CURRENT DEVELOPMENTS IN NUTRITIONO R IG I N AL RESEARCH Food and Nutrition Policy Caregivers’ Understanding of Ingredients in Drinks Served to Young Children: Opportunities for Nutrition Education and Improved Labeling Melissa L Jensen,1,2 Yoon Y Choi,1 Frances Fleming-Milici,1 and Jennifer L Harris1 1UConn Rudd Center for Food Policy and Obesity, University of Connecticut, Hartford, CT, USA and 2School of Nutrition, University of Costa Rica, San José, Costa Rica ABSTRACT Background: Against expert recommendations, sugar-sweetened beverages, especially fruit drinks, are consumed by young children. Misperceptions about drink ingredients and healthfulness can contribute to caregivers’ provision. Objectives: To assess caregivers’ reasons for serving sweetened fruit-flavored drinks and unsweetened juices to their young children (1–5 y) and perceptions of product healthfulness and drink ingredients. Methods: A cross-sectional online survey assessed participants’ (n = 1614) perceptions of sweetened fruit-flavored drinks (fruit drinks and flavored water) and unsweetened juices (100% juice and water/juice blends) provided to their child in the past month, including product healthfulness, reasons for providing, and knowledge of product ingredients [added sugar, nonnutritive sweeteners (NNSs), percentage juice]. One-factor ANOVA compared perceived healthfulness of drink categories and types of sugar and NNSs, and differences between participants who could compared with those who could not accurately identify drink ingredients. Results: Participants’ top reasons for providing sweetened drinks included child liking it, being inexpensive, child asking for it, and being a special treat. Participants perceived 100% juice as healthiest, followed by juice/water blends, flavored waters, and, lastly, fruit drinks (P < 0.05). Many participants inaccurately believed the fruit drink or flavored water they served their child most often did not contain NNSs (59.0% and 64.9%) and/or added sugars (20.1% and 42.2%), when in fact they did, and 81.3–91.1% overestimated the percentage juice in the drink. Perceived healthfulness of fruit drinks was associated with caregivers’ belief that the drink contained added sugar (P < 0.05), but not with their belief that it contained NNS; increased accuracy was associated with decreased perceived healthfulness (P < 0.05). Conclusions: Inaccurate understanding of added sugar, NNSs, and percentage juice in drinks served to young children was common and could contribute to sugary drink provision. Public health efforts should seek to improve labeling practices and revise nutrition education messages. Curr Dev Nutr 2022;6:nzab151. Keywords: fruit-flavored drink, sugar-sweetened beverage, added sugars, nonnutritive sweeteners, food labeling C© The Author(s) 2021. Published by Oxford University Press on behalf of the American Society for Nutrition. This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial License (https://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Manuscript received October 27, 2021. Initial review completed December 10, 2021. Revision accepted December 15, 2021. Published online December 22, 2021. This work was supported by a grant from the Robert Wood Johnson Foundation, Princeton, NJ. The views expressed here do not necessarily reflect the views of the Foundation. The Robert Wood Johnson Foundation had no role in the design, analysis, interpretation of the data, writing of this article, or decision to submit this article for publication. Author disclosures: The authors report no conflicts of interest. Supplemental Tables 1 and 2 are available from the “Supplementary data” link in the online posting of the article and from the same link in the online table of contents at https://academic.oup.com/cdn/. Address correspondence to MLJ (e-mail: melissa.jensen@uconn.edu). Abbreviations used: HFCS, high-fructose corn syrup; NNS, nonnutritive sweetener; SSB, sugar-sweetened beverage; WIC, Special Supplemental Nutrition Program for Women, Infants, and Children. Introduction Domestic and global health organizations recommend limiting the con- sumption of sugar-sweetened beverages (SSBs) in children (1–3), given their long-term effects on health such as weight gain (4), type 2 di- abetes, and cardiovascular disease, among others (5). Despite recom- mendations, SSBs are still highly consumed among young children (6, 7). Fruit drinks (which include fruit-flavored and juice drinks) in par- ticular, are the most common type of SSB consumed by children aged <4 y (7) and the top source of added sugar in toddlers (8). Flavored waters, which are sweetened fruit-flavored drinks labeled as water, are also a popular drink commonly marketed towards children (9). In addi- tion to sugar, most of these drinks also contain nonnutritive sweeteners (NNSs), ingredients increasingly present in US food and beverage pur- chases (10). NNSs are not recommended for consumption by children (1, 2, 11), given potential effects on sweet taste preferences, microbiome health, and other unknown longer-term health outcomes (12–15). Provision of SSBs starts as early as the first year of life, and factors such as education level, socioeconomic status, race, and mother’s age have been associated with provision (16). Because dietary patterns early in a child’s life play a critical role in future consumption habits, inter- ventions to prevent caregivers’ provision of sugar-sweetened drinks are 1 D ow nloaded from https://academ ic.oup.com /cdn/article/6/1/nzab151/6479116 by guest on 18 January 2022 https://orcid.org/0000-0002-9830-076X https://creativecommons.org/licenses/by-nc/4.0/ mailto:journals.permissions@oup.com https://academic.oup.com/cdn/ mailto:melissa.jensen@uconn.edu 2 Jensen et al. needed (17–19). However, there is a gap in understanding the reasons why caregivers serve these drinks to young children. Previous research has shown certain types of SSBs, such as fruit drinks, are perceived as healthier than others, such as soda (20–22), which might begin to ex- plain their provision at an early age. In this study, we focused on 4 types of drinks commonly marketed for young children to consume (9): unsweetened juices—1) 100% juice and 2) juice/water blends—and sweetened fruit-flavored drinks—3) fla- vored waters and 4) fruit drinks. Unsweetened juices contain no added sugars or NNS and include 2 drink categories: 100% juice consists only of juice (can be from concentrate), whereas juice/water blends consist of juice or juice concentrate and water only. Sweetened fruit-flavored drinks contain added sugars and/or NNS and include 2 categories: fla- vored waters are water beverages (as indicated on product package), whereas fruit drinks are fruit-flavored drinks or juice drinks (some can have some juice) (9). These drinks marketed for children typically con- tain nutrition-related claims (9) (e.g., “100% vitamin C,” “low sugar”), which substantially affect consumers’ purchasing decisions (23). In ad- dition, pictures of fruit on packages, cross-branding with unsweetened juices, and visuals suggesting the product is “natural” can also influence caregivers’ perceptions of a drink’s healthfulness (24). Recent research has shown that caregivers have difficulty recognizing the presence of added sugar, NNS, and percentage juice in these drinks (25), which might also contribute to parents serving these to their children at an early age. The goal of our study was to understand the reasons and perceptions that underlie caregivers’ provision of sweetened fruit-flavored drinks and unsweetened juices to their young children (aged 1–5 y). Specific objectives included: 1) to assess caregivers’ reasons for serving sweet- ened fruit-flavored drinks and unsweetened juices, 2) to determine per- ceived healthfulness of different drink types and their ingredients, 3) to assess accuracy in identifying drink ingredients (added sugars, NNS, and percentage juice), and 4) to investigate associations between ingre- dient accuracy and perceived product healthfulness. We hypothesized that accuracy in identifying drink ingredients would be low, and that it would be positively associated with perceived product healthfulness. Methods This study used a cross-sectional online survey of caregivers with young children (aged 1–5 y). Data were collected in October 2019. Study design and participants Participants were recruited by Innovate MR (26), an online survey com- pany that maintains a large panel whose members voluntarily agree to participate in online surveys. Participants receive rewards and gift cards for participating in the panel, as well as points when they com- plete a survey, but do not receive monetary incentives for individual surveys, to promote quality of responses. Furthermore, Innovate MR recruits its panel members through social networks, in-app banner ad- vertising, and numerous web and SMS databases (26). Innovate sent an e-mail to a sample of their qualified panel members [i.e., adults with young children (aged 1–5 y) in their household] to invite them to par- ticipate in the survey. The e-mail included a link to the online sur- vey if they wished to participate. Quota sampling ensured ≥150 each black, Hispanic, and Asian participants for comparison purposes. Eligi- bility for study participation included being responsible for what their child eats and drinks (either primary or shared) and child not having a disease or condition requiring a special diet (such as lactose intoler- ance, celiac disease, phenylketonuria). Participants who had >1 eligible child were asked to report information about the child with the most recent birthday. The study was determined to be exempt by the Uni- versity of Connecticut’s Institutional Review Board (document number X19-134). Study instrument Participants first read an information sheet about the study and then checked a box to indicate their consent to participate