Abstract
Objectives. We investigated how the removal of bottled water along with a minimum healthy beverage requirement affected the purchasing behavior, healthiness of beverage choices, and consumption of calories and added sugars of university campus consumers.
Methods. With shipment data as a proxy, we estimated bottled beverage consumption over 3 consecutive semesters: baseline (spring 2012), when a 30% healthy beverage ratio was enacted (fall 2012), and when bottled water was removed (spring 2013) at the University of Vermont. We assessed changes in number and type of beverages and per capita calories, total sugars, and added sugars shipped.
Results. Per capita shipments of bottles, calories, sugars, and added sugars increased significantly when bottled water was removed. Shipments of healthy beverages declined significantly, whereas shipments of less healthy beverages increased significantly. As bottled water sales dropped to zero, sales of sugar-free beverages and sugar-sweetened beverages increased.
Conclusions. The bottled water ban did not reduce the number of bottles entering the waste stream from the university campus, the ultimate goal of the ban. With the removal of bottled water, consumers increased their consumption of less healthy bottled beverages.
Bottled water has gained the public’s attention in recent years as towns and universities have banned the sale of bottled water to be more environmentally conscious. Americans use approximately 50 billion plastic bottles each year, 38 billion of which end up in landfills.1 Such bans are instigated to reduce the number of disposable bottles entering the waste stream by convincing consumers to start carrying reusable water bottles or to drink from water fountains instead of purchasing single-use plastic water bottles.1
More than 50 colleges and universities have banned the sale of bottled water,1 but little is known about the environmental and health impacts of such bans. According to independent research by the Beverage Marketing Corporation, approximately 73% of the growth in bottled water consumption in recent years has come from those who previously drank caloric drinks, such as soft drinks, juices, and milks.2 Another study by an International Bottled Water Association member company reported that on the basis of an Internet survey of 13 500 consumers, 63% would choose a sugar-sweetened bottled beverage rather than tap water if bottled water was removed from the beverage offerings.2 If these reports are accurate, banning bottled water could lead to an increase in consumers’ calorie and added sugar consumption.
Although the causes of excess weight gain are multivariate, there is growing evidence that added sugars, particularly added sugars from sugar-sweetened beverages (SSBs), are large contributors.3–5 Some studies have disputed the connection between SSB consumption and overweight, but the vast majority of research supports an association.6 A 20-ounce soft drink has nearly 17 teaspoons of added sugars, far exceeding the American Heart Association’s recommended limit of 6 teaspoons per day for women and 9 teaspoons per day for men.7 According to National Health and Nutrition Examination Survey data, soft drinks alone are the number 1 single source of calories in the US diet and total SSB consumption contributes 46.2% of the added sugars in the US diet.8,9
Ludwig et al. noted that among 548 schoolchildren, for each additional 12-ounce serving of a SSB, the odds of becoming obese increased by 1.6, whereas the increased consumption of diet soda decreased the incidence of obesity.4 Other intervention studies have tried to combat obesity by changing children’s beverage environment. In intervention studies, de Ruyter et al. and Ebbeling et al. found that limiting the consumption of SSBs by providing only bottled water or low-calorie beverages reduced the body mass index (defined as weight in kilograms divided by the square of height in meters), skin-fold thickness, and fat mass of children and adolescents compared with a control group with no intervention.3,10 Although such studies show promising results when SSBs are replaced with low-calorie options, research on the effects of removing bottled water from beverage offerings is limited.3,10
We examined how the removal of bottled water on a university campus, along with the implementation of a minimum healthy beverage requirement, affected how many bottled beverages consumers purchased, the healthiness of their beverage choices, and their calorie, total sugar, and added sugar consumption.
