Experiences and perspectives of sugar-sweetened beverage consumption among Indigenous adults living in Manitoba

Sugar-sweetened beverages (SSB) are a health policy target. Indigenous populations are among the highest consumers of SSB in Canada. However, the Truth and Reconciliation Commission calls on governments to recognize health disparities among Indigenous populations as a consequence of colonialism and governmental policies. The purpose of this analysis was to explore emergent perspectives of Indigenous adults on experiences and perspectives of SSB consumption. We conducted a community-based participatory study in partnership with three Indigenous-led organizations. From 2019 to 2022, we completed qualitative interviews with Indigenous adults living in Island Lake Anisininew First Nation, Flin Flon


Introduction
SSB 2 are defined as all types of beverages containing free sugars including "carbonated or non-carbonated soft drinks, fruit/vegetable juices and drinks, liquid and powder concentrates, flavoured water, energy and sports drinks, ready-to-drink tea, ready-to-drink coffee, and flavoured milk drinks" (WHO, 2017).Sugar may also be added to beverages at the point of consumption, such as coffee or tea.Energy drinks are a type of SSB that include not only high amounts of sugar, but also caffeine, taurine, and other stimulants with known cardiovascular effects (Gualberto et al., 2024;Jagim et al., 2022).SSB intake has been linked to adverse health outcomes including type 2 diabetes (Malik et al., 2010), cardiovascular disease (Fung et al., 2009), and dental caries (Evans et al., 2013;Valenzuela et al., 2021).Though SSB consumption has been declining since the year 2000 (Della Corte et al., 2021), Indigenous Peoples around the world remain some of the highest consumers of SSB (Cartwright et al., 2023).In Canada, Indigenous Peoples 3 living off-reserve, 4 report drinking an average of 303 ml of SSB per day, the equivalent of slightly less than one soda can; this intake exceeds that of White (203.9ml/day), Chinese (116.4 ml/day), South Asian (197.4 ml/day), and Black (221.7ml/day)populations in Canada (Jones et al., 2019).Relative to White settlers, Indigenous populations in Canada also suffer from persistent and substantial health disparities (Greenwood et al., 2018), which all levels of government have been called upon to address through partnerships with Indigenous Peoples (Truth and Reconciliation Commission of Canada, 2012).
Intervening effectively to reduce SSB consumption among Indigenous Peoples requires an understanding of influences on SSB consumption at different socioecological levels, from the individual level (e. g., taste preferences, convenience) to the policy level (e.g., public health campaigns, government policy).At the environmental level, two of the most widely cited determinants of SSB consumption in Indigenous communities are water quality concerns and the availability of SSB; specifically, where communities lack safe and accessible water sources, SSB may represent a relatively affordable, well-stocked, tastier, and more easily accessible alternative (Cartwright et al., 2023).As of 2023, thirty-two boil water advisories in Canada were recorded in First Nations communities, not including those with intermittent boil water advisories or potable-but-not-palatable water (Short-Term Drinking Water Advisories, 2017).Although the number of boil water advisories has declined by 134 since 2015 (Short-Term Drinking Water Advisories, 2017), many Indigenous communities in Canada remain without access to clean drinking water, for which responsibilities lie with the federal government (Government of Canada, 2021a).Indigenous communities may also face barriers to accessing other SSB alternatives; for example, in Manitoba, milk prices were found to be 63-69 percent higher in First Nations communities, compared to the provincial capital, Winnipeg, and nearby non-Indigenous communities (Wendimu et al., 2018).Thus, ongoing water safety issues and high prices of perishable beverages may put Indigenous Peoples living on-reserve in a position where SSB are the most accessible beverage.

