The Urban Adolescents’ Perception on Sugar-sweetened Beverages

and Food Label: A Photovoice Study

Imas Arumsari

, Imawati Eka Putri

, Wengki Ariando

and Sarah Handayani

Nutrition Study Program, Universitas Muhammadiyah Prof. DR. Hamka, Indonesia

International Program of Environment Development and Sustainability, Graduate School, Chulalongkorn University,

Thailand

Public Health Study Program, Universitas Muhammadiyah Prof. DR. Hamka, Indonesia

Keywords: Adolescents, Food label, Sugar-sweetened beverages

Abstract: The trend of sugar-sweetened beverage (SSB) consumption in Indonesia has been increased in the past decade

from 253 million litres to 780 million litres a year. High sugar diet has been linked to the increased risk of

diabetes mellitus via the lack of regulation on hepatic uptake. Adolescents are the most prone to risk of high

consumption of SSB because of the affordability, influence of marketing, and influence from peers. The

affordability of SSB is also often related to the less awareness to read the food label (nutritional label and

halal label) in the package. Therefore, this study aimed to explore perceptions of adolescents in Jakarta,

Indonesia about SSB and food label by using Photovoice method. The Photovoice study involved five

adolescents (three males, two females) recruited from Muhammadiyah 11 Jakarta High School, Indonesia to

participate in two sessions of Focus Group Discussion (FGD) conducted between May – June 2021. The

transcripts from FGDs were analysed using SHOWeD methodology approach sorted by the perception on

SSB consumption and food label (nutritional and halal label). Participants reported that peer group influence

their decision to purchase SSB. Moreover, price, location, and brand also define the consideration to choose

certain products. Participants rarely read the food label as it is considered as time-consuming activity even

though they knew that it is important. Halal label also not become a priority on choosing product, mostly

because of the brand trust and the safe feeling as they are living in a Muslim majority country.

1 INTRODUCTION

Non-communicable diseases (NCD), including

coronary heart disease, cancer, diabetes mellitus, and

chronic pulmonary disease, has been contributed to

70% death worldwide (World Health Organization,

2018). Aside from its contribution to the premature

death, NCD also related with the economic burden,

both in developing and developed countries.

One of the NCD risk factors is obesity, which

induced by high consumption of sugar. High sugar

diet increases the risk of obesity and type II diabetes

(MacDonald, 2016, Savona, 2018). A longitudinal

study showed that high sugar-sweetened beverage

(SSB) consumption is linked to high waist-to-hip

ratio (Hodge et al., 2018). The direct mechanisms

explained by the abnormal regulation of hepatic

uptake and fructose metabolism which eventually

leads to the accumulation of body fat content,

dyslipidemia, low insulin sensitivity, and increased

level of uric acid. Increase of body weight and body

fat percentage from high consumption of sugar is

related to the lack regulation of leptin (Stanhope,

2016).

The trend of SSB consumption in Indonesia

increased sharply from 51 million litres in 1996 to

253 million litres in 2014 (Ardiansyah, 2017). The

high purchase of SSB is possibly related to

affordability of SSB products and the sweet taste

which is mostly preferrable in all age group,

particularly adolescents. In Indonesia, Adolescents

(10 – 17 y.o) are age groups that consume SSB in the

highest proportion compared to other age groups

(Laksmi et al., 2018). The high consumption of SSB

among adolescents is more likely related with obesity

and becoming concern as it might increase the risk to

develop NCD when they become adult.

The awareness to control SSB consumption is in

line with the awareness to read food label, which also

consists of nutrition and halal label. The araweness to

Arumsari, I., Putri, I., Ariando, W. and Handayani, S.

The Urban Adolescents’ Perception on Sugar-sweetened Beverages and Food Label: A Photovoice Study.

