Paul Branscum: If you were to just... Allowed to say one food or drink could be labeled as unhealthy that in general just stay away from it, that it would probably be sugary drinks.

James Loy: This is Reframe, the podcast from the College of Education, Health and Society on the campus of Miami University in Oxford, Ohio. For many of us, drinking sugar-sweetened beverages can be a daily ritual. We may have a juice in the morning, a soda or two with lunch and dinner, and even a sports drink after the gym. But increasingly public health professionals are showing a growing concern over our consumption of these drinks, especially when it comes to children. Reports from the department of health show that for each 12 ounce soft drink that children consume per day increases their likelihood of becoming obese by 60%. Sweetened soft drinks are also associated with nearly a 100% increase of cavities and tooth decay and they can also lead to much higher risks of heart disease and type 2 diabetes later in life.

James Loy: So today we have two Miami University Public Health researchers who are here to discuss some of the changing cultural trends around the ways we consume and view sugar-sweetened beverages as well as how parents can help their children make more healthier choices overall.

Paul Branscum: My name is Paul Branscum and I'm an associate professor here in the kinesiology and health department and specifically the area of public health. And a lot of my research right now focuses on a number of things, but the main drive has really always started and is childhood obesity prevention. And so I've done a number of studies with kids and then that kind of slowly evolved to working more with parents and trying to understand those interactions.

Paige Keizer: So my name is Paige [Keizer 00:00:01:51]. I am a master's student in the department of kinesiology and health. I work very closely with Dr. Branscum and then also Dr. Phillips Smith. My research focus right now is on sugar-sweetened beverages and parenting practices and how those go hand in hand, how that affects all of that. I also do have an interest just in children overall. I've worked at a daycare in my hometown for the past six years, so I've gotten very close to some of those people and they will end up being part of my research study that we're going to talk about.

James Loy: Dr. Branscum, Paige, thank you. Thank you for talking about this topic today. When it comes to sugar-sweetened beverages, it seems like there's much more of awareness today about the health risks or how they might not be so good for us, especially if we overconsume them, but at the same time it seems like they're everywhere with more and more frequency. So from a public health perspective or from a nutritional perspective, what's the big headline? What do we really need to know?

Paul Branscum: When we talk about diet and certain foods and drinks, as a dietician, there was something I was always taught as an undergrad, and that is when it comes to your diet and foods that we consume, there are no technically quote, unquote "bad foods", right? All foods, at least what the dietetic association talks about, all foods can be part of a healthy diet. The goal is that we want to balance the foods that we have. So if we have sugar-sweetened beverages in a day, we want to balance that maybe with more healthy options.

Paul Branscum: So it's interesting then that a lot of my research is about with kids and parents and either focusing on them to either stop consuming sugar-sweetened beverages or to at least reduce the consumption of. So when it comes to sugar sweetened beverages, I wouldn't say for example, that they're dangerous or that it's a bad thing that you should definitely stay away from. I think that's kind of taking it a little too far. I would definitely say that about smoking, right? Smoking cigarettes and now with vaping, those are dangerous things. But I was going to say there's a caveat that if you're really to ask dietitians, if you were to just... Allowed to say like one food or drink could be labeled as unhealthy that you, in general, just stay away from it. I have a guess that it would probably be sugary drinks, sugar-sweetened beverages that really... There's just not a really good value to it. They're essentially just calorie delivery devices, right? They're just, it's a source of calories and that's about it. You don't get much other nutritional value out of it.

James Loy: Paige, what are some of the reasons why you think this is an interesting topic to study?

Paige Keizer: Just working with Dr. Branscum so closely, since I have an interest in kids, we were kind of trying to come up with a topic like what is really hindering child health today? What is leading to child obesity overall? And this is something that he's very familiar with and so I just decided that it would be a good topic and that it was also something that the daycare center that I've worked with for so long was interested in learning more about and trying to reach their parents and figure out what are parents doing? What are they willing to do? What are they not willing to do when it comes to sugar sweetened beverages and their child's consumption.

James Loy: When you talk about there being no quote, unquote "good or bad" foods, that kind of makes sense if you see sugar-sweetened beverages in the context of like a dessert, like sure, have one every once in awhile. But I feel like soda is drank with every meal almost for a lot of people. And then also the volume of which we drink them all throughout the day. So is that really what the concern is? The rise of frequency and volume and even the age at which we consume these?

