An Exploratory Qualitative Study of Beverage Sweetening Practices in Middle Eastern Families

Abstract

Over the last 30 years, there has been a continuing global shift in eating patterns and associated behaviors toward the consumption of foods and beverages rich in refined sugars in developed and undeveloped countries. The behavior of adding sugar to milk and other beverages has been observed as a major underlying factor in developing countries, including the Eastern Mediterranean Region. This qualitative study fills a knowledge gap by exploring the “adding sugar behavior” in primary caregivers and the underlying factors behind this common practice. In this study, a total of 26 in-depth interviews were conducted with the mothers, fathers and grandmothers of students from 4 public schools in Lebanon and thematically analyzed. The adding sugar behavior was common among the participants. Primary caregivers reported adding sugar to milk and to other beverages. Only a few primary caregivers stated that sugar was harmful and should be avoided. A common theme that emerged was that adding sugar to milk and beverages was a habit and a social norm within a locality. Findings of this innovative study in a Middle Eastern setting showed that the adding sugar behavior was influenced by specific personal and cultural behavioral factors. Strategies in future health behavior modification programs should include the children’s family and the behaviors and habits within the culture.

Contribution to Health Promotion

● Findings indicate that strong habits can undermine mothers’ intentions to cut sugar, highlighting a need for targeted health strategies.

● This research emphasizes the importance of culturally-sensitive health promotion strategies to support low-income Lebanese families in reducing their children’s sugar intake.

● These findings offer insights for developing interventions that address parental habits and empower them to make healthier choices for their children.

Introduction

Over the last 30 years, developing countries, including the Eastern Mediterranean region, have been experiencing a rapid nutritional transition in diet and lifestyle.^1,2 With this shift in food consumption to a more westernized diet, the Lebanese children and youth have strayed from the Mediterranean diet. ³

Previous studies have examined regional variations in sugar consumption, highlighting differences in dietary patterns and cultural practices. Research from North America and Europe often focuses on sugar intake through processed foods and sugar-sweetened beverages,^4,5 while studies in Asia have explored traditional dietary influences and emerging trends in sweet consumption.^6,7 In contrast, limited literature exists on sugar consumption behaviors within Middle Eastern households, particularly regarding the culturally embedded practice of adding sugar to milk and other beverages.

A review by Nasreddine et al ⁸ found that children (5-12 years) in several Eastern Mediterranean region countries were experiencing both malnutrition and obesity (11.5%-34.9% and 23%, respectively), as well as micronutrient deficiencies, ⁹ accompanied by an increased incidence of non-communicable diseases (NCD), such as diabetes, and metabolic syndrome (MetS). Birth through adolescence is a critical time when proper nutrition is vital for healthy growth and development, establishing a solid base for the prevention of early onset of these NCD diseases. ⁹

The adding sugar behavior (ASB) refers to the habitual or intentional act of incorporating sugar typically in the form of granulated white sugar, brown sugar, syrups (such as honey, maple syrup, or high-fructose corn syrup), or other sweetening agents into food or beverages. A child’s eating behavior is strongly influenced by family and social environments. ¹⁰ The characteristics of these environments include parents’ eating behaviors and child-feeding practices. Parents can encourage the development of healthy eating habits and thus healthy weight, or they may put their children at risk of obesity through unhealthy eating behaviors.^11,12 In a randomized controlled trial of 51 dyads, sugar-sweetened beverages (SSBs) and maternal weight were found to have a direct positive correlation to child obesity. Using mHealth technology targeting the mothers, a reduction of child SSBs/juice intake was noted in addition to the mother losing weight over 6 months. ¹³ Jomaa et al ¹ also documented high intake of free sugars by children in Lebanon, ranging from 43% of children under 5 years of age to 62% of school-aged children and adolescents ¹ thus exceeding the World Health Organization (WHO) upper limit of >10% energy intake/day. ¹⁴

The WHO, Non-governmental organizations (NGOs) and national programs have developed strategies to combat the growing concern of NCD.^14,15 To support these efforts, it is important to understand the underlying issues and root causes of the adding sugar behavior to better structure effective action. This paper addresses a novice research question regarding parents’ and grandparents’ views on adding sugar to beverages, particularly milk. This study explored the personal, cultural and environmental factors that may influence the adding sugar behavior to children’s beverages of Lebanese parents and grandparents whose children attend public schools. This paper highlights how parental habits influence the adding sugar behavior to children’s beverages.