DOI: 10.5220/0010757300003235

In Proceedings of the 3rd International Conference on Social Determinants of Health (ICSDH 2021), pages 27-34

ISBN: 978-989-758-542-5

read food label, is a higher step on the effort to limit

or increase certain nutrient consumption based on

daily needs. However, the overloaded activity in

urban daily routine might limit time and effort to read

the details on food label, more spesifically, the halal

label for Muslim.

There are several strategies to control SSB

consumption, for example to control SSB price, Sugar

Tax is implemented in several countries and proven

that it could effectively control SSB consumption

(Phulkerd et al., 2020). Another strategy is on

modification of lifestye by developing functional

foods as an alternative to choose healthier products

(Sofyaningsih and Arumsari, 2021). School-based

health promotion also designed to promote healthy

lifestyle and balanced nutrient intake (Arumsari and

Putri, 2021, Fitriani et al., 2020).

Different strategies to control SSB consumption,

from education to policy implementation, might

results in different perception on SSB among

adolescents. Built mindset about SSB consumption as

the results from different controlling strategies in

certain location or country shaped the perception and

behavior to consume SSB. Therefore, this study

aimed to explore perception of adolescents in Jakarta,

Indonesia about SSB and food label (nutrition label

and halal label).

2 METHODS

This research used the photovoice method as a

qualitative study. Photovoice is a community-based

participatory study which allow the participants to

identify and represent the community’s opinion about

certain topic by using photography technique

(Catalani and Minkler, 2010). There were three

aspects explored in this research which are

adolescents’ perception about sugar-sweetened

beverage (SSB) consumption, food label, and halal

label.

Five student representatives consist of three

males and two females from Muhammadiyah 11

Jakarta High School, Indonesia. Random sampling

was implied in selecting the number of participants.

Also, there were gender proportional number

consideration in random sampling method. The

research inclusion criteria for participants and teacher

intervention selected 2

grade students as suitable

participants due to time availability and limited

research. The Focus Group Discussion (FGD) was

conducted in total two sessions during May – June

2021. Due to COVID-19 restriction, FGD was done

online via Zoom platform.

The first FGD was designed with following

agendas: (1) explanation of Photovoice study, (2) pre-

test, and (3) brainstorming of photo themes. In this

FGD session, researchers explained the research

questions and discussed with participants about

related photo topics that could answer those

questions. The participants were assigned to list the

type of camera that they would be used to present the

photos. The informants were given two weeks to

collect three to five photos for each research question

individually. The number of photo submitted was

considered by previous study (Streng et al., 2004).

The second FGD was conducted two weeks after

the first meeting. The agenda was discussion the

photos obtained, presentation of nutrition and food

label information, and post-test. The discussion of

photos was obtained with SHOWeD methodology

approach. SHOWed methodology is a discussion

approach used in Photovoice studies that has been

validated to explore the response on photograph and

bridge the discussion into community action

(Catalani and Minkler, 2010). There are six questions

in this methodology as follows:

1. What do you see here?

2. What is really happening here?

3. How does this relate to our lives?

4. Why does this concern/situation/strength

exist?

5. How can we become empowered through

our new understanding?

6. What can we do about it?

Photovoice study is a participatory study which

also encourage the community to empower

themselves with knowledge and problems

identification basis. Therefore, at the end of FGD

sessions, researchers explored informants’ opinion

about how to disseminate the information they gained

through two sessions of FGD to their friends,

teachers, and school community. The pre- and post-

test were implied in this method aiming to see the

participant understanding about the topic.

The transcripts from FGDs were analysed using

the SHOWeD methodology approach sorted by the

perception on SSB consumption and food label

(nutritional and halal label). Data from pre- and post-

test of nutrition knowledge were also analysed to

complement the results from Photovoice study. The

final data was presented in descriptive and narrative

writing style.

ICSDH 2021 - International Conference on Social Determinants of Health

2.1 Ethical Clearance

The ethical clearance was obtained from Ethical

Committee for Health Research, University of

Muhamadiyah Prof. DR. Hamka. Informed consent

was explained to the informants prior to the FGD

processes.