Paige Keizer: I would say yeah, definitely for children. Just from my own experience working with children and working in the daycare setting. They bring juice and chocolate milk and things like that. Things that are sweetened beverages for breakfast, for lunch, for their snacks. And you hardly ever see them drink anything that's unsweetened, such as just plain water. Just from babysitting some of those children as well, their parents are really lenient on what they consume. So I think there is a trend that it's rising, that there's more consumption. It doesn't necessarily have to be soda. I would definitely say that that's probably the one that you're not seeing them drink as much, but people sometimes forget that juice and Gatorade, and things like that still have a large amount of sugar in them and that they are sugar-sweetened beverages.

James Loy: Right. That seems to be the one where the soda is... People are becoming more aware of maybe that's not as good, but there's all these other things that fit the bill, right?

Paul Branscum: I think overall you're exactly right when it comes to things like soft drinks, like the pops and the sodas. Actually they're starting to find that the overall sales of those are starting to decrease a little bit, but other categories that are increasing are the sports drinks, energy drinks, and I think coffee drinks was the other one that was kind of increasing. And so, what I really kind of equate that to is, first off, there's a little bit of a stigma definitely around that's starting to become a little bit more socially acceptable to have the stigma around soft drinks. At the same time, due to really good marketing, they've been able to kind of convince us that sports drinks, on the other hand, aren't maybe as bad. So even though you look at a food label and they would have a very similar level of sugar, for example, for some reason they've been able to market it such that people equate the full sugared sports drinks as being healthy or something. If you're an athlete you should have or you should attribute it to being an athlete, versus, like you were talking about the stigma around pop kind of being a bad thing.

Paul Branscum: So it's really kind of an interesting phenomenon that's happened, this idea that... Just that the public zeitgeists in a sense, right? The public awareness can shift. They've learned some lessons, I feel like, these beverage manufacturer have been burned a little bit through groups vilifying some of their products and so they're learning that, okay, how do we then create new categories? How do we create new products that addresses the concerns people have, but maybe still contain sugar and that people will buy eventually.

James Loy: Can you speak to how this intersects with public health for people who are studying it or for people who have careers in this field? Is this part of the job? I mean, are they responsible for educating people who are unaware of the differences between these certain products with these sugar sweetened beverages, for example? How does that look for people who are in this profession dealing with these issues?

Paul Branscum: Yeah, so in public health we do a lot of things. It starts, or at least for me, it starts with at the people level. And so educating, persuading, campaigning, going out to the community and at least teaching people healthy habits, healthy behaviors, and hoping that through that diffusion people adopt healthy behaviors. But in public health we don't just do individual level approaches. We also do things like advocating. And so, yeah, public health people are always part of the conversation when it comes to whether or not communities, states, federal government, is going to put bans on certain things or just regulate certain products. Public health officials are involved with sort of all of these steps, right?

Paul Branscum: In public health we oftentimes talk about the ecological model. Ecological model talks about all these points of influence that influences health disparities in our personal behaviors and those levels being the individual level, the interpersonal level, which is our relationships with others, the organization's organizational level, the community level and the public policy level. And so public health officials tend to be thinking about interventions in ways to get involved at all those levels.

James Loy: I wonder, Paige, how does that align with what you hope to do with your career?

Paige Keizer: Finding ways to change behavior is the overall goal. We focus on interventions and what functions of interventions work best? Whether that be just educating people, like how do you ultimately get them to change behavior?

James Loy: Yeah. So what do we know about that? I mean, when it comes to the research, Dr. Branscum, I know you've studied a lot of different areas with regard to childhood obesity and sugar-sweetened beverages and also with parents and children and how to monitor and influence behaviors. So what are some of the research studies you've done in this area and what have been some of the key findings?

Paul Branscum: Yeah, so given I did my master's thesis and my doctoral work on working with kids, when I got to university of Oklahoma, my first job, I knew that I wanted to start working with parents because they're the natural gatekeepers, right? They're the ones that are in the homes. They purchase the foods and drinks that they bring into the home. They model, behaviors in front of their kids. And so if you're going to really want to impact the kids, it's important to educate and persuade them, but also important to get to their parents and do the same.

Paul Branscum: And so I did some studies at University of Oklahoma and the one that stood out to me the most was the one where I looked at different factors that determined how parents monitor their children's sugary drink consumption. And one of the interesting things that I found was that mothers tend to take a much more involved role than fathers. Moms had stronger positive attitudes about wanting to monitor their kids. Moms felt like they could do it more, they had stronger self-efficacy. And then when you actually looked at what predicts parents to actually monitor their kids' sugary drinks, we found that with moms, motivation was really the key, that if you could get the mom motivated enough to monitor their sugary drink, then they were more likely to do it. With fathers it wasn't so much. So if we motivate them a lot, they still may or they may not. What what was really key with fathers was their skillfulness and whether or not they had the ability to actually do things like talk to their kids about sugary drinks and purchase the right kinds of things or not purchase.