METHODS
Policy changes related to the types of bottled beverages sold at the University of Vermont in Burlington, Vermont, provided an opportunity to study how changes in beverage offerings affected the beverage choices as well as the calorie and total and added sugar consumption of consumers. First, in August 2012, all campus locations selling bottled beverages were required to provide a 30% healthy beverage ratio in accordance with the Alliance for a Healthier Generation’s beverage guidelines.11 Then, in January 2013, campus sales locations were required to remove bottled water while still maintaining the required 30% healthy beverage ratio.
We used beverage shipment data as a proxy for calorie, total sugar, and added sugar consumption under the assumption that the university ordered only drinks that consumers were buying and people on campus purchased only beverages that they intended to consume. We collected shipment data for all bottled beverages sold to the university from the 9 beverage vendors who had contracts with the university’s food service management company 1 semester before any changes were enacted (spring 2012), the semester when beverage offerings were changed to 30% healthy beverages (fall 2012), and the semester when bottled water was removed from the beverage offerings while maintaining the 30% healthy beverage ratio (spring 2013).
We used the shipment data to create a database of all beverages shipped to campus during the 3 semesters. We combined the nutrition information for each beverage with the shipment data to determine changes in beverage choices as well as calorie, total sugar, and added sugar consumption over the 3 semesters.
We scored beverages on the basis of their nutrition information using the Nutrition Environment Measures Survey-Vending (NEMS-V) calculator, an online tool used to calculate the healthiness of beverages.12 We categorized beverages into 1 of 3 NEMS-V categories. Green beverages, which can be consumed regularly, included water without flavoring, additives, or carbonation, low-fat (1%) and nonfat (skim) milk (in 8 oz. portions), lactose-free and soy beverages, flavored milk with no more than 22 grams of total sugars per 8-ounce portion, and 100% fruit or low-sodium vegetable juice in 8-ounce containers. Yellow beverages, which can be consumed in moderation, include nonfortified low-sodium beverages with less than 5 calories per portion as packaged (with or without nonnutritive sweeteners, carbonation, or flavoring). Red beverages, which should be limited or exchanged for healthier options, include all beverages that do not fall in the green or yellow category.12
We organized beverages into beverage categories with similar characteristics, calories, and added sugar content, which we used to assess how consumer beverage choices changed over the 3 semesters. These categories included 100% juice, sugar-free drinks (≤ 10 kcal/8 oz), low-calorie drinks (11–50 kcal/8 oz), SSBs (> 50 kcal/8 oz), milk and protein drinks, and plain water.
We focused on campus consumers’ consumption of single-serving bottled beverages. We did not consider beverages with more than 34 ounces per container to be single-serving beverages, and we therefore excluded them from the study. We considered measuring fountain drinks and hot tea and coffee beyond the scope of this study because they were not bottled beverages, but ended up excluding them. These exclusions made the study results conservative estimates of the liquid calories and sugars being consumed by the university population.
We conducted statistical analyses using SPSS, version 22, predictive analytics software (SPSS, Inc., Chicago, IL). We set significance at P < .05 and considered P < .1 a trend. We used the χ2 test to compare the percentage of beverages shipped to campus with a green, yellow, and red NEMS-V rating over the 3 semesters. We also used the χ2 test to compare the percentages of beverages from different beverage categories shipped to campus over the 3 semesters. We then compared shipments of beverages within each NEMS-V rating and beverage category using a repeated measures analysis of variance using linear mixed models to determine if there was a significant overall change in consumers’ beverage choices when the 30% healthy beverage ratio was enacted and when bottled water was removed. We used location as the subject (n = 8 campus locations), NEMS-V rating or beverage category as the between subject effect, and semester as the repeated measure.
We divided the calories and total and added sugars of beverages shipped to campus for each semester by the campus population to determine the average per capita consumption of calories and total and added sugars from bottled beverages. The campus population included the total number of students, faculty, and staff present on campus during each semester (spring 2012: n = 16 582; fall 2012: n = 16 968; spring 2013: n = 16 220). We also compared the per capita results with a repeated measures analysis of variance using linear mixed models. When significant changes were indicated, we conducted the paired t test on single beverage categories and NEMS-V grades over the 3 periods to test for significant variation.