3 RESULTS

All participants are 2

grade students of

Muhammadiyah 11 Jakarta High School, Indonesia,

three males and two females were participated in this

study. The average of age was 17.5 years which

define as early adolescent group of age. The results

are presented based on the objective per FGD session,

the first session aimed to brainstorm photo theme to

answer the research question: the perception on

sugar-sweetened beverage (SSB), the perception on

food label, and the perception on halal label. Second

FGD session aimed to explore participants’

perception related to those research questions.

3.1 Results of Pre- and Post-test

Pre-test was conducted in the beginning of the study

and post-test at the end of the study. The design of

questions followed the general information about

SSB, food and halal label. It could describe how the

young age group understanding about those three

discussions. The results reported that there is no

increase on the total score from pre-test (mean= 58)

and post-test (mean= 58). This research argued that

the perception and understanding of young people is

average. However, we could notice the increase of

score in some item of question as shown in table 1.

Table 1: Breakdown of pre- and post-test results by item of

question

Question

Number

of true

answer

in pre -

test

Number

of true

answer

in post-

test

Limit of daily added sugar

consumption is 40 grams/3

tablespoon

1 1

Excess sugar consumption

causes obesit

5 5

Halal logo from LPPOM MUI

could be freely drawn by the

manufacture

1 3

The first thing that need to be

noticed in food label is the

serving size

2 3

Carbohydrate content interprets

the content of sodiu

5 4

Halal logo from LPPOM MUI

should be

resented in

reen

3 2

Child obesit

cause adult obesit

5 4

Adolescents drink SSB the most

amon

other a

rou

4 5

Vitamin A consumption should

e limited to prevent obesit

3 3

AKG stands for Asosiasi

Keluarga Gizi

1 1

The results demonstrated that number of true

answers were increased in about several topics:

regulation of halal label claim in Indonesia, important

steps on reading the food label, and trend of SSB

consumption among adolescents. The decrease of

score on questions about the role of nutrient and

health issues also could be taken into account. Even

though this participatory study is potential to increase

the awareness on SSB and food label, the low score

on nutrient-related content suggested that nutrition

education is still needed in this population.

3.2 Brainstorming of Photo Themes

During the session, researchers asked what photo

themes matched with the research questions. Samples

of photo were provided to start the discussion during

brainstorming.

Participants viewed that to answer research

question about the perception on SSB, they should

take photos about SSB purchase in shops, role of

technology in SSB purchase, role of public figure and

SSB consumption, and the role of price, promotion,

and discount. Themes to answer perception of

nutrition are food label in food and drink, nutrition

label, ingredients and other labels. Perception of food

The Urban Adolescents’ Perception on Sugar-sweetened Beverages and Food Label: A Photovoice Study

label includes different types of halal label, halal label

from imported foods, halal label in restaurant, and

halal label in non-food products.

3.3 The Perception on Sugar-

Sweetened Beverages (SSB)

Participants defined SSB as coloured drink products

with sugar content. Participants viewed that

nowadays coffee identic with SSB. It means that they

mainstreamed the SSB and coffee due to

overexposure with the coffee products in every

merchant they visit. The participants state that coffee

is always deserved with SSB as revealed in many

coffee shops presently. Adding more, these group of

young people preserve that drinking coffee must be

added with sugar or milk. They enjoy coffee as a

lifestyle, not as coffee connoisseurs with all the

philosophies behind it. As adolescents, participants

expressed that desire to order SSB depends on timing

and mood. Furthermore, brand becomes a

consideration when choosing SSB product.

Part of them also reported that they frequently

order SSB by ojek online service. With the current

updates in technology, it makes them easier to access

SSB product. They can easily order the product by

online and the product will reach them shortly. It

becomes more convenience and help them with daily

business. Online service also helped them to buy the

desired product in the restriction period during

COVID-19.