Paul Branscum: And so that was a really interesting dichotomy that we found with what sort of leads moms versus what leads dads to monitor, that there's actually these two different things. So from public health approach, when you think about intervening, what might work for moms, interventions that might work for moms, might not work for dads. Another thing that we did in Oklahoma was I worked with Karena Laura in the nutrition department there. And we went out and we interviewed low-income Hispanic mothers of preschoolers. And very interesting that we found that fathers, overall, were just not supportive of the mothers when the mothers wanted to feed their kids healthy foods and healthy drinks. So when you think about our public health approaches, when we go out and we try to work with groups, it's something also to think about that even though we might want to work with, let's say, this population, low-income Hispanic mothers, we want to work with them and teach them about sugary drinks and how to provide other healthier alternatives to their children, we might forget that, well, they live in a household where fathers are not supporting this and might actually be countering any effect the mother's trying to have.

Paul Branscum: And so just another kind of caveat when you're looking at public health approaches, sometimes we look at it from a very head-on approach of, well this is the problem, let's attack that problem, without thinking about these underlying factors that might influence whether or not the mothers are actually going to be successful. And so from that standpoint, we might do an intervention where part of it's just how do you deal with the father, and what are the negotiation skills, or what are the strategies that you're going to use when they're trying to undermine those messages?

James Loy: And I know there's a brand new research study that you're involved, in the middle of right now, with sugar-sweetened beverages. What's this new study all about? What does it entail and what are you hoping to learn?

Paul Branscum: So, what I'll do is I'll maybe prep it and I'll let Paige take over. And so, this is definitely... All this work that I've been doing over these years, and it's been a marathon, has kind of led us to this point where I'm at with Paige. And so in the past we've always looked at parental monitoring as a sort of broad behavior, right? But when you think about what parental monitoring sort of involves, there's a lot of things that are involved in monitoring that you can start to pick apart. And so as Paige and I started to look at different ideas to how to further this area, we started thinking about the idea of monitoring and how could we look at it from a... instead of a broad but more of a specific standpoint.

Paul Branscum: And so we looked at this framework developed by Susan Michie, a professor of health psychology and the director of the center for behavior change at University College London and her team. And what they did was they developed this system called the Behavior Change Wheel. Behavior Change Wheel is a guide that gives anyone who's trying to change, who's trying to help behavior change happen in a population, it gives them a framework to go by. And so what we were going to do is, what we're proposing to do, is look at parental monitoring of sugar-sweetened beverages from the vantage point of these intervention functions. So whereas these intervention functions are more what a public health practitioner might do in a community with a group of people to change their behavior, we're trying to take those principles and transform them to how parents might interact with their children to potentially get them to change their behaviors.

Paige Keizer: So Susan Michie's Behavior Change Wheel identifies nine different intervention functions. So you have education, persuasion, training, coercion, incentivizing, modeling, restriction, environmental restructuring and enablement. So we've kind of taken all of these different intervention functions and operationalized them using the reasoned-action approach from Martin Fishbein and Icek Ajzen, trying to find out what attitudes, intentions, perceived behavioral control and norms that parents feel about these nine different intervention functions. So the focus is on children aged two to five at the daycare that I have previously worked with and trying to understand what parents are currently doing, what they're willing to do, what they're not willing to do, so that we can kind of find an intervention function out of these nine that would best suit them for an intervention to limit their child's sugar-sweetened beverage consumption to no more than eight ounces per week, which has kind of been a recommendation throughout the literature review that we've done.

James Loy: Eight ounces per week. All right, well that's a concrete recommendation that I think parents can can keep in mind. So when you think about the context of this new study, and especially regarding everything you've learned from previous research regarding how parents can help influence and monitor their children's behaviors when it comes to healthy eating or healthy living, what does all this mean for parents? What are some practical applications or some advice you can give them for things they can do and think about right now?

Paul Branscum: Yeah, so this listing of intervention functions is a really good starting point. I think that even without this research, parents can at least start thinking about, well, how do I interact with my kids, first off. When I want my kid to do something, what do I do? Do I incentivize them? Basically giving them an expectation that if they do it, they get some kind of reward. Do I coerce them? Which is the opposite. Do I tell them if they don't do something then they'll get a punishment? Right? And so there are definitely some tried and true things that we tend to promote. Things like modeling. Modeling is something that should start very, very young where the behavior kind of becomes faded into the background, where it's not something that we're actually focused on that we're trying to promote, but through the practice of modeling, it just becomes a normal thing. There may be things that... You think about brushing your teeth. We're not really always focused on us as adults to make sure we remember to brush our teeth. It's something that we've created a habit that's been through, very likely, modeling, is very young. We see people do it and we sort of instill that as something that just becomes part of the background, part of who we are.

