesity and other diet related problems around the globe. Therefore it
is essential to explore efforts that have been taken to minimize health related problems
associated with soft drink consumption. Increased concern about burden of diet related diseases
in the world has raised some questions on which policy actions might address health eating
issues at best (Caraher and Cowburn, 2005). There are some governments which have taken
actions to limit presence of soft drinks especially in schools. This is because the soft drink
industry is targeting schools as channels to reach young consumers (Hawkes, 2010). For
example countries like the Netherlands and France have established guidelines applied to school
meals. In Belgian and Thailand schools, voluntary actions have been taken to restrict
availability of soft drinks in their schools (Hawkes, 2010). School surroundings have a potential
influence on pupils’ food choice and dietary quality thus more attention has been paid to the
function of schools in improving children’s diets (Jaime and Lock, 2009). In addition nutrition
education programs promoting the consumption of fruits and vegetables and limiting the
consumption of soft drinks or other less nutritious foods are easily provided in schools
(Vereecken et al., 2005). Schools offer good starting point for interventions to reduce
consumption of sugar sweetened beverages (Hawkes 2010). Likewise in USA an intervention
had been established to eliminate or limit availability of vending machines in schools. This
might help students to reduce intake of soft drinks and opt for healthier and nutritious beverages
like water and milk. However no study has proven that limiting vending machines improved
students’ health (Finkelstein et al., 2004).
Another strategy to minimize consumption of soft drinks is taxation since a tax increases
beverage price thus reducing economic incentive for consumers to buy (Thow et al., 2010). For
example four types of specific taxes on soft drinks have been identified in the Pacific Island
nations; these are import excise taxes, domestic excise taxes, special import levy and production
and consumption taxes all aiming at increasing revenue and reducing consumption. However
data is lacking to calculate the impact of these taxes on consumption of soft drinks by the
population (Thow et al., 2010). Study findings from USA postulated the impact of soft drinks
taxes on BMI, overweight and obesity. Results showed that an increase of soft drink tax rate by
17
1% point caused a decrease in BMI by 0.003 points, obesity decreased by 0.01% and
overweight by 0.02% points. Adults’ soft drink consumption was greatly influenced by soft
drink taxation with varying results depending on the income distribution. For example, there
was a decrease of 0.08% points on BMI for an increase of 1% tax among adults with lowest
income category, but the impact magnitude of taxation is still small (Fletcher et al., 2010). Soft
drink taxation is proposed to be the most effective policy measure in reducing consumption and
eventually obesity (Lin et al., 2011), but on the other hand consumers may compensate the
decreased soft drinks consumption by taking other high energy drinks like high fat milk and
fruit juices (Jou and Techakehakij, 2012).
Norway introduced various health initiatives aimed at reducing the intake of sugar sweetened
foods and beverages among children for the period between 2001 and 2008. These included;
school prevention to soft drink access, promoting availability of cold drinking water, increased
taxes on sugar sweetened soft drinks and prohibition of unhealthy food and beverage marketing
(Stea et al., 2011). The results from the conducted study showed a decrease in regular soft
drinks, fruit juice and lemonade consumption and an increase in the consumption of diet soft
drinks. France and Singapore for example set some regulations that banned all vending
machines in schools. Also France and Sweden banned advertisements on sugary beverages from
children and teens exposure media (Popkin, 2009).
18
Based on the review of the literature the following research hypotheses were developed.
1. Belgian adults are likely to have high consumption levels of regular and light soft
drinks.
2. Belgian adults are likely to have favourable attitude towards consumption of regular and
light soft drinks
3. Consumers with high level of objective nutrition knowledge consume less regular soft
drinks and more light soft drinks.
4. People with children purchase and consume more regular soft drinks than light soft
drinks.
5. Consumers with a high BMI consume less regular soft drinks and more light soft drinks
6. People with high BMI have less objective nutrition knowledge than people with normal
BMI
7. Consumers with high levels of objective nutrition knowledge use more nutrition
information and higher acceptance of policy measures to reduce soft drinks consumption
than people with less objective nutrition knowledge.
19
CHAPTER 3: METHODOLOGY
A cross-sectional study was conducted among Belgian adults by using a quantitative consumer
survey during the period of February to March 2012. Participants were selected through an
existing panel of Belgian adults. Data on soft drink consumption, consumers’ attitude towards
(light, regular) soft drinks, their nutrition knowledge, use of nutrition information, acceptance of
government policies in soft drink reduction and their attitude towards sweeteners in soft drinks
were collected.
3.1. Study population
A total of 507 individuals completed the present study, while 31 individuals (or 6%) dropped
out of the study and were excluded from the final sample because of incomplete information.
The final sample included 209 males and 293 females between the ages of 17 and 85 years with
an average age of 43.4 ± 15.4 years. Three age categories were defined. The first group
comprised of young adults ranging from 17-30 years. The second group of middle aged adults
ranges from 30-50 years and the last group was composed of adults above 50 years. Young
adults (17-30 years) as defined by Hattersley et al. (2009), is a group which is in the life stage
of increased self reliance and autonomy. Many young people are moving away from their
homes and parents, thus become more independent on food and beverage choices as well as
purchase decisions (Hattersley et al., 2009). Middle aged adults mostly are full dependent
working group (employed or self employed) and to some extent they are parents whose life
styles including food habits have potential impact on their (adolescent) children (Verzeletti et
al., 2009). Most of the existing studies have examined soft drink consumption among children
and adolescents, however factors affecting soft drink consumption may differ between
adolescents and adults (Hattersley et al., 2009). Hence the present study aims at examining
adults’ soft drink consumption, their attitude towards consumption, nutrition knowledge, use of
nutrition information, acceptance of government policies to reduce soft drink consumption and
their opinion regarding sweeteners used in soft drinks. The study sample is more biased to old
age above 50 years. This may be due to online survey accessed mainly by old people, however
gender balance was quite representative based on the total sample. Three levels of education
were categorized, these included; low level (those with primary or unfinished lower secondary
20
education and general secondary education). The second category was medium level (those with
special secondary education, technical secondary education and art secondary education). The
third category was high education (those with high school education and beyond university).
Most of the participants had higher education level. Occupation levels were defined in four
categories. The first category was paid work (included full-time paid work and part-time paid
work), the second category was retired people and third was people working full time in higher
education. The last category was people who are unemployed (included job seekers and non job
seekers). Four groups of BMI status were also identified; underweight, normal weight,
overweight and obese individuals. Financial situation was classified into ‘not well’, ‘modest’
and ‘well’ and majority of participants were ‘well’.
Table 3. Description of the final sample in percentages (n=507)
Gender male 41.2
female 57.8
Age (years) 17-30 years 27.0
30-50 years 33.3
above 50 years 39.1
Education level low 12.9
medium 12.5
high 74.5
Occupation paid work 70.8
retired 13.7
full-time university 10.3
unemployed 5.2
BMI status underweight 3.0
normal 52.0
overweight 28.0
obese 15.0
Income not well off 5.1
modest 20.2
well off 74.7
Children < 14 years in H/H no 88.2
yes 11.7
21
Figure 2. Percentage of participants on dieting
Figure 2, shows the percentage of consumers who are currently on a specific diet, it is less than
20% of participants are dieting. The highest being 18.3% on fat diet, followed by energy and
sugar, the rest are below 10%. Generally large percent of participants are not on diet.
Figure 3. Percentage of participants and family members with health related problems
0
2
4
6
8
10
12
14
16
18
20 p
ercen
tag
e
type of diet
0 5
10 15 20 25 30 35 40 45
23.3
6 3.8
17.9
7.8
24.1
4.6
40.6 38.6 41.8 42.2
16.6
27 27.3
per
cen
tag
e
dietary related problems
%myself
%family member
22
Figure 3 shows the percentage of dietary related health problems among participants and their
family members. The figure shows that most of the health problems are affecting family
members rather than the participants themselves. The leading diseases among family members
are high blood pressure, high blood cholesterol levels, cancer and cardiovascular diseases.
Obesity affects almost equally both the participants of the study and their family members.
Food allergies are less common among both groups.
3.2. Measures
Data collection was conducted by means of an online survey method. This method has the
following advantages: low costs, fast responses from participants and guarantees data of optimal
quality (Verbeke et al., 2008). A questionnaire was developed as a tool for data collection. It
was structured in a comprehensive way to cover several aspects with regard to specific
objectives and research questions of the study. The questionnaire was self completed and
included two major parts. First part involved questions related to soft drinks consumption
patterns, nutrition knowledge, attitudes towards soft drinks consumption, acceptance of policies
for reduction of soft drink consumption and opinions on sweeteners used in soft drinks. The
second part included questions about personal characteristics of the respondents such as socio-
demographics.
3.2.1. Questionnaire on consumption patterns
Participants were asked about their frequencies of consumption (see Annex 1: question 1) of
regular and light (diet) soft drinks on a scale ranging from never to several times a days. Based
on these consumption frequencies of regular and light soft drinks a cluster analysis was
performed to group the participants according to their consumption pattern. Hierarchical
clustering with Ward’s method and squared Euclidean distance was performed, followed by a
K-Means cluster analysis with initial cluster centres that resulted from the hierarchical
procedure. From this cluster analysis five segments or groups were identified and profiled, these
are: non-users (n=50), low users (n=209), medium users (n=79), heavy light users (n=83) and
heavy regular users (n=83). The mean values of the segmentation variables for the different
groups are presented in Table 4.