Figure 1: An ojek driver get online order of SSB

Participants reported that price, location, and taste

become consideration in choosing SSB product.

Participants think that marketing, particularly

advertisement in social media affected their decision

to purchase SSB products. Range of price that they

consider as affordable to buy SSB product is at IDR

35,000 – 50,000. It reveals that adolescence

nowadays will spend their money to purchase SSB

products as much as their daily spending. Some of

participant mentioned that they need to take extra

money from their parents in fulfilling their

willingness to order SSB products.

Participants felt that peer group influence their

decision to purchase SSB. In their point of view, SSB

consumption is related with current youth lifestyle

and it helps to lift up the bad mood. Moreover, the

SSB consumption also identical with social

construction among youth. In order to have a

conducive socialized environment, the participants

mentioned that their needs to buy SSB products is a

way to show their social class. Café with SSB as the

main menu is often chosen as place to gather with

friends. Therefore, the store location also being

considered. Some of them already have certain

favourite café that often being a hangout place with

their peers.

Participants viewed that influencer or public

figure also play role in shaping decision on buying

SSB. For example, a photo that they have been

collected also showed a café owned by Indonesian

public figure, and participant said that for some

groups, it might engage people to buy because of the

owner popularity.

Figure 2: Example of café owned by Indonesian public

figure

Regarding to the health risk, participants reported

that they actually know that excess sugar

consumption could be detrimental for health. The

risks reported are diabetes mellitus and obesity. They

also reported that they did not know what are the

government policy to control SSB consumption.

“…saya tahu mengkonsumsi minuman

berpemanis berlebihan itu berbahaya terutama

untuk kesehatan karena bisa menyebabkan berbagai

penyakit, tapi kadang saya masih tetap saja

mengkonsumsi…”

(…I know the overconsumption of SSB products

is not good for health because it accelerated the

health problems, but I still consume it…”

ICSDH 2021 - International Conference on Social Determinants of Health

These young people admit they know the negative

impact of SSB products on their health, but they still

consume SSB products. These different motives and

actions can illustrate how young people tend to

choose SSB products as a lifestyle over health reason.

The decision to purchase SSB products and the

external influences are the main factors in the current

adolescence lifestyle. Moreover, the perspective from

pricing, the healthy food price is assumed by

participants as more expensive than SSB at the same

merchant because there is a hidden value for healthy

foods. In addition, participants are starting to get a

freedom in choosing their foods and drinks,

especially outside the home, so it is necessary to

develop an easier effort for them to make healthier

choices.

3.4 The Perception on Food Label

Participants reported that they know what food label

is. In their point of view, food label is a group of

letter, image, or combination of both of them that give

information about percent of nutrients which

provided in package of food or beverage products.

Although the participants know what food label is,

their consideration to read the content of food label is

not the priority.

Participants felt that food label become their last

priority to read in the food product package when

selecting a food and beverage products. Food label is

read after considering the brand, the quality of

package, price, taste, and expired date. Sometimes

they even only grab the product without considering

anything because they just want to drink or eat the

product without any consideration as presented in

following perception quotes. The less preference to

read food label happens for both foods and drinks.

"Saya pertama kali lihat merek."

“I first look at the brand (of product)”

“Males aja. langsung milih produknya aja

sih…”

“I am just lazy to the point I will just take the

product that I want…”

Interestingly, female participants tend to be more

consider to read food label for certain kind of foods,

particularly in sweet products, such as yogurt and

bread. They felt that the sugar content in sweet

products will be dangerous for health. Contrarily, the

male ones thought that food label is not really

important to consider and thus not interested to

explore it.

Figure 3: Food label in SSB product

Participants also reported huge challenge on

reading food label because of the academic terms

used in the label. They did not understand some terms

in the nutrition facts and ingredients. Some of them

try to look in in the internet for the terms, but it needs

a bigger effort. For example, in figure 4, the did not

understand what alpha-tocopherol is.