Methods

Study Design

This qualitative exploratory investigation used semi-structured face-to-face interviews with caregivers of children attending a sample of public schools. Thematic content analysis of the interview transcripts was used to analyze the data. This study was reported based on the COREQ (Consolidated Criteria for Reporting Qualitative Research) checklist for comprehensive reporting of qualitative studies. ¹⁶ Participants included fathers, mothers, grandmothers, and grandfathers of students who were recruited from Lebanese public schools throughout Lebanon. Exclusion criteria were: parents of children over the age of 12 years or under the age of 9 years, attending private schools, and parents who did not report the practice of adding sugar to their children’s beverages during the screening phase.

Sampling Strategy

Participants were selected using purposive sampling techniques to identify various points of view toward the adding sugar behavior. ¹⁷ One public school was randomly selected from 4 regions: North, South, Beirut, and Mount Lebanon governorate (representing diverse religions and subcultures). We aimed to recruit 28 primary caregivers of children. Seven male and female students were randomly selected from each of the 4 schools, and their mothers, fathers, grandmothers, and grandfathers were contacted to be recruited. Two mothers of female students and 2 mothers of male students were interviewed, in addition to one father of a male or female student. Besides parents, 2 grandparents were selected randomly from each school. The average Interviews stopped when data saturation was achieved, and no new information was provided by participants. The appropriate level of data saturation was agreed upon by the researchers. ¹⁸

Ethical Approval and Recruitment

Approval of the study was obtained from the University Ethical Committee (HSCR12/91), United Kingdom. Additional approval was obtained from the Lebanese Ministry of Education and Higher Education (MEHE), Department of School Health Programs, which is the authoritative body that provided the initial consent to contact public schools in Lebanon. MEHE sent a copy of the study approval to all public schools to inform them about the study. Thereafter, the principal researcher met with the school principals and explained the study and its objectives. During these visits, the researcher asked for verbal approval from the principals to allow access to the sixth-grade student list, aged 11 years, and the contact information for their caregivers. Although parents were asked to consent in writing, MEHE allowed verbal consent from grandparents who were illiterate.

After the ethics permissions were granted, participants were contacted via telephone to explain the study’s purpose. Written informed consent for participation was obtained from those who expressed their interest. The consent form outlined the purpose of the study and information on risks and confidentiality.

After giving their consent, parents were invited for an interview. The interview’s date, time, and location were based on participant’s preferences and carried out in the participant’s natural setting (ie, at home), allowing the researcher to capture the social and cultural dynamics of the adding sugar behavior. Participants were informed by the researcher that they were inquiring only about granulated white sugar (table sugar), scientifically known as sucrose. During the interviews, the researcher presented participants with samples of table sugar and a teaspoon as a measuring tool. Table sugar is known as sucrose which is a disaccharide composed of 2 monosaccharides, glucose and fructose. ¹⁹ Sucrose’s water solubility and ease of crystallization properties made it suitable for table sugar production. ²⁰ The principal researcher, who received training on qualitative interviewing skills, conducted all the interviews over a 6-month period. The interviews were administered at home and in the Colloquial Arabic language by the researchers who were “native” to the country, to better interpret the intricacies of participants’ culture.

The sample targeted in this phase of the qualitative study was composed mainly of female caregivers. The small number of males recruited in this study was due to cultural sensitivity where mothers are the ones who usually take care of their children and oversee eating and drinking behaviors, while husbands are usually at work. In addition, there was no participation by any grandfathers due to either their unavailability, their living apart from their families who were residing in the city, or their refusal to participate in the study believing that the issue of the ASB was the responsibility of women.