23
Table 4. Initial cluster centers
Cluster
1 2 3 4
q1_consumregular
2 2 5 6
q1_consumlight 2 6 5 2
Input from FILE Subcommand
Other questions related to the consumption patterns were the locations where they purchase soft
drinks (see Annex 1: question 2) (e.g. supermarket, vending machines, restaurants), and at
which occasions (see Annex 1: question 4) (e.g. home/work, family occasions, being on visit).
They were also asked how likely they consume soft drinks as an alternative to, for example,
water, milk, tea, alcohol, energy drink, snacks, coffee. (see Annex 1: question 3). These items
were measuring the same concept hence combined to one construct by cronbach’s alpha test
with a score of 0.715 which shows good internal reliability (A reliable construct variable is
obtained when Cronbach’s α score is >0.6) therefore a new variable ‘soft drink alternative’ was
computed.
3.2.2. Subjective nutrition knowledge regarding soft drinks
Also questions assessing consumers’ subjective nutrition knowledge on soft drinks were
examined, such as their own understanding, their own rating and evaluation regarding soft
drinks. The following items were used to measure subjective knowledge (see Annex 1: question
5) as adapted from Pieniak (2008), which was also consistent with Pieniak et al. (2010). (i) ‘My
friends consider me as an expert in the health aspects of soft drinks’, (ii) ‘I have a lot of
knowledge about how to evaluate the quality of soft drinks’, (iii) ‘I know which soft drinks are
good for me’, (iv) ‘I have a lot of knowledge about how to evaluate the nutritional value of soft
drinks’. These items were then checked for internal reliability (Cronbach’s alpha) and a value of
24
0.839 was obtained denoting good internal consistency, hence a single construct ‘subjective
knowledge’ was computed.
3.2.3. Objective nutrition knowledge regarding soft drinks
Objective knowledge was measured with 20 statements (see Annex 1: question 6) focusing on
the nutritional composition of soft drinks (such as sugar, calories, acidity, and caffeine) and
their health impacts (e.g. overweight/obesity, dental erosion, diabetes). In this question they had
to indicate if these statements are true or false or no idea which gave them 20 score points
(adapted from Spillmann et al., 2011). Furthermore, objective nutrition knowledge was also
computed into two categories of pass and fail. A score of 10 points and above was considered as
pass and below 10 points as fail.
3.2.4. Questions on policy measures to reduce soft drink consumption and information use
Acceptance of policy measures (see Annex 1: question 7) set by government to reduce soft
drinks consumption was measured on a 7-point scale from ‘totally disagree’ (=1) to ‘totally
agree’ (=7) in which participants were asked to which extent they agree or disagree with various
government interventions. These includes; banning of the soft drinks advertisements, banning of
vending machines in schools and work places, nutrition labelling of soft drinks, provision of
education to reduce soft drinks consumption, posing high taxes on soft drinks. Due to a large
number of policy measures (10 policy measures) a factor analysis was done to reduce data and
finally two factors/components were obtained. The first factor combined 4 policies (policy 7, 8,
9 and 10) and the second factor also combined 4 policies (policy 2, 3, 4 and 5) (see Annex 1:
question 7). Policy 1 and 6 were excluded in the factor calculation. The reason was that factor
loading for policy 6 was more than two times higher the factor loading for policy 1. The rule of
thumb regarding factor analysis is that for a rotated matrix, factors should only or heavily load
on one factor only, or the highest factor should be more than two times the second highest factor
loading. From this two new variables were calculated for analysis by taking the average of the
items corresponding to one factor. These factors were labelled; ‘limiting availability’, for
policies aiming at reducing consumption of soft drinks and ‘provide information’, for policies
aiming at providing education about soft drinks. Participants were also asked ( see Annex 1:
25
question, 8) how often they use nutrition information on food in general and soft drinks in
particular on a 7-point interval scale from never (=1) to always (=7).
3.2.5. Questions on attitudes and consumption habits
Participants completed questions about their attitudes towards soft drinks consumption and
consumption habits. Several factors were included under attitude (see Annex 1: question 9-12).
For example participants were required to indicate based on 7-point scale to which extent they
either agree or disagree on various items of regular and light soft drinks like. For example
regular and light soft drinks are; healthy, nutritious, pleasant, cheap, satisfactory, refreshing,
body hydration, taste, easily available, and feelings experienced when drinking. For general
attitude towards consumption they were asked how they feel when they consume soft drinks e.g.
bad/good, unsatisfied/satisfied, negative/positive. Question on consumption habits (see Annex
1: question 13) included items such as; ‘consuming soft drinks is something...’ (i) ‘that belongs
to my routine’, (ii) ’I have been doing for a long time’, (iii) ‘I’m used to from my childhood’,
(iv) ‘I learned from my parents’. Due to the fact that many items were measuring the same
concept Cronbach’s alpha test was performed before analysis. All items under attitude questions
were reliable with cronbach’s alpha >0.6. Therefore three new variables were computed under
attitude, these include; general attitude with cronbach’s alpha value of 0.764 was formed based
on the 5 items of question 9 (see Annex 1: question 9). Attitude towards regular soft drinks with
cronbach’s alpha value of 0.847 was formed based on the 10 items of question 10 and 3 items of
question 12 (see Annex 1; question 10 and 12). Attitude towards light soft drinks with
cronbach’s alpha value of 0.892 was formed based on 10 items of question 11 and 3 items of
question 12(see Annex 1: question 11 and 12). The new variable for consumption habits was
‘habit’ constructed after internal reliability of 0.903, this variable was formed based on six items
of question 13 (see Annex 1; question 13). New variables were used for analysis.
3.2.6. Question regarding consumers’ opinions on sweeteners
This question was also measured on 7-point scale from totally disagree (=1) to totally agree
(=7). It was about to which degree participants either agree or disagree on sweeteners used in
soft drinks (see Annex 1: question 14). Examples: (i) ‘I’m concerned about amount of sugar
26
used in regular soft drinks’, (ii) ‘diet soft drinks with artificial have an aftertaste compared to
regular soft drinks’, (iii) ‘artificial and/or natural sweeteners are unhealthy’, (iv) ‘I believe the
best way to reduce calories in soft drinks is to use artificial sweeteners’. This question was also
subjected to factor analysis to reduce dimension. The first two items under this question were
excluded from factor analysis because they did not express either positive or negative attitude to
sweeteners. The items number 4 and 7 were also recorded into 4R and 7R. Three
factors/components were computed. The first factor was ‘health aspects which combined items
6, 5 and 4R. The second factor was taste aspects which combined items 8 and 3, and the last
factor was anti-sweeteners which consisted of one item 7R.
3.2.7. Questions on personal characteristics
The second part of the questionnaire included questions on characteristics of the respondents
(see Annex 1; question 15- 28) these includes; gender, age, education, occupation, income,
household composition (including presence/absence of children), health status reflecting diet
related diseases and being on diet or not. Also Body Mass Index (BMI) (self reported weight
and height) were included in the questionnaire. Apart from gender which is categorical by
nature most of the personal characteristics were defined into various categories as explained
above under section 3.1. Associations between these personal characteristics and consumption,
attitude, knowledge and policy acceptance on soft drinks were studied. Generally most (2 times)
of the questions were measured based on a 7 point scale ranging from 1 ‘never’ to 7 ‘often’ or
from 1 ‘totally disagree’ to 7 ‘totally agree’ except for objective knowledge. The original
questionnaire was developed in English and was then translated into Dutch (a language
convenient to participants).
3.3. Data analysis
3.3.1. Descriptive statistics
Descriptive statistics such as frequency distributions, percentages, means and standard
deviations, were used to describe sample characteristics such as age, gender, BMI status,
education and occupation levels. Dependent variables such as age and BMI are introduced as
categorical variables so as to make comparison between groups. Independent variables like
27
knowledge, attitude and consumption patterns are considered as continuous variables. Data
were analyzed by computer software program Statistical Package for Social Science (SPSS)
version 20.
3.3.2. Checking for assumptions
Before analysis, assumptions such as normality and variance were checked. One-Sample
Kolmogorov-Smirnov Test, QQ-Plots and histograms were used to check whether the data were
normally distributed or not. If normality was assumed (P-value >0.05) parametric tests
(independent-samples t-tests for two categorical variables and one-way Anova F-test for more
than two categories) were selected for analysis. If data were not normally distributed (P<0.05)
non- parametric tests (Kruskal Wallis and Mann- Whitney) were used. Levene’s test was used
to test the assumption of equality of variances among groups. Normality and homogeneity of
variances were only checked for continuous variables.
3.3.3. Univariate statistics
For two categorical variables (dependent and independent) such as gender and groups of soft
drink users, a cross tabulation was used to verify/assess their association through Pearson’s chi-
square test. Correlation was used to assess association between two continuous (interval scaled)
variables such as subjective nutrition knowledge and attitude towards consumption of soft
drinks. The correlation was significant at 0.05 levels. One way Anova F-test was used to verify
whether more than two categories have different mean values on an interval scaled variable (e.g.
use of nutrition information versus three categories of education level). Bonferroni post hoc
analysis was used to detect differences within groups.
3.4. Limitation of the study
Some limitations should be acknowledged that need to be addressed before discussing the
results. First this was a cross sectional survey conducted in a short period (about one month)
Second the data of the study was collected through online survey which apart from its beneficial
impacts, makes it difficult to locate the actual geographical place where the sample was taken.
Another limitation is that very few studies have been done in Europe and specifically in
28
Belgium to assess attitude towards soft drinks consumption in adults, nutrition knowledge and
policy acceptance, hence hardens the finding of relevant literatures to compare with. The
questionnaire was a little bit long with some detailed questions causing respondents
burden/fatigue. Data of this study are based on self reports which might be subjected to
participants’ bias. Most of the questions were closed ended (although makes data analysis easy)
which may result in missing out of useful information from participants. Last but not least this
study was only limited to soft drinks, attitude and nutrition knowledge with regard to other
energy dense foods (such as high fat foods) could not be taken into account. However the
findings of the study can provide some insight for further studies and once published will
contributes to literature on assessment of adults’ attitudes, nutrition knowledge, and acceptance
of policy measures on soft drinks since very few studies have investigated these aspects.
