Background: Sugar sweetened beverages (SSBs) comprise the largest source of added sugars in US adolescents’ diets. SSB consumption is pervasive in US culture and is a critical risk factor for weight gain and obesity in adolescents. This thesis evaluates multi-level factors that influence adolescent SSB consumption. Methods: The first two aims of this thesis utilized data from the cross sectional, internet based Family Life, Activity, Sun, Health and Eating (FLASHE) study to: 1) examine availability of SSBs in multiple settings (home, school, neighborhood) and adolescent SSB consumption, 2) examine the associations between perceptions of parenting practices and adolescent SSB consumption. The third aim used focus group discussions to understand adolescents’ perceptions about SSBs. Results: We found that SSB availability in the home was an important predictor of adolescent SSB consumption, regardless of SSB availability in other settings. Also, parenting practices that facilitate adolescent SSB consumption are associated with higher adolescent SSB consumption, but discussing/negotiating SSB behaviors is not associated with adolescent SSB consumption. Adolescents’ described their attitudes, reinforcements, knowledge, and sources of influence around SSBs which are multifactorial and complex. Conclusions: This thesis identified potential targets for addressing adolescent SSB consumption through availability of SSBs at home, parenting practices, and adolescent perceptions around SSBs. These are important modifiable factors in the adolescents’ sociocultural environment that should be targeted in future dietary interventions to influence adolescent SBB consumption.

Indiana University-Purdue University Indianapolis (IUPUI)

Unhealthy eating habits are one of the main causes of deteriorating health and premature death among Sweden’s population. Foods containing added sugars are common today and they rarely contain the nutrients that are essential for our bodies to stay healthy. Overconsuming sugar can lead to several diseases, including obesity and caries. Obesity in turn increases the risk of suffering from cardiovascular diseases, cancer, stroke, and diabetes type 2. The health effects of sugar are costly to society and a sugar tax on sugar-sweetened beverages is a possible financial instrument to improve public health and at the same time reduce healthcare costs. The cost savings and tax revenue can then be used to finance further implementations of strategies to improve the public health of the citizens of Sweden. The purpose of this essay is to investigate whether it is socio-economically viable to introduce an excise tax on sugar-sweetened beverages in Sweden. The drinks that would be affected by the tax are sodas, juices, energy drinks, sport drinks and ciders. A cost-benefit analysis is the economic method that will be used in this essay to investigate the issue. The possible costs and benefits from the implementation of a tax are identified and valued in monetary terms. In addition to this, a sensitivity analysis is carried out to test how sensitive the project is to differences in estimated costs and benefits. The calculations of costs and benefits are based on secondary data and statistics from previous studies as well as reports and statistics from Swedish authorities. The results of this essay show that the benefits of a tax on sugar-sweetened beverages had exceeded the costs, which is also showed by the cost-benefit ratio which is 1,47 and thus exceeds 1. The sensitivity analysis shows that the results are stable and credible since alternative values of costs and benefits also would lead to cost-benefit ratios exceeding 1. Based on the results, a recommendation is made to introduce an excise tax on sugar-sweetened beverages in Sweden, since the introduction is estimated to be socio-economically viable. / I denna uppsats utförs en kostnads-nyttoanalys för att undersöka om det är samhällsekonomiskt lönsamt att införa en punktskatt på sötad dryck i Sverige. De drycker som skulle påverkas av skatten är läsk, juice, saft, energidryck, sportdryck, cider samt måltidsdryck som är sötade med socker eller naturligt innehåller en hög sockerhalt. Socker har endast negativ påverkan på vår hälsa och överkonsumtion av socker är en orsak till ett flertal sjukdomar som är vanligt förekommande idag, bland annat övervikt och karies. Övervikt ökar i sin tur risken för att drabbas av fetma, hjärt- och kärlsjukdomar, cancer, stroke och diabetes typ 2. Hälsoeffekterna av socker är kostsamma för samhället och en sockerskatt på dryck är ett möjligt styrmedel för att förbättra folkhälsan och samtidigt minska dessa kostnader. Kostnadsbesparingarna kan därefter distribueras till viktiga ändamål, exempelvis för att finansiera ytterligare strategier för en bättre hälsa hos befolkningen. Resultaten i uppsatsen visar att fördelarna av en skatt på sötade drycker hade överstigit kostnaderna, vilket går att se då nyttokostnadskvoten som beräknas uppgår till 1,47 och alltså överstiger 1. Utöver kostnads-nyttoanalysen utförs även en känslighetsanalys för att testa hur känsligt resultatet är för förändringar av värdet för olika parametrar som kommer påverkas av införandet av skatten. Känslighetsanalysen visar att resultatet är stabilt och trovärdigt då även alternativa värden leder till en nyttokostnadskvot som överstiger 1. Resultatet används som grund för en rekommendation om att införa en punktskatt på sötade drycker i Sverige, då införandet är samhällsekonomiskt lönsamt.

