Early Evaluation of the Balance Calories Initiative

Deborah Cohen, MD, MPH Laura Bogart, PhD Gabriela Castro,

Funded by the Robert Wood Johnson Foundation

Balance Calories Initiative

• Goal: to help fight obesity: reduce beverage calories consumed per person nationally by 20 percent by 2025

• Dr. Pepper/Snapple, Coca-Cola, PepsiCo (“Big 3”) and the Alliance for a Healthier Generation

• Started intensive efforts to reduce sugar-sweetened beverage (SSB) consumption in low income areas in NY, Los Angeles, and Arkansas in 2015

• Added Montgomery AL and the North Delta, MS in late 2016

• Plans to target up to 10 low income areas in the US

“Big 3” Pledges • Increasing Interest in and Access to Reduced

Calorie Beverage Choices with Special Community-Level Focus – increase interest in and expand access to water, no-

and lower-calorie beverages and smaller-portion sizes – increase access to no- and lower-calorie products and

smaller-portion packages and drive interest in these products through proven promotional efforts like

• product placement • featured merchandising • couponing • other incentives

Methods • Marketing: Assessment of randomly selected retail food

outlets in East LA/Boyle Heights (12), Montgomery, AL(23) and North Delta, MS (17), as well as 2 comparison communities: Birmingham AL (26) and South Delta. MS (23); Assess billboards on major streets

• Perceptions: Stakeholder (store owner/manager) and consumer interviews in 3 intervention communities (adults and adolescents)

• Consumption: Survey of adolescents and adults in AL and MS

Retail Assessments

• To document placement and promotion of beverages: SSB, low/no cal beverages, water – Placement on end of aisles, aisles, special displays,

perimeter of store, cash registers and front of store, logos/ads/coupons for Balance Calories Initiative

– For restaurants: availability on menu, drive through, portion sizes, refill policy

• Trained observers documented placement independently, compared findings then developed consensus

Publix, Montgomery, AL (Coupon is 10/1/16 to 10/21/16)

Supermarkets/Groceries (percentage of in-store displays with beverages)

Groceries/Supermarkets N=44 SSBs Low/No Cal Water End aisle displays 24% 16% 8% Aisles 25% 16% 13% Floor displays 16% 7% 7% Perimeter walls 50% 37% 24% Cash register displays 65% 48% 45% Avg. Potential Exposures 25 15 11

ABA SSBs ABA Lo/NoCal ABA Water End aisle displays 20% 16% 4% Aisles 18% 14% 7% Floor displays 12% 5% 4% Perimeter walls 35% 20% 13% Cash register displays 63% 44% 38% Avg Potential exposures 19 12 8

Mini-Cans in Supermarkets/Groceries (percentage of in-store displays with beverages)

Mini Cans End aisle 3% Aisle 4% Cash register 2% Floor display 0% Perimeter Wall 0%

Convenience Stores (percentage of in-store displays with beverages)

Convenience store N=17 SSBs Low/No-Cal Water End aisle displays 29% 4% 11% Aisles 15% 8% 15% Floor displays 34% 8% 10% Perimeter walls 64% 41% 28% Cash register displays 12% 12% 12% Avg. Potential Exposures 7 2 3 ABA

SSBs ABA

Low/No-Cal ABA

water End aisle displays 17% 4% 2% Aisles 13% 3% 11% Floor displays 28% 8% 2% Perimeter walls 64% 34% 27% Cash register displays 12% 12% 12% Avg. Potential Exposures 5 1 1 Mini-cans 0% 0% 0%

2 years after campaign initiation in East LA/Boyle Heights vs. South

Supermarkets/Groceries

South

ABA SSBs N=44

East LA/Boyle Heights

ABA SSBs N=8

South

ABA Lo/NoCal

East LA Boyle

Heights ABA

Lo/NoCal

South

ABA Water

East LA/ Boyle

Heights ABA

Water

End aisle displays 20% 28% 16% 12% 4% 3%

Aisles 18% 20% 14% 14% 7% 4%

Floor displays 12% 8% 5% 2% 4% 1%

Perimeter walls 35% 53% 20% 34% 13% 22%

Cash register 63% 58% 44% 54% 38% 29%

Avg. Potential Exposures

19 17 12 10 8 4

Billboards

Consumer Interviews-Adolescents and Parents (6-mos post-intervention) • Participants in Montgomery, AL:

– 13 parents of children under age 18 years (5 fathers and 10 mothers) – 15 adolescents aged 10-17 (10 boys and 5 girls) – 4 store managers/owners (of 2 supermarkets and 2 convenience

stores) – 1 restaurant manager in Montgomery, Alabama

• Participants were asked to think aloud as they viewed logos and tag-lines from the initiative, including “Find your balance, find your flavor” and “Balance what you eat, drink, and do”

• Adolescents were recruited through a youth-serving organization, and parents were recruited via street intercept near food establishments or by snowball sampling. (gift card incentives)

• Managers and owners were recruited at their businesses.