29
CHAPTER 4: RESULTS AND DISCUSSION
This chapter presents a detailed description of results and discussion with regard to soft drinks
consumption, socio-demographic differences among soft drink users, objective and subjective
knowledge, attitudes towards soft drinks, information use on food and soft drinks labels, policy
acceptance of government policies and attitudes towards sweeteners used in soft drinks.
4.1. Consumption characteristics of regular and light soft drink users
4.1.1. Frequency of consumption
Despite the increase in consumption of soft drinks in western countries (Sartot et al., 2011), to
around one can per day (Renwick and Nordmann, 2007), general results of this study showed
that consumption of both regular and light soft drinks was low with mean values of 2.82 and
2.73 respectively. On a 7-point scale these means indicate that the consumption is almost once
per week (based on the general results hypothesis no.1 is not confirmed). Table 5 compares the
frequency of consumption between five groups of soft drink users: non, low, medium, heavy
light and heavy regular. However heavy light and heavy regular users are groups of interest
(based on the hypotheses) to compare. Results showed that heavy light users, who consume
light soft drinks daily or almost every day, have very low consumption of regular soft drinks to
almost less than once per week. Heavy regular users had high frequency of regular drinks
consumption from 2-4 times a week to several times a day but they had a frequency of less than
10% of light soft drinks consumption. On the other hand lower users consume at least more
regular drinks than light drinks. Majority of medium users consume regular drinks less
frequently, once a week and two to four times a week. However about 75% of medium users
consume light soft drinks two to four times a week. Non users of soft drinks had zero
consumption frequency.
4.1.2. Locations for soft drinks purchases
Results showed that there are differences in places where consumers obtain soft drinks among
the different user groups (all P-values <0.001). Consumers of both regular and light soft drinks
purchase their soft drinks mostly from supermarkets compared to other places like vending
30
machines, bars, canteens and restaurants. (Table 5 gives mean scores of various places of
purchase). Astrup et al. (2008) reported that places like vending machines, are fast food
channels for sugar sweetened soft drinks because they are easily accessible. But results of this
study indicate that interventions aiming at reducing the availability of soft drinks in vending
machines, bars, canteen and restaurants will have little impacts on adults because most of
consumers do not buy soft drinks from these places. Therefore much effort could be employed
in reducing availability of soft drinks in supermarkets.
4.1.3. Soft drinks used as alternative and occasions for consumption
Consumers of regular and light soft drinks reported that they are less likely to consume soft
drinks as alternative to water, milk, tea, coffee, alcohol, energy drink, snacks and meals (Table 5
gives mean score differences for soft drink alternatives). Heavy light and heavy regular users
preferably consume soft drinks with meals in bar, restaurant and at home, also in family
occasions, being on visit and when having guests at home (Table 5). These differences in
occasions for soft drinks consumption was significant at P<0.001. Generally speaking it can be
said that soft drinks consumption is rarely used as alternative to other drinks but occasions of
consumption has some impact on overall consumption. Heavy regular users were found to have
more consumption habit of soft drinks than low users. This means consumption of soft drinks is
a common behaviour to heavy regular users (habitual).
31
Table 5. Consumption characteristics of soft drink user groups (n=504)1
Non users Low users Medium
users
Heavy light
users
Heavy
regular users
P-value
Total sample 50 209 79 83 83
Frequency of consumption
Regular soft drinks
(2.82±1.76)5
1.00±0.00 2.36±0.85 3.13±1.15 1.63±0.68 5.94±0.80 <0.0012
never 0(0) 21 (10) 8 (10.1) 40 (48.2) 0 (0)
less frequently 0(0) 120 (57.4) 25 (31.6) 34 (41.0) 0 (0)
once a week 0(0) 39 (18.1) 19 (24.1) 9 (10.8) 0 (0)
2-4 times a week 0(0) 29 (13.9) 17 (21.5) 0 (0) 29 (34.9)
daily/almost everyday 0(0) 0 (0) 9 (11.4) 0 (0) 30 (36.1)
several times a day 0(0) 0 (0) 1 (1.3) 0 (0) 24 (28.9)
Light soft drinks
(2.73±1.99)5
1.00±0.00 1.58±0.63 4.47±0.93 6.19±0.63 1.54±0.67 <0.0012
never 0(0) 104 (49.7) 0 (0) 0 (0) 45 (54.2)
less frequently 0(0) 89 (42.6) 0 (0) 0 (0) 32 (38.6)
once a week 0(0) 16 (7.7) 10 (12.6) 0 (0) 5 (6.0)
2-4 times a week 0(0) 0 (0) 59 (74.7) 10 (12.7) 1 (1.2)
daily/almost everyday 0(0) 0 (0) 8 (10.1) 47 (56.6) 0 (0)
several times a day 0(0) 0 (0) 2 (2.5) 26 (31.3) 0 (0)
Place of purchase
supermarket 1.68 ± 1.50 3.57 ± 1.85 5.30 ± 1.52 6.14 ± 1.31 6.16 ± 1.04 <0.0013
vending machines 1.08 ± 0.27 1.83 ± 1.16 2.62 ± 1.48 2.96 ± 1.51 2.94 ± 1.63 <0.0013
bar 1.34 ± 0.79d 2.80± 1.59
c 3.91± 1.61
a 3.45±1.54
a,b 3.61± 1.64
a,b <0.001
4
canteen 1.12 ± 0.48 1.45 ± 0.94 2.28 ± 1.81 2.29 ± 1.74 2.22 ± 1.62 <0.0013
restaurant 1.28 ± 0.75 2.71 ± 1.63 3.85 ± 1.66 3.39 ± 1.66 3.64 ± 1.62 <0.0013
Occasions for consumption
with meal at
bar/pub/restaurant
1.41 ± 0.06 3.22 ± 1.73 4.32 ± 1.65 4.82 ± 1.85 4.95 ± 1.63 <0.0013
bar alternative to alcohol 1.94 ± 1.48 3.55 ± 1.84 4.25 ± 1.86 4.87 ± 1.92 4.55 ± 1.92 <0.0013
with meal at home 1.24 ± 0.89 1.79 ± 1.23 3.18 ± 1.78 4.22 ± 2.16 4.28 ± 1.99 <0.0013
home alternative to alcohol 1.30 ± 1.12 2.25 ± 1.78 2.72 ± 1.95 3.48 ± 2.19 3.33 ± 2.25 <0.0013
32
home alternative to tea/coffee 1.14 ± 0.70 1.77 ± 1.22 2.52 ± 1.62 3.14 ± 1.92 2.94 ± 2.04 <0.0013
family occasions 1.42 ± 1.01 3.12 ± 1.69 4.22 ± 1.36 4.49 ± 1.70 4.80 ± 1.52 <0.0013
home alternative to water 1.16 ± 0.72 2.07 ± 1.47 3.45 ± 1.94 4.49 ± 2.09 3.95 ± 2.12 <0.0013
having guests at home 1.18 ± 0.72 2.77 ± 1.73 3.92 ± 1.62 4.76 ± 1.59 4.55 ± 1.52 <0.0013
being on visit 1.36± 0.92 3.12 ± 1.68 4.33 ± 1.46 4.89 ± 1.48 4.87 ± 1.31 <0.0013
Soft drink as alternative 1.49 ± 0.85 2.47 ± 1.17 2.69 ± 0.97 3.27 ± 1.09 3.10 ± 1.25 <0.0013
Consumption habit 1.58 ± 1.01d 2.32± 1.48
c 3.58 ±1.52
b 4.05±1.69
a,b 4.64 ± 1.43
a <0.001
4
1 All values are means value ± Standard deviations
2 P
values are from the chi-square test for comparison between consumption characteristics and soft drink users.
3 P values delivered from non parametric test (Kruskal
Wallis test)
4 P values delivered from parametric test-one factor ANOVA
5 Overall mean for regular and light soft drinks
4.2. Socio-demographic differences among soft drinks users
Generally most participants, males and females were low users of soft drinks representing 41%
and 40% respectively (Table 6). There were no differences between males and females (P=
0.260). The mean age was different (P<0.001) among groups of soft drink users and the
significant difference was between non users and the rest of the groups. Non users were in
general older than other groups, and age decreased from low users to heavy regular users,
(Table 6). These results revealed that older people limit their soft drink consumption, which is
in line with the study of Kvaavik, et al. (2004) and Vandevijvere et al. (2008). Kuusela et al.
(1999) also found that, children had a higher consumption of soft drinks (more than once per
day) compared to adults. Similar results were found by Zoellner et al. (2012), reporting that
younger people consumed more sugar sweetened (regular) beverages than older people. The age
difference may attribute to difference in taste preferences between older and younger people.
Old people might also spend most of their time at home where their access to soft drinks is
limited.
The mean BMI of participants was 25.2±4.6, which indicates overweight in the general sample,
but this differed significantly between groups of soft drink users (P<0.001). Mean BMI was
observed to be significantly higher in heavy light users (confirming hypothesis no.5) compared
to the remaining groups (Table 6). Results are supported by Grenby (1991) who wrote that
although low energy foods and drinks supply few calories to the body, excessive intake can lead
to accumulation of many calories resulting to overweight and obesity. However these data do
33
not provide enough evidence to establish the effect unless a prospective study is done to
investigate the causal relationship between excessive intake of diet soft drinks and the
development of overweight and obesity.