Data Collection—Interview Topic Guide

Interviews were the method of choice because parents were able to provide information without the fear of being judged about their children’s diets. Moreover, interviewing is more appropriate in a society where it is very difficult to group men and women together due to cultural sensitivity from the different religions represented. Grandparents were included to assess whether adding sugar behavior was inherited from one generation to another. Moreover, interviewing parents and grandparents allowed triangulation to improve the validity of the qualitative research. ²¹

An interview topic guide (Supplemental material) was developed prior to conducting the in-depth interviews. Studies about the factors affecting children’s eating behaviors were mainly used to design the topic guide. ²² Probes about the following issues were discussed with the participants: children’s usual food choices and drinks, likes and dislikes, meal patterns and drink patterns, milk and hot beverage consumption, views about the adding sugar behavior, the role of peers and family, and how it influences this behavior. The researchers followed the refining stages of the topic guide mentioned by Krueger and Casey. ²³

The topic guide was pilot tested with 3 mothers residing in Beirut to check the clarity of the questions. Modifications were made based on the feedback of the participants. Subsequent pilot testing was undertaken with another 2 mothers to ensure modifications were clear. (Interviews lasted between 40 and 60 min and were 5), transcribed verbatim, and anonymized, and field notes were made throughout and utilized during the initial coding identification.

Data Analysis

Interview transcripts (originally in Arabic and transcribed verbatim) were translated to English by a certified translator. The researcher verified the accuracy and completeness of the translations by reviewing both versions. Thematic analysis was then conducted on the English transcripts, informed by repeated readings of both English and Arabic versions. ²⁴ Initial codes were developed by identifying frequent keywords, expressions, behaviors, and attitudes. Following coding and quote collation, the principal investigator identified 4 major themes by refining and combining the initial 31 codes.

Two researchers transcribed the interviews and read the transcripts several times to gain familiarity with the data. The 2 researchers resolved disagreements by discussion with a third author. Reliability between the 2 researchers was calculated by simple percentage agreement to measure consistency in coding. ²⁵ Independently, 3 researchers analyzed a sample of the transcripts (six) to confirm the generated beliefs and the codes which were generated from the belief statements. After that, the codes were categorized into overarching themes by the first author. Nvivo9 software was used to facilitate the retrieval of coded sections of transcripts. The themes were discussed and agreed upon by all researchers. The final analysis of 31 codes was conducted using the Arabic transcripts so as not to lose any thematic material.

Research Team and Reflexivity

To ensure credibility, interviewing researcher paid attention to adopt a non-judgmental position when conducting the interviews. She made sure that her position would not affect her interaction with the interviewees. Additionally, 2 researchers used a coding manual to code and analyze the interview responses, and the inter-rater reliability was calculated. One senior researcher monitored and reflected on the interview process and analysis to ensure that the analysis was always a true reflection of the data. To confirm transferability, the researchers described the findings and supported the descriptions with anonymous quotes from the interviews.^26,27

Results

A total of 26 caregivers of students in public schools were interviewed; 16 mothers, 8 grandmothers and 2 fathers. The study participants included mothers with an average age of 39.6 years, fathers averaging 42 years, and grandmothers, with an average age of 72.3 years. All participating families were classified as low-income, with only 15% of the total sample reporting very low average incomes. The mothers were primarily housewives (62.5% unemployed), 18.5% had temporary employment, and 19% were employed as janitors, nurses, or hairdressers. Most mothers completed 6 to 7 years of education, with one holding a technical nursing degree. The interviewed fathers (n = 2) were a 48-year-old driver with 5 years of education, and a 36-year-old shop worker with 7 years of education. The grandmothers (n = 8) were equally divided between being illiterate and had 6 years of education, and all had exclusively worked at home or on family farms, consistent with their generation and culture.

A total of 4 themes were identified, which included the thoughts that were evoked when parents and grandparents talked about the adding sugar behavior. Hereinafter, the “caregivers” are referred to as “participants.”

Theme 1: Social and Subjective Norms of Adding Sugar to Beverages at Home

The adding sugar behavior (ASB) by participants seemed to be applicable to most drinks children consumed, ranging from the addition of sugar to milk, juice, tea, and other herbal infusions (eg, anise, mixed herbs zhourat), as well as to water. Seven participants reported adding sugar to formula in baby bottles for infants during the first few months after birth.