RESULTS
Per capita shipments of bottled beverages did not change significantly between spring 2012 and spring 2013 (P = .71) but did increase significantly from 21.8 bottles per person in fall 2012 to 26.3 bottles per person in spring 2013 (P = .03; Table 1). Calories, total sugars, and added sugars shipped per capita also increased significantly between fall 2012 and spring 2013, as shown in Table 1 (P = .02, P = .02, and P = .03, respectively). Calories per bottle shipped increased significantly over the 3 semesters by an average of 8.76 calories per bottle each semester (P < .001).
TABLE 1—
Changes in the Number of Bottles, Calories, Total Sugars, and Added Sugars Shipped per Capita to 8 Campus Locations Over 3 Semesters: University of Vermont, 2012–2013
| Variable | Spring 2012 | Fall 2012 | Spring 2013 |
| Bottles | 24.21a,b | 21.82a | 26.27b |
| Calories, kcal | 3248.91a | 3106.19a | 3957.93b |
| Total sugars, g | 714.11a | 675.77a | 863.97b |
| Added sugars, g | 528.45a | 492.26a | 638.12b |
Note. In spring 2012 the baseline campus population = 16 582. In fall 2012, when the minimum healthy beverage requirement was enacted, campus population = 16 968. In spring 2013, when bottled water was banned, the campus population = 16 220. Values in a row with different superscripts were significantly different (P < .05).
The comparison of beverages with NEMS-V grades of green, yellow, and red across the 3 semesters showed a significant decrease in the percentage of green beverages shipped to campus over the 3 semesters (P < .001; Table 2). Green beverages fell 6.6% between spring 2012 and fall 2012 (P = .007) and an additional 6.3% between fall 2012 and spring 2013 (P = .009), with an overall decrease of 12.9% between spring 2012 and spring 2013 (P < .001). The decrease in green beverages was accompanied by a significant increase in red beverages across the 3 semesters (P < .001). Red beverages shipped to campus increased 3.5% between spring 2012 and fall 2012 (P = .03), 5.0% between fall 2012 and spring 2013 (P = .004), and 8.5% between spring 2012 and spring 2013 (P < .001). There were no significant changes in the percentage of yellow beverages across semesters, although there was a trend of increased shipments of yellow beverages (P = .051). A significantly higher percentage of red beverages than yellow and green beverages were shipped to campus in all 3 semesters (P < .001), and in spring 2013 there was a significantly higher percentage of yellow beverages shipped to campus than green beverages (P < .001).
TABLE 2—
Change in the Percentage of Beverages Shipped by Nutrition Environment Measures Survey-Vending Rating to 8 Campus Locations Across 3 Semesters: University of Vermont, 2012–2013
| Beverage | Spring 2012, % | Fall 2012, % | Spring 2013, % |
| Green (consume regularly) | 23.52a | 16.92b | 10.58c |
| Yellow (consume in moderation) | 19.28a | 22.37a | 23.73a |
| Red (limit or exchange for healthier options) | 57.20a | 60.71b | 65.69c |
Note. In spring 2012 the baseline campus population = 16 582. In fall 2012, when the minimum healthy beverage requirement was enacted, campus population = 16 968. In spring 2013, when bottled water was banned, the campus population = 16 220. Values in a row with different superscripts were significantly different (P < .05).
We compared the percentage of beverages shipped each semester across beverage categories (Table 3). The percentage of sugar-free beverages (≤ 10 kcal/8 oz) shipped was significantly higher in spring 2013 than in both fall 2012 and spring 2012 (P = .01 and P = .008, respectively). There was a decrease in the percentage of low-calorie beverages (11–50 kcal/8 oz) between spring 2012 and fall 2012 (P = .006), with no significant differences between spring 2013 and either spring 2012 or fall 2012. SSBs (≥ 50 kcal/8 oz) trended toward an increase as a percentage of total beverages shipped between spring 2012 and fall 2012 (P = .09) and significantly increased between spring 2012 and spring 2013 (P = .03).