Bakgrund: Sockersötade drycker är drycker till vilka sockerarter tillsatts. Dessa drycker konsumeras globalt och många gånger överskrids rekommendationerna om intag av tillsatt socker, vilket kan leda till negativa hälsoeffekter. Sockersötade drycker kan öka risken att drabbas av övervikt, fetma och typ 2-diabetes som i sin tur är riskfaktorer för att utveckla bukspottkörtelcancer. Det finns därför ett ökat intresse att undersöka den potentiellt ökade cancerrisken vid konsumtion av sockersötade drycker. Syfte: Syftet var att undersöka om intag av sockersötade drycker kan öka risken att drabbas av bukspottkörtelcancer. Metod: Arbetet är en litteraturstudie där vetenskapliga artiklar sökts med databasen PubMed. Sökorden var ”sugar-sweetened beverages” och ”pancreas cancer”. Av de artiklar som erhölls inkluderades observationsstudier och kliniska studier. Utifrån ytterligare inklusions- och exklusionskriterier valdes sju studier ut och granskades. Resultat: Resultat från tre av sju studier visar att det inte förekommer något samband mellan konsumtion av sockersötad dryck och risk för bukspottkörtelcancer medan resultat från tre studier påvisar samband. Resultat från en studie visar att det finns samband hos kvinnor men inte hos män. Slutsats: Hälften av studierna visar ett samband mellan konsumtion av sockersötad dryck och en ökad risk att drabbas av bukspottkörtelcancer. För att minska risken kan det således vara fördelaktigt att följa de rekommendationer som finns kring tillsatt socker. / Background: Sugar-sweetened beverages are beverages to which sugars are added. These beverages are consumed globally and many times the recommendations on added sugar are exceeded, which can lead to negative health effects. Sugar-sweetened beverages may increase the risk of overweight, obesity and type 2 diabetes which are risk factors for developing pancreatic cancer. Thus, there is an increased interest to study the potentially increased cancer risk associated with the consumption of sugar-sweetened beverages. Aim: The aim was to examine whether consumption of sugar-sweetened beverages can increase the risk of pancreatic cancer. Method: This work is a literature study using scientific articles searched with the database PubMed. The search terms were “sugar-sweetened beverages” and “pancreas cancer.” Of the articles obtained, observational studies and clinical studies were included. Based on inclusion and exclusion criteria, seven studies were selected and reviewed. Results: Results from three of seven studies show that there is no relationship between consumption of sugar-sweetened beverages and risk of pancreatic cancer, while results from three other studies show that there is a relationship. Results from one study show that there is a relationship in women but not in men. Conclusion: Half of the studies shows that there is a relationship between consumption of sugar-sweetened beverages and increase the risk of pancreatic cancer. To reduce the risk, it can be beneficial to follow the recommendations that exist regarding added sugar.