before completing the survey. The survey included 4 sections: 1) frequency of providing differ- ent types of drinks to their child and reasons for serving, 2) accuracy in identifying ingredients contained in the drinks served, 3) perceived healthfulness and other behavioral factors, and 4) demographic charac- teristics. Supplemental Table 1 includes specific questions of the survey instrument. The survey was administered via Qualtrics survey software and took ∼25 min to complete. Responses to additional survey ques- tions have been previously reported (25). Measures Drink provision. Provision of specific products in 4 categories commonly served to chil- dren was assessed, including unsweetened juices—1) 100% juice and 2) juice/water blends—and sweetened fruit-flavored drinks—3) flavored waters and 4) fruit drinks. For each category, participants were asked, “In the last month, did you give your child any [drink category]?” fol- lowed by a definition of the drink type. In the same question, they were asked, “Please select all that you gave your child in the past month” fol- lowed by a list of popular products in that category, with options to write in another product or select “I did not give my child any [drink category] in the past month.” The products listed in each drink category included those commonly provided to children, based on 2018 sales data (9). For brands containing products in >1 category (e.g., Capri Sun), the survey listed both the brand and variety name (e.g., Capri Sun Origi- nal compared with Capri Sun Roarin’ Waters). Caregivers also reported whether they served other categories of drinks to their child during the past month: plain water, plain milk, toddler milk, flavored milk, soda (regular and diet), sports drinks, iced teas, and smoothie drinks. Reasons for providing. Caregivers who reported serving unsweetened juices and/or fruit- flavored drinks then selected the top 3 reasons for providing the specific brand they reported providing most often to their child, from a list of reasons identified in previous research (20), with an open-ended option for “other.” Accuracy in identifying ingredients. For each drink category that caregivers reported serving their child in the past month, they were then asked to indicate whether they thought the specific brand they reported serving most often contained added sugar (yes/no), NNSs (yes/no, described as “diet sweeteners” in the survey, a term best understood in previous focus groups) and the CURRENT DEVELOPMENTS IN NUTRITION D ow nloaded from https://academ ic.oup.com /cdn/article/6/1/nzab151/6479116 by guest on 18 January 2022 Ingredients in drinks served to young children 3 percentage juice (0–100% sliding scale). Accuracy (yes = 1, no = 0) was defined as correctly identifying each ingredient (presence of added sugars and NNS, and percentage juice range) for each drink category. Supplemental Table 2 presents criteria used for defining accuracy for each drink category and brand. Perceived healthfulness of drink categories, added sugar, and NNSs. All caregivers rated the healthfulness of fruit drinks, flavored water, 100% juice, and juice/water blends, including categories they had not served their child; as well as plain water, plain milk, and regular and diet soda for comparison purposes. They also rated the healthfulness of commonly used added sugars [sugar, cane sugar, high-fructose corn syrup (HFCS), sucrose, and agave] and NNSs (sucralose, aspartame, ste- via). Answers were given on a scale of 1 (very unhealthy) to 10 (very healthy). Demographic variables. We collected age, gender, and race for caregiver and child. For care- givers, we also collected Hispanic ethnicity, education level, family his- tory of nutrition-related health conditions (obesity, hypertension, dia- betes, and cardiovascular disease), and participation in the Special Sup- plemental Nutrition Program for Women, Infants, and Children (WIC). Data cleaning and analysis A total of 2591 participants responded to the survey invitation. After excluding those who did not agree to participate (n = 59), did not meet eligibility criteria (n = 703), or did not complete the survey (n = 215), the final analytic sample included 1614 caregivers. Data were analyzed using STATA statistical package version 16 (StataCorp LLC). In addition to ingredient-specific accuracy, we created a composite accuracy score for each drink category served by summing the 3 individual ingredient scores (added sugars, NNSs, and percentage juice). This composite ac- curacy score ranged from 0 to 3 for the number of ingredients accurately identified. One-factor ANOVAs with post hoc comparisons, applying Bonfer- roni correction, were used for comparisons of interest as follows: 1) Drinks: 100% juices compared with a) juice/water blends, b) flavored waters, and c) fruit drinks; juice/water blends compared with a) flavored waters and b) fruit drinks; flavored waters compared with fruit drinks; and fruit drinks compared with regular soda. 2) NNSs: sucralose com- pared with a) aspartame and b) stevia; aspartame compared with stevia. 