TABLE 3—
Percentage of Beverages Shipped by Drink Category to 8 Campus Locations Across 3 Semesters: University of Vermont, 2012–2013
| Beverage | Spring 2012, % | Fall 2012, % | Spring 2013, % |
| 100% juice | 15.3a | 13.6a | 15.1a |
| Sugar free (≤ 10 kcal/8 oz) | 11.9a | 14.5a | 21.2b |
| Low calorie (≤ 50 kcal/8 oz) | 11.2a | 8.4b | 9.4a,b |
| Sugar sweetened (> 50 kcal/8 oz) | 28.2a | 32.2a,b | 35.3b |
| Milk and protein drinks | 17.3a | 20.6a | 20.2a |
| Water | 17.6a | 13.2a | 0.0b |
Note. In spring 2012 the baseline campus population = 16 582. In fall 2012, when the minimum healthy beverage requirement was enacted, campus population = 16 968. In spring 2013, when bottled water was banned, the campus population = 16 220. Percentages in a row with different superscripts were significantly different (P < .05).
The percentage of water shipped to campus decreased significantly from 17.6% of total shipments to 13.2% between spring 2012 and fall 2012 (P = .04) and dropped to zero with the bottled water ban in spring 2013. As Figure 1 shows, the increase in sugar-free drinks and SSBs closely matched the decline in bottled water consumption. Compared with baseline (spring 2012), bottled water shipments as a percentage of total shipments fell 5.2% in fall 2012 and 18.4% in spring 2013, whereas sugar-free beverage and SSB shipments increased 5.9% in fall 2012 and 15.7% in spring 2013.
FIGURE 1—
Change in the percentage of beverages shipped by drink category over 3 semesters: University of Vermont, 2012–2013.
Note. In spring 2012 the baseline campus population = 16 582. In fall 2012, when the minimum healthy beverage requirement was enacted, campus population = 16 968. In spring 2013, when bottled water was banned, the campus population = 16 220.
The number of bottles of water with flavoring or carbonation, which were still permitted to be sold following the bottled water ban, increased significantly in spring 2013 compared with spring 2012 (P = .002). In spring 2012, 3033 bottles of seltzer (flavored and carbonated water) and flavored noncarbonated water were shipped to campus. In fall 2012 the number fell to 2652. Then, in spring 2013, 16 824 bottles of seltzer and flavored water were shipped to campus.
DISCUSSION
The number of bottles per capita shipped to the university campus did not change significantly between spring 2012 (baseline) and fall 2012, when the minimum healthy beverage requirement was put in place. However, between fall 2012 and spring 2013, when bottled water was banned, the per capita number of bottles shipped to campus increased significantly. Thus, the bottled water ban did not reduce the number of bottles entering the waste stream from the university campus, which was the ultimate goal of the ban. Furthermore, with the removal of bottled water, people in the university community increased their consumption of other, less healthy bottled beverages.
The significant decrease in the percentage of beverages shipped to campus that received a green (healthy) NEMS-V rating and the significant increase in beverages receiving a red (unhealthy) NEMS-V rating when bottled water was removed in spring 2013 as well as the increase in calories per bottle suggest that consumers not only continued to buy bottled beverages but also made less healthy beverage choices after the ban was in place.
The comparison of the percentage of bottles shipped by beverage category helps to explain the changes in NEMS-V grades. As the shipments of water decreased to zero, most of the beverage categories remained relatively constant as a percentage of total shipments. However, the percentage of sugar-free beverages and SSBs increased, closely matching the decrease in water. This, paired with the finding that overall shipments increased each semester, suggests that many consumers who previously drank bottled water replaced bottled water with sugar-free or sugar-sweetened bottled beverages (Figure 1).