Addictive-like consumption as an explanation for SSB intake
We have chosen to apply an addictive-like consumption framework in the present study, which acknowledges the multiple individual and systemic influences on SSB consumption, as an alternative to top-down, deficit-based approaches to understanding health behaviours in Indigenous communities (Barnabe, 2021).It is worth noting that the concept of addictive-like eating has been hotly debated (Lacroix et al., 2018).Two positions on this issue are the substance-based food addiction hypothesis, which posits that individuals become addicted to chemical substances in foods (Schulte et al., 2017), and the behavioural "eating addiction" model, which posits that individuals become addicted to the behavioural aspect of eating rather than any specific food substances (Hebebrand et al., 2014).Alternatively, it has been argued that addictive-like eating should be conceptualized as a severe subtype of binge eating disorder (BED; Davis, 2013), or along a spectrum of uncontrolled eating that transverses diagnostic boundaries (Vainik et al., 2015).Another perspective is that the concept of addictive-like eating pathologizes normative hedonic overeating and lacks utility (Finlayson, 2017).The purpose of the current study is not to support or refute any of these perspectives on the addictive-like eating debate, or to apply them to SSB consumption, but instead, to share our participants' perspectives and experiences.
Whereas the most common scale used to measure food addiction, the Yale Food Addiction Scale, directly applies substance use disorder criteria to food, we instead define addictive-like eating in line with previous qualitative research as a "pattern of overeating characterized by lack of control over one's intake, psychological and functional preoccupation with foods, and distress regarding weight gain, health issues, or other negative consequences" (Lacroix & von Ranson, 2020, p. 443).Accordingly, we use the term "addictive-like SSB consumption" to reflect our agnostic position regarding how this pattern should be conceptualized, while acknowledging how our participants applied the lens of addiction to situate their lived experiences of SSB consumption.An exception to our use of the term "addictive-like SSB consumption" is that when discussing the results of previous research, we use the same terminology as the authors of these prior studies.
Researchers have argued that sugar should be considered an addictive substance (DiNicolantonio et al., 2018), and have positioned SSB consumption within the addictive-like eating framework, by drawing parallels between SSB consumption and substance use disorder symptoms and positing that SSB may have addictive properties (Sylvetsky et al., 2020).For example, in a study where habitual SSB consumers, limited to those who consumed low levels or no caffeine, ceased drinking SSB for three days, participants reported withdrawal symptoms such as increased SSB cravings and headaches, as well as decreased motivation, contentment, ability to concentrate, and overall well-being (Falbe et al., 2019).However, we acknowledge that it is unclear which, if any, ingredients in SSB may be most strongly associated with addictive-like consumption (Jagim et al., 2022), for example, sugar or caffeine.Addictive-like consumption has been cited as a reason for widespread SSB consumption by Torres Strait Islander women (Wood et al., 2021) and young adults in Australian remote Indigenous communities (Tonkin et al., 2017).However, no research to date has specifically focused on the addictive patterns of SSB consumption among Indigenous Peoples in Canada.
Addictive-like explanations of SSB consumption may be highly pertinent for Indigenous Peoples in Canada.As with substance use disorders, addictive-like eating is strongly associated with lifetime trauma exposure; compared to individuals with no trauma history, individuals who report the greatest number of posttraumatic stress disorder (PTSD) symptoms are more than twice as likely to experience food addiction (Mason et al., 2014).Indeed, the associations found between food addiction and trauma have been so strong that food addiction has been posited as a proxy or marker for trauma (Brewerton, 2017).Though research on this link is in its early stages, two potential mechanisms that have been posited to explain the link between trauma and food addiction are emotion dysregulation and impulsivity (Jacques-Tiura et a., 2021).Due to colonization, residential schools, and ongoing violence, amongst other factors, Indigenous Peoples experience adverse childhood experiences and trauma at disproportionately higher rates than 2 Sugar-sweetened beverages. 3Indigenous Peoples in Canada include First Nations, Métis and Inuit Peoples.However, Canadian legislation of the Constitution 1982 and the Indian Act defines Indigenous Peoples collectively as "Aboriginal" or "Indians".
4 "On-reserve" refers to lands and the laws that apply therein held by the federal Crown for Bands (meaning recognized First Nations), as outlined by the Indian Act.
non-Indigenous populations in Canada (Graham et al., 2021;Radford et al., 2022).As such, Indigenous populations may be at particularly high risk for addictive-like eating and SSB consumption.
Another consideration that has been linked to addictive-like eating is food insecurity.Household food insecurity is defined by Health Canada (2020) as "the inability to acquire or consume an adequate diet quality or sufficient quantity of food in socially acceptable ways, or the uncertainty that one will be able to do so".Food insecurity is experienced by 48% of on-reserve First Nations households, a rate three to five times higher than general Canadian households (12%; FNFNES, 2021).Off-reserve Indigenous households also face a 27% higher prevalence of food insecurity (Tarasuk et al., 2019).People living in food-insecure households are more likely to experience food addiction symptoms, with a reported 21-56% higher prevalence compared to those in food-secure households (Parnarouskis et al., 2022).As a result, Indigenous populations in Canada may be at a higher risk for addictive-like eating patterns due to high rates of food insecurity.
The aim of the current study was to explore experiences and perspectives of Indigenous adults on SSB consumption, with a focus on addictive-like consumption.This qualitative study took place within a broader project exploring acceptability of SSB taxation among Indigenous communities.Although participants were not specifically asked about addictive-like SSB consumption during the interviews, they talked extensively about such experiences, drew parallels to addiction, and cited addiction as a reason they expected SSB taxation to be ineffective (Kisselgoff et al., 2023).As a result, community research partners identified this theme as crucial to explore further, given the centrality of these experiences and the lack of previous research on Indigenous perspectives regarding addictive-like SSB consumption.Notably, we did not assess whether experiences might meet a clinical definition of addiction.

Design
This analysis is derived from a multi-partner, community-based participatory study carried out in Manitoba to explore the acceptability of a proposed tax on SSB among Indigenous populations using qualitative, semi-structured interviews.For the present analysis, we examined participants' views regarding their and others' SSB consumption, using the lens of addictive-like consumption.We followed the communitybased participatory research principles outlined by Minkler and Wallerstein (2008) and Israel et al. (2008).A settler researcher from the University of Manitoba (NR) partnered with National Indigenous Diabetes Association (CT), Four Arrows Regional Health Authority (BB, LW), and Fearless R2W (MC, RD) to design and conduct this study (Fearless, 2022;Four Arrows Regional Health Authority, 2022;National Indigenous Diabetes Association, 2022).All partners signed research agreements outlining the shared study values and their consent, roles, responsibilities, and data ownership, control, access, and possession (FNGIC, n. d.).The study was approved by our institutional Health Research Ethics Board (HS21878 H2018:234).

Positionality
Our author team includes Indigenous (MT) and settler scholars (NR, EL, AB) who identify with diverse disciplinary backgrounds, including clinical psychology, critical social sciences, law, Indigenous health, epidemiology, and nutrition.The author team also includes Indigenous community partners.Several trainee authors, both Indigenous and non-Indigenous, were trained through the data collection (Kelsey M, Krista M, MK, AW), data analysis (GS, LK) and interpretation.The author team was gender diverse, and we engaged reflexively in the data analysis and our collective interpretation of the data.
The broader study was informed by equity concerns of a SSB tax and potential negative unintended effects for Indigenous populations (Riediger & Bombak, 2018).We have previously analyzed the interviews with participants from the North End to explore experiences purchasing SSB (Kisselgoff et al., 2024) and acceptability of a SSB tax (Kisselgoff et al., 2023).In another arm of the study we reported participants' perspectives of SSB using a critical weight studies lens (Waugh et al., 2023), as well as acceptability of a SSB tax using theories of health moralism and tax psychology (Waugh et al. 2024) with White participants living in a middle-to higher income neighbourhood in Winnipeg.An additional analysis focused on perspectives of small businesses (Quayyum et al., 2023).Organically arising from our data, we detected among participants a concern regarding addiction, which we report on here.