Objetivos: Estudar a influência que a renda das famílias e os preços dos alimentos exercem sobre a aquisição de alimentos mais saudáveis (frutas e hortaliças, F&H) e menos saudáveis (bebidas adoçadas, BA). Metodologia: Utilizaram-se dados sobre aquisição de alimentos coletados pela Pesquisa de Orçamentos Familiares (POF), realizada entre julho de 2002 e junho de 2003 pelo IBGE em uma amostra probabilística de 48.470 domicílios do país. A influência da renda familiar e do preço de frutas e hortaliças e de bebidas adoçadas sobre seu consumo foi estudada empregando-se técnicas de análise de regressão múltipa para estimação de coeficientes de elasticidade, controlando-se variáveis sócio-demográficas e preço dos demais alimentos. Resultados: Com a diminuição do preço de F&H haveria aumento da participação desses alimentos no total de aquisições: 10 por cento de redução nos preços de F&H aumentaria em 7,9 por cento sua participação no total calórico. Com o aumento da renda familiar também haveria aumento na participação calórica de F&H: 10 por cento de aumento na renda aumentaria em 2,7 por cento a participação de F&H no total calórico. O efeito dos aumentos de renda tendeu a ser menor nos estratos de maior renda. Haveria significativa redução na aquisição de bebidas adoçadas frente a aumentos no seu preço: para cada 10 por cento de aumento nos preços de bebidas adoçadas haveria uma redução de 8,4 por cento no consumo desses produtos. Aumentos na renda familiar também influenciariam o consumo de bebidas adoçadas, mas com efeito oposto e de magnitude inferior à metade do observado com o aumento de preços: para cada 10 por cento de aumento na renda familiar haveria um aumento de 4,1 por cento no consumo de bebidas adoçadas. Conclusões: Políticas de ajuste de preços como a imposição ou isenção de uma taxa podem ser utilizadas como ferramentas na promoção da alimentação saudável no país, seja estimulando o consumo de alimentos saudáveis ou desestimulando o consumo de não saudáveis / Objectives: To study the influence of family income and food prices on the acquisition of items that act as indicators of a healthy (fruits and vegetables, F&V) or an unhealthy (sugar-sweetened beverages, SSB) food intake. Methods: We used data from the Household Budget Survey (HBS) carried out by IBGE between July 2002 and June 2003 in a probabilistic sample of 48,470 Brazilian households. The influence of family income and the price of fruit and vegetables and sugar-sweetened beverages on its consumption was studied employing techniques multiple regression analysis to estimate elasticity coefficients, controlling for demographic variables and price of other foods. Results: Reducing the price of F&V would increase its participation on total food purchases: 10 per cent reduction in prices of F&V would increase by 7.9 per cent its share of total calories. The increase in family income would also increase the proportion of calories from F&V: 10 per cent increase in income would increase by 2.7 per cent the participation of F&V on total calories. The effect of a raise in income tended to be lower in higher income groups. On the other hand, an increase in the price of SSB would result in considerable reduction in its consumption: for every 10 per cent increase in the prices of SSB a reduction of 8.4 per cent in the consumption would be expected. Increases in income also influence the consumption of SSB, but having the opposite effect, and magnitude less than half that observed for the increase in prices: each 10 per cent increase in family income would increase by 4.1 per cent the consumption of SSB. Conclusions: Public policies aiming the adjustment of prices - as the imposition or exemption of a tax - can be used as a tool in promoting healthy eating in Brazil, either encouraging the consumption of healthy foods or discouraging the consumption of unhealthy products

Objetivos: Estudar a influência que a renda das famílias e os preços dos alimentos exercem sobre a aquisição de alimentos mais saudáveis (frutas e hortaliças, F&H) e menos saudáveis (bebidas adoçadas, BA). Metodologia: Utilizaram-se dados sobre aquisição de alimentos coletados pela Pesquisa de Orçamentos Familiares (POF), realizada entre julho de 2002 e junho de 2003 pelo IBGE em uma amostra probabilística de 48.470 domicílios do país. A influência da renda familiar e do preço de frutas e hortaliças e de bebidas adoçadas sobre seu consumo foi estudada empregando-se técnicas de análise de regressão múltipa para estimação de coeficientes de elasticidade, controlando-se variáveis sócio-demográficas e preço dos demais alimentos. Resultados: Com a diminuição do preço de F&H haveria aumento da participação desses alimentos no total de aquisições: 10 por cento de redução nos preços