Figure 4: Ingredients in food label

Regarding to the low preference to read food label

among adolescents, participants argued that it could

be happen because of the lack of knowledge about

food label. On the another side, part of them also

argued that even though the knowledge about food

label is good, they probably will not read it because

of the eagerness to consume that product. Moreover,

The Urban Adolescents’ Perception on Sugar-sweetened Beverages and Food Label: A Photovoice Study

they also tend to not read the label because it is a time

consuming activity.

“Mungkin karena kurangnya pengetahuan.

Tapi bisa juga pengetahuan ada, tapi karena

pengen banget mengkonsumsi itu, jadi ga

dibaca labelnya.”

“It might be because of the lack in knowledge,

but it is also could happen even though we

know (that it is important), but did not read it

since (we) really want it (the product)”

Participants reflected the low preference on

reading the food label among them could be enhanced

by increasing the self-motivation. They valued

education is important to give better understanding on

food label and eventually increase the motivation to

read it. Participants expressed that public figure or

influencer is not really give a significant motivation

to read the food label or influence people to consume

certain product. However, part of them thought that

actually public figure does have the role to influence

people, but specific for certain groups, for example

the fans.

Participants reported that education or promotion

in social media or national media (in television for

example) is effective enough to engage adolescents

for doing certain behaviour. They assumed it could

also be applied in education of food label.

“Public figure ga terlalu berpengaruh sih utk

saya. keinginan utk baca label pangan muncul

dari diri sendiri, kalo mau tahu baca aja.”

“Public figure does not really affect me, the

willingness to read food label must come from

each individual (motivation)”

“Mungkin tulisan label pangan harus dibuat

lebih besar. Public figure banyak diikuti juga

khususnya oleh penggemar.”

“Maybe the letter in food label should be made

bigger, for public figure, they are followed by

their fans.”

“Remaja mungkin paling efektif melalui

sekolah atau media sosial, misal Instagram.”

“(Education for) adolescents might be effective

in social media, such as Instagram.”

This quote implies the preferable media that

chosen by participants to empower themselves and

their community. Social media is still being a popular

media platform among adolescents. Hence this

potential could be applied as the opportunity to

deliver nutrition and health-related messages (Jones

et al., 2014).

3.5 The Perception on Halal Label

Participants defined halal label as the label in the food

package stated from MUI (Indonesian Council of

Ulama) that declare its halal status according to

Islamic law. They viewed that halal label is

important, especially in imported products. Halal

label also important because it declares that the

product is not dangerous.

Participants reported that halal logo is one of the

thing that they will consider first when buying an

imported product. However, for food products from

Indonesia, they rarely check the halal label because of

the sense of security. They felt that as a majority

Muslim, they should not be much worry about halal

label from food. Interestingly, they also rarely check

the halal label from a well-known brand product.

Participants viewed that they have a low

awareness on checking halal label even though halal

is mandatory for Muslim. In their opinion, the thing

that could be done to improve the awareness is doing

education through popular social media, such as

Instagram or TikTok, to community about the

importance on checking the halal label, particularly

for Muslim.

“… Kalau remaja edukasi di tiktok dan

Instagram..., Karena saya sering lihat di tiktok,

orang makan produk impor tapi ga ada logo

halalnya….”,

“… For teenagers, halal education on Tiktok

and Instagram might be a good way, Because I

often see on Tiktok, that many people eat

imported products but there is no halal label”

From figure 5, they noticed that the colour of halal

label could be different among package, therefore, it

is also important to check the validity of halal label

from MUI.