My son drinks formula in the bottle; he drinks three times per day. I used to put a little amount of sugar in the bottle. (Mother, 50 years, intermediate, unemployed).

Nineteen participants stated that they did not add sugar to formula for newborns. Two reasons were mentioned: first, because it was not written on the formula container that sugar should be added; and second, because the formula they used already contained sugar.

But when the baby is first born and you are giving him baby formula, well you don’t add sugar to that. It has everything in it; it has nutrition, sugar. . . (Grandmother, 68 years old, primary, employed)

However, the participants’ adding sugar behavior changed when their children got older and started drinking formula in cups. There was a clear distinction between newborns and older children. Moreover, most participants talked about the acquired “sweet” taste among older children, who would ask for more sugar in their cup of milk made from powdered milk.

So at the age of one year and a half, I started to give my son cups of milk. . .When a child grows up he starts to distinguish between different tastes so he demands sugar. Now, I put one tablespoon of sugar with 3 tablespoons of powdered milk. (Mother, 35 years, Secondary, employed)

The addition of sugar to juices was also common among all participants.

Natural and fresh juice is the best kind. They don’t include any ingredient and I want my children to take it so adding table sugar makes it really tasty (Mother, 35 years, illiterate, employed)

Tea and anise were reported as highly consumed herbal infusions among children and newborns, respectively. Sugar was always added to tea, ranging for 1 teaspoon to several teaspoons per cup.

During breakfast and dinner at night, they drank tea. [. . .] yes they add sugar to tea, just one spoon per cup of tea. They like it in large amounts. (Grandmother, 64 years, illiterate, unemployed)

Anise with sugar was mainly given to newborns especially during episodes of uncontrollable crying, known as colic, as it seemed to be soothing and relaxing for babies.

For newborns we give them anise for colic and sleeping longer. But anise could not be taken without sugar. Of course we need to add many teaspoons of sugar to the anise. (Grandmother, 63 years, intermediate, employed)

Water with sugar was also observed. It was mainly given shortly after birth, especially to breastfed babies until breastmilk supply was adequate.

Yes, I used to give him water and sugar. You know when a child is first born, they give them a bottle of milk or water and sugar. This is relaxing and lets my child sleep well and deep. (Mother, 28 years, intermediate, unemployed)

Honey, molasses and other sweeteners were also reported to have been added to children’s drinks.

Only the eldest daughter, we used to put some honey with the formula and she would drink it, but the rest no. (Father, 58 years, primary, employed)

As early as 4 months, cereal was introduced to the formula. The brands of instant cereals mentioned by participants were already sweetened, to which some also added sugar.

For a small bottle, I would put three tablespoons of formula, and with it I would put one tablespoon of [instant cereal] which is better at making the baby full. I also add sugar to the bottle. (Mother, 35 years, illiterate, employed)

Four out of the 26 participants talked about the numerous benefits of honey and why they add it to milk. Honey was considered to be nourishing and full of vitamins, as well as relaxing.

I didn’t try to give him milk without honey because honey contains almost all the vitamins. (Father, 58 years, Primary, employed)

Theme 2: Socially Constructed Knowledge, Attitudes and Beliefs

Several perceptions of health benefits of sugar seemed to be developed by cultural influence. The idea that sugar was a highly nutritional and beneficial substance may have originated from the Lebanese culture. The participants affirmed that adding sugar to milk and other beverages for their children, was based on diverse beliefs about the health benefits of sugar.

One of the major perceived health benefits of consuming sugar is boosting energy, that is, consuming sugar provides children with the power to be more active. Indeed, one mother related the capacity of her child to function was due to the added sugar to his milk.

Milk is better if you add sugar to it. . . ., the kids become more alert and stronger, instead of being lazy and sleepy. That’s why you need to give them sugar. Milk and sugar are very healthy. (Grandmother, 68 years old, primary, employed)

Moreover, sugar mixed with water was considered a cure for jaundice in newborns.

I used to give him water with sugar when he had jaundice, my doctor told me to do so. He told me it decreases the jaundice. (Mother, 40 years, intermediate, unemployed)

Adding sugar was also associated with decreased irritability and bad temper. Mothers felt compelled to provide sugar to their children whenever they were agitated and restless to calm down and relax.

