Recent WHO guidelines recommend limiting free sugars from all food and beverages to less than 10% of the total energy intake, in order to reduce the associated health hazards [1
]. According to the WHO, free sugars encompass all monosaccharides and disaccharides added to foods and drinks by the manufacturer, cook, or consumer, as well as naturally present sugars in honey, syrup, fruit juice concentrates, and 100% fruit juices [1
]. However, intrinsic sugars in whole fruits and vegetables, and lactose in milk and milk products are considered to be of lower or no risk and are therefore not included in this definition [2
Among the wide spectrum of sweet products on the market, sugar-sweetened beverages are major contributors of free sugars to diet. High intake of these beverages has been associated with an increased risk of obesity [3
], dental caries [5
], and major chronic diseases, such as type 2 diabetes [6
], cardiovascular disease [8
], and possibly cancer [10
The WHO defines sugar-sweetened beverages as all beverages containing free sugars, i.e., carbonated or non-carbonated soft drinks, 100% fruit/vegetable juices and drinks, liquid and powder concentrates, flavored water, energy and sports drinks, ready-to-drink tea, ready-to-drink coffee, and flavored milk drinks [11
]. Plant-based milk substitutes, which might contain considerable amounts of free sugars, are not included in this definition [12
In contrast, the majority of studies define sugar-sweetened beverages as beverages with sugars that are added during processing, such as carbonated and non-carbonated soft drinks, fruit drinks, and sports drinks that contain added caloric sweeteners, such as high fructose corn syrup, sucrose, or fruit juice concentrates [4
]. In these studies, however, beverages with naturally present sugars such as 100% juices are excluded.
Another beverage category that is not considered in the above definitions is low or zero calorie sweet beverages. These beverages benefit from increased consumption and might be perceived as healthier choices due to their few or no calories; however, their health effects are controversial [14
]. Their consumption was similarly associated with all-cause mortality, as sugar-sweetened beverages [17
] and some low-calorie sweeteners were suggested to increase glucose intolerance by altering the intestinal microbiota [18
Following the recent WHO recommendation to limit free-sugars intake, many nutritional societies have adapted their sugar recommendations to promote this goal. Additional measures aimed at targeting sweet beverages at the policy level, such as taxes, have also been introduced in a variety of countries [19
]. However, in the application of a sugar tax, the WHO definition of sweet beverage does not seem to be consistently applied, leading to the exclusion of several beverages containing free sugars. For example, when defining which beverages should be subject to a sweet beverage tax, the majority of countries apply the tax to beverages with added sugar, but not to beverages containing naturally-present sugars, such as 100% juices (no added sugar) [20
]. More information on this from a selection of countries can be found in Appendix A
: Table A1
. Alongside beverages with added sugar, low-calorie sweet beverages are also taxed in some countries, such as France and Philippines [20
], but not in others [21
] (Appendix A
: Table A1
In Switzerland, the first national representative data on food consumption and dietary behavior, the menuCH survey [25
], was recently conducted and the first report summarized the consumption of all foods and beverages [25
]. Average daily intake of sweet beverages was 240.6 g (labeled ‘soft drinks’ in the report) and included the following beverage types—soft drinks, fruit, and vegetable juices with added sugar and low-calorie sweet beverages (corresponding to the current SB–CUR definition used in the present analysis) [25
]. However, unlike yoghurts and breakfast cereals for which the food industry has committed to decreasing the quantity of added sugar by 2018 [28
], no strategy has been directed at decreasing the quantity of added sugar in sweet beverages in Switzerland.
The above health concerns and the inconsistent application of sweet beverage definitions were the motivation for the present study. Our interest was to explore a new definition of sweet beverages (SB–NEW), which could lead to a more comprehensive assessment of sweet beverage consumption. The SB–NEW definition includes all beverages containing free sugars (as proposed by WHO) with the addition of plant-based milk substitutes and low-calorie sweet beverages. Using the menuCH survey, the aim of the present analysis was to identify the beverages that contribute to sweet beverage consumption, according to two different definitions, i.e., the current definition (SB–CUR) used in Switzerland [25
], and SB–NEW as defined above. Through the lens of analysis, the aim was to determine the sociodemographic characteristics associated with this consumption, and to possibly reveal target groups for public health interventions.
shows the sociodemographic characteristics of the study participants—75.7% of adults consumed SB–NEW classified beverages, whereas only 52.5% consumed SB–CUR classified beverages. According to the SB–NEW definition, the average daily consumption of sweet beverages in Switzerland was 329.7 g/day, compared to 240.6 g/day, under the SB–CUR definition (p
< 0.001) (see Appendix A
: Table A2
); the majority of the difference (66%) was due to the consumption of 100% juices (no added sugar) (58.6 g/day).