3) Added sugars: sugar compared with a) cane sugar, b) HFCS, c) su- crose, and d) agave. Independent sample t tests determined differences in mean perceived healthfulness of fruit drinks and flavored waters by ingredient perception (i.e., participants who believed the drink con- tained an ingredient compared with those who did not). ANOVAs with Scheffe post hoc correction test determined whether perceived health- fulness of sweetened drinks differed by composite ingredient accuracy score. Results Sample characteristics Participants in the study were mostly female, between the ages of 25 and 44, and diverse in race, ethnicity, and education (Table 1). About TABLE 1 Sociodemographic characteristics of study participants (n = 1614) n % Caregivers’ characteristics Female 1272 78.8 Age, y <25 142 8.8 25–34 821 50.9 35–44 531 32.9 ≥45 104 6.4 Education level High school or less 351 21.7 Some college, or 2-y degree 658 40.8 College complete, 4-y or more 591 36.6 WIC participant 332 20.6 Race White only 943 58.4 Black only 237 14.7 Asian only 144 8.9 Mixed/other 136 8.4 Hispanic 318 19.7 Family history Obesity 218 13.5 Hypertension 226 14.0 Diabetes 280 17.3 Cardiovascular disease 71 4.4 Any of the above 509 31.5 Child characteristics Female 773 47.9 Age, y 1 to 2 620 38.4 3 to 5 994 61.6 Race White only 906 56.1 Black only 222 13.8 Asian only 110 6.8 Mixed/other 236 14.6 one-fifth reported currently participating in WIC. Participants’ children were 48% female, and 62% were 3–5 y old. Drink provision and reasons for providing The most commonly provided drink type was 100% juice (90.7% pro- vided), followed by fruit drinks (61.0%), juice/water blends (61.3%), and flavored waters (48.6%). Caregivers’ reasons for providing differed by category, although some reasons were commonly mentioned across drink categories (Table 2). For example, their “child likes it” was the top reason in all 4 categories (selected by >50%). More than 30% selected “it’s healthy” for unsweetened juices; “my child asks for it” for sweetened fruit-flavored drinks; and low cost for fruit drinks. Figure 1 displays the percentage of caregivers who provided additional categories of drinks to their child in the past month. Accuracy in identifying ingredients Figure 2 shows the actual percentage juice, added sugar, and NNS content of the brands identified in each category. All 100% juice and juice/water blend brands did not contain added sugar or NNS. The per- centage juice in most juice/water blends ranged from 35% to 70%. All sweetened fruit-flavored drinks contained added sugar, and most con- tained NNS (3 of 4 flavored waters and 8 of 9 fruit drinks). Flavored CURRENT DEVELOPMENTS IN NUTRITION D ow nloaded from https://academ ic.oup.com /cdn/article/6/1/nzab151/6479116 by guest on 18 January 2022 4 Jensen et al. TABLE 2 Caregivers’ reasons for serving different types of unsweetened juices and sweetened fruit-flavored drinks (n = 1614)1 Unsweetened juices Sweetened drinks Reason 100% juices (n = 1435) Juice/water blends (n = 930) Flavored waters (n = 774) Fruit drinks (n = 982) My child likes it 63.4 49.9 55.0 56.9 It’s healthy 35.3 38.7 25.5 12.5 It was inexpensive 16.9 15.2 22.6 35.3 My child asks for it 24.5 23.2 31.4 33.5 It comes in a box or pouch 18.2 28.7 21.1 20.2 It provides vitamins or nutrients 27.0 23.4 17.1 11.3 It’s a special treat 18.0 18.6 26.4 28.5 It’s what we always buy 18.3 11.3 14.6 18.6 It was on sale or a special deal 17.4 19.7 17.4 18.9 It provides fruits or vegetables 19.6 18.9 8.4 6.1 1Numbers reported are percentages of the subsample reporting provision of each beverage type. waters had 0% juice, whereas the percentage juice in fruit drinks ranged from 0% to 11%. Participants’ accuracy in identifying ingredients in the drinks they served their child most often varied by category, brand, and specific ingredient assessed (Table 3). When estimating percent- age juice, accuracy was lowest for flavored waters (9% answered cor- rectly) and fruit drinks (19%), with most caregivers perceiving that they contained more juice than they actually did (data not shown). On av- erage 58% knew that flavored waters contained added sugar, and 53% to 54% knew that 100% juice and juice/water blends did not, whereas the accuracy of knowing that fruit drinks contained added sugar was considerably higher (80%). More than 80% knew that 100% juice and juice/water blends did not contain NNSs. However, <30% of partici- pants who served their child a fruit drink or flavored water that con- tained NNS accurately answered that it contained NNS. Figure 2 additionally displays composite accuracy score by drink cat- egory. Overall accuracy was lower for flavored waters and fruit drinks, with 76% and 57% of participants accurately identifying 0 or 1 ingre- dient, respectively. In contrast, the majority