Community‐based interventions to reduce sugar intake in healthy populations: A systematic review

• Published date: 01 December 2022
• Author: Zeinab Nikniaz,Jafar S. Tabrizi,Mahdieh Abbasalizad Farhangi,Mohammad‐Salar Hosseini,Sanaz Tahmasebi,Leila Nikniaz
• Date: 01 December 2022
• DOI: http://doi.org/10.1002/wmh3.524

Received: 7 September 2021

|

Revised: 15 January 2022

|

Accepted: 18 February 2022

DOI: 10.1002/wmh3.524

ORIGINAL ARTICLE

Community‐based interventions to reduce

sugar intake in healthy populations: A

systematic review

Zeinab Nikniaz

1

|Jafar S. Tabrizi

2

|

Mahdieh Abbasalizad Farhangi

3

|Mohammad‐Salar Hosseini

4

|

Sanaz Tahmasebi

4

|Leila Nikniaz

5

1

Liver and Gastrointestinal Diseases

Research Center, Medicine Faculty, Tabriz

University of Medical Sciences, Tabriz, Iran

2

Tabriz Health Services Management

Research Center, Faculty of Management

and Medical Informatics, Tabriz University of

Medical Sciences, Tabriz, Iran

3

Drug Applied Research Center, Tabriz

University of Medical Sciences, Faculty of

Nutrition, Tabriz, Iran

4

Student Research Committee, Tabriz

University of Medical Sciences, Tabriz, Iran

5

Tabriz Health Services Management

Research Center, Health Management and

Safety Promotion Research Institute, Tabriz

University of Medical Sciences, Faculty of

Management and Medical Informatics,

Tabriz, Iran

Correspondence

Leila Nikniaz, Tabriz Health Services

Management Research Center, Panahi St.,

Daneshgah Ave, Tabriz, Iran.

Email: nikniazleila@gmail.com

Abstract

This study aimed to assess community‐based interventions

to decrease sugar intake among healthy people. According

to PRISMA guidelines, in this systematic review, databases

including PubMed/MEDLINE, Scopus, EMBASE, Cochrane

Library, Web of Science, ProQuest, and Google Scholar

were searched up to August 2021. Randomized clinical

trials or quasi‐experimental studies reporting the effect of

community‐based interventions to reduce sugar intake in

general population were included. The quality of eligible

studies was assessed using The Joanna Briggs Institute

Critical Appraisal Checklists. Our search strategy resulted in

a total of 1384 articles out of which 59 articles were included

in the study. Of 59 included studies, 48 studies reported

significant decrease in sugar intake or intention to sugar

sweetened beverages (SSBs) intake or purchasing SSBs.

Of the 48 effective studies, 45 (93.7%) had a low risk of

bias. Based on the results of low risk of bias studies,

interventions performed in schools, household, and com-

munity were effective in reducing sugar intake. Almost all

types of interventions (educational, multiple and changing in

law) had the same effectiveness on reducing sugar intake.

In addition, interventions which had a duration of 24–48

weeks were less successful than the others. Interventions

with the repetition span of more than 1 month were less

successful than the others. The application of multiple

interventions appears to be the most effective approach to

reducing sugar intake in healthy populations. However,

long‐term and well‐designed future studies in different

settings are recommended to confirm these results.

World Med. & Health Policy. 2022;14:698–749.wileyonlinelibrary.com/journal/wmh3698

|

© 2022 Policy Studies Organization.

KEYWORDS

community‐based interventions, refined carbohydrate, sugar,

systematic review

Key points

•Educational and multiple interventions are suggested.

•Applying educational and multiple interventions

together can be more effective.

•Implementation of the interventions depends on

countries' resources.

INTRODUCTION

High intake of sugar (sucrose) is a considerable problem in both developed and developing

countries (Abdelmalek & Day, 2015; Adachi‐Mejia et al., 2013). A growing body of evidence

showed added sugar may result in obesity and metabolic syndrome that increase the

probability of type 2 diabetes mellitus, cardiovascular disease, and nonalcoholic fatty liver

disease (Eckel e t al., 2005). Different studies have shown an increase in the consumption of

sweetened foods and drinks over the last decade ( Abdelmalek & Day, 2015;Adachi‐Mejia

et al., 2013; Ahlfeld, 2009; Aller et al., 2011; New Zealand Beverage Guidance Panel, 2014).

Different social and environmental factors are related to the increase in purchasing and

consumption of sweetened products. These factors vary from the effect of watching television

or social media advertisements to higher availability of sweet products and consumption of

semi‐prepared foods (Battram et al., 2016; Davy et al., 2014; Jou & Techakehakij, 2012).