Setting
Interviews took place with participants in three locations in Manitoba: Flin Flon, Island Lake Anisininew First Nations (Garden Hill First Nation, Wasagamack, Red Sucker Lake, St. Theresa Point), and Winnipeg's North End neighbourhood.Interviews in Flin Flon, Island Lake, and the North End were completed in June-August 2019, July 2021-June 2022, and November 2019-August 2020, respectively.Manitoba is home to the highest proportion of Indigenous people compared to all other provinces (Government Of Canada, 2022) and the second highest provincial First Nation population, both total and on-reserve (Government of Canada, 2010).
Flin Flon (off-reserve) is located in northern Manitoba, 763 km north of Winnipeg with year-round road access to larger urban centres and regular access to clean drinking water.Flin Flon is a mining city with a population of just over 4900 people, and 22.4% identifying as Indigenous (Statistics Canada, 2023), largely First Nations and Métis.All interviews were conducted face-to-face.
The North End is located in the inner city of Winnipeg and is on Treaty One territory as well as the homeland of the Métis nation.Of all major Canadian cities, Winnipeg is home to the largest urban Indigenous population (Government Of Canada, 2022).The North End neighbourhood is characterized as the lowest income cluster in the city, with a high proportion of Indigenous people, at 29% (Winnipeg Regional Health Authority (WRHA), 2021).Finally, the North End is categorized as a food desert, defined as a low-income area with >500 m distance from full service or national chain food stores (Manitoba Collaborative Data Portal, 2021), with a high concentration of small convenience stores (Tursunova et al., 2020).Notably, Winnipeg also has access to safe, clean drinking water.Six interviews in the North End were completed face-to-face prior to the beginning of the COVID-19 pandemic, with the remaining fourteen interviews occurring over the phone by MK and NR (Kisselgoff, 2023).
All four Island Lake Anisininew First Nation communities are located in northeastern Manitoba approximately 650 km northeast of Winnipeg, near the Ontario border and considered on-reserve.The communities are remote, meaning only accessible by air during most of the year and by seasonal winter roads.While some homes in the communities have direct access to the water treatment plants, the majority of homes lack running water.Many residents get water delivered to cisterns or barrels via a small tanker truck, of which deliveries are not always consistently frequent (Elash & Walker, 2019).Residents do not usually drink water from barrels and as such, drinking water is largely purchased.Nineteen interviews were conducted in person, and twenty over the phone.

Data collection
In each study location, we conducted purposive sampling through inclusion criteria, which included adults over 18 years of age, selfidentifying as Indigenous (First Nation in Island Lake Anisininew First Nations), and English speaking in Flin Flon and North End.Recruitment in Island Lake and North End was carried out by community research assistants from Four Arrows Regional Health Authority and Fearless R2W, respectively, mostly by reaching out directly to potential participants and to a lesser extent snowball sampling and poster advertisement.Recruitment in Flin Flon was carried out through poster advertisement and word-of-mouth.We utilized purposive sampling to recruit mothers, persons who identified as "overweight" or "obese", and regular consumers of SSB; however, these were not explicit inclusion criteria.We sought to include these groups as they were vital to a more complete understanding of perspectives of SSB taxation, as individuals who might be both discursively associated with SSB, targeted, and/or impacted by SSB taxation, and therefore, may experience weight-based stigma or parenting judgement, which we sought to explore in other analyses (Kisselgoff et al., 2023).Interviews were conducted by authors NR, MK, and RD in the North End; Kelsey M, MJH, and LW in Island Lake; and Krista M in Flin Flon.In person interviews were conducted at various locations, sometimes decided by participants, and were sometimes conducted in public spaces or in workplaces with other individuals present.
All participants in Flin Flon and North End provided written, individual, informed consent, as did participants from Island Lake Anisininew First Nations for whom interviews were conducted in person.Verbal consent was obtained from participants from Island Lake Anisininew First Nations for whom interviews were conducted over the phone.All participants received a $50 honorarium for their participation.
Trained research assistants administered a short demographic questionnaire to characterize the sample, followed by a qualitative, semi-structured interview.The interview guide has been published previously (Kisselgoff et al., 2023) and a similar version was utilized with other population groups (e.g.Bombak et al., 2019;Waugh, 2023).However, the guide was not piloted with Indigenous communities, but was developed with the author team and community partners.The interview guide included questions regarding participants personal, familial, and community beverage intake, how intake may have changed over time, experiences purchasing beverages, perspectives regarding the proposed taxation of SSB, and how participants thought drinks with sugar affect (or do not effect) individuals' health.The interview guide did not include questions pertaining to addictive-like SSB consumption.The demographic questionnaire included questions relating to gender, age, Indigenous group (First Nation, Métis, Inuk/Inuit), education level, employment status, self-rated health, and SSB consumption frequency (Table 1).
Both in-person and phone interviews were audio recorded and transcribed verbatim.Interview guides were updated throughout the study in each setting to capitalize on emerging themes and to align with input from community partners.Specific to the present analysis, we added additional probing questions if participants mentioned addiction to sugar or SSB verbatim, sometimes following up later in the interview (Robinson, 2023).The most common examples of an explicit probing question about addictive-like consumption was "Do you think sugar is addictive?","Can you tell me what you mean by addiction?"or some variation of these same questions.Other probing questions sought to encourage participants to discuss their experiences in more detail, such as, "how does that make you feel?" or "tell me more".Non-verbal prompts such as silence were utilized to encourage further discussion or nodding, which could be considered an affirmation probe (Robinson, 2023).Probing allowed us to gather some additional data regarding experiences or perspectives of addictive-like SSB intake, such as some of the sub-themes presented in the findings.
The majority of the interviews, with the exception of some with Island Lake Anisininew First Nations, included detailed field notes.The field notes were written by interviewers, and documented impressions of the interview, details about the setting of the interview and characteristics of the participant (e.g.what we thought the participant was doing while on the phone such as walking or if there was a TV or children in the background), and other non-verbal interactions in the interview that would not be captured in transcriptions.We respect and uphold the principles of Indigenous data sovereignty and therefore transcripts are not publicly available (Government of Canada, 2021b), however the corresponding author has full access to the data reported in this manuscript.