Sweet beverages consumed in the highest amounts were soft drinks (139 g/day), particularly carbonated drinks (sodas) (60.4 g/day), followed by all low-calorie sweet beverages (59.2 g/day), and 100% juices (58.6 g/day) (Figure 1
There were statistically significant differences (p
< 0.001) in the consumption of sweet beverages across sex and age groups, as well as between SB–NEW and SB–CUR (see Figure 2
and Appendix A
: Table A2
). With both definitions, men consumed 1.6 times more sweet beverages (391.8 g/day SB– NEW and 305.9 g/day SB–CUR) than women (250.3 g/day SB–NEW and 164.7 g/day SB–CUR). In particular, men consumed higher amounts of carbonated drinks (83.3 g/day), iced tea (43.6 g/day), low-calorie soft drinks (40.9 g/day), syrup (38 g/day), “Schorle” (a carbonated mixture of apple juice and water) (28.5 g/day), and sport drinks (11.4 g/day) than women, whereas women consumed twice as much plant-based milk substitute (7.6 g/day) as men.
Adults aged 18–29 years consumed more sweet beverages than any other age group (446.1 g/day and 345.3 g/day, according to SB–NEW and SB–CUR, respectively). This age group consumed particularly high amounts of soft drinks, at around 240.6 g/day. Statistically significant differences were not found for the consumption of 100% juices (no added sugar) across sociodemographic groups, and all groups consumed between 40 and 67 g/day.
Considering all foods and drinks, total average consumption of sugar in Switzerland was 106 g/day, and average energy intake was 2225.7 kcal/day (see Figure 3
and Appendix A
: Table A3
). All differences between men and women, and between SB–NEW and SB–CUR were statistically significant (p
< 0.001). For men, sweet beverage consumption represented 26.4% (SB-NEW) and 20.2% (SB-CUR) of total sugar consumption, whereas for women, the corresponding contributions to total sugar were 19.5% (SB-NEW) and 12.4% (SB-CUR). The subcategories of 100% juices (5.6%), carbonated drinks (5.4%) and syrup (3.7%) were the highest contributors of total sugar intake. The sugar contribution of these three categories represents 16.7% and 12.3% of the total sugar intake for men and women, respectively (see Appendix A
: Table A3
For men, SB–NEW consumption provided 5.4% of total energy intake (3.8% by SB-CUR), compared with 4.9% (2.7% by SB–CUR) for women.
Socio-Demographic, Anthropometric, and Lifestyle Correlates with Sweet Beverage Consumption
Based on the regression analysis, several sociodemographic and lifestyle factors were highly associated with the consumption of SB–NEW (see Table 3
). In general, men, young adults (18–29-years old), individuals with a lower educational level, individuals living in the German-speaking region and individuals with obesity, consumed significantly more SB–NEW classified beverages. The sensitivity analysis showed that the same sociodemographic and lifestyle factors were significantly associated with the consumption of the beverages defined by SB–CUR.
Men consumed 53.2% more SB–NEW beverages than women. Similarly, adults 18–29-years old consumed more SB–NEW beverages than any other age group (Table 3
). Adults aged 30–44, 45–59, and 60–75-years old consumed 18%, 35.3%, and 60.3% less SB–NEW beverages, respectively, than young adults 18–29-years old. Furthermore, people living in the French and Italian regions consumed less SB–NEW beverages than the German-speaking region (25.7% and 38.7%, respectively), and people with a lower educational level consumed 16% more SB–NEW beverages than those with a higher educational level. Finally, individuals with obesity consumed 32.6% more SB–NEW beverages than normal BMI people.
The latter variables were significantly associated with higher consumption of soft drinks and low-calorie sweet beverages (Table 3
), except for BMI, which was not significantly associated with the consumption of soft drinks. Similarly, sex and education were not significantly associated with the consumption of low-calorie sweet beverages. In particular, men (103% more than women) and people with a lower educational level (55% more than higher educational level) had a higher consumption of soft drinks. Similarly, smoking (55.5% more than non-smokers) and obesity (148.9% more than normal BMI) were strongly associated with the consumption of low-calorie sweet beverages.