de F&H aumentaria em 7,9 por cento sua participação no total calórico. Com o aumento da renda familiar também haveria aumento na participação calórica de F&H: 10 por cento de aumento na renda aumentaria em 2,7 por cento a participação de F&H no total calórico. O efeito dos aumentos de renda tendeu a ser menor nos estratos de maior renda. Haveria significativa redução na aquisição de bebidas adoçadas frente a aumentos no seu preço: para cada 10 por cento de aumento nos preços de bebidas adoçadas haveria uma redução de 8,4 por cento no consumo desses produtos. Aumentos na renda familiar também influenciariam o consumo de bebidas adoçadas, mas com efeito oposto e de magnitude inferior à metade do observado com o aumento de preços: para cada 10 por cento de aumento na renda familiar haveria um aumento de 4,1 por cento no consumo de bebidas adoçadas. Conclusões: Políticas de ajuste de preços como a imposição ou isenção de uma taxa podem ser utilizadas como ferramentas na promoção da alimentação saudável no país, seja estimulando o consumo de alimentos saudáveis ou desestimulando o consumo de não saudáveis / Objectives: To study the influence of family income and food prices on the acquisition of items that act as indicators of a healthy (fruits and vegetables, F&V) or an unhealthy (sugar-sweetened beverages, SSB) food intake. Methods: We used data from the Household Budget Survey (HBS) carried out by IBGE between July 2002 and June 2003 in a probabilistic sample of 48,470 Brazilian households. The influence of family income and the price of fruit and vegetables and sugar-sweetened beverages on its consumption was studied employing techniques multiple regression analysis to estimate elasticity coefficients, controlling for demographic variables and price of other foods. Results: Reducing the price of F&V would increase its participation on total food purchases: 10 per cent reduction in prices of F&V would increase by 7.9 per cent its share of total calories. The increase in family income would also increase the proportion of calories from F&V: 10 per cent increase in income would increase by 2.7 per cent the participation of F&V on total calories. The effect of a raise in income tended to be lower in higher income groups. On the other hand, an increase in the price of SSB would result in considerable reduction in its consumption: for every 10 per cent increase in the prices of SSB a reduction of 8.4 per cent in the consumption would be expected. Increases in income also influence the consumption of SSB, but having the opposite effect, and magnitude less than half that observed for the increase in prices: each 10 per cent increase in family income would increase by 4.1 per cent the consumption of SSB. Conclusions: Public policies aiming the adjustment of prices - as the imposition or exemption of a tax - can be used as a tool in promoting healthy eating in Brazil, either encouraging the consumption of healthy foods or discouraging the consumption of unhealthy products

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / Fundação de Amparo à Pesquisa do Estado do Rio de Janeiro / Nas últimas décadas, tem sido observado o aumento da oferta de bebidas com elevado conteúdo calórico e com grandes quantidades de açúcar de rápida absorção. Essas bebidas adoçadas, cujo consumo tem aumentado no Brasil assim como em outras partes do mundo, são consideradas fatores de risco para obesidade e diabetes. O consumo de bebidas adoçadas pode levar ao balanço energético positivo e consequentemente ao ganho de peso. Essa associação pode ser explicada pelo mecanismo regulatório de compensação de calorias líquidas. Compensação calórica ocorre quando há redução no consumo de calorias provenientes de alimentos sólidos para compensar as calorias líquidas adicionadas à refeição ou dieta. No entanto, não há consenso em relação a evidências da compensação calórica, dificultando a elaboração de recomendações sobre essas bebidas em saúde pública. Razões para a falta de consenso incluem a diversidade de desenhos de estudos, experimentos realizados em ambientes controlados e não reais em relação ao consumo de alimentos e bebidas, e estudos com amostras pequenas ou de conveniência. Esta dissertação estudou a associação entre bebidas adoçadas e consumo calórico, verificando se calorias de bebidas adoçadas são compensadas em refeições realizadas em um ambiente pragmático. Os dados de consumo calórico de 34.003 indivíduos, com idade igual ou superior a dez anos, foram obtidos pelo Inquérito Nacional de Alimentação 2008-2009, em todo território nacional. Os participantes completaram dois registros alimentares, em dias não consecutivos da mesma semana. Foram selecionadas as refeições dos períodos café da manhã, almoço e jantar de cada indivíduo