No association was found between educational level and the amount of soft drinks consumption
(P>0.05). This means that the level of education is not related to consumption of soft drinks in
this study. About 85.9% of consumers were living together with other members in the
household but there was no difference in consumption of soft drinks with those living alone
(P=0.172). The number of children in the household was found not to be associated with the
degree of soft drink consumption as there was no significant difference observed between
households with children and those without children (P=0.511). This may be due to the fact that,
very few participants (11.8%) reported to have children in their households which might affect
comparison between groups. The result is in contradiction with the hypothesis number four of
this study, that people with children consume more soft drinks.
An association was observed between the occupational level and groups of soft drink users
(P<0.001). Income levels were not found to be significantly different among groups of soft
drink users (P= 0.137).
34
Table 6. Socio-demographic differences among soft drink users n (%)1
Characteristic Total
sample
Non users Low users Medium
users
Heavy light
users
Heavy
regular users
P-value
Popn 504 (99.5) 50 (9.9) 209 (41.2) 79 (15.6) 83 (16.4) 83 (16.4)
Gender 0.2602
male 208 (41.7) 23 (11) 86 (41.3) 34 (16.3) 26 (12.5) 39 (18.6)
female 291 (58.3) 27 (9.3) 119(40.1) 45 (15.5) 57 (19.6) 43 (14.8)
Age(y) 43.4±15.4 54.5±14.3a 45.5±15.7
b 40.0±14.3
c 41.4±11.7
b,c 36.5±14.7
c <0.001
3
BMI 0.0052
underweight 16 0 (0) 7 (43.8) 2 (12.5) 3 (18.8) 4 (25)
normal weight 263 31 (11.8) 112 (42.6) 42 (15.9) 29 (11) 49 (18.6)
over weight 141 14 (9.9) 63 (44.7) 17 (12) 25 (17.7) 22 (15.6)
obese 75 2 (2.7) 23 (30.7) 16 (21.3) 24 (32) 7 (9.3)
BMI(kg/m2) 25.2±4.6 24.8±3.9
b 24.9±4.5
b 25.0±4.1
b 27.3±5.3
a 24.1±4.4
b <0.001
3
Education level 502 48 (9.6) 209 (41.6) 79 (15.7) 83 (16.5) 83 (16.5) 0.3212
low level 65 5 (7.7) 29 (44.6) 6 (9.2) 15 (23.1) 10 (15.4)
medium level 63 6 (9.5) 19 (30.1) 12 (19.1) 11 (17.5) 15 (23.8)
high level 374 37 (9.9) 161 (43.0) 61 (16.3) 57 (15.2) 58 (15.5)
Living 502 50 (9.9) 208 (41.4) 79 (15.7) 83 (16.5) 82 (16.3) 0.1722
alone 71 8 (10.9) 20 (28.2) 13 (18.3) 16 (22.5) 14 (19.7)
together with 431 42 (9.7) 188 (43.6) 66 (15.3) 67 (15.5) 68 (15.8)
Children
<14y/hh
442 48 (10.9) 180 (40.7) 69 (15.6) 71 (16.1) 74 (16.7) 0.5112
no children 390 44 (11.3) 161 (41.3) 58 (14.9) 60 (15.4) 67 (17.2)
having children 52 4 (7.7) 19 (36.5) 11(21.2) 11(21.2) 7 (13.5)
Occupation 504 50 (9.9) 209 (9.9) 79 (15.7) 83 (16.5) 83 (16.5) <0.0012
paid 357 25 (7.0) 149 (41.7) 59 (16.5) 70 (19.6) 54 (15.0)
retired 69 19 (27.5) 32 (46.6) 9 (13.0) 3 (4.3) 6 (8.7)
full time high
education
52 0 (0) 22 (42.3) 8 (15.3) 6 (11.5) 16 (30.8)
unemployed 26 6 (23.1) 6 (23.1) 3 (11.5) 4 (15.4) 7 (26.9)
35
Income levels
not well
modest
well
495
25
100
370
2(8)
11(11)
36(9.7)
8(32)
37(37)
163(44.1)
4(16)
14(14)
58(15.7)
4(16)
17(17)
61(16.5)
0.137
7(28)
21(21)
52(14.1)
1 Except if otherwise stated, i.e. mean value ± standard deviation (SDs)
2 P values are from the chi-square test for comparison of sample characteristics between groups of soft
drink users 3 Value derived from parametric test (one way ANOVA)
Superscript letters refer to significant differences by one-factor ANOVA
4.3. Objective and subjective nutrition knowledge
4.3.1. Objective nutrition knowledge
Objective nutrition knowledge of participants was measured in relation to selected demographic
variables. The mean score for objective nutrition knowledge was 12.7±3.3 measured on 20
points. This indicates that most participants scored higher.
There were no observed differences between objective nutrition knowledge with gender, BMI
categories and the educational level (P>0.05) (Table 7). From these findings it means that
gender, BMI categories and educational levels do not have any association with objective
nutrition knowledge (hypothesis no.6 is not confirmed). However significant differences in
objective nutrition knowledge were found between age groups on one hand and soft drinks user
groups on the other hand (P<0.001). Objective nutrition knowledge was significantly higher in
the age groups of 17-30 and 30-50 years compared to the age group above 50 years. Objective
nutrition knowledge was also observed to be significantly higher among heavy light users than
in heavy regular users (hypothesis no. 3 confirmed), non users and low users (P<0.001). These
results are somehow surprising, because age group 17-30 and heavy light users found with
higher objective nutrition knowledge but they are also higher consumers of soft drinks. This
might indicate that they do not actually apply their knowledge to limit consumption. Another
reason could be, since the questions under objective nutrition knowledge were true and false
items there might be higher chances for guess answers. On the other hand it is possible that
heavy light users have knowledge on negative health impacts of regular soft drinks which may
explain their preference to light soft drinks. Further analysis found a positive correlation
36
between objective nutrition knowledge and information use on food and soft drinks, and the
correlation was significant at 1%. This indicates that people with more objective nutrition
knowledge use more nutrition information (according to hypothesis [number 7]). But this
cannot be assured that consumers apply their knowledge to reduce their soft drink consumption.
For example Grunert et al. (2010) found variation in the use of nutrition information depending
on the product category, through his finding about 23% of shoppers looked for information on
carbonated soft drinks.
Table 7. Objective nutrition knowledge about soft drinks of participants (n=507)1 in
relation to selected variables
Objective nutrition knowledge P-value
Gender 0.0642
male 12.33 ± 3.54
female 12.70 ± 3.14
BMI category 0.3923
underweight 12.88 ± 3.84
normal weight 12.48 ± 3.20
overweight 12.87 ± 3.47
obese 13.05 ± 3.38
Soft drinks user groups <0.0013,4
non user 11.50 ± 3.61b
low user 12.52 ± 3.24b
medium user 13.04 ± 3.40a,b
heavy light user 14.44 ± 2.86a
heavy regular user 11.71 ± 3.01b
Educational level 0.1013
low level 12.15 ± 3.38
medium level 12.16 ± 3.72
high level 12.71 ± 3.32
Age groups <0.0014
17-30 years 12.91 ± 3.13a
30-50 years 13.40 ± 3.22a
above 50 years 11.96 ± 3.41b
37
Information use on food <0.0015
Pearson’s correlation 0.296**
Information use on soft
drinks
<0.0015
Pearson’s correlation 0.657**
1 All values are means value ±SDs
2 Value derived from non parametric (Mann -Whitney U test)
3 Value derived from non parametric Kruskal Wallis test
4 Value derived from parametric test (one Factor ANOVA)
5 Value derived from Pearson’s correlation
** Correlation is significant at the 0.01 level.
Superscript letters refer to significant differences by one-factor ANOVA
4.3.2. Subjective nutrition knowledge
Associations were studied between the subjective nutrition knowledge and other descriptive
variables such as: gender, BMI categories, the educational level and other variables such as
information use and groups of soft drink users (Table 8). There were no differences found in
subjective nutrition knowledge between all tested demographic variables (all P>0.05). The
mean score for all variables was low, showing that most participants estimated their subjective
nutrition knowledge about soft drinks to be rather low. They did not consider themselves as
experts in evaluating nutritional aspects of soft drinks. It is important for policy makers to
reinforce policies regarding information provision on soft drinks to impart enough subjective
nutrition knowledge. However a positive association was found between subjective nutrition
knowledge and the use of nutrition information on food and soft drinks labels, but it cannot be
assured that people with subjective nutrition knowledge use more nutrition information.
This study opposes the study reported by Grunert et al. (2012), that subjective and objective
knowledge relate with gender and education. They found that females and people with higher
education have higher levels of both subjective and objective nutrition knowledge. However a
relation between socio-demographic factors and nutrition knowledge has not been confirmed in
most studies. House et al. (2004) reported significant variations between nutrition knowledge
with age and education. Older people with lower education tend to have lower levels of both
objective and subjective knowledge. Also subjective knowledge was negatively associated with
the amount of information obtained by consumers during food purchase decision (House et al.,
2004).