Sugar‐sweetened beverages (SSBs) contribute to obesity through their “add‐on”caloric load

(Basu, Seligman, et al., 2014;Beaglehole,2014;Becketal.,2014; Bermudez & Gao, 2010;

Blakely et al., 2014; Nikniaz et al., 2018; Van Gaal & Michiel, 2005). In addition, different

studies have shown a positive relation between consumption of sweetened beverages and

disorders such as diabetes (Baltaci et al., 2012; Basu, Vellakkal, et al., 2014;Belalcazar

et al., 2014; Bleich & Wang, 2011;DeKoningetal.,2011), high blood triglyceride (Barrio‐

Lopez et al., 2013;Bray,2012; Duffey et al., 2010), cardiovascular diseases (Grasser

et al., 2014; Johnson et al., 2009; Keller, 2014; Mucci et al., 2012; Sonestedt et al., 2015;

Thornley et al., 2012), nonalcoholic fatty liver (Abdelmalek & Day, 2015;Maetal.,2015;

Moore et al., 2014), increase of uric acid in blood (Gao et al., 2007;Hochulietal.,2014;

Nguyen et al., 2009), gout (Dalbeth et al., 2015;Merrimanetal.,2014), and tooth decay

(Bernabé et al., 2014;Freeman,2014; Lueangpiansamut et al., 2012;Marshall,2013). From

another perspective, consumption of sweetened beverages is a substitution for consuming

healthy drinks like milk; therefore, it can also affect the quality of daily diet (Kohlboeck

et al., 2012; Leung et al., 2013,2012;Libudaetal.,2009).

The consumption rate of sugar and sweet beverages is still high, even though different

strategies have been programmed to reduce it. Some of these strategies are as follow:

increasing the availability of water and other healthy drinks such as milk, reducing

availability of sweet beverages, reducing the price of healthy drinks, and so forth (Veitch

et al., 2011; Visscher et al., 2010; Zheng et al., 2015). To identify interventions to reduce

consumption of sugar and sweet beverages, it is essential to review some successful

community‐based strategies and evaluate their effectiveness to help policymakers in

choosing best policy options with respect to specific situations of each country. Considering

the numerous evidence available and the lack of a systematic review study in this field, this

study was conducted to evaluate the community‐based interventions performed worldwide

to reduce sugar consumption.

COMMUNITY‐BASED INTERVENTIONS TO REDUCE SUGAR

|

699

MATERIAL AND METHODS

The present study aimed to systematically review the studies which evaluated the effect of

community‐based interventions in reducing sugar intake in general population. The main

outcome of present systematic review was reducing sugar intake in general population. The

reporting procedures followed the guidelines presented by Preferred Reporting Items for

Systematic Reviews and Meta‐Analysis (PRISMA) (Moher et al., 2010).

Search strategy

The following electronic databases were searched to identify relevant studies from January

2000 to August 2021: PubMed/MEDLINE, Scopus, EMBASE, Cochrane Library, Web of

Science, ProQuest, and Google Scholar. Strategy search was created using a combination

of the MeSH (Medical Subject Headings) terms from the PubMed database and free text

words. For each electronic database, the search strategy was adopted.

The search strategy for PubMed was as follows: Search (“sugar intake”[Title/Abstract])

OR (“sugar consumption”[Title/Abstract]) OR “refined carbohydrate”[Title/Abstract]) OR

“sucrose”[Title/Abstract]) OR “food reformulations”[Title/Abstract]) OR “sugar substitute”

[Mesh]) OR “sugar substitute”[Title/Abstract]) OR “sugar‐Sweetened Beverages”[Mesh])

OR “sugar‐Sweetened Beverages”[Title/Abstract]) OR SSB [Title/Abstract]) OR beverages

[Mesh]) OR soda [Title/Abstract]) AND “community based”[Title/Abstract]) OR community‐

based [Title/Abstract]) OR population‐based [Title/Abstract]) OR “population based”[Title/

Abstract]) OR evidence‐based [Title/Abstract]) OR practice [Title/Abstract]) OR education

[Mesh]) OR education [Title/Abstract]) OR “food policy”[Title/Abstract]) OR intervention

[Title/Abstract]) OR implementation [Title/Abstract]) OR approach [Title/Abstract]) OR

strategy[Title/Abstract]) AND “national program”[Title/Abstract]) OR country [Title/Abstract])

OR community [Title/Abstract]). The reference lists of the retrieved articles were also

searched to identify potentially relevant studies. Gray literature was also searched using the

guidelines presented by the European Association for Gray Literature Exploitation (EAGLE)

and the Healthcare Management Information Consortium (HMIC). All search results were

imported into the Endnote software for screening. The entire article‐screening procedure

was conducted independently by two researchers (ZN and LN). Where disagreement was

evident, a final decision was made by discussion and consultation with a third person (MAF).

Inclusion and exclusion criteria

Randomized clinical trials (RCTs) or quasi‐experimental studied in English language were

included if they: (i) enrolled all age groups of general population; (ii) evaluated the effect of

community‐based intervention to reduce the intention to consumption of SSBs, or reduce the

intake of SSBs or sugar or reduce the purchase of SSBs.

Studies conducted on pregnant or lactating women and subjects with mental illness and

chronic diseases such as cardiovascular diseases, diabetes, and hypertension were

excluded from the study. Individual interventions, economic evaluations, modeling studies,

and clinical and laboratory studies were also excluded. The research question based on

Population, Intervention, Comparison, and Outcome (PICO) is available in Table 1.

It is noteworthy to indicate that community‐level interventions were defined as group‐

based health promotion, education, advice, counselling or subsidy interventions, or

interventions conducted in a community setting (e.g., a workplace, community center,

sports center, and shop) (McLeroy et al., 2003).

700

|

NIKNIAZ ET AL.