When your child is crying a lot, you just give him sugar. Then they feel full, sleep well and feel relaxed. (Mother, 35 years, intermediate, unemployed)

One participant mentioned that sugar relieves stomach aches.

Adding sugar to the milk bottles helps in reducing stomach ache for children that’s why I used to add sugar to their milk bottles and my kid’s health was fine. (Mother, 52 years, Intermediate, unemployed)

Doctors’ recommendations were also influential. Seven out of 24 participants (mothers and grandmothers) reported that they had consulted their physicians about adding sugar to milk and their physicians approved, without any objection. Some even recommended adding honey to milk, as a healthier alternative to sugar.

I told the doctor that I give milk with sugar to my children and honey as well. He said that it is ok. He told me that I can give them honey and I can add sugar but moderately since he is afraid of the effects of sugar as they get older. (Grandmother, 64 years, illiterate, unemployed)

A common reason that arose for not offering milk without sugar was the participants’ attitude and belief about the taste: the mothers did not like the taste of milk without sugar, so they assumed that their children would not like it either without sugar.

I think it is not possible that he drinks milk without sugar, but he never tried having milk without sugar. I used to add sugar to his milk, now he does that by himself. (Mother, 52 years, intermediate, unemployed)

When questioned about the harmful aspects of sugar, three-quarters of the participants firmly stated that sugar was not harmful, as ASB actually contributed to their good health. Ten participants believed that sugar was not harmful if used in moderation.

Sugar, like any substance, it’s needed. But every substance, if it’s used in excess it’s bad for you. But how is it possible that sugar is bad for him? Maybe, if he adds too much. The body doesn’t need too much sugar. But it needs some. . . (Father, 58 years, Primary, employed)

Sixteen participants never considered that sugar might be harmful, and were even surprised by the question, as adding sugar to beverages is the norm in their culture.

At our home, we drink fresh milk: we boil it very well and add sugar. We always add sugar in milk, yes, it is normal and it is a regular thing. Why you are even asking about [adding sugar], it is the way it should be. (Mother, 35 years, illiterate, unemployed)

Some participants stated that though sugar was harmful, they still added it to their children’s beverages.

Although we like it and I and my children add sugar to beverages, it has many disadvantages, and it is not healthy. It causes diabetes, high cholesterol and dental caries. (Mother, 35 years, illiterate, unemployed)

Theme 3: Ingrained Behaviors Across Generations

Many behaviors can be traced from one generation to the next such as ASB being inherited from grandparents to parents from the old habits in the region. ASB was mainly related to the beliefs that sugar is healthy and needed by the body (discussed under theme 2).

My mother told me to raise my children the same way I was raised. She told me to add sugar with milk and with Anise because it will satisfy the children. We have this habit because sugar makes them sleep more and nourishes them. (Grandmother, 78 years, illiterate, unemployed)

Furthermore, 23 out of 26 participants simply agreed that ASB is an inherited habit that they can hardly break free of, and that they did not even question it.

My dad does not put much sugar, just a little to give it taste; my mother-in-law adds half of a coffee cup of sugar. She used to cut the orange into halves and add sugar. I stayed with the parents of my husband and took from them this habit. (Mother, 50 years, intermediate, unemployed)

Grandparents perceived that using sugar and adding it to food is a very old custom in preparing meals, especially when formula was not available.

My mother breastfed us all. She didn’t use bottles. There wasn’t any formula. Sometimes there wouldn’t be any milk. So they’d make ‘Tineh’, white flour and sugar. They’d boil it and feed us. (Grandmother, 81 years, illiterate, unemployed)

Theme 4: Parenting and Sugar

The introduction of sugar was reported during the child’s first months.

My grandmothers, a long time ago, used to give the newborn one teaspoon of sugar to let him sleep for longer hours. (Mother, 53 years, intermediate, employed)

The practice of ASB also originated when mothers used to go to work leaving their baby sucking on a piece of Loukoum (gelatine-like sugary cubes covered with powdered sugar) wrapped in gauze to help them calm down and sleep well, before pacifiers were available.