38
Table 8. Subjective nutrition knowledge about soft drinks of participants (n=507)1 in
relation to selected variables
Subjective nutrition knowledge P-value
Gender 0.8042
male 3.22 ± 1.52
female 3.26 ± 1.49
BMI category 0.6703
underweight 3.48 ± 1.32
normal weight 3.21 ± 1.56
overweight 3.32 ± 1.46
obese 3.18 ± 1.46
Soft drinks user groups 0.4433
non user 3.60 ± 1.76
low user 3.18 ± 1.51
medium user 3.13 ± 1.41
heavy light user 3.73 ± 1.56
heavy regular user 3.15 ± 1.37
Educational level 0.0584
low level 2.91 ± 1.52
medium level 3.14 ± 1.40
high level 3.33 ± 1.51
Age groups 0.6784
17-30 years 3.17 ± 1.29
30-50 years 3.32 ± 1.52
above 50 years 3.23 ± 1.51
Information use on food (n=504) <0.0015
Pearson’s correlation 0.383**
Information on soft drinks (n=506) <0.0015
Pearson’s correlation 0.364**
1 All values are means value ± SDs
2 Value derived from non parametric (Mann -Whitney U test)
3 Value derived from non parametric Kruskal Wallis test
4 Value derived from parametric test (one Factor ANOVA)
5 Value derived from Pearson’s correlation
**. Correlation is significant at the 0.01 level.
39
4.4. Attitude of participants towards soft drink consumption
4.4.1. General attitude towards consumption of soft drinks
Findings of this study showed significant differences in general attitudes towards soft drink
consumption between groups of consumers (P<0.001) (Table 9). Heavy regular users, heavy
light users and medium users had more positive general attitudes towards consumption of soft
drinks compared to low and non users. However non users had the most negative attitude.
General attitudes towards soft drinks consumption was not different between males and females
(P=0.410). This means that both sexes have the same general attitude to soft drinks. These
results oppose the study done by Ollikainen and Kultanen (1985) who found that females had
more negative attitudes to normal sweetness (9%) in soft drinks compared to males. In the
presence of low sweetness (5%) males showed an increased negative attitude that means they
are more attracted with the sweetness in soft drinks. A significant difference in general attitude
towards soft drink consumption was seen according to the BMI (P<0.001). Obese people had a
more favourable attitude towards soft drink consumption than normal weight individuals. These
results are in line with the study of Sartor et al. (2011) who found that obese people have high
preference or implicit attitude towards soft drinks consumption compared to non-obese
counterparts. There are significant differences in general attitudes towards consumption of soft
drinks between the age groups (P<0.001). Consumers aged 17-30 years had more positive
attitudes towards general consumption of soft drinks than group above 50 years. Educational
levels and nutrition objective knowledge were found to have no association on with the general
attitudes of participants towards soft drink consumption (P>0.05). A significantly weak and
negative correlation was found between subjective nutrition knowledge and general attitudes
towards consumption of soft drinks (P= 0.041). This might indicate that people with more
positive general attitude towards soft drink consumption have low levels of subjective nutrition
knowledge.
4.4.2. Attitude towards consumption of regular soft drinks
Results (Table 9) showed that, heavy regular users of soft drinks had the most positive attitude
towards regular soft drink consumption compared to the remaining groups. This might indicate
that they consume more regular drinks because they are satisfied. Heavy light and medium users
40
also have a more positive attitude towards regular drinks in comparison to low users and non
users. Non users had the most negative attitude towards regular soft drinks (Table 9). Results
also showed differences between males and females in their attitude towards regular soft drinks
where males had a favourably higher mean score compared to females. This was also found by
Zoellner et al. (2012), namely that men and younger people consumed more regular soft drinks
(Sugar Sweetened Beverages) compared to females, but he found no variation between
consumption of SSB and education, or BMI which is the same with this study. Attitudes
towards regular soft drinks consumption was not different among the BMI categories (P=0.628,
Table 9). There were significant differences in attitudes towards regular consumption of soft
drinks between the age groups (P<0.001). Participants in the age range of 17-30 years had the
most positive attitude towards regular soft drinks consumption compared to groups 30-50 and
above 50 years. Elfhag et al. (2007) found similar results where regular drinks were preferred
by younger individuals with low education. Educational levels did not differ with the attitude
towards regular soft drinks consumption (P>0.05). Therefore the appropriate interventions
towards reduction of regular soft drinks consumption should be targeted to the age group of 17-
30 years and the heavy regular users. Although attitude seems to be generally low, it may
influence behaviour after a certain period of exposure to soft drinks. Results also indicated that
there was no difference in attitude towards regular soft drinks consumption according to the
nutrition objective knowledge (P >0.05). Also no correlation was found between subjective
nutrition knowledge and attitudes towards regular soft drinks consumption.
4.4.3. Attitude towards consumption of light soft drinks
Attitude towards light soft drink consumption differed among groups of consumers. Significant
differences were found between non, low, medium, heavy light, and heavy regular users and
attitudes towards light soft drinks. All groups had more attitude compared to non users. Heavy
light and medium users had a more positive attitude to light soft drinks than low and heavy
regular users. However heavy light users were most interested in light soft drinks and non users
were least interested. These differences (Table 9) were significant (P<0.05). Males and females
showed significant difference in their attitude towards light soft drinks (P=0.015), with males
having a higher mean score compared to females. This was also found by Freeman and Booth,
(2010) that young females liked diet drinks as they perceived that sweetness refers to amount of
41
energy in the soft drinks. A significant difference was also observed in the attitude towards light
consumption of soft drinks between BMI categories (P<0.001). Obese people had a more
positive attitude towards light soft drink consumption than normal weight individuals
(Hypothesis [number 5] confirmed). This result is in line with results of Elfhag et al. (2007)
who wrote that people with high body weights prefer light soft drinks because they avoid intake
of excessive amounts of energy. Objective nutrition knowledge had positive and strong
association with attitudes towards consumption of light soft drinks (P<0.001), indicating that
people with high objective knowledge prefer light soft drinks over regular soft drinks
(Hypothesis no.5). No association was found between attitudes towards consumption of light
soft drinks and (1) age (P=0.283), (2) educational level (P=0.498) and (3) subjective knowledge
(P=0.462). Generally it can conclude that attitude is the determinant of behaviour as postulated
by Ajzen (1991). From these results consumers had favourable attitudes to general consumption
of soft drinks (hypothesis no.2).
Table 9. Attitude towards soft drink consumption, all p values are delivered from ANOVA
unless stated otherwise
General
attitude
P2-
value
Attitude
regular
P2-
value
Attitude light P2-
value
Soft drinks user groups
non users
N=468
2.92±1.25c
<0.001
N=493
2.68 ± 1.04d
<0.001
N=492
2.35 ± 1.00d
<0.001
low users 3.99 ± 0.88b 3.49 ± 0.89
c 2.91 ± 0.96
c
medium users 4.36 ± 0.67a 3.94 ± 0.76
b 3.93 ± 0.85
b
heavy light users 4.56 ± 0.67a 3.82 ± 0.93
b 4.40 ± 0.66
a
heavy regular users 4.61 ± 0.81a 4.34 ± 0.72
a 2.86 ± 1.03
c
Gender
Males
females
N=466
4.19 ± 0.97
4.15 ± 0.96
0.4104 N=492
3.93 ± 0.89 a
3.50 ± 0.99 b
<0.0015 N=490
3.40 ± 1.08
3.15 ± 1.15
0.0155
42
BMI category
underweight
normal weight
overweight
obese
Age groups
17-30 years
30-50 years
above 50 years
N=463
4.43 ± 0.56a,b
4.05 ± 1.02b
4.15 ± 0.90a,b
4.63 ± 0.87a
N=471
4.38 ± 0.84a
4.11 ± 0.93a,b
4.03 ± 1.06b
0.006
0.003
N=487
3.93 ± 0.77
3.66 ± 1.00
3.72 ± 0.98
3.62 ± 0.93
N=496
3.99 ± 0.86a
3.55 ± 0.91b
3.55 ± 1.06b
0.628
<0.001
N=486
3.35 ± 1.04a,b
3.12 ± 1.08b
3.31 ± 1.17a,b
3.53 ± 1.18a
N=495
3.35 ± 1.12
3.27 ± 1.12
3.16 ± 1.14
0.038
0.283
Educational level
low level
medium level
high level
Objective knowledge
Pearson’s correlation
Subjective knowledge
Pearson’s correlation
N=469
4.24 ± 1.08
4.26 ± 0.99
4.14 ± 0.96
N=471
0.042
N=471
-0.094*
0.565
0.3633
0.0413
3.59 ± 1.00
3.78 ± 1.02
3.68 ± 0.97
N=496
0.032
N=496
-0.70
0.548
0.4803
0.1213
3.03 ± 1.62
3.46 ± 1.76
3.08 ±1.84
N=495
0.167**
N=495
0.033
0.498
<0.0013
0.4623
1 All values are means value ± SDs
2 Value derived from parametric test (one way ANOVA)
3 Value derived from Pearson’s correlation
4 Values derived from Mann-Whitney test
5 Values derived from independent t-test
* Correlation is significant at the 0.05 level (2-tailed)
**Correlation is significant at the 0.01 level (2-tailed) Superscript letters
indicate significant differences between groups by one-factor ANOVA
43
4.5. Use of nutrition information on food and soft drinks
This study also assessed the use of nutrition information on labels of food in general and soft
drinks in particular. Female participants were observed to use nutrition information on food
more often than males (Table 10). This may be contributed by the fact that more females in this
study reported to do most of the shopping for their household than males (67% and 33%
respectively). This finding is in line with the study of Baltas (2001). No significant differences
in information use on soft drinks were observed according to gender (P=0.065). A significant
difference was found between age groups in which people between 30-50 years used more often
information on soft drinks than people above 50 years (P=0.015). This result matches with study
by Baltas (2001) who reported that older people limit their use of information about a certain
product before making purchasing decision and they less often look at food labels. This might
be explained by the fact that older people may lose interest in reading because of problems with
their sights. Also no differences in information use were observed between BMI categories and
according to the educational level (P>0.05). Heavy light and non users of soft drinks were found
to use more nutrition information on food labels than heavy regular users. Also heavy light
users used more information on labels of soft drinks than heavy regular, lower and non users of
soft drinks (Table 10). Heavy light users were also observed to have high objective knowledge
as discussed above under section 4.4.1. From this study it can be generally conclude that use of
nutrition information on soft drinks was relatively low.