Analysis
We conducted a thematic analysis (Braun & Clarke, 2006) using NVivo 12 software, which began with transcription and repeated reading of transcripts from each setting separately.Transcripts from Flin Flon were initially coded to answer the research questions: how do participants describe SSB intake and the experiences of consuming SSB? Transcripts from the North End were initially coded for other research questions related to experiences purchasing SSB and SSB tax acceptability.However, it became clear through repeated readings that addictive-like consumption of SSB was a repeating pattern in the data that we did not initially anticipate.Given that this pattern did not appear to differ substantially between study settings, and following discussion with community partners, we made the decision to combine interview transcripts from all locations with Indigenous adults for this research question and conduct a focused thematic analysis on consumption of SSB, utilizing an addictive-like consumption lens.We conceptualized additive-like consumption based on the literature as including emotional drivers of consumption and adverse physical outcomes, for example.In contrast, while we heard that participants purchased SSB in Island Lake First Nations due to the lower price compared to bottled water, we conceptualized this finding as related to SSB purchasing (which will be reported in a separate forthcoming paper), not SSB consumption, which is reported in this paper.Similarly, we heard that participants would often purchase large amounts of SSB or greater volume of SSB with the intent of sharing SSB.While community practices of sharing SSB relates to SSB consumption, we conceptualized sharing SSB as relating primarily to purchasing, and which was previously reported from North End participants (Kisselgoff et al., 2024).
Coding was performed by GS and AW and reviewed together with NR to generate themes and sub-themes.Themes/sub-themes were reviewed with study partners (MC, BB, LW) as a form of member checking at a community gathering in August 2022.Quotations are reported using pseudonyms with community in parentheses (FF, IL, NE).We reached data saturation in the sense that addictive-like SSB consumption was a repeating pattern in the data.However, data saturation regarding how participants conceptualized or experienced addictive-like SSB consumption or what contributed to addictive-like SSB consumption was not reached, due to the iterative nature of this analysis and this topic not being identified a priori as an interview question or primary research objective.

Results
We conducted 74 interviews, including 40 in-person and 34 virtually.Demographic characteristics of the study sample have been previously reported (Riediger et al., 2024), and are summarized in Table 1.Participants ranged in age between 20 and 67 years old and the majority were either working full-time (46%) or not working (46%; self-reported as unemployed, does not include retired participants).Approximately half of the interviews (n = 39) were conducted with participants from Island Lake, with similar numbers in each of the four communities, followed by 20 interviews in the North End, and 15 in Flin Flon.Interviews averaged just over 30 min in length.
All 74 interviews were coded, despite only 29 participants referring explicitly to "addiction" or some variation thereof.Some participants who did not use some variation of the term "addiction", may have described SSB intake as habitual, or describe theirs or others' intake in such as way we perceived their description of falling within an "addiction" construct.The use of term "addiction" occurred in various sections of the interview such as when discussing their own or others SSB intake, in explaining their perceived (in)effectiveness of a SSB tax, or when discussing the perceived health effects of drinks with sugar.In addition to the primary theme of addictive-like consumption of SSB, we identified two other themes, i) perceived drivers and contexts of SSB consumption and ii) health outcomes as a motivator for change, which further explore the trajectory of SSB consumption, including, but not limited to, addictive-like consumption.Our coding scheme with corresponding themes and sub-themes is summarized in Table 2.

Addictive-like consumption of SSB
Many participants, across all three locations, repeatedly and consistently described SSB or sugar intake as an addiction, which formed the primary theme of this manuscript, addictive-like consumption of SSB.This included perspectives of their own and others' consumption of SSB.We understood this slippage between SSB and sugar to mean that some participants perceived SSB as addictive, at least partially due to their sugar content.Many types of SSB also include caffeine (for example, energy drinks), which also potentially contributes to addictive-like consumption or perceptions/experiences of addictive-like consumption; while caffeine was mentioned by participants, it was invoked less frequently than sugar as specifically addictive.Some participants described habitual or regular SSB intake or referred to consumption as a "habit", and some used both terms, such as Lynne: They always had that [SSB] around them when they were small and they're just used to it.They can't help themselves sometimes.It's just an addiction to habit, like candy, drinks and pops.-Lynne (IL) Implied within some participant discussions was the sense that while they described SSB as an addiction, SSB were not necessarily universally viewed as addictive in wider society.After describing SSB as an addiction, one participant when prompted to explain what they meant, began explaining why SSB was an addiction, then stopped mid-sentence to allege that the interviewer used the term addiction [the participant first brought up the term, "addiction"], perhaps suggesting some ambivalence with the use of the term to describe SSB intake.One participant linked sugar and addiction to the broader forces of colonialism and governmental policies, referring to rations provided by the federal government, such as flour, sugar, salt, milk, and lard: They [government] know that we are addicted to sugar.They got us addicted to sugar -Leah (IL) Within the primary theme, addictive-like consumption encompassed the comparison of SSB to other addictive substances, loss of control over one's intake of SSB, and the physical symptoms resulting from SSB intake (both positive and adverse) and withdrawal or attempting to reduce SSB intake.

Comparison of SSB to other addictive substances
Comparisons between SSB, or sugar, to other addictive substances, such as cocaine, alcohol, cigarettes, or more generally as a "gateway drug", suggested a need to situate their perceptions of SSB to other more well-known addictions.For example, Gerry describes: I always needed a Pepsi in my hand.It's almost like an alcoholic that always needs a can of beer in their hand, you know?-Gerry (NE) In this same vein, Alan (NE) suggests that research does not currently exist, but is needed to fully capture and understand SSB as an addiction, particularly among Indigenous communities: Well, I think it's, um, there's no studies to really show what happens to people when they stop drinking sugar.But I think it's more of a, a cultural and social type of addiction because it's so prevalent, it's so normalized.Alan (NE) This quote also illustrates, consistent with many of the other interviews, that SSB are highly consumed and largely normalized among the Indigenous communities that were included in the study.