accurately identified 2 or 3 ingredients in 100% juices (74%) and juice/water blends (64%). Perceived healthfulness of drinks, added sugars, and NNSs Caregivers’ perceptions of the healthfulness of different drink cate- gories and ingredients are presented in Figure 3. Among the 4 cat- egories, caregivers perceived 100% juice to be healthiest, followed by juice/water blends, flavored waters, and lastly fruit drinks. Plain water and milk were rated as the healthiest drinks, whereas regular and diet soda were rated as significantly less healthy than fruit drinks. Among types of NNS, stevia was perceived as healthier than both sucralose and FIGURE 1 Percentage of caregivers who provided different types of drinks for their child in the past month (n = 1614). CURRENT DEVELOPMENTS IN NUTRITION D ow nloaded from https://academ ic.oup.com /cdn/article/6/1/nzab151/6479116 by guest on 18 January 2022 Ingredients in drinks served to young children 5 FIGURE 2 Number of ingredients (added sugars, nonnutritive sweeteners, percentage juice) accurately identified in different types of drinks provided to children. aspartame. Among types of added sugars, sugar was rated healthier than HFCS and sucrose, but less healthy than cane sugar and agave. All con- trasts were statistically significant (P < 0.05). Healthfulness of drinks by caregivers’ beliefs and accuracy regarding ingredients Table 4 displays caregivers’ perceived healthfulness of fruit drinks and flavored waters stratified by their beliefs and accuracy regarding ingre- dients. For both drink categories, caregivers who believed the drink did not contain added sugar rated it as healthier (1–10 scale) compared with those who knew it contained added sugar: 5.9 ± 2.8 compared with 4.7 ± 2.3 for fruit drinks (P < 0.001), and 6.9 ± 2.5 compared with 6.4 ± 2.3 for flavored waters (P = 0.002). In addition, caregivers who overestimated the percentage juice in a fruit drink rated it as health- ier than those who were accurate about juice content (5.3 ± 2.5 com- pared with 3.5 ± 1.9; P < 0.001). Finally, for fruit drinks only, mean perceived healthfulness differed according to composite accuracy score (P < 0.001); that is, increased ingredient accuracy was associated with decreased perceived drink healthfulness. Discussion In this cross-sectional online study, we found that misperceptions re- garding ingredients in drinks caregivers serve their children were com- mon, with many inaccurately believing the drinks they served did not contain added sugar and/or NNSs, and overestimating the drinks’ per- centage juice. These misperceptions were widespread and might con- tribute to sugary drink provision. Our study confirms prior research that has shown that perceived healthfulness of sugary drinks varies by drink type (20–22) and that caregivers are prone to misperceptions re- garding product ingredients (25). We extend this prior research by as- sessing how perceived healthfulness relates to ingredient accuracy and identifying common misperceptions for different types of drinks and ingredients. The composite accuracy score, which sought to assess mispercep- tions for each drink category as a whole, showed that participants were more likely to inaccurately identify ingredients in fruit drinks and fla- vored waters compared with unsweetened juices. This is concerning, be- cause these drinks contain ingredients not recommended for children (1), such as NNSs and added sugars. In particular, caregivers did not realize that many of the drinks they served contain NNSs. For example, ∼60% inaccurately thought that the fruit drink they provided their child did not contain NNS, when in fact it did. Health and nutrition organi- zations caution against consumption of drinks with NNSs by children (1, 11), yet many products that are marketed to children contain them (9). Caregivers express concerns about serving drinks with NNS to their children (20, 27), which suggests that caregivers might not provide these drinks if the NNS content was clearly disclosed on the package. That differences in perceived healthfulness of NNSs depend on the type also reveals consumer misperceptions. Participants considered stevia to be healthier than sucralose and aspartame, which might be because it is a plant extract and often marketed as “natural.” However, all types of NNS are not recommended for children given how they might affect devel- opment of sweet taste preferences and as a precautionary measure given unknown longer-term effects (15). CURRENT DEVELOPMENTS IN NUTRITION D ow nloaded from https://academ ic.oup.com /cdn/article/6/1/nzab151/6479116 by guest on 18 January 2022 6 Jensen et al. TABLE 3 Accuracy regarding ingredients contained in unsweetened juices and sweetened fruit-flavored drinks caregivers served to their child in the past month (n = 1614)1 Accuracy by ingredient Products served most often by drink category Number of caregivers2 Percentage juice Added sugars NNS n % n % n % 