44
Table 10. Use of nutrition information on food and soft drinks labels (n=507)1
Information on
food
P-value Information on soft
drinks
P-value
Gender <0.0012 0.065
2
male 4.22 ± 1.64 3.56 ± 1.88
female 4.76 ± 1.56 3.88 ± 1.88
Age groups 0.0613 0.015
3,4
17-30 years 4.26 ± 1.77 3.70 ± 1.86a,b
30-50 years 4.76 ± 1.56 4.07 ± 1.90a
above 50 years 4.53 ± 1.62 3.50 ± 1.86b
BMI category 0.2213 0.460
3
underweight 4.06 ± 1.84 3.31 ± 1.82
normal 4.46 ± 1.66 3.69 ± 1.88
overweight 4.55 ± 1.62 3.76 ± 1.86
obese 4.90 ± 1.36 4.03 ± 1.89
Educational levels 0.7413 0.956
3
low level 4.62 ± 1.67 3.78 ± 1.91
medium level 4.44 ± 1.55 3.70 ± 1.88
high level
Soft drink user groups
non users
low users
medium users
heavy light users
heavy regular users
4.53 ± 1.63
4.90 ± 1.29a
4.41 ± 1.66a,b
4.62 ± 1.48a,b
5.09 ± 1.55a
3.95 ± 1.68b
<0.0013,4
3.76 ± 1.89
2.98 ± 2.17c
3.59 ± 1.87b,c
4.08 ± 1.72a,b
4.46 ± 1.76a
3.51 ± 1.79b,c
<0.0013,4
1 All values are means value ± SDs
2 Values delivered from non-parametric test Mann- Whitney
3 Values delivered from non-parametric test- Kruskal Wallis
4 Values delivered from parametric test- one factor ANOVA.
Superscript letters indicate significant differences between groups by one-factor ANOVA
45
4.6. Acceptance of policy measures to reduce soft drink consumption
Table 11 describes the acceptance by the participants of government policies/interventions
aiming at reducing soft drink consumption. Two policy measures from factor analysis (‘limiting
availability’ and ‘information provision’) were compared against various demographic variables
and groups of soft drink users. The first factor comprised policy measures aiming at limiting the
availability of soft drinks (e.g. banning of vending machines and imposing high taxes on soft
drinks), while the second factor grouped policy measures aiming at provision of information
(e.g. through food labels and information campaigns). Acceptance of policies concerning
information provision was higher compared to policies aiming at limiting availability of soft
drinks (Table 11). Gender was not found to be associated with the acceptance of both policy
measures (P=0.985) for limiting availability policies and (P=0.187) for information provision
policies. This indicates that both males and females have the same level of policy acceptance.
Significant differences in policy acceptance were found between age groups (P<0.001). People
aged between 30-50 years and above 50 years had a higher acceptance of policies focusing on
limiting availability of soft drinks than people aged between 17-30 years. This can be explained
by the fact that young adults were found to be the highest consumers of soft drinks so it could
be difficult for them to support policies aiming at limitation of soft drinks. On the other hand,
adults above 50 years had low consumption levels of soft drinks so again it is likely for them to
support these policies. Elderly people (above 50 years) were also more supportive of policies
focusing on the provision of information than the other age groups (P<0.05, Table 11). This
might be contributed by the fact that elders are low consumers of soft drinks and might have
prior knowledge on health impacts of high soft drink consumption. There were also significant
differences in policy acceptance according to occupational levels. Retired people had higher
acceptance of both policies aiming at limiting availability and provision of information
compared to people doing paid work and those working full time in higher education (P<0.001)
(Table 11). No significant difference in the acceptance of policies focusing on provision of
information was observed according to educational levels (P=0.829), while acceptance of
policies aiming at limiting availability of soft drinks was related to education (P=0.004). People
with high and medium education supported these policies more than people with low education.
Policy acceptance also differed significantly among groups of soft drinks users. Non users
supported policies aiming at limiting availability of soft drinks more than other groups of users.
46
They also supported policies for information provision more compared to medium and heavy
regular users. There was no association between objective nutrition knowledge and accepting
policies aiming at limiting availability of soft drink, on the other hand, small correlation was
found between objective nutrition knowledge and policies aiming at provision of information
(hypothesis no.7 not real confirmed). Generally, it can be said that policies aiming at provision
of information are more acceptable than policies focusing on limiting availability of soft drinks.
This result can be evidenced by the study done to parents in USA which showed that parents
had negative opinions on the presence of vending machines in high schools with the idea that
adolescents are grown up enough to make their own decision on whether to consume soft drinks
or not (Paterson et al., 2004).
47
Table 11. Policy acceptance of the respondents against the tested variables
Variable (n) Limiting
availability policies
P-value Providing
information policies
P-value
Overall mean 4.14 ± 1.58 <0.0012 5.42 ± 1.16 <0.001
2
Gender (497) 0.9853 (496) 0.187
3
males 4.12 ± 1.59 5.31 ± 1.21
females 4.14 ± 1.58 5.48 ± 1.13
Age groups (502) <0.0014 (501) <0.001
4
17-30 years 3.57 ± 1.44b 5.07 ± 1.09
c
30-50 years 4.16 ± 1.59a 5.37 ± 1.22
b
above 50 years 4.52 ± 1.55a 5.70 ± 1.09
a
Educational levels (500) 0.0044 (499) 0.829
4
low education 3.52 ± 1.43b 5.33 ± 1.12
medium education 4.22 ± 1.49a 5.42 ± 1.15
high education 4.22 ± 1.59a 5.43 ± 1.18
Occupational levels (502) <0.0014 (501) <0.001
4
paid work 4.17 ± 1.58b 5.43 ± 1.15
b
retired 4.77 ± 1.36a 5.83 ± 0.94
a
full time higher education 3.14 ± 1.44c 4.95 ± 1.19
c
unemployed
Soft drink user groups
non users
low users
medium users
heavy light users
heavy regular users
Objective knowledge
correlation
3.90 ± 1.40a,b,c
(499)
5.22 ± 1.41
a
4.45 ± 1.50
b
3.94 ± 1.55
b,c
3.59 ± 1.59
c
3.46 ± 1.41
c
(500)
0.046
<0.0014
0.3015
5.05 ± 1.41b,c
(498)
5.87 ± 1.27
a
5.52 ± 1.13
a,b
5.22 ± 1.16
b,c
5.48 ± 1.04
a,b
4.97 ± 1.17
c
(498)
0.102*
<0.0014
0.0235
1 All values are means value ± SDs
2 Values from one sample t-test
3 Value delivered from Mann-Whitney
4 Values delivered from one Factor ANOVA
48
5 Values delivered from Pearson’s correlation
Superscript letters indicate significant differences between groups by one-factor ANOVA
*correlation is significant at 0.05 levels (2-tailed)
Figure 4. Presenting percentages of consumer’s acceptance on policy measures
Note: the first and the last three categories have been combined for agree and disagree
45.4
11.1
9.4
23.7
4
38.4
43.3
22.3
30
48.7
32.5
14.8
12.6
22.3
6.3
23.7
23.4
17.4
18.5
23.5
21.5
73.8
77
53.3
89.4
36.8
33.1
59.9
50.7
27.4
0 20 40 60 80 100
policy1
policy2
policy3
policy4
policy5
policy6
policy7
policy8
policy9
policy10
percentage
po
licy
mea
sure
s
agree
neither agree nor disagree
disagree
49
4.7. Consumers attitudes towards sweeteners used in soft drinks
Results in Table 12 show that participants’ attitude towards sweeteners used in soft drinks is
different among soft drink users. Attitude towards health aspects regarding sweeteners was
higher in low users than in medium and heavy regular users. Heavy regular users showed more
concerns about taste aspects of sweeteners compared to other groups of users (P<0.001, table
12). This looks almost similar with results of Tuorila et al. (1990) who found that users of diet
soda and non users (of either regular or diet) paid much attention to weight related issues, while
users of regular soda paid less attention. This indicates heavy regular users are more concerned
with taste than health aspects. For those with no attitude towards sweeteners (anti-sweeteners)
did not show any different between different groups of soft drink users. Other variables like
gender, educational levels and age groups were also not found to be associated with attitudes
towards sweeteners (P>0.05). However Nabors (1999) reported that highly educated American
adult women had positive healthy attitudes towards low caloric beverages and consumed them
regularly. Negative association was found between objective nutrition knowledge and attitude
towards taste aspects of sweeteners. However no association was observed between attitudes
towards health aspects and anti-sweeteners and objective nutrition knowledge. This was also
similar to subjective nutrition knowledge which did not associate with attitudes towards
sweeteners. General results indicated neutrality towards sweeteners, this may be due to the fact
that people do not have enough information regarding sweeteners. Therefore provision of
adequate information may create awareness of sweeteners in terms of their health and taste
aspects.