Loss of control
Participants who reported personally experiencing SSB as an addiction, described a feeling of not having control over their intake, and for some a feeling of "I shouldn't be doing this" or in the case of Carolyn, feeling "scared" about their intake of energy drinks specifically, when discussing which beverages they thought would be taxed if a tax was implemented: I could drink three of them a day and I get scared that if I go on my second one, like I literally have one in the morning, one at the afternoon, and once it hits, and then one in the evening.But by the time I get on the end of my second one, I'm already thinking of my third one and I'm scared my heart is going to bust or start like going too crazy.-Carolyn (NE)

Physical and emotional symptoms
Some participants described getting energy from consuming SSB and satisfying the urge to drink one; in this way, SSB intake was described largely positively.However, the feeling of losing control described above, associated urges, and physical symptoms related to SSB intake or withdrawal were described mostly negatively.Several participants described adverse symptoms of consuming too much SSB, particularly headaches or a migraine, as described by Julia (NE):  It was just the sugar, sugar high, and same thing like I used to say, um, that I had a headache.My mom tells me just now, "Oh, you always had a headache and that was from all the sugar you were drinking".-Julia (NE) In contrast, Sarah (FF) reports building up "a tolerance" to energy drinks such that she has become accustomed to drinking a certain amount of energy drink, which again is related to the sub-theme of losing control.
Like I always like I remember when I was working as a Health Care Aide at the manor, uhh in the morning I'd have my energy drink and they'd always be like I don't know how you can drink that, that's so much sugar.But, I don't know, just you build up a tolerance to it right?Like now like If I go like two days without having an energy drink I, I can tell that I haven't had an energy drink right?Yeah, so that's where I'm like puttin on a coffee and hoping that works and if that doesn't work, I'm like okay I gotta get myself one -Sarah (FF) Several participants described symptoms from not having had SSB recently, or symptoms associated with wanting an SSB.Symptoms included headaches and "aches and pains all over".You know like the headaches were just too much and, and I would never get headaches on anything for any reason, hangovers or whatever right.And as soon as I cut back, completely cut out 7-Up I was getting the worst headaches.So I'd like, I, it was almost like I needed that 7-up just to get that headache to go away.-Molly (FF) A number of participants also described how wanting/needing SSB impacted theirs or others' moods.Specifically, these feeling/behaviours were described as "irritated", "annoyed", "edgier", "anger", "rage", "moody", and "acting completely different", and that when someone gets an SSB, "their whole mood just completely changes".Alan (NE) forebodingly describes "that once you remove it [referring to SSB], you don't know, uh, sort of the reactions that people will have".Similarly, Somebody who wants to have sugar, needs it and can't have it, they get irritated ….I have experienced it because I was drinking a lot of pop and then I ran out.And then ending up getting irritated and I was getting annoyed that I didn't have pop.-Shelly (NE)

Perceived drivers and contexts of SSB consumption
This theme, perceived drivers and contexts of SSB consumption, captured what participants reported influenced or contributed to theirs, or others', consumption of SSB, particularly when the participant described addictive-like consumption.However, we included perceived drivers or contexts of SSB consumption in this analysis regardless of whether participants explicitly discussed addictive-like consumption, as we considered these perspectives as still pertinent to our analysis.These perceived drivers or contexts included how i) SSB intake is intertwined with other addictions or addictive substances; ii) SSB is used to cope with stress, boredom, and poverty; and iii) drinking alone.

SSB is intertwined with other addictions or addictive substances
Primarily by participants in the North End, SSB intake was as intertwined with the use of other addictive substances, including attempts to stop or avoid using other addictive substances.As Carolyn (NE) described, "In reality it's like if we can't do drugs, we're going to cross addict to sugar".Alcohol was the substance described most often by participants as related to SSB intake, by drinking them together or when attempting to stop drinking alcohol: So, when I, you know, I sobered up, I was still kind of … Um, I was eating a lot of chips and drinking pop, probably every other day.It seems like when I, when I stopped drinking, I, I craved junk food more.Food-wise, when I was drinking, I didn't really eat at all, right?So, then, so, I was drinking pop, eating chips for the first, oh, six months when I sobered up, and then I slowly weaned myself off within a year.You know, I just kind of was, like, you know, I was drinking coffee with, like, four sugars, four creams, and then I was getting really bad headaches from all that sugar and … plus drinking pop -Walter (NE) Amanda was the only participant who mentioned methamphetamine and linked others' use and their attempts to quit as being related to SSB intake: I find that when people are trying to stop using um meth, they eat candy … a lot.Like a lot of candy and then that's the next thing they have the wean themselves down-down on, to stop eating so much candy or consuming as much Pepsi or whatever it is that they are doing.Um, it generally takes about six months -Amanda (NE) Interestingly, both Walter and Amanda mention a 6-month period following attempts to quit alcohol or methamphetamine that result in increased SSB intake.
Additionally, several participants specifically mentioned being addicted to the caffeine in SSB, typically pop, energy drinks, and/or coffee (with sugar).Caffeine itself was also linked to withdrawal symptoms related to SSB.For example, Jordan, who reported drinking coffee with sugar described the following: Like, the caffeine.Just staying addicted to caffeine and stuff.Drinking coffee every day and-and your body just wants it more.-Jordan (NE)

SSB is used to cope with stress, boredom, and poverty
A few participants mentioned stress and emotional eating as influencing SSB intake specifically: It could be, you know, if there's, there's more of an underlying issue then of why the sugary drink is addiction, right?Like, maybe they're stressed out, you know?Maybe they're stress eaters, so, you know, Pepsi or Coke is something that they … That's like their comfort food almost or their comfort drink when, really, there's, there's, there's more to it than just grabbing a pop and drinking it, right?….It's a replacement for, you know, something that they're struggling with.
-Walter (NE) Interestingly, Sarah (FF) mentioned drinking soda in response to boredom and to "keep children happy", particularly when money is tight: Because well I don't know.I just have nothing, I don't know I'm bored so I'll go grab myself a soda or something from Super K ….
Mm well you usually see Aboriginals more, you see them, they have, well they'll buy like, when you go like on welfare day you'll see they, they'll buy like bottles and bottles and bottles of pop.It's cause they're buying bottles, and bottles, and bottles of pop to keep their kids happy throughout the month.-Sarah (FF) Annika (IL) also references another family treating the kids once a month to a slush at child tax time, but not giving the children pop at any other time.Both references to "once a month" or "throughout the month" refer to the financial and income challenges related to being dependent on social assistance, and specifically the additional challenges for parenting and children.
While not mentioning stress or boredom, specifically, Brooke (IL) discussed starting to drink SSB at the first day of the COVID-19 pandemic lockdown in the community: That was like two years ago, that's when I starting uh that's when I started drinking coke.Like I would just sit in my room and I like watching TV in my evening and I would have a six-pack and uhh I consume about six cans of coke when I just sit there in the evening watching TV.-Brooke (IL) This finding may also be inter-related with the next sub-theme of drinking alone, as discussed below.