Consumer Interviews-Adolescents and Parents (6-mos post-intervention) • Results showed mixed understanding of the tag-lines

– There were numerous misinterpretations, including: • Broaden beverage choices to include new flavors and different brands • Drink more soda • Soda has been reformulated to be healthier

– Some participants understood the message of healthy beverage consumption, but most did not understand the full message related to balanced eating, drinking, and physical activity

• Many viewed sports drinks as healthy • Participants in the South perceived “white” drinks (e.g.,

Sprite) to be much healthier than “dark” drinks (e.g., Coke) • Few were aware of the Balance Calorie Initiative or any

associated changes

Interpretations of Billboard • “I guess these drinks could help you with something, with sports, or being

sick at home - like when you have a stomach virus, some stuff that you drink is good to help you not have it no more. Words mean drinks that has a good flavor and not a lot of calories in it. Balance means it has nutrients, good with sports and food, like a good drink you can have” --15 yr. old boy

• “…Balance = find the right drink you want, probably a Powerade or Sprite or water. …Balance means you have to go to the right place to get the right drink (like Walmart, Dollar General, Winn Dixie). The right drinks are Sprite, Powerade, water” –10 yr. old boy

• “Balance means if you fall, lose balance, catch yourself. It means what types of drinks do you want, do you like the drink or not? Drink when you're tired, when you’re running, before and after, drink Powerade and blue fountain (blueberry drink)” ---11 yr. old boy

Logo interpretation

• “Keep up the good things that you eat and healthy and unhealthy things - keep up with the things you drink as you work out.” --14 yr. old girl

• “Don't swallow too fast, don't drink soda too fast. Balance means to slow down.” --11 yr. old boy

• “This picture says to me: what you eat, make sure you're not allergic to it, what you drink, make sure it doesn't have something in it that can kill you. Or, your parents tell you can't drink it, but you drink it anyway, you shouldn’t drink it. Balance means: you should balance your diet so you know what to eat and not to eat. Balance with salad, smoothie, anything that has fruit in it, balance it with a side of meat.” --12 yr. old boy

Favorite beverage advertisement

• Le Bron James Sprite ad “The drink makes him stronger - he drinks it and goes to the court and dunks and says, “Choose Sprite” - that's how I really like Sprite, because of the commercial and all of the ads that show me what I need to drink”-- 10 year old boy

Store Manager Interviews (post-intervention)

• No follow-up after initial announcement of initiative

• No changes in the store • Managers saw discounting of beverages as an

effective marketing strategy • Managers viewed soda is the biggest selling

item; not interested in promoting water

Intercept Surveys Outside Food Outlets (Beverage consumption yesterday)

AL and MS Adolescents (n=3,425)

Adults (n=11,310)

Average age 13.6 years 38.0 years % African American 88% 85% % drinking beverage yesterday Regular Soda 70% 67% Diet soda 25% 29% Sports drink 48% 40% Fruit juice 66% 59% Sweetened fruit/coffee/tea 57% 55%

% Drinking 2 or More Cans

AL and MS Adolescents (n=3,425)

Adults (n=11,310)

Average age 13.6 years 38.0 years % African American 88% 85% % drinking 2+ cans yesterday Regular Soda 37% 40% Diet soda 12% 15% Sports drink 29% 24% Fruit juice 33% 29% Sweetened fruit/coffee/tea 28% 26%

Summary • Primary evidence of campaign is the logos and

billboards – However, message is ambiguous – Young adolescents misinterpret messages

• No apparent change in retail environments after initiative announced, except presence of logos

• Mini-cans have higher prices/oz; pricing favors larger containers of SSBs, which dominate other beverages

• Young adolescents in the South have exceptionally high consumption of SSBs

Conclusion

• Early findings in 10 year campaign; changes may be forthcoming

• Unclear whether the small changes being made with logo placement, billboards, and more expensive smaller cans will have a large impact on reducing SSB consumption

• Hampering sales of their best-selling products is contrary to interests of profit-seeking industry