Ideally, when bottled water was removed, those who previously purchased bottled water would have adjusted their behavior and started carrying reusable water bottles. The university made several efforts to encourage consumers to carry reusable beverage containers. Sixty-eight water fountains on campus were retrofitted with spouts to fill reusable bottles, educational campaigns were used to inform consumers about the changes in policy, and free reusable bottles and stickers promoting the use of reusable bottles were given out at campus events. Although these efforts may have influenced some consumers, the ban does not appear to have achieved its goal of decreasing the number of plastic bottles entering the waste stream from the university campus.
Because it appears that many bottled water consumers instead decided to purchase other bottled beverages, the best result, nutritionally, would have been for them to select calorie- and sugar-free options, such as seltzer, unsweetened tea, or diet soda. However, the data suggest that some consumers increased their consumption of calorically sweetened drinks, such as soda and sports drinks, which could add to their liquid calorie and added sugars consumption, thus increasing the risk of weight gain.
Our findings are consistent with those in the literature, which has shown that consumption of calories from beverages, especially SSBs, has increased incrementally over the past several decades. Research also suggests that people of college age (19–39 years) have the highest consumption of bottled beverages among all age groups.13–15 The removal of bottled water seems to magnify the undesirable beverage consumption patterns observed in the literature and may influence people to select less healthy beverage options.
Our study was limited by the short duration of data collection. Having additional data from both before and after the campus beverage options changed would be advantageous. Additional data from before the ban would help determine whether the incremental increase in bottled beverage consumption occurred only as beverage policies changed or whether consumption was increasing before the changes took place. Data from semesters after spring 2013 could show whether consumers changed their behaviors and began carrying reusable water bottles over time as the bottled water ban was in place longer.
Our study was also limited by the small number of campus locations where beverages were shipped (n = 8), thus limiting the statistical power of the analysis. However, despite the limited power, significant associations were apparent. Additionally, the necessity of using shipment data as a proxy for consumption may have resulted in an overestimation of the actual calories and total and added sugars consumed.
A further limitation was the dependence on beverage companies for shipment records, which could have led to inconsistent data. To address this limitation, we compared trends in the data across locations to identify possible gaps in sales records. When we identified missing data, we made every effort to obtain complete records from the beverage companies. Furthermore, because of the observational nature of the research, no causalities can be drawn between the removal of bottled water and the increase in unhealthy beverage consumption or in calorie and added sugar consumption, although associations exist.
Despite these limitations, the study has many strengths. We collected data on more than 1 million bottles that were shipped to campus over the 3 semesters. The number of bottles shipped to campus increased over the 3 semesters across all beverage companies, suggesting that the increases were meaningful and not merely anomalies. In addition, we collected data on all shipments to all campus beverage sale locations for the 3 semesters, allowing a complete picture of the changes occurring on campus during the bottled water ban.
Further research is needed on the long-term implications of removing bottled water for the health status of consumers to better understand whether consumers adjust their behavior over time to make healthier beverage choices. Remembering to carry a reusable water bottle, like any other behavior change, takes time. Therefore, long-term observations may reveal that the potential negative impact of banning bottled water on health is merely a short-term setback.
Our study raises questions about the overall bottled beverage consumption patterns of the university community. Our findings suggest that per capita consumption of bottled beverages, and especially SSBs, increased over time. If this trend continues over the long term it may have negative implications for the health and weight status of the campus community. Additional research should be conducted in other communities because both the young age of the university community and the location in Burlington, Vermont, a midsized city that is notoriously invested in both environmental and physical well-being, may have affected the beverage choices of consumers.
Acknowledgments
Funding was provided by the University of Vermont Summer Research Award Fund and the Bickford Scholar Research Fund.
The authors would like to thank Caylin A. McKee for her assistance with data collection and Alan B. Howard, MS, for his assistance with the statistical analysis.
Human Participant Protection
This project was determined to be exempt from University of Vermont institutional review board review because the project did not involve human participants.
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