Drinking alone
While not an especially prominent finding, some participants mentioned a preference to drink SSB alone, to avoid others seeing them: Most times uh that I drink pop when nobody is around … even my wife says I drink too much pop … so when I'm alone I drink it -Dorian (IL) Several participants did mention health concerns from family regarding their personal SSB intake.For some participants, like Dorian above, this resulted in not wanting family to see them consuming SSB.In response to an interview question about where they would feel least comfortable drinking an SSB, Margaret responds similarly: "maybe like in front of my parents … just anywhere in front of them …. when I got sick I think it scared everybody, cause it scared me too.Cause um I almost got my foot amputated and they were scared for me too so they-they don't want that to happen again so they watch me -Margaret (IL) This quote also relates to the perceived health effects of consuming SSB identified by participants, which included type 2 diabetes, diabetes complications, and dental caries.The community research team discussed how drinking alone may not necessarily imply judgement, but rather be a way adults sought to protect children from seeing adults consume SSB in an addictive-like manner.Concern for children's health was also a repeating pattern in the data, not explored in this paper.However, in the interviews we did not explicitly hear that adults would conceal their drinking of SSB to specifically protect children.

Health consequences as a motivator for change
Participants often spoke of SSB consumption, including addictivelike consumption, in the context of describing struggles in trying to reduce SSB intake.A number of participants, many of whom discussed being diagnosed with type 2 diabetes, talked about reducing or eliminating SSB for their health.Most mentioned a switch to diet pop or using non-nutritive sweeteners (e.g.aspartame or sucralose) in coffee to reduce sugar intake.We reported perspectives of diet beverages in a separate paper (Riediger et al., 2024).One participant described their prioritization of health in response to a question regarding whether their consumption patterns of beverages had changed over time: I kinda stopped [referring to SSB intake] earlier in the year cause um I got sick and I was hospitalized for 2 months and um most of it had to do with me not taking care … me not taking diabetes seriously and taking care of myself.-Margaret (IL) Reducing SSB intake was also reported in response to general declarations of not feeling physically well, or because of headaches: I used to drink a case of 12 a day no problem.But lots of headaches, lots of migraines, so I had to switch.And I went green, green tea, and then I went just straight water.I try to drink a lot of water.-Dakota (NE) Some participants also mentioned reducing SSB intake specifically for prevention of type 2 diabetes, like Nancy (FF), "I'm just scared to get diabetes.My dad's always saying you better watch yourself and so I'm just more conscientious, yeah".Reducing SSB intake as a preventative health measure also extended to children's health.
So when I had my son, he breastfed.I breastfed him.He breastfed for 17 months.And so it was kind of around the same time, uh, when I had him, I kind of really put a leash on, uh, like, pop and all that.I kind of stopped doing … stopped drinking caffeine, um, because it wasn't good for him.-Louise(NE) A couple participants also mentioned that they reduced SSB intake to feel good about themselves and generally for wellbeing, implying that drinking SSB made them feel bad about themselves.I definitely want it, yeah I was like, like I said, I was going to the gym a couple of times a-a day, and, um, I just watched everything that I put into my body and, uh, I cut off all sugar, I tried to anyways, I just figured whatever I was eating for supper and breakfast and lunch, I was getting enough sugar from that.So, that's what I kinda figured, so I just cut off like everything and, uh, yeah I just really wanted it, I wanted to feel healthy, feel good about myself, and I think that was one of the main reasons.-Raymond (NE) This theme of health as a motivator to change captured the health concerns participants attributed to SSB intake and what we interpreted as the primary motivator for cessation, or management, of SSB consumption for themselves and others, which may or may not have been described as addictive-like consumption.

Discussion
This study explored experiences of SSB consumption among Indigenous adults living in Manitoba.Interviews were conducted within the context of a larger study on perceptions of SSB taxation, where many participants, despite not being prompted to speak about addiction, described addictive-like patterns of SSB consumption and drew direct parallels to substance use.In accordance with guidance from community partners, the aim of the current study was to describe SSB consumption among our participants, including patterns of addictive-like SSB consumption.Through thematic analysis, we identified three main themes: (1) addictive-like consumption of SSB, including comparisons to other substances, loss of control and physical symptoms; (2) perceived drivers and contexts of SSB consumption, such as substituting to SSB or when abstaining from other substance use, using SSB to cope, and drinking alone; and (3) health consequences as a motivator for change.