Paul Branscum: Now, modeling is something great we can do very young, especially this age that we're working with, are the preschoolers. But obviously our research wants to go further and start looking at, well, what about parents of older kids or even parents of pre-adolescent and teens. And so that's where some of these other interactions might start to become important, right? I mean modeling is always going to be there, but what really would be a good factor is yet to be seen. Is it better to just restrict certain things in the house or is it better to educate or persuade? At this point, I'd say a little bit of everything can't hurt. Education's always going to be important, that people have to know what is you want them to do if you expect them to do it. But we know education alone is not enough to get behavior change to happen.

Paul Branscum: And so that's really getting into the nitty-gritty of if we know that, okay, basic education is good, modeling is good, persuasion is probably a good thing to always promote, questions are, how far do you take it and what's sort of the good mix of... Is it education, persuasion and incentivizing and a little bit of training? What is the ultimate key? And that that always kind of boils down to what works, when does it work and with whom does it work best? It's likely we'll probably never have the full answer to that because things change. Kind of like how I talked about with the cultural norms and attitudes about smoking. We see it right now with sugary drink consumption, how some things have started to become a little more taboo and a little less acceptable, but things are also starting to become more acceptable with the sports drinks. And so that's kind of... We're in the thick of it right now to kind of understand what things together could work. First, understanding of an individual level and then trying to understand the interactive effects they may have.

James Loy: Is that hard to stay ahead of? Because with the cultural attitudes that seem to change so quickly over time, like, back to smoking again, even people who currently smoke today, I don't think any of them are really going to argue that they think it's still healthy. We all know. There seems to be more of a growing awareness around soda specifically, but then there's all these other beverages that seem to just get wrapped up into the fold. So is it hard to stay ahead of that curve as a public health professional?

Paul Branscum: Definitely. And that's sort of the thing about research. Research doesn't happen overnight. It takes a lot of time to kind of design these studies, plan for these studies, implement the studies. It takes time to write them up, publish them in a journal. And so, in public health we try to teach students about the power of advocacy and about how when you are working with groups and you're developing these findings, and you're discovering things that are new, to also be an advocate for health and public health. And so that's something hopefully we kind of instill in our students, the do your best, try to stay up to date, know that your results are adding to our knowledge base, so don't lose hope that what you're doing today could be outdated tomorrow, that, at minimum, your research is going to be part of this larger knowledge base. That's worth something and that's why in public health we just have to keep current, right? We have to understand that the targets that we have are our moving targets. It's a challenge.

James Loy: That seems to connect back to your research in a way because if you find out what are the things that parents can do to most effectively influence the behavior of their children, it almost doesn't matter what the unhealthy behavior is. It could change whatever it is this day or this era, as long as they're doing the things that influence their children's behavior, that almost seems like it will always apply to the things they want their children to do or not to do. That seems universal almost in a way.

Paul Branscum: Right, and that's what Susan Michie really did with her Behavior Change Wheel and what she's trying to do at least is develop these intervention functions. She developed these nine intervention functions that are supposed to be universal and are supposed to be all-encompassing. If you really boil interventions down and what people do to change behavior, essentially they're saying is that these nine intervention functions are what people do. And it's pretty all-encompassing. Now again, you also have to remember this is outside of changing the environment and changing policies. This is more about someone developing an intervention or implementing an intervention would have with their target population.

James Loy: And Paige, future plans? What do you hope to do or what would be your ultimate goal or dream job that you'd like to do after graduating?

Paige Keizer: I'm not entirely sure. I have looked at things around the Columbus area, working with their department of health, just seeing what's out there. My ultimate goal would be to end up with the CDC, Center For Disease Control and Prevention in Atlanta, Georgia, just working either as a health analyst, intervention planner, public health program planner, something in that realm.

James Loy: All right, well, good luck, certainly, and with that Paige, Dr. Branscum, thank you so much for being on the podcast today.

Paige Keizer: Thank you.

Paul Branscum: Thank you.

James Loy: Dr. Paul Branscum is a Miami University associate professor of Public Health, and Paige Keizer is a graduate student here at Miami where she is working towards her master's degree in kinesiology and health. This is The Reframe Podcast, which is always available for free. Please share with your friends, family, colleagues, and students. You can find more episodes on Apple podcasts or wherever you listen.