em cada um dos dias. Para cada refeição, foi calculado o valor calórico de alimentos e de bebidas adoçadas consumidos. Para testar a compensação calórica, um modelo de regressão linear multinível com efeitos mistos foi ajustado para analisar cada período. A variável reposta utilizada foi consumo calórico proveniente de alimentos e a variável explicativa foi consumo calórico de bebida adoçada na refeição. Os efeitos intra-indivíduo da bebida adoçada no consumo calórico foram estimados e interpretados. Esses efeitos são considerados não-enviesados pois são controlados pelas características constantes dos indivíduos, tendo assim o indivíduo atuando como seu próprio controle na análise. Covariadas incluídas no modelo foram variáveis da refeição: local, dia da semana, horário, consumo calórico na refeição anterior e intervalo de tempo desde a última refeição; e do indivíduo: sexo, faixa etária, categoria de Índice de Massa Corpórea e quartos de renda per capita. Efeitos aleatórios dos indivíduos e dos domicílios foram incluídos no modelo para melhor estimar a estrutura de erros de dados correlacionados. A compensação calórica foi de 42% para o café da manhã, não houve compensação no almoço e para o jantar, compensação variou de 0 a 22%, tendo interação com quartos de renda per capita. A conclusão desta dissertação é que as bebidas adoçadas não são completamente compensadas em refeições realizadas em ambiente pragmático. Assim, a redução do consumo de bebidas adoçadas em refeições pode ajudar a diminuir o consumo calórico excessivo e levar a um melhor controle do peso em indivíduos. / Over the past decades, an increase has been observed in the availability of beverages that are high in energy and rapidly absorbed sugar. These sugar-sweetened beverages, whose consumption has increased in Brazil as well as in other parts of the world, are considered risk factors for obesity and diabetes. The consumption of sugar-sweetened beverages can lead to positive energy balance and consequently to weight gain. This association can be explained by the compensatory regulation of liquid calories. Caloric compensation occurs when there is a reduction in the caloric consumption derived from solid food to compensate for the liquid calories added to the meal or diet. However, the evidence for a public health policy recommendation remains inconclusive. Among reasons for the lack of consensus are the diversity of study designs, experiments conducted in controlled environments that do not reflect the natural consumption of food and beverages, and the use of small or convenient samples. This dissertation studied the association between sugar-sweetened beverages and energy intake, analyzing if calories of sugar-sweetened beverages are compensated during meals in a pragmatic environment. The dietary data was obtained from the National Dietary Survey 2008-2009, which collected information on food consumption from 34,003 individuals, aged 10 years and older, from within the entire national territory. The participants completed two food records over non-consecutive days of the same week. The meals breakfast, lunch and dinner were identified for each individual on each of the days. For each meal, energy intake from food and sugar-sweetened beverages was measured. To test for caloric compensation, a multi-level mixed-effects linear regression model was adjusted for each meal type. The outcome variable was food energy intake and the explicative variable was energy from sugar-sweetened beverages during the meal. The intra-individual effects of the sugar-sweetened beverages on food energy intake were estimated and interpreted. These effects are considered unbiased because they are controlled by all stable characteristics of the subject, and thus the individual acts as his/her own control in the analysis. Covariates included in the model were the meal variables, such as location, day of the week, time of day, energy intake in the previous meal and time interval since the previous meal. And variables of the subject included sex, age group, BMI category and quartiles of per capita income. Random effects of subjects and of households were included in the model to better estimate the structure of errors within the correlated data. The caloric compensation was 42% for breakfast; there was no compensation for lunch; and for dinner, compensation ranged between 0 and 22%, with significant interaction with quartiles of per capita income. The conclusion of this dissertation is that sugar-sweetened beverages are not completely compensated in meals that take place in a pragmatic environment. Therefore, a reduction in the consumption of sugar-sweetened beverages in meals may help reduce excessive caloric consumption, leading to better weight control.