50
Table 12. Consumers’ attitudes towards sweeteners used in soft drinks (n=507)
Variable (n)5 Health
aspects
P-value Taste aspects P-value Anti-
sweeteners
P-value
Soft drink user
groups
499 <0.0011 500 <0.001
1 499 0.762
1
non users 4.46 ± 1.27a,b
4.11 ± 1.39b 4.06 ± 1.77
low users 4.82 ± 1.13a 4.27 ± 1.26
b 4.34 ± 1.54
medium users 4.57 ± 0.99b 3.94 ± 1.31
b 4.39 ± 1.43
heavy light users 4.14 ± 1.06b 3.39± 1.1.41
c 4.34 ± 1.44
heavy regular users 4.58 ± 0.95a,b
4. 85 ± 1.09a 4.38 ± 1.46
Gender (497) 0.0972 (498) 0.163
2 (497) 0.235
2
males 4.50 ± 1.13 4.25 ± 1.26 4.44 ± 1.53
females 4.64 ± 1.09 4.08 ± 1.38 4.27 ± 1.51
Educational level (500) 0.0773 (501) 0.813
3 (500) 0.519
3
low level 4.45 ± 0.98 4.11 ± 1.33 4.26 ± 1.43
medium level 4.39 ± 1.12 4.10 ± 1.23 4.16 ± 1.37
high level 4.65 ± 1.12 4.16 ± 1.36 4.38 ± 1.56
Age groups (502) 0.7933 (503) 0.343
3 (502) 0.865
3
17-30 years 4.56 ± 0.98 4.18 ± 1.36 4.30 ± 1.22
30-50 years 4.63 ± 1.16 4.03 ± 1.35 4.31 ± 1.57
above 50 years 4.57 ± 1.14 4.21 ± 1.31 4.38 ± 1.66
Objective nutrition
knowledge
(500) 0.1354 (501) 0.006
4 (502) 0.974
4
Pearson correlation 0.067 -0.122** 0.001
Subjective
nutrition
knowledge
(499) 0.3664 (500) 0.255
4 (499) 0.636
4
Pearson’s correlation 0.041 -0.051 0.021
1 Values delivered from parametric test (one way ANOVA)
2 Values delivered from non parametric test (Mann -Whitney U test)
3 Values delivered from non parametric test -Kruskal Wallis test
4 Values delivered from Pearson’s correlation
** Correlation is significant at the 0.01 level (2-tailed) 5
Means value ± SDs (all such values)
51
CHAPTER 5: CONCLUSION AND RECOMMENDATIONS
5.1. Conclusion
High consumption of soft drinks, especially sugar sweetened (regular drinks) have been
reported by various studies to have a direct link with diet related health problems (Brownell et
al., 2011; James et al., 2004; Malik et al., 2010; Popkin and Nielsen, 2003; Schulze et al.,
2004; Ventura et al., 2010). The intake is high in western countries for the last 3 decades (Sartor
et al., 2011). In Belgium consumption is high among adolescents (Vandevijvere et al., 2008).
This study aimed at assessing consumers’ attitudes, nutrition knowledge, use of nutrition
information on soft drinks labels, acceptance of government policies focusing on reduction of
consumption and consumers’ opinion on sweeteners used in soft drinks among adults.
General consumption of soft drinks was found to be low, on average around once per week.
This is because most adults above 50 years are non-consumers of soft drinks and they form a
large fraction of subjects involved in this study. Apart from age, BMI and occupation levels,
other demographic variables such as education, gender, income and family composition did not
differ with the consumption of soft drinks. Most participants obtain their soft drinks in
supermarkets, therefore policies should also focus on reducing availability of soft drinks in
supermarkets.
Heavy light users were found to be most obese in this study, however long prospective studies
are needed to establish this cause-effect relationship. Objective nutrition knowledge was high in
adults aged 30-50, young adults 17-30 years and heavy light users, also associated with
information use. However young adults were the most consumers of regular soft drinks and
heavy light users had the highest weight (obese). This shows high objective nutrition knowledge
does not guarantee the application of this knowledge in reducing soft drinks intake. Subjective
knowledge did not correlate with most of the tested variables like gender, BMI, education level,
age e.t.c however correlation was found between subjective knowledge and use of nutrition
information.
More positive general attitude towards soft drinks was found in heavy light users, heavy regular
users and medium users, which means that heavy regular users preferred regular soft drinks and
heavy light users and obese people preferred light soft drinks. Young adults (17-30 years) had
positive general attitudes towards soft drinks and positive attitude towards regular soft drinks.
52
People in the age group of 30-50 years used nutrition information on soft drink labels the most
compared to other groups. Also heavy light users used more information on soft drinks
compared to heavy regular users. Other variables like gender, education and occupation were
not associated with the use of information. Government policies aiming at providing
information are evaluated more positively by consumers than policies aiming at reducing
availability of soft drinks. Older people, retired and well educated had higher acceptance of
policies. From findings of this study, provision of adequate information and knowledge will be
useful in raising objective and subjective nutrition knowledge among adults who are soft drink
users. Young adults (17-30 years) was the group with most positive attitude, consume more soft
drinks, and are less supportive to government policies aiming at limiting availability of soft
drinks. Therefore further studies on nutrition interventions on soft drinks should pay more
attention to this group. Efforts in raising awareness about information use on soft drinks are
necessary.
5.2. Recommendations
Due to increased concern of dietary related health problems in developed countries,
development of new sweeteners (together with other factors) is important for controlling energy
intake from soft drinks (Grenby, 1991). For example stevia, a sweetener believed to be of
natural origin is now receiving increased attention for its use in soft drinks. It is so because the
demand for low caloric foods and drinks is high in developed countries (Grenby, 1991).
Consumption of light soft drinks can be encouraged because they contain low amount of energy
but precaution should be taken to limit excessive intake because it may lead to accumulation of
much energy in the body causing overweight and obesity (Grenby, 1991). Moreover regular soft
drinks should not form the essential part of the meal and/or can be completely avoided during
meals. A moderate intake of light soft drinks can be selected instead. Alternatively water and
low-fat milk products can replace sugar-rich soft drinks (Astrup et al., 2008).
Intervention to reduce soft drinks consumption especially sugar sweetened drinks should have
theoretical basis as review of the literature shows theory based interventions of other health
behaviour change has substantial effects (Zoellner et al., 2012 ). On this aspect the theory of
planned behaviour has been found to be promising in explaining and predicting eating and
drinking behaviours (Zoellner et al., 2012). Although this study found generally low
53
consumption of soft drinks and low attitudes towards consumption of soft drinks, but it sheds
some light for policy implication and practices. Adults can still play a significant role in
behavioural change of their children and adolescents. This can be implemented through
reinforcement of parental rules, knowledge and skills, since children and adolescents are mostly
affected by negative health consequences resulting from excessive soft drink consumption.
Another policy implication could be promoting awareness through information campaigns and
addressing environmental cues related to soft drink consumption (Hattersley et al., 2009).
Furthermore soft drink industries should innovate and produce new soft drinks products with
regulated amounts of sweeteners and small size packages to limit intake of sugar and reduce the
amount of intake.
Before implementing policy measures to reduce soft drinks consumption the government should
consider; the prevalence of health effects caused by consumption of soft drinks (such as obesity
and cardiovascular diseases) in the target population. The levels of soft drinks intake (which are
determined by consumption frequency and amount) in the general population and the existing
policy measures which have worked (Jou and Techakehakij, 2012). In order to check for
effectiveness of informative intervention targeting at adult’s soft drink consumption, their
attitude and nutrition knowledge and information use, long prospective studies are needed.
Promoting menu labelling at restaurants and fast food areas can help people who eat frequently
in these places to estimate energy content of their portion sizes, therefore easy-to-use and clear
nutrition information during food ordering are essential as consumers can make informed food
choices (Energy Density Guide, 2010).
Increase of nutrition knowledge is also necessary since this knowledge is not static, it changes
as knowledge on health and diet increase, subjecting dietary recommendations to changes as
well (Spillmann et al., 2011).
54
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.
ANNEX 1. PART A.
QUESTIONNAIRE ON SOFT DRINKS
The following questions are about your consumption of soft drinks. By soft drinks we mean carbonated
beverages including sugar-sweetened or “regular” carbonated beverages and artificially sweetened or
“diet” carbonated beverages.
1. How often do you consume following beverages? Please circle one answer in each row.
Several
times a day
Daily or
almost
every day
3-4 times a
week
2 times
a week
Once a
week
Less
frequently Never
Regular soft drinks 1 2 3 4 5 6 7
Diet soft drinks 1 2 3 4 5 6 7
Fruit juice 1 2 3 4 5 6 7
2. How often do you buy or obtain soft drinks from...? Please circle one answer in each row.
3. How likely is that you consume soft drinks as an alternative to...? Please circle one answer in
each row.
Never Sometimes Always
... supermarkets and
grocery shops
1 2 3 4 5 6 7
... vending machines 1 2 3 4 5 6 7
... cafes/pubs/bar 1 2 3 4 5 6 7
...working canteens 1 2 3 4 5 6 7
.. .restaurants 1 2 3 4 5 6 7
Very
unlikely
Very
likely
... water 1 2 3 4 5 6 7
... milk 1 2 3 4 5 6 7
... tea or coffee 1 2 3 4 5 6 7
... alcohol 1 2 3 4 5 6 7
... energy drink 1 2 3 4 5 6 7
... snacks 1 2 3 4 5 6 7
... meals 1 2 3 4 5 6 7
4. How often do you consume soft drinks at the following occasions? Please circle one answer in
each row.
5. In the following different statements about your knowledge regarding soft drinks have been
listed. Please indicate to which degree you agree or disagree with the statements. Please circle
one answer in each row.