Addictive-like consumption of SSB
Participants in this study often compared their SSB consumption to other well-known addictive substances.By making these comparisons, they were able to explain or rationalize their high intake of SSBs.However, it is important to note that there is a lack of consensus and a need for a universal definition of addictive-like eating in the literature (Lacroix et al., 2018).The lack of a well-defined and recognized understanding of addictive-like eating in the academic and health professional spheres may contribute to individuals drawing parallels to more established and familiar forms of addiction.Additionally, community partners noted that discussions around addictions were common in their communities generally.Furthermore, there were more available resources to address addictions in the city of Winnipeg compared to on-reserve, likely shaping the different discussions from participants in different locations.Given the magnitude of discussion of addictive-like SSB consumption among Indigenous communities reported here, further research is needed to understand the underlying factors within Canada's colonial context.This research can inform the development of prevention strategies that are tailored to the needs of Indigenous Peoples across Canada to improve overall health and well-being.
Participants who experienced addictive-like SSB intake reported feeling like they had no control over their consumption, and in some cases, were unable to stop consuming SSB despite fear of adverse health consequences of SSB consumption.This finding is consistent with previous qualitative studies on addictive-like eating; a review of qualitative research found that loss of control was the most common and prominent feature associated with addictive-like eating and argued that loss of control should be considered a central and defining characteristic of this pattern (Lacroix & von Ranson, 2020).The centrality of loss of control to addictive-like eating has also been identified in quantitative research (e. g.Meadows et al., 2017), which found, through regression analysis, that a perceived lack of self-control was the factor that best distinguished those who saw themselves as addicted to food from those who did not.The current study offers additional support for the notion that loss of control plays a central role in addictive-like eating.Specifically, our findings expand on this notion by describing lived-experience accounts of its role in SSB consumption among Indigenous Peoples in Canada, a group that has yet to be represented in research on addictive-like eating and SSB consumption.This lack of representation may be at least partially due to challenges regarding the collection of health data about, and by Indigenous Peoples (Smylie & Anderson, 2006).
Participants reported experiencing a range of physical and emotional symptoms associated with their consumption of SSB, from both high consumption of SSB, and withdrawal.Symptoms included headaches and increased energy resulting from high SSB intake, as well as urges, headaches, anger, and moodiness when attempting to reduce or withdraw from SSB.These findings are consistent with existing literature that explores the relationship between SSB intake or reduction and the manifestation of physical and emotional symptoms.For instance, a study conducted by Falbe et al. (2019) implemented a 3-day cessation intervention among "overweight"5 and "obese" adolescents who consumed at least three SSBs daily.During the SSB cessation period, the participants exhibited withdrawal symptoms, including heightened SSB cravings, headaches, reduced motivation, contentment, ability to concentrate, and overall well-being (Falbe et al., 2019).Similarly, Kristjansson (2014) observed a positive correlation between high-caffeine SSB consumption and physical symptoms in children aged 10-12 years.The study revealed that a higher frequency of caffeinated SSB intake was associated with physical complaints such as headaches, stomach aches, sleeping problems, and diminished appetite (Kristjansson et al., 2014).Therefore, adverse symptoms may arise from both excessive SSB consumption and its cessation.Thus, further research is warranted to investigate the complex relationship between high SSB intake and the manifestation of negative emotional or physical symptoms.

Perceived drivers, or contexts, of SSB consumption
Participants also described how their, or others, SSB consumption (and sometimes addictive-like SSB consumption) related to other types of addiction and their attempts to quit or reduce substance use.This finding aligns with existing literature on addiction substitution, which refers to the process of individuals substituting one addiction for another during recovery.A systematic literature review on addiction substitution during recovery found that a substantial percentage of studies (17.65%) supported the occurrence of addiction substitution (Kim et al., 2021).Different theories propose various explanations for the process of addiction substitution.For example, Adler (1966) argues that addiction substitution occurs when a new addictive behavior serves the same function as the previous addiction.Mansky (1999) suggests that the development of a new addiction serves to cope with negative emotions that were previously masked by the primary addiction.Though it has been proposed that addiction substitution can act as a form of harm reduction when the newly developed addiction is less harmful than the primary addiction (Mattick et al., 2009), addiction substitution was associated with worse treatment outcomes in a prior systematic review (Kim et al., 2021).These findings suggest a need for early nutritional intervention strategies for individuals in their recovery journey to prevent or reduce the occurrence of substance substitution, as well as more research to explore addiction substitution in general.
Participants identified several factors that made it challenging for them to control their consumption of SSBs or which contributed to their, or others, SSB consumption.These included using SSB as a coping mechanism for boredom, stress, or financial hardship.Emotional coping motives for addictive-like eating have been identified in previous qualitative research, for example in a study conducted in Brazil where many participants reported eating in response to emotions such as anxiety (Lacroix et al., 2019).Unique to this study were participants' accounts of SSB consumption in relation to financial hardship, a theme not previously noted in other qualitative research on SSB consumption or addictive-like eating.However, longitudinal research has shown that early and sustained economic hardship predicts increased stress among parents, which can in turn increase child consumption of foods high in saturated fats and added sugars (Shuler et al., 2021).It is important to recognize state-imposed environmental, policy and legal barriers to healthy eating as contributors to increased stress.Our study revealed multiple layers to the relationship between SSB consumption and financial stress.Some participants shared that they gave SSB to their kids to bring them joy during difficult times, and another participant viewed SSB as a monthly treat when they received social assistance payments.In this way, SSB consumption not only served to cope with difficult emotions and experiences, as in previous studies (e.g., Lacroix et al., 2019), but also as a small source of joy or a way to keep children content in difficult circumstances.

Outcomes of SSB consumption
Participants in the current study also identified secrecy surrounding their consumption of SSB, preferring to drink SSB alone and conceal it from concerned family members.This theme also aligns with prior research on addictive-like eating; for example, studies where participants described going to great lengths to conceal eating patterns from their children and partners (Lacroix et al., 2019;Schiestl, 2021).Participants' secrecy surrounding SSB consumption may be partly due to existing health moralist messages that attach value judgements to food choices, often without recognizing systemic barriers that may limit food options and affordability (Bombak, 2015;Bombak et al., 2019;Waugh et al., 2023).Crawford (1980) described healthism, or health moralism, as the construction of health at the individual-level, such that maintaining "healthy" behaviours are a moral good.In this sample of Indigenous adults in Manitoba, the moralistic messaging surrounding SSB may intersect with racialized and classist stereotypes to further compound participants' urge to conceal SSB consumption.In this regard, we have previously reported the judgement participants living in the North End experienced when procuring SSB that some attributed to be exacerbated by their weight (Kisselgoff et al., 2024).
Conversely, some participants in the study expressed motivation to reduce or eliminate their SSB intake due to ongoing health conditions, health consequences, or general well-being.Notably, the literature highlights numerous health consequences associated with high SSB intake (e.g.Evans et al., 2013;Fung et al., 2009;Tseng et al., 2021;Valenzuela et al., 2021).This theme aligns with prior research that explores the role of physical and health consequences as drivers for behavior change.For example, a study investigating what factors influenced intentions to reduce intake of SSB in an Australian sample identified that the perceptions of future health risk had the strongest association with the intention to reduce SSB consumption, particularly for individuals who already felt they were consuming too much SSB (Dono et al., 2021).Our findings suggest Indigenous adults are very concerned about their personal health risk and risk to their children.Awareness of and concern for the high prevalence of type 2 diabetes among Indigenous communities was prominent in the interviews, as was the role of SSB in diabetes prevention and development.This suggests policies and programs addressing the potential drivers of SSB consumption may be more impactful than education regarding the health impacts.