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / Fundação de Amparo à Pesquisa do Estado do Rio de Janeiro / Nas últimas décadas, tem sido observado o aumento da oferta de bebidas com elevado conteúdo calórico e com grandes quantidades de açúcar de rápida absorção. Essas bebidas adoçadas, cujo consumo tem aumentado no Brasil assim como em outras partes do mundo, são consideradas fatores de risco para obesidade e diabetes. O consumo de bebidas adoçadas pode levar ao balanço energético positivo e consequentemente ao ganho de peso. Essa associação pode ser explicada pelo mecanismo regulatório de compensação de calorias líquidas. Compensação calórica ocorre quando há redução no consumo de calorias provenientes de alimentos sólidos para compensar as calorias líquidas adicionadas à refeição ou dieta. No entanto, não há consenso em relação a evidências da compensação calórica, dificultando a elaboração de recomendações sobre essas bebidas em saúde pública. Razões para a falta de consenso incluem a diversidade de desenhos de estudos, experimentos realizados em ambientes controlados e não reais em relação ao consumo de alimentos e bebidas, e estudos com amostras pequenas ou de conveniência. Esta dissertação estudou a associação entre bebidas adoçadas e consumo calórico, verificando se calorias de bebidas adoçadas são compensadas em refeições realizadas em um ambiente pragmático. Os dados de consumo calórico de 34.003 indivíduos, com idade igual ou superior a dez anos, foram obtidos pelo Inquérito Nacional de Alimentação 2008-2009, em todo território nacional. Os participantes completaram dois registros alimentares, em dias não consecutivos da mesma semana. Foram selecionadas as refeições dos períodos café da manhã, almoço e jantar de cada indivíduo em cada um dos dias. Para cada refeição, foi calculado o valor calórico de alimentos e de bebidas adoçadas consumidos. Para testar a compensação calórica, um modelo de regressão linear multinível com efeitos mistos foi ajustado para analisar cada período. A variável reposta utilizada foi consumo calórico proveniente de alimentos e a variável explicativa foi consumo calórico de bebida adoçada na refeição. Os efeitos intra-indivíduo da bebida adoçada no consumo calórico foram estimados e interpretados. Esses efeitos são considerados não-enviesados pois são controlados pelas características constantes dos indivíduos, tendo assim o indivíduo atuando como seu próprio controle na análise. Covariadas incluídas no modelo foram variáveis da refeição: local, dia da semana, horário, consumo calórico na refeição anterior e intervalo de tempo desde a última refeição; e do indivíduo: sexo, faixa etária, categoria de Índice de Massa Corpórea e quartos de renda per capita. Efeitos aleatórios dos indivíduos e dos domicílios foram incluídos no modelo para melhor estimar a estrutura de erros de dados correlacionados. A compensação calórica foi de 42% para o café da manhã, não houve compensação no almoço e para o jantar, compensação variou de 0 a 22%, tendo interação com quartos de renda per capita. A conclusão desta dissertação é que as bebidas adoçadas não são completamente compensadas em refeições realizadas em ambiente pragmático. Assim, a redução do consumo de bebidas adoçadas em refeições pode ajudar a diminuir o consumo calórico excessivo e levar a um melhor controle do peso em indivíduos. / Over the past decades, an increase has been observed in the availability of beverages that are high in energy and rapidly absorbed sugar. These sugar-sweetened beverages, whose consumption has increased in Brazil as well as in other parts of the world, are considered risk factors for obesity and diabetes. The consumption of sugar-sweetened beverages can lead to positive energy balance and consequently to weight gain. This association can be explained by the compensatory regulation of liquid calories. Caloric compensation occurs when there is a reduction in the caloric consumption derived from solid food to compensate for the liquid calories added to the meal or diet. However, the evidence for a public health policy recommendation remains inconclusive. Among reasons for the lack of consensus are the diversity of study designs, experiments conducted in controlled environments that do not reflect the natural consumption of food and beverages, and the use of small or convenient samples. This dissertation studied the association between sugar-sweetened beverages and energy intake, analyzing if