The findings of the present study provide important insights into the consumption levels of sweet beverages, according to two different definitions and reveal sociodemographic and anthropometric characteristics associated with their consumption. It was difficult to compare our data with other studies, due to the varying definitions of sweet beverages. However, the average daily consumption of sweet beverages, estimated by the SB–CUR definition, was 240.6 g/day in Switzerland, compared to 100 g/day in Central Europe (where sweet beverages were defined as carbonated beverages, energy drinks, and fruit drinks) [13
]. The higher daily consumption measured with the SB–NEW definition was mainly due to the consumption of 100% juices, which were excluded from the SB–CUR definition. With both definitions (SB–NEW and SB–CUR), the consumption of sweet beverages was higher among men and younger populations, consistent with other studies [35
We found that 100% of the juices were consumed in equally high amounts as carbonated drinks (each around 60 g/day) and both subcategories contributed similarly to the total sugar intake. In the Swiss population, the total sugar from 100% juices and carbonated drinks was twice as high as the corresponding sugar intake in France [37
Although WHO guidelines specify that 100% juices deliver free sugars, these beverages are still generally perceived as healthier drinks by consumers and represent an important source of vitamins. In some nutritional guidelines, like those provided in Switzerland and the US, one serving of 100% fruit juice could replace one daily portion of fruit or vegetables, based on their vitamin contribution [38
]. This might partly account for the comparable amounts of 100% juices consumed across sociodemographic groups. Regarding the differences between sugar types, consumers might know that 100% juices do not contain added sugar (sucrose), but are likely less aware that they contain as much sugar (naturally present) and energy as carbonated drinks. There is a great deal of controversy regarding health outcomes related to the consumption of 100% fruit juices [10
]. Their consumption is associated with increased risk of cardiovascular mortality, type 2 diabetes, and cancer [10
]. Beneficial effects from juice intake have been shown in energy-matched substitution studies, while adverse effects have been shown in additional studies, due to the induced excess in energy intake [41
]. In contrast, other studies identified positive effects from fruit juice bioactives on oxidative stress and inflammation [42
Given the high consumption of 100% juices and their comparable consumption across sociodemographic subgroups, the Swiss population might benefit from clearer and more consistent information about the quantities of free sugars present in 100% juices, which needs to be considered and counterbalanced with the vitamin contribution of this type of beverages.
4.1. Low-Calorie Sweet Beverages and Plant-Based Milk Substitutes
Low-calorie sweet beverages, which represent potential solutions for reducing sugar and energy intake, were consumed at levels as high as 100% juices and carbonated drinks. However, there is considerable controversy concerning the associated health effects of the consumption of these beverages [14
]. Emerging evidence shows that non-sugar sweeteners do not contribute to weight loss in adults or children with overweight or obesity actively trying to lose weight [15
]. Other outcomes were also linked with consumption of low-calorie sweeteners, such as increased all-cause mortality [17
] and increased glucose intolerance [18
]. In contrast, evidence for a decreased desire for sweet foods [45
], reduced appetite, and energy intake was suggested for some low-calorie sweeteners [46
]. Clearly, there is a need to clarify the effects of low-calorie sweeteners, as they continue to be widely used to replace sugars in foods and beverages.
The overall average consumption of plant-based milk substitutes was low but was two-fold higher among women than men. These beverages might be perceived as healthier alternatives than milk, however, they contain considerable amounts of free sugars [12
] and have lower nutritional quality compared to cows’ milk [47
The consumption of both low-calorie sweet beverages and plant-based milk substitutes should be carefully monitored by health authorities. Consumers should also be better informed about their overall composition and possible health risks.
4.2. Sociodemographic Characteristics Associated with Sweet Beeverage Consumption
Our analysis showed that the most significant correlates of SB–NEW beverage consumption were male, younger age, lower educational level, living in the German-speaking region, and individuals with obesity. These factors were also associated with the consumption of soft drinks. Similarly, current smokers, individuals with obesity and those living in the German-speaking region had a higher consumption of low-calorie sweet beverages.
The regression analyses for SB–NEW as well as for soft drinks showed higher consumption among men, young adults, and people with a lower educational level in Switzerland; these trends were consistent with previous studies [36
]. Additionally, SB–NEW beverage consumption was higher in the German-speaking region than in the other regions. This supports previous results of dietary pattern analysis, indicating a lower quality diet in the German-speaking region, compared to the French and Italian regions [50
In contrast to Mullie et al., we found higher SB–NEW beverage consumption among individuals with obesity [51
], but did not find a significant association between obesity and soft drink consumption. This might imply that individuals with obesity avoided soft drinks due to their calorie and sugar content, but consumed higher amounts of other sweet beverages in an attempt to drink healthier beverages.