Mothers used to go to the plantation of tobacco, they used to put their child in a small bed and give them a piece of sweets wrapped in a gauze and attached to the bed, the baby would spend hours sucking on it like a pacifier. He would sleep more, gain weight and become healthier. (Mother, 50 years, intermediate, unemployed)

Pacifiers were also dipped in a mixture of water and sugar, honey, or even dipped directly in sugar. A total of 14 out of the 26 participants reported immersing the pacifier in blossom water and sugar to increase its acceptability.

I used to immerse the pacifier in a cup of blossom water after adding sugar to it to enhance its acceptability. (Mother, 36 years, primary, unemployed)

At the age of about 6 months, parents and grandparents typically replace milk with sweetened biscuits smashed and soaked with fruit juice. Since many children stop drinking milk after being weaned off the bottle, mothers try to compensate lack of milk consumption with alternatives. For example, desserts made with milk, sugar, and mainly rice (Known as Mouhalabieh and Riz-bi-Halib) are often offered to toddlers. These desserts are considered an adequate alternative to compensate for the nutritional value of milk.

I do prepare rice with milk, pudding. [. . .] When they were young, I used to prepare custard and rice with milk. I replaced milk with sweets. (Grandmother, 75 years, illiterate, unemployed)

Discussion

This study is unique in providing an understanding of the origin of ASB in beverages by Lebanese primary caregivers. The study presented the views of parents and grandparents concerning this particular behavior against the canvas of a specific culture.

The 4 themes that were extracted from the transcripts were (1) Social and subjective norms describing ASB to milk and other beverages; (2) Socially constructed knowledge including the reasons and health benefits of adding sugar to beverages including milk; (3) Ingrained behaviors covering the tradition from grandparents to parents; and (4) The habits from parenting related to the introduction of sugary food items at different life stages and how the choice of food is left to children. ASB was common not only to milk but also to water, juices, tea, and other infusions.

Theme 1: Social and Subjective Norms of Adding Sugar to Beverages at Home

Adding sugar to formula prepared in cups was reported by the majority of parents, particularly when their children switched to drinking formula in cups. This early dietary exposure to sugar could shape food preferences through adulthood which can have adverse health effects. Individuals who had been introduced to added sugars at an earlier stage of life, tend to consume table foods with a higher content of added sugar and experience accelerated weight gain.^28,29 Kong et al ³⁰ found that added sugars from formulas comprised 66% of added sugars consumed daily by formula-fed infants and concluded that sugar in formulas predicted rapid weight gain in infants and toddlers. ³⁰ This is alarming because most of our participants reported ASB to formulas, which are typically high in sugar content.

Honey, molasses and instant cereal were also reported as sweeteners added to milk. The addition of cereal and sweeteners to formulas has been observed in other studies. Ellison et al ³¹ in their cross-sectional study in south eastern U.S. found that 25% of the mothers added cereal and corn syrup to the infant formula. ³¹ In a cross-sectional study by Brazil Without Poverty, the prevalence of introducing sugar as an inappropriate complementary feeding to infants before 4 months of age was 35.5%. ³²

After weaning, we found that sweetened instant cereals, sweetened biscuits mixed with fruit juice, and different traditional desserts were introduced to infants between the ages of 4 and 6 months. Mothers of children who stopped drinking milk, would make several desserts prepared with milk and sugar to compensate for the lack of milk consumption. Harris and Pomeranz, ³³ discussed the effects of marketing emerging formulas that are high in corn syrup solids or other caloric sweeteners in addition to high sodium levels, such as “toddler milk” or “growing up milk” could contribute to high caloric intake and unhealthy taste. ³³ Advertisements promoting such formulas use the terms easy and nutritious, thus enticing parents to use these products. Qazi et al ³⁴ surveyed 114 different baby foods in the Indian market. Their study showed that 28% of the products had >20% calories from sugar including dry baby foods, cereal, pureed desserts, and snacks. A total of 51% of the sampling listed sugar in the top 4 ingredients. ³⁴ Therefore, whether homemade baby deserts or purchased ready-made from stores, the amount of sugar consumed during the first year or 2 of life seems excessive.