calories of sugar-sweetened beverages are compensated during meals in a pragmatic environment. The dietary data was obtained from the National Dietary Survey 2008-2009, which collected information on food consumption from 34,003 individuals, aged 10 years and older, from within the entire national territory. The participants completed two food records over non-consecutive days of the same week. The meals breakfast, lunch and dinner were identified for each individual on each of the days. For each meal, energy intake from food and sugar-sweetened beverages was measured. To test for caloric compensation, a multi-level mixed-effects linear regression model was adjusted for each meal type. The outcome variable was food energy intake and the explicative variable was energy from sugar-sweetened beverages during the meal. The intra-individual effects of the sugar-sweetened beverages on food energy intake were estimated and interpreted. These effects are considered unbiased because they are controlled by all stable characteristics of the subject, and thus the individual acts as his/her own control in the analysis. Covariates included in the model were the meal variables, such as location, day of the week, time of day, energy intake in the previous meal and time interval since the previous meal. And variables of the subject included sex, age group, BMI category and quartiles of per capita income. Random effects of subjects and of households were included in the model to better estimate the structure of errors within the correlated data. The caloric compensation was 42% for breakfast; there was no compensation for lunch; and for dinner, compensation ranged between 0 and 22%, with significant interaction with quartiles of per capita income. The conclusion of this dissertation is that sugar-sweetened beverages are not completely compensated in meals that take place in a pragmatic environment. Therefore, a reduction in the consumption of sugar-sweetened beverages in meals may help reduce excessive caloric consumption, leading to better weight control.

Submitted by Aline Batista (alinehb.ufpel@gmail.com) on 2018-05-24T12:28:55Z No. of bitstreams: 2 license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) Dissertacao_Bruna_Ribas.pdf: 3067129 bytes, checksum: b1562f9e78dc58c29b7b6d01f7bd6e5c (MD5) / Approved for entry into archive by Aline Batista (alinehb.ufpel@gmail.com) on 2018-05-24T13:55:48Z (GMT) No. of bitstreams: 2 license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) Dissertacao_Bruna_Ribas.pdf: 3067129 bytes, checksum: b1562f9e78dc58c29b7b6d01f7bd6e5c (MD5) / Approved for entry into archive by Aline Batista (alinehb.ufpel@gmail.com) on 2018-05-24T13:55:57Z (GMT) No. of bitstreams: 2 license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) Dissertacao_Bruna_Ribas.pdf: 3067129 bytes, checksum: b1562f9e78dc58c29b7b6d01f7bd6e5c (MD5) / Made available in DSpace on 2018-05-24T13:55:58Z (GMT). No. of bitstreams: 2 license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) Dissertacao_Bruna_Ribas.pdf: 3067129 bytes, checksum: b1562f9e78dc58c29b7b6d01f7bd6e5c (MD5) Previous issue date: 2017-07-31 / Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - CAPES / As doenças cardiovasculares são a principal causa de morte no Brasil e no mundo. Uma vez já ocorrido o desfecho clínico cardiovascular, a prevenção secundária é fundamental. O objetivo deste trabalho foi avaliar a adequação do consumo alimentar de vitaminas e minerais antioxidantes, e associar o consumo de bebidas açucaradas à variáveis antropométricas e bioquímicas em pacientes com aterosclerose manifesta participantes do projeto Dieta Cardioprotetora Brasileira. Para isso, realizou-se um estudo transversal aninhado a um ensaio clínico randomizado, com a utilização de dados secundários referente à primeira consulta de todos os pacientes incluídos no projeto. Foram coletados dados clínicos, antropométricos, bioquímicos e alimentares. A análise estatística foi realizada no programa GraphPad® Prism 5. A amostra foi composta por 2172 pacientes com doença aterosclerótica manifesta, sendo a maioria do sexo masculino (58,5%), idosa (63,6%), de nível econômico C (57,3%), com escolaridade fundamental (45,8%), sedentários (65,8%), com excesso de peso (62,7%) e com doença arterial coronariana tratada (69,0%). O consumo alimentar de vitaminas e minerais antioxidantes foi inadequado, com exceção da vitamina C que foi adequada em homens e em mulheres e do