100% fruit juices3 1435 674 47.0 756 52.7 1241 86.5 Mott’s 100% juice 377 202 53.6 173 45.9 334 88.6 Capri Sun 100% juice 330 118 35.8 215 65.2 263 79.7 Juicy Juice 100% juice 263 140 53.2 129 49.0 236 89.7 Apple & Eve 100% juice 144 58 40.3 59 41.0 125 86.8 Minute Maid 100% juice 130 54 41.5 97 74.6 105 80.8 Tropicana Orange Juice 103 42 40.8 53 51.5 93 90.3 Juice/water blends4 930 269 28.9 501 53.9 775 83.3 Capri Sun 373 135 36.2 136 36.5 286 76.7 Honest Kids 318 80 25.2 222 69.8 291 91.5 Apple & Eve 120 23 19.2 75 62.5 94 78.3 Mott’s Sensibles 106 27 25.5 62 58.5 93 87.7 Flavored waters5 774 69 8.9 449 58.0 244 31.5 Capri Sun 409 11 2.7 246 60.1 84 20.5 Vitamin Water 156 18 11.5 81 51.9 109 69.9 Tum E Yummies 143 5 3.5 102 71.3 32 22.4 Fruit drinks6 982 184 18.7 785 79.9 369 37.6 Capri Sun Original 213 20 9.4 154 72.3 179∗ 84.0 Sunny D 147 17 11.6 115 78.2 39 26.5 Kool-Aid ready-made 145 33 22.8 129 89.0 37 25.5 Kool-Aid drink mix 123 53 43.1 106 86.2 26 21.1 Minute Maid Lemonade 95 14 14.7 83 87.4 25 26.3 Hawaiian Punch 94 15 16.0 77 81.9 28 29.8 Little Hug 74 8 10.8 62 83.8 18 24.3 Hi-C 59 11 18.6 43 72.9 13 22.0 1NNS, nonnutritive sweetener. 2Numbers within brands do not add to total per category because “other” brands not listed. Brand listed refers to the brand served most often to child. “Other” additional brands were written in for 6.1% of 100% juice (88 of n = 1435), 1.4% of the juice/blends (13 of n = 930), 3.3% of the fruit drinks (32 of 982), and 8.5% of the flavored waters (66 of n = 774). 3All 100% juices contained 100% juice, no added sugar, and no NNS. 4Most juice/water blends contained no added sugar and 38–66% juice. Capri Sun for this category included Fruit & Veggie Blends, Organic, Refreshers. Mott’s Sensibles contains fruit juice + coconut water, so although a juice/water blend, the information panel lists 100% juice. 5Includes Roarin’ Waters, Sport. All flavored water contained added sugar and NNS, except Vitamin Water, which did not contain NNS. 6All fruit drinks contained added sugar and NNS, except Capri Sun Original, which did not contain NNS. Kool-Aid ready-made included Jammers and Bursts. Misperceptions regarding whether or not a drink contained added sugar were more prevalent for unsweetened juices (100% juice and juice/water blends), with almost half our sample believing they have added sugars, when they do not. For fruit drinks, close to 1 in 5 care- givers believed that the products had no added sugars, when in fact they did. These misperceptions could reflect consumer confusion regarding differences between total and added sugars. In January 2020, the FDA’s requirement to disclose added sugars on labels came into full effect for large manufacturers (28), and participants were interviewed in 2019. In a randomized experiment (29), the new label disclosing added sugars was found to improve understanding regarding added sugar content in a diverse set of products compared with the label not disclosing these, which is encouraging. However, disclosure did not affect purchase in- tentions of the products. Health warning labels [e.g., “Drinking bever- ages with added sugar(s) contributes to obesity, diabetes and tooth de- cay”] could hold promise for improving caregivers’ understanding of health harms associated with overconsumption of SSBs and lowering purchase intentions (30, 31). For fruit drinks specifically, warning la- bels decreased perceived product healthfulness and consumption inter- est (32) and reduced odds of selecting fruit drinks for child consump- tion, an effect mediated by changes in health beliefs and risk perceptions (21). Because perceived healthfulness of drinks has been associated with providing the drink to children (20, 22), it is important to understand what might influence caregivers’ perceptions of a drink’s healthfulness. In our study we found that caregivers’ beliefs that a drink contained added sugar was associated with lower perceived healthfulness, but this was not the case for NNSs. That is, caregivers who believed a drink con- tained NNS did not rate the healthfulness of the drink they served differ- ently than those who did not believe it contained NNS. These findings are somewhat unexpected given prior research on caregivers’ concerns regarding NNSs in the drinks they serve their children (20) as well as in foods in general (33, 34), showing that they prefer to avoid NNSs and have negative feelings about these. Although the latest Dietary Guide- lines for Americans state that NNSs are not recommended for children aged <2 y (2), they do not include statements regarding consumption by other age groups. However, other expert recommendations advise against serving drinks with NNSs to children aged <5 y (1) and against prolonged consumption by children in general (11). These inconsisten- cies might contribute to caregiver confusion about NNS. CURRENT DEVELOPMENTS IN NUTRITION D ow nloaded from https://academ ic.oup.com /cdn/article/6/1/nzab151/6479116 by guest on 18 January 2022 Ingredients in drinks served to young children 7 FIGURE 3 Perceived healthfulness reported for different types of beverages, nonnutritive sweeteners, and added sugars (n = 1614). (A) Perceived healthfulness of different drink categories. (B) Perceived healthfulness of nonnutritive sweeteners and added sugars. Numbers reported are means ± SD. For panel A, all pairwise comparisons are statistically significant (P < 0.05), per ANOVA with Bonferroni adjustment, except for regular compared with diet soda. ∗P < 0.05. HFCS, high-fructose corn syrup. Limitations and strengths Our study does have limitations. Our sample was drawn from an online panel of consumers who voluntarily participated in the survey. There might be reasons that motivated participants to participate in the sur- vey (compared with those who did not) that make them different from the broader population, which might affect our study’s generalizability. However, online panel surveys are broadly used when assessing con- sumers’ knowledge and behavior. Participants might have been subject to misreporting in brands and frequency, given that they were asked about the drinks provided to their children in the previous month (as opposed to the previous day). However, given the frequency of con- sumption reported in previous studies, assessing over the past month was appropriate for our research questions. Given that products from different drink categories have similar names and marketing strategies, parents might have misidentified the drink category(ies) they provided their child. To minimize this possibility, the survey questions included both definitions of drink categories and a list of popular products in the category, including both brand and variety names, when assessing whether participants provided drinks in each category. Despite these limitations, our study had strengths worth high- lighting. Perceived healthfulness of drink categories has been assessed in other studies (20–22, 35), but our study also assessed perceived CURRENT DEVELOPMENTS IN NUTRITION D ow nloaded from https://academ ic.oup.com /cdn/article/6/1/nzab151/6479116 by guest on 18 January 2022 8 Jensen et al. TA B LE 4 P er ce iv ed he al th fu ln es s o f sw ee te ne d fr ui t- fla vo re d d ri nk s ac co rd in g to ca re g iv er s’ b el ie fs an d ac cu ra cy re g ar d in g in g re d ie nt s Fr ui t d ri nk s (n = 98 2) Fl av o re d w at er s (n = 77 4) P er ce iv ed he al th fu ln es s1 P er ce iv ed he al th fu ln es s1 n % M ea n SD F P va lu e n % M ea n SD F P va lu e A d d ed su g ar B el ie ve s d rin k co nt ai ns it 78 5 80 4. 7 2. 3 39 .6 < 0. 00 12 44 9 58 6. 4 2. 3 9. 8 0. 00 22 B el ie ve s d rin k d oe s no t co nt ai n it 19 7 20 5. 9 2. 8 32 5 42 6. 9 2. 5 N on nu tr iti ve sw ee te ne r (N N S) B el ie ve s d rin k co nt ai ns it 22 4 23 5. 0 2. 4 0. 1 0. 78 83 18 2 24 6. 5 2. 2 0. 2 0. 65 53 B el ie ve s d rin ks d oe s no t co nt ai n it 75 8 77 4. 9 2. 7 59 2 76 6. 6 2. 5 Pe rc en ta g e of ju ic e in d rin k O ve re st im at es 79 8 81 5. 3 2. 5 75 .8 < 0. 00 14 70 5 91 6. 6 2. 4 1. 6 0. 20 5 A cc ur at e 18 4 19 3. 5 1. 9 69 9 6. 9 2. 4 C om p os ite ac cu ra cy sc or e 0 ac cu ra te in g re d ie nt s 10 9 11 6. 0 2. 6 17 .1 < 0. 00 15 20 3 26 6. 7 2. 6 0. 5 0. 59 3 1 ac cu ra te in g re d ie nt 45 6 46 5. 1 2. 4 38 8 50 6. 5 2. 4 2 or 3 ac cu ra te in g re d ie nt s 41 7 42 4. 5 2. 4 18 3 24 6. 5 2. 2 1 M ea su re d on a sc al e of 1 = ve ry un he al th y to 10 = ve ry he al th y. 2 D en ot es si g ni fic an ce in co m p ar in g m ea n p er ce iv ed he al th fu ln es s b et w ee n p ar tic ip an ts w ho th ou g ht th e d rin k co nt ai ne d ad d ed su g ar co m p ar ed w ith th os e w ho d id no t th in k it co nt ai ne d it. 3 D en ot es si g ni fic an ce in co m p ar in g m ea n p er ce iv ed he al th fu ln es s b et w ee n p ar tic ip an ts w ho th ou g ht th e d rin k co nt ai ne d N N S co m p ar ed w ith th os e w ho d id no t th in k it co nt ai ne d it. 4 D en ot es si g ni fic an ce in co m p ar in g m ea n p er ce iv ed he al th fu ln es s b et w ee n p ar tic ip an ts w ho ov er es tim at ed th e p er ce nt ag e of ju ic e in th e d rin k co m p ar ed w ith th os e w ho w er e ac cu ra te . 5 Pe r Sc he ffe p os t ho c te st al lc on tr as ts w er e si g ni fic an t at P < 0. 05 fo r “F ru it d rin ks :” 0 vs .1 (P = 0. 00 3) ,0 vs .2 –3 (P < 0. 00 1) ,1 vs .2 –3 (P = 0. 