Theme 2: Socially Constructed Knowledge, Attitudes and Beliefs

This theme pertains to socially accepted knowledge. Fischler ³⁵ explained that sugar was associated with medicinal preparations documented as far back as the 14th century. Historians collectively described the introduction of sugar as a 3-step phenomena: first as an expensive medicine, then as a food for invalids (those in poor health), and to being of growing importance in general cooking. ³⁵ Understanding this social history, similarly our participants reported that ASB to children’s beverages and foods has many nutritional benefits. In addition to being added to baby formula, sugar was also added with water and given to newborns to treat jaundice, regulate blood sugar, or to calm the baby until the milk supply was adequate. Sugar was also added to anise infusions for episodes of colic, and pacifiers were dipped in sugar to decrease irritability in infants. These actions can be linked back to the family and socially constructed knowledge. For example, participants told stories about their great grandmothers who used to go to work leaving their babies sucking on a piece of loukoum (a sweet and soft candy made with gelatine, sugar, water, and orange flavor) wrapped in gauze.

We also found that parents’ lack of knowledge regarding the harmful effects of adding sugars to children’s beverages and foods could affect their children’s eating behaviors. In a study by Heller et al, ³⁶ parents of low and non-low-income households were found to request information on healthy eating. Low-income households requested information on how to maintain a healthy but affordable diet, but those of higher income requested information on allergens, transitioning to solids, and creating structured mealtimes; however, all parents requested information on healthy complementary feeding. ³⁶

Theme 3: Ingrained Behaviors Across Generations

The complex interaction between innate, learned, and environmental factors greatly affects the development of children’s food preferences and eating patterns. Habits passed from generation to generation for feeding children sweet foods increase their preference for these foods. ³⁷ Exposure to foods is a process through which children learn to eat foods that adults present as “safe,” directing them neurobiologically and physiologically on how food “should” taste including the levels of sweetness and saltiness. Research has shown that children’s food preferences are more influenced by exposure than innate taste preferences. ¹⁰ Similarly, a preference for sweet taste was a major reason behind ASB to milk and other drinks by the caregiver, though they thought having a sweet tooth was passed on from one generation to another. Results in the current study showed that some mothers attributed the “sweet tooth” of the child to their food choices during pregnancy, based on what they were eating. This finding was supported by Goran et al ³⁸ and Boesveldt et al ³⁹ who reported that an infant’s first exposure to flavors begins in utero because whatever the mother eats during pregnancy is transmitted to her amniotic fluid, which in turn shapes the formation of food preference. It also contributes to the child’s metabolism, taste perception and obesity risk.^38,39 Furthermore, sweets are a tradition among Middle Eastern North African (MENA) populations, especially Arabs who are known for serving sweets during social events. Thus, a high intake of sugar is part of the cultural habits of the Eastern Mediterranean region. ⁴⁰

Theme 4: Parenting and Sugar

In addition to food preferences, the parents have a direct impact on shaping their child’s diet and eating habits, by acting as role models in demonstrating good eating habits. ¹² ASB was indeed attributed to inherited traditions and habits learned from grandparents and parents who added sugar to their own beverages. Our findings confirmed the significance of parental role modeling at home. The analysis of 24-h dietary recalls from children and adolescents in 2 U.S. national surveys found that 55% to 70% of all sugar-sweetened beverages calories were consumed at home as compared to 7% to 15% at school.^12,41

Our findings also showed that few mothers expressed regret about introducing sugar to their children and wished they tried to offer milk without sugar early on. Fazzino and Kong ¹⁰ found that infants are highly receptive to a wide range of flavors when exposed to diverse healthy foods during the early stages of complementary feeding (6-12 months). Their research further indicates that such early exposure is associated with healthier eating patterns at 4 to 6 years of age. It is evident that repeated taste exposure can either increase acceptance of healthy foods or the inclination toward unhealthy food choices. One mechanism of taste development is mere exposure to a certain food explaining the particular taste preferences in different cultures.^10,42,43

Our participants also reiterated the need to provide parents with better child-feeding modeling. This would initiate an impact on children’s preferences and food intake, thus may diminish the anxiety of parents, and help them modify the food environment in a way that increase the child’s acceptance of a wider range of foods and encourage healthier diets. ¹²