zinco em mulheres. O consumo de bebidas açucaradas foi associado a maiores valores de índice de massa corporal (p= 0,029), circunferência da cintura (p= 0,004) e triglicerídeos (p= 0,023). Esses resultados reforçam a necessidade de intervenção nutricional, especialmente sobre o consumo desses nutrientes e do desaconselhamento em relação ao consumo de bebidas açucaradas, a fim contribuir na prevenção de um novo evento cardiovascular. / Cardiovascular diseases are the leading cause of death in Brazil and worldwide. Once cardiovascular clinical outcome hás occurred, secondary prevention is fundamental in these patients. The objective of this study was to compare dietary intake of antioxidant vitamins and minerals with proposed daily intake recommendations and also to analyze possible associations between consumption of sugar-sweetened beverages and anthropometric and biochemical variables in patients with established atherosclerosis in Brazilian Cardioprotective Nutritional Program (BALANCE Program). A cross-sectional study was carried out with secondary data of a randomized clinical Trial referring to the first visit of all patients included in project. Clinical, anthropometric, biochemical and dietary variables were collected. Statistical analysis was performed in GraphPad® Prism 5. The sample consisted of 2,172 patients, most of them male (58.5%), elderly (63.6%) from C economic level (57.3%), with elementary school (45.8%), sedentary (65.8%), overweight (62.7%) and treated coronary artery disease (69.0%). The dietary intake of antioxidant vitamins and minerals has been inadequate, with the exception of vitamin C that has been adequate in men and women and zinc in women. The consumption of sugar-sweetened beverages was associated with higher values of body mass index (p = 0.029), waist circumference (p = 0.004) and triglycerides (p = 0.023). These results emphasize the need for nutritional intervention, especially on consumption of these nutrients and the advice to avoid consumption of sugar-sweetened beverages, in order to prevent occurrence of new cardiovascular event.

In recent time, several reports have been published about a more and more unhealthy population world wide, with increasing Body Mass Index (BMI) in welfare countries, such as Sweden. Diseases, such as obesity and diabetes, which is strongly connected to a high BMI, have increased and together with them also the medical expenses for society/state. Several initiatives have been started, in different countries, to tackle these problems and some have introduced a “sugar tax” on unhealthy products, like candy and soda, which has become a well- debated subject also in Sweden today. In this MBA master thesis, a literature study has been conducted with the goal of evaluating if an excise tax should be introduced in an efficient way on unhealthy sugar-sweetened beverages in Sweden. This case study is built on secondary data where reports and official statistics, from governments and health authorities/organizations, have been studied both for Sweden as well as from other countries. There has been a particular focus on Sweden's neighbouring countries Denmark and Finland, who has both experiences in the implementation of a “sugar tax”. Our theory is that introducing an excise tax on sugar-sweetened beverages will reduce the demand and consumption of these products, which will reduce welfare disease such as obesity and diabetes and yield a tax income for the state. However it is important to have in mind that the reduced consumption also will result in less tax income from the no longer sold goods, fewer personnel employed in the producing industries etc. The results showed that the overall sugar consumption actually has decreased in Sweden, as well as the overall consumption of sugar-sweetened beverages. However during the same time period the average calorie consumption and BMI has continued to increase resulting in a more unhealthy population that results in increased medical expenses. In conclusion an excise tax on sugar-sweetened beverages will not solve the welfare disease problems but may positively influence health. However it comes with a price also for the state from both gains and loss in tax incomes and increased administrations costs for managing the new tax. Finally it should be noted that since sugar-sweetened beverages are unhealthy products, which do not contribute to any positive health effects, sugar taxation might still be considered.