00 3) . healthfulness of specific ingredients and caregivers’ accuracy in under- standing ingredients in the drinks they serve their child. Furthermore, assessing perceived healthfulness and ingredient accuracy for specific brands within the drink categories enabled us to further identify areas for improvement in labeling and nutrition education efforts. Finally, our large and diverse sample ensured adequate subsamples to make compar- isons among those reporting providing the different drink categories. Implications for policy and practice Public health campaigns are necessary and could highlight several key messages. First, our findings suggest that additional campaigns recom- mending plain water and milk as the only drinks for toddlers and young children are needed. Second, juice/water blends are a lower-calorie, lower-sugar alternative to 100% juice, which is an important distinction to convey given that caregivers perceived juice/water blends to be less healthy than 100% juice. Third, educational campaigns should inform caregivers that flavored waters and fruit drinks contain added sugar and NNSs, which are not recommended for young children, and that they contain little or no juice. Flavored waters, in particular, may be prone to confusion due to their name, which might imply they are “just wa- ter.” As shown in our results, they were perceived as healthier than fruit drinks. Finally, health professionals in clinical settings such as pediatri- cians and dietitians should reinforce these public health messages. As has also been also shown in prior research (25, 36), current label- ing of sweetened fruit-flavored drinks and unsweetened juices makes it difficult to distinguish between different product types, as well as iden- tify those that have added sugar and/or NNSs. Front-of-package disclo- sures for these key nonrecommended ingredients could improve accu- racy in identifying ingredients in drinks. Since January 2020, the FDA has required food companies to disclose added sugars in the nutrition facts panel of their products. Although this requirement might help to better inform consumers, nutrition panels are not always read or under- stood (37), a barrier that could be reduced by providing standardized disclosures and/or warning labels on package fronts. Further complicating public health efforts to discourage consump- tion of sweetened drinks, healthfulness was not a top reason for pro- vision. Even though caregivers who provided fruit drinks rated them as healthier than caregivers who did not provide them, they provided them for other reasons such as low cost and children’s requests. There- fore, policies that affect underlying factors related to food choice are required. Krieger and colleagues (38) provide a helpful framework of potential policies. Sugar taxes, for example, would increase the price of SSBs while raising revenue that could finance additional public health campaigns. In addition, the importance of children’s requests in parents’ provision of sweetened fruit-flavored drinks indicates a continued need to reduce children’s exposure to marketing for these products. Unhealthy food and beverage marketing is an important determi- nant of dietary intake and food preferences in children (39, 40), and chil- dren’s exposure remains high despite industry self-regulation of adver- tising to children (9, 41). Indeed, “pester power”—defined as children’s influence through requests for certain products to caregivers—can un- dermine attempts by caregivers to provide their child with a healthy diet (42). Furthermore, in the United States, black youth are disproportion- ately exposed to television food advertising compared with white youth CURRENT DEVELOPMENTS IN NUTRITION D ow nloaded from https://academ ic.oup.com /cdn/article/6/1/nzab151/6479116 by guest on 18 January 2022 Ingredients in drinks served to young children 9 (43, 44), and advertising on Hispanic- and black-targeted TV program- ming is more likely to promote unhealthy food categories, including sugary drinks (45). This targeted marketing likely contributes to dis- parities in diet and diet-related diseases affecting communities of color (6, 46). Policies seeking to discourage sugary drink consumption could be approached, therefore, with a health equity lens in mind. Conclusion In summary, misperceptions regarding sweetened fruit-flavored drinks and unsweetened juices (and their ingredients) that caregivers provide young children are common. Effective public health efforts must address the underlying factors leading to sweetened drink provision, including misperceptions about drink ingredients, low cost, and child requests, to contribute to improved diet, health, and well-being of young children in the longer term. Acknowledgments We thank Ahmad Kibwana-Jaff and Haley Gershman for their assis- tance in data collection. The authors’ responsibilities were as follows—JLH, FF-M: led the conceptualization, obtained funding, and acquired the data for this study; MLJ: conducted the analyses and wrote the first draft of the manuscript with substantial input from all coauthors; and all authors: assisted with data interpretation, provided critical revisions, and read and approved the final manuscript. Data Availability Data described in the manuscript, code book, and analytic code will be made available upon request pending authorization from the senior author of the study. References 1. 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