Consistent with Paulsen et al. we found that individuals with obesity consumed more low-calorie sweet beverages than those with a normal weight [49
], which is likely linked to the desire to lose weight and avoid sugars and calories. We also found that people currently smoking and living in the German-speaking region consumed more low-calorie sweet beverages.
4.3. Strengths and Limitations
The menuCH study is the first national representative data that provides detailed information about the types and amounts of beverage intake in Switzerland. Furthermore, the survey used state-of-the-art dietary assessment tools and included a pilot study to optimize these tools [26
]. The interview-led 24 HDR method has many advantages over other self-reported methods, especially relevant for capturing beverage consumption, which is frequently consumed outside of meals and is easily forgotten. Probing by the interviewer helps to retrieve these events [52
]. One limitation of the menuCH survey is the absence of a food frequency questionnaire to account for day-to-day variations in food consumption over a longer period. The low participation rate and a high proportion of educated and healthy study participants might have led to an underestimation of our findings, as people with a higher education and better health were overrepresented in the survey [25
]. In addition, people were more likely to underreport portion sizes for high-calorie foods, including regular soda [53
]. Moreover, underreporting of energy intake was more likely among menuCH participants with a high BMI [54
]. It is therefore likely that the consumption of sweet beverages in this study was underreported. Likewise, for dieting reasons, individuals with obesity might replace sweet beverages with low-calorie sweetened beverages, and reverse causation in the association of the latter beverages and obesity could not be excluded [55
]. Another limitation was that ready-to-drink coffees containing sugar were excluded from the analyses, as it was not possible to identify the beverages that contained added sugar or sweeteners in the dataset. Since the consumption of these beverages is increasing and new beverages with high amounts of sugar continue to be launched on the market, further analysis is warranted to include ready-to-drink coffees as a new sweet beverage sub-category. In further dietary assessments, additional information, such as brand name and recipe, should be collected to facilitate the quantification of sugars from these beverages. Finally, to be consistent with previous analyses that used menuCH [25
], this study used the average of the two-day interviews to quantify the average daily consumption of sweet beverages (g/day) per person. Although methods like MSM or NCI proved to be more robust to estimate usual intake, only minor differences between MSM and the average of the two-day interviews were found [25
]. Our results and interpretations would likely not differ based on the method used. In line with the WHO recommendation, this study only focused on sugar and did not take into account other nutritional values. The limitation of this approach is that beverages with different nutritional properties are equally considered based on their free sugar content, regardless of their nutritional value.
Since menuCH was the first survey to collect information on the consumption of sweet beverages, it was not possible to compare trends over time. Thus, further studies should aim to monitor possible changes in sweet beverage consumption patterns of adults in Switzerland over time. Similarly, no data from menuCH were available on the consumption of sweet beverages by children and adolescents, despite new estimates showing that 15% of children in Switzerland were overweight or obese [56
]. Thus, further research should be undertaken to determine the rate of consumption of sweet beverages among these population groups.
4.4. Policy Implications
The findings of the present study provide insights on the patterns of consumption of sweet beverages, according to two different definitions and across different population groups. Our study showed that the application of the SB–CUR rather than SB–NEW led to a much lower estimation of sweet beverage consumption. This would subsequently impact public health and other policy-measures aimed at reducing sugar intake, which rely on this amount. Effective policies aimed at decreasing sweet beverage consumption included, among others, traffic-light labeling, promotion of healthier beverages in public places, and limiting or removing access to sweet beverages in schools, among other [19
]. In particular, sweet beverage taxes were demonstrated to be a cost-effective policy tool for decreasing consumption among populations at risk [11
Thus, in addition to following the WHO recommendation to limit free-sugar intake to less than 10% of total energy intake, the SB–NEW definition proposed here might be considered in health-policies aimed at reducing sugar intake, particularly among the target groups identified in this study.
In Switzerland, the high daily sweet beverage consumption and the substantial variation across different sociodemographic and lifestyle groups call for action to plan and implement strategies towards reducing the consumption of these beverages. While soft drinks and 100% juices were the most consumed beverages contributing to a similar sugar intake, 100% juices are currently not counted as sweet beverages in Switzerland. We also found that low-calorie sweet beverages, considered to be alleged solutions for decreasing sugar intake were consumed in comparable amounts to soft drinks, suggesting that this beverage group might also represent an important public-health target. The proposed SB–NEW definition has the merit of providing a more comprehensive assessment of total sugar intake in liquid form.
This suggests that the application of the new definition, SB–NEW, as well as the close monitoring of sweet beverage consumption will be important measures for developing effective public health policies to reduce sugar intake in Switzerland and in other countries implementing strategies.