Never Sometimes Always
To accompany a meal at a restaurant, pub or cafe 1 2 3 4 5 6 7
At a pub/club as an alternative to alcohol 1 2 3 4 5 6 7
To accompany a meal at home 1 2 3 4 5 6 7
At home as an alternative to alcohol 1 2 3 4 5 6 7
At home as an alternative to water 1 2 3 4 5 6 7
At home/work as an alternative to tea, coffee 1 2 3 4 5 6 7
Family occasions 1 2 3 4 5 6 7
When having guests to my home 1 2 3 4 5 6 7
When being on visit 1 2 3 4 5 6 7
Totally
disagree
Neither agree nor
disagree
Totally
agree
My friends consider me as an expert in soft
drinks 1 2 3 4 5 6 7
I have a lot of knowledge about how to
evaluate the quality of soft drinks 1 2 3 4 5 6 7
I know which soft drinks are good for me 1 2 3 4 5 6 7
I have a lot of knowledge about how to
evaluate the nutritional value of soft drinks 1 2 3 4 5 6 7
6. Please indicate whether the following statements are true or false. Please circle one answer for
each statement.
False True No
idea
Regular soft drinks are high in calories
Diet soft drinks are high in calories
Fruit juice is high in calories
Regular soft drinks are high in sugar
Diet soft drinks are high in sugar
Fruit juice is high in sugar
Regular soft drinks and fruit juice contain the same amount of sugar
Diet soft drinks and fruit juice contain the same amount of sugar
Diet soft drinks have lower levels of acidity than regular soft drinks
Diet coke has lower levels of caffeine than regular coke
Regular soft drinks contain about 10 times more calories than diet soft drinks
Fruit juice is just as healthy as one serving of fresh fruit
High levels of soft drink consumption contributes to overweight
High levels of soft drink consumption contributes to dental erosion
High levels of soft drink consumption is associated with diabetes
High levels of soft drink consumption is associated with osteoporosis
High levels of fruit juice consumption contributes to overweight
One gram of sugar contain the same amount of calories than one gram of fat
One gram of sugar contain the same amount of calories than one gram of
sweetener
One gram of sugar contain the same amount of calories than one gram of fibre
7. Please indicate to which degree you agree or disagree with the following statements about
government interventions to reduce soft drink consumption. Please circle one answer in each
row.
Policy measure Totally
disagree
Neither agree
nor disagree
Totally
agree
The government should ban advertising for
soft drinks 1 2 3 4 5 6 7
The government should spend money for
information campaigns informing people about
the risks of consuming soft drinks
1 2 3 4 5 6 7
Education to reduce consumption of soft
drinks should be provided in all schools 1 2 3 4 5 6 7
The government should subsidise firms which
provide programmes to train their employees
in reducing their soft drink consumption
1 2 3 4 5 6 7
All soft drinks should be required to carry
labels with calorie and nutrient information 1 2 3 4 5 6 7
All bars and restaurants should be required to
provide calorie and nutrient information on
served soft drinks
1 2 3 4 5 6 7
The government should impose taxes on soft
drinks and use the proceeds to promote
healthier eating
1 2 3 4 5 6 7
Vending machines should be banned from
schools 1 2 3 4 5 6 7
VAT rates should be higher for soft drinks and
lower for healthy alternatives such as water
and milk
1 2 3 4 5 6 7
Vending machines should be banned from
company canteens 1 2 3 4 5 6 7
8. How often do you use nutrition information on...? Please circle one answer in each row.
9. In the following we would like you to think about how you feel when you consume soft drinks.
Please indicate for each row which word best describes how you feel.
When I drink soft drinks (regular or diet), I feel ...
Bad 1 2 3 4 5 6 7 Good
Unsatisfied 1 2 3 4 5 6 7 Satisfied
Unpleasant 1 2 3 4 5 6 7 Pleasant
Dull 1 2 3 4 5 6 7 Exciting
Terrible 1 2 3 4 5 6 7 Delightful
Negative 1 2 3 4 5 6 7 Positive
10. Please indicate to which degree you agree or disagree with the following statements about
consuming regular soft drinks. Please circle one answer in each row.
Consuming regular soft drinks... Totally
disagree
Neither
agree nor
disagree
Totally
agree
... is healthy 1 2 3 4 5 6 7
... is nutritious 1 2 3 4 5 6 7
...at meals is appropriate 1 2 3 4 5 6 7
... is pleasant 1 2 3 4 5 6 7
... is cheap 1 2 3 4 5 6 7
... makes me feel relaxed 1 2 3 4 5 6 7
... gives energy 1 2 3 4 5 6 7
... satisfies my thirst 1 2 3 4 5 6 7
... refreshes me 1 2 3 4 5 6 7
... hydrates the body 1 2 3 4 5 6 7
Soft drinks are easily available 1 2 3 4 5 6 7
Soft drinks have a good taste 1 2 3 4 5 6 7
Soft drinks have a pleasant mouth feeling 1 2 3 4 5 6 7
Never Sometimes Always
... foods and drinks in general 1 2 3 4 5 6 7
... soft drinks 1 2 3 4 5 6 7
...fruit juice 1 2 3 4 5 6 7
11. Please indicate to which degree you agree or disagree with the following statements about
consuming diet soft drinks. Please circle one answer in each row.
Consuming diet soft drinks... Totally
disagree
Neither
agree nor
disagree
Totally
agree
... is healthy 1 2 3 4 5 6 7
... is nutritious 1 2 3 4 5 6 7
...at meals is appropriate 1 2 3 4 5 6 7
... is pleasant 1 2 3 4 5 6 7
... is cheap 1 2 3 4 5 6 7
... makes me feel relaxed 1 2 3 4 5 6 7
... gives energy 1 2 3 4 5 6 7
... satisfies my thirst 1 2 3 4 5 6 7
... refreshes me 1 2 3 4 5 6 7
... hydrates the body 1 2 3 4 5 6 7
1 2 3 4 5 6 7
1 2 3 4 5 6 7
1 2 3 4 5 6 7
12. Please indicate to which degree you agree or disagree with the following statements about
regular and diet soft drinks. Please circle one answer in each row
Totally
disagree
Neither agree nor
disagree
Totally
agree
Regular soft drinks are easily available 1 2 3 4 5 6 7
Regular soft drinks have a good taste 1 2 3 4 5 6 7
Regular soft drinks have a pleasant mouth
feeling 1 2 3 4 5 6 7
Diet soft drinks are easily available 1 2 3 4 5 6 7
Diet soft drinks have a good taste
Diet soft drinks have a pleasant mouth
feeling
13. Please indicate to which degree you agree or disagree with the following statements about your
habits regarding soft drink consumption. Please circle one answer in each row.
Consuming soft drinks is something ... Totally
disagree
Neither agree
nor disagree
Totally
agree
... that belongs to my routine 1 2 3 4 5 6 7
... I have been doing for a long time 1 2 3 4 5 6 7
... I have no need to think about doing 1 2 3 4 5 6 7
... I am used to from my childhood 1 2 3 4 5 6 7
... I learned from my parents 1 2 3 4 5 6 7
... we often did at my home 1 2 3 4 5 6 7
14. Please indicate to which degree you agree or disagree with the following statements about
sweeteners in soft drinks. Please circle one answer in each row.
Totally
disagree
Neither agree
nor disagree
Totally
agree
I am concerned about the amount of sugar in
regular soft drinks 1 2 3 4 5 6 7
I believe that the best way to reduce calories in
soft drinks is to use low quantities of sugar 1 2 3 4 5 6 7
Diet soft drinks with artificial sweeteners have
an aftertaste compared to regular soft drinks 1 2 3 4 5 6 7
I believe that the best way to reduce calories in
soft drinks is to use artificial sweeteners
If available, I am more likely to drink a soft
drink with natural low-calorie sweetener than
with artificial sweetener
1 2 3 4 5 6 7
Artificial sweeteners are unhealthy 1 2 3 4 5 6 7
Natural sweeteners are unhealthy 1 2 3 4 5 6 7
Diet soft drinks with artificial sweeteners are not
as sweet as regular soft drinks 1 2 3 4 5 6 7
ANNEX 1. PART B.
PERSONAL DATA QUESTIONNAIRE
15. What is your gender?
16. How old are you?
17. Are you living alone or together with others?
Living alone
Co-habiting (with partner, parents, children, friends, etc.)
18. How many adults (including yourself) and children of 15 years and older are living in your household?
|__|__| adults and children aged 15 or older
19. How many children (0-14 years old) are living in your household?
|__|__| children younger than 15
20. What is the age of the youngest child living in your household?
|__|__| year
There are no children living in my household
21. What is the highest level of education that you have completed?
Male
Female
Primary or unfinished lower secondary (until 15 years)
General secondary education (15-18 years)
Special secondary education (15-18 years)
Technical secondary education (15-18 years)
Art secondary education (15-18 years)
High school (18 years and older)
University beyond (18 years and older)
22. What is your working status?
23. How would you describe your household’s financial situation?
Not well off
Difficult
Modest
Reasonable
Well off
Don’t know
24. Do your do most of the grocery shopping for your household?
Yes
No
As frequent as someone else in my household
25. Thinking now of your own nutrition, are you currently on one of the following diets?
Full-time paid work
Part-time paid work (more than 8 hours per week)
Part-time paid work (under 8 hours per week)
Retired
In full time higher education
Unemployed (seeking work)
Not in paid employment (not seeking work)
Yes No
Low salt diet
Low sugar diet
Low energy diet
Low fat diet
Vegetarianism
Veganism
Other diet: …………………………………..
26. Do you or does someone else in your household have any of the following health problems?
Yes – Myself Yes – Someone in my family No
High blood cholesterol levels
Cardiovascular/heart disease
Type of cancer
High blood pressure
Food allergies
Overweight/Obesity
Diabetes
Other …………………………
27. What is your weight?
|__|__|__| kilograms
28. What is your length?
|__|metres |__|__| centimetres
Thank you for completing the questionnaire