Addictive-like SSB consumption among Indigenous populations
Some participants in this study described addictive-like patterns of SSB consumption that resemble addictive-like eating behaviour detailed in many different populations around the world (Lacroix & von Ranson, 2020).Although the patterns of addictive-like SSB consumption in our sample shared much in common with the experiences of other populations, historical trauma and inequalities in the social determinants of health may increase the likelihood and complexity of addictive-like SSB consumption among Indigenous Peoples.Specifically, Indigenous Peoples in Canada face racialized weight stigma (Cyr & Riediger, 2021;Kisselgoff et al., 2024), financial hardships (Kendall, 2022), barriers to accessing high-quality foods and beverages (Cidro et al., 2015), profound historical and ongoing colonial trauma, political oppression (Mitchell, 2019), and resultant stress from these structures, narratives, and context.Indigenous populations were forced to abandon traditional ways of life due to the implementation of reserve systems, residential schools, and other colonial policies, resulting in a historical and emotional imprint of shame, defeat, and self-hatred (Ross, 2006).In addition to their emotional impacts, the nutritional conditions at residential schools were often poor and substantially different from Indigenous Peoples' traditional food practices, contributing to the higher burden of type 2 diabetes presently (Mosby & Galloway, 2017a).As well, the continued issues with safe water, including, but not limited to, boil water advisories in First Nations communities and the inadequacy of governmental responses also contributes to further inequities and limited choices (White et al., 2012).The lack of safe water in First Nations communities, and the potential substitution with SSB (Cartwright et al., 2023) further emphasizes the complexity of SSB consumption patterns.The patterns of addictive-like SSB consumption described by our participants must be considered in context of these historical factors.
In light of the push by some researchers to conceptualize food addiction as a substance use disorder (e.g., Gearhardt & Shulte, 2021) including adding it to the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2013), it is important to avoid pathologizing participants' experiences (Finlayson, 2017) and to consider that addictive-like SSB consumption may represent a normal response to trauma and food insecurity, and an effort to avoid engaging in higher-risk behaviours like substance use.Given prior literature showing that addiction substitution is associated with poorer outcomes in substance use disorder treatment (Kim et al., 2021), we are cautious regarding consuming SSB as an intentional addiction substitution strategy.However, we do find it helpful to consider our findings through the wider lens of a harm reduction model.Harm reduction includes a "spectrum of strategies", typically to address drug, or substance use more generally, and the associated negative consequences (NHRC, 2020).An approach informed by harm reduction considers quality of life, reducing stigma, context, safety of individuals involved with substance use, and seeks to give people who use drugs or substances voices and empower them as primary agents of change (NHRC, 2020).Many of our findings from this study, including the intertwining of SSB with other addictions, and using SSB to cope, along with many aspects of the context of SSB consumption by Indigenous Peoples in Canada, could fit into an existing embrace of harm reduction.

Strengths and limitations
The study is subject to limitations.Interviews both within and across the three locations, were conducted by different interviewers, with different interview dynamics.Arguably, this may also serve as a strength, as diversity in the interview process could have allowed for more perspectives to be captured in the interviews.Similarly, recruitment approaches varied in each location owing to the community-based participatory approach and individual community research assistants.However, the base interview guide was initially the same in each location but updated iteratively throughout the study with new prompts to capitalize on emerging themes, which may have impacted later interviews more.Overall, the theme of addictive-like SSB consumption was much more prominent among the North End participants, as partially evidenced by the volume of quotes, but was present in all locations.The collection of interviews from several locations within Manitoba enhances the transferability of the findings.
Another limitation is that the study and interview guide were not specific to addiction, and we did not prompt participants with questions pertaining to addiction unless they brought it up.In line with this limitation, we were unable to ascertain if or how participants conceptions of addictive-like SSB consumption may have aligned with various criteria or constructs of addiction, distinguish between addictive or nonaddictive SSB consumption, or explore components of SSB that participants perceive as addictive (e.g.sugar, caffeine, carbonation, etc).Therefore, findings related to potential drivers or contexts of SSB consumption likely included participant's perceived drivers or contexts of both non-addictive, and addictive-like SSB intake.However, we view this finding of addictive-like consumption as an indication of the robustness of our results and the need to further explore addictive-like eating among Indigenous communities, due to its emergence within our study.

Conclusions
Indigenous adults report addictive-like consumption of SSB.More research is required to fully explore addictive-like eating more broadly among Indigenous communities considering the colonial context, associated intergenerational traumas, and persistent and growing disparities in type 2 diabetes in Manitoba (Ruth et al., 2020).This study also adds more broadly to the literature regarding addictive-like experiences of SSB intake.Findings may have important implications for universal policies being developed to address SSB intake as well as programs or interventions addressing other substance use disorders.

Funding sources
This study was funded by the Canadian Institutes of Health Research (CIHR) (grant # 156260) and NR was the recipient of a CIHR Early Career Investigator Award (grant # 155435).MK and AW were both recipients of a CIHR Canada Graduate Scholarship-Masters as well as top-up funding from the University of Manitoba, Faculty of Graduate Studies.Krista M was the recipient of a Prairie Indigenous Knowledge Exchange Network (PIKE-Net) summer research internship and funding from the Murphy Foundation.GS was funded by an Undergraduate Summer research award from the University of Manitoba.The funders did not have any role in the study design or dissemination.

Table 1
Demographic summary by location.
*if numbers do not sum to 100%, participants may have selected no answers, or multiple answers to demographic questions.