Limitations

The study has some limitations that must be acknowledged. The small sample size, the purposive sampling and participant selection method might limit the generalizability of the findings across different Middle Eastern populations. A key limitation of this study was the inability to perform member checking^44,45 due to practical constraints preventing participant re-contact for verification of their recorded or transcribed responses. This inability compromised a significant technique for ensuring data trustworthiness, credibility and methodological rigor. Specifically, tracing interviewees post-data collection proved infeasible, compounded by initial difficulties in contacting parents and grandparents, primarily due to the prevalence of cellular rather than landline phone numbers.

Recommendations for Future Research

Future research may address these limitations using a larger and more diverse sample across Middle Eastern countries to enable regional comparisons. Quantitative or mixed-methods approaches could also complement qualitative studies to strengthen generalizability. Longitudinal studies would be valuable in examining the long-term health consequences of regular sugar consumption in beverages, particularly its contribution to chronic conditions such as obesity and diabetes. Additionally, more focused investigations into family social environment and habits, including parenting styles and the role of extended family in shaping children’s dietary habits, are necessary. Moreover, future research should consider using focus groups with children to gain a deeper understanding of their beliefs and factors influencing their sugar-sweetened beverages intake. Further studies might also explore children’s genetic predisposition toward sweet tastes and how early food exposure, repetition, and modeling can affect their acceptance or rejection of beverages without added sugars. Importantly, interventions should equip parents with effective child-feeding strategies that support children’s taste development and reduce parental anxiety related to feeding and food refusal. Future research could investigate other types of sweeteners used by the target population to provide an overall assessment of sugar intake

Recommendations for Interventions to Reduce Sugar Intake

Findings inform the following recommendations to reduce sugar intake. Implement mandatory nutrition standards in public schools to guide eliminating sugary drinks. Engage children in age-appropriate programs that highlight the health risks of excess sugar to empower them to make healthier dietary choices. Implement culturally adapted and family-centered health behavior modification programs taking into consideration the collective norms, the broader social environment and cultural context in which ASB occur to influence change in dietary practices in Middle Eastern households.

Conclusion

The findings of this innovative study in a Middle Eastern setting showed that ASB was influenced by personal and cultural behavioral factors and highlights the need for further research to define and measure behavior of adding sugar to beverages in Middle Eastern families, particularly in under-represented regions. Given the health risks associated with addiction to unhealthy eating habits, we recommend incorporating awareness sessions for parents and students in school health programs in public schools. These sessions should highlight potential adverse health outcomes of adding sugars to beverages such as diabetes, obesity, and cancer particularly if these behaviors become ingrained. We also suggest that the Ministry of Higher Education and the Ministry of Public Health in Lebanon collaborate and communicate to the public our findings and recommendations to discourage the habit of adding sugars to beverages, especially among vulnerable children. Moreover, to contribute to global health efforts, we have shared our findings with the WHO.

Supplemental Material

sj-pdf-1-inq-10.1177_00469580251359507 – Supplemental material for An Exploratory Qualitative Study of Beverage Sweetening Practices in Middle Eastern Families

Supplemental material, sj-pdf-1-inq-10.1177_00469580251359507 for An Exploratory Qualitative Study of Beverage Sweetening Practices in Middle Eastern Families by Abir Abdel Rahman, Nada O. F. Kassem, Marc Edwards, Juliana Abboud and Bahia Abdallah in INQUIRY: The Journal of Health Care Organization, Provision, and Financing

Supplemental Material

sj-pdf-2-inq-10.1177_00469580251359507 – Supplemental material for An Exploratory Qualitative Study of Beverage Sweetening Practices in Middle Eastern Families

Supplemental material, sj-pdf-2-inq-10.1177_00469580251359507 for An Exploratory Qualitative Study of Beverage Sweetening Practices in Middle Eastern Families by Abir Abdel Rahman, Nada O. F. Kassem, Marc Edwards, Juliana Abboud and Bahia Abdallah in INQUIRY: The Journal of Health Care Organization, Provision, and Financing