Figure 5: The difference of halal label among products

“

Kalau agama islam wajib baca label halal

kalau non islam ga wajib, karena yang islam

ICSDH 2021 - International Conference on Social Determinants of Health

wajib makan yang halal. kalau bentuk dan

warna label halal pada produk kayaknya ga

ada pengaruh”

“Maybe for Muslim read the halal label is the

important things to do because Muslim are

required to eat halal food, but it’s not

mandatory for non-Muslim. And for the colour

and shape of the halal label, I think it doesn’t

seem to have any differences”

3.6 Strategy of Dissemination

In this study, we also gained information from the

participants on what they could do to improve the

knowledge regarding to the current issue in their

community. Participants argued that they can

disseminate the information they gained from this

study to the school community. Participant viewed

that actually they could involve all elements in the

school in the program, so that the community

empowerment could be sustainable.

The knowledge from this study could be merged

into current school programs by involving the student

body (OSIS), school teachers, school community,

staff of canteen, and parents. From the best of their

knowledge, the example of available program

currently is class meeting and school festival. In the

future, they also plan to discuss with teachers about

placement of health-promoting media in the strategies

places, such as in the canteen.

4 DISCUSSION

SSB consumption is often related to release stress and

lift up the mood. The theory that sugar might improve

the mood actually was challenged in the recent

studies. The role of sugar in mood improvement, or

usually known as “sugar rush”, is actually considered

as a myth (Mantantzis et al., 2019). An experimental

study also confirmed that there is no effect of sugar

consumption on mood (Giles et al., 2018). The

satisfying and better feeling after consuming sugar

perhaps comes from serotoninergic effect of sugar

that occur in specific conditions, such as, stress (Giles

et al., 2018).

Advertisement in social media increase SSB

consumption. It has been known that adolescents are

primary audience of food advertiser. The role of

public figure in the marketing also scaling up the

decision made to purchase SSB product.

Conventional media, such as television, showed

decrease in trend of fast food and beverage

advertisement exposure among adolescents, probably

due to the shift of media consumption to social media

(Czoli et al., 2020). Food advertisement in YouTube,

online purchasing, and online advertisement is

strongly related with the consumption of unhealthy

diet among adolescents (Baldwin et al., 2018).

According to this study, the power of branding

related with the decision to choose certain product.

There are several steps on brand building that

determine consumer’s decision. Among millennial

consumers, brand image and brand trust play vital

role on consumer’s decision. Moreover, consumer’s

experience on certain brand also increase brand

attachment (Kim and Chao, 2019). It explains why in

this study some participants have already been

attached to certain SSB brands or specific

manufacturers.

This study also reported that the availability of

SSB in the online delivery service, ojek online in

Indonesia case, increase the purchasing behaviour. It

has been demonstrated that environmental factor that

support adolescents to easily access SSB, play key

role on the increasing trend of SSB consumption

(Hess et al., 2019). Other environmental factors that

reported in the present study are also the labelling,

price, promotion, and community awareness,

including peer groups and social construction.

Several factors are reported on challenging the

awareness to read food label according to this study,

namely: Low food label awareness (participants

know it is important, but majority rarely notice the

food labels), (2) Male participants have lower food

label awareness compared to females, (3) Low

knowledge on the content terms, (4) Most participant

thinks that read the food label is a time consuming

activity, (5) Participants have a less awareness and

less knowledges in reading halal label (they would

only interested in halal label if they might be

personally bought imported products), and also (6)

Participant feels safe and secured about halal label

because Indonesia is a Muslim majority country.

These findings are supported by previous study

that only a few participants noticed labelling of food

products information (Evans et al., 2016). Other

studies found that 50% of adolescents in US rarely or

never using the nutrition information on food

products (Wojcicki and Heyman, 2012). This finding

also strengthen the current problem among adolescent

that they are rarely care about nutrient intake.

However, in certain population with chronic diseases,

food label is considered as important thus, the desire

to read food label even better that healthy population

(Post et al., 2010).

The Urban Adolescents’ Perception on Sugar-sweetened Beverages and Food Label: A Photovoice Study

ACKNOWLEDGEMENT

This research is supported by grant from Institute of

Research and Development (Lemlitbang), University

of Muhammadiyah Prof. DR. Hamka

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