Food prices and obesity: evidence and policy implications for taxes and subsidies

Global Implementation of Obesity Prevention Policies: a Review of Progress, Politics, and the Path Forward

PURPOSE OF REVIEW

This review describes policy and regulatory strategies to prevent obesity and summarizes worldwide progress and impediments to scaling up strategies globally.

RECENT FINDINGS

While there is considerable variation in the breadth and depth of uptake of recommended strategies, the adoption of effective obesity prevention policies has been slow and inconsistent. There is broad consensus that strong government, corporate, and consumer actions, including regulatory measures, are needed to advance obesity prevention policies. Governments have lacked sufficient will to take necessary action, the food industry has actively worked to thwart policies to protect its commercial interests, and consumers have not exerted sufficient influence or demand to produce change. Advancing obesity prevention will require the use of effective strategies to shape and influence the information environments and political environments towards messages and actions to support public health. Greater emphasis is needed on reducing the influence of commercial interests, mobilizing civil society, and targeting vulnerable populations through equity-focused frameworks.

Insights on the Influence of Sugar Taxes on Obesity Prevention Efforts

PURPOSE OF REVIEW

This review will present the latest evidence on the impacts of sugar taxes on obesity with a focus on sugar-sweetened beverages (SSB).

RECENT FINDINGS

Evidence of direct impacts of SSB taxation policies on obesity prevalence continues to be limited. Natural experiments involving SSB taxation policies implemented in Mexico and Berkley, CA, indicate that this type of intervention alters beverage consumption patterns. Naturalistic evidence in combination with modeling studies suggests that SSB taxation is a viable anti-obesity policy. However, researchers and public health practitioners need to be vigilant of industry tactics to curtail SSB lowering efforts. To maximize the impacts of SSB taxation, it should be combined with interventions that increase access to non-sweetened beverages, educate consumers about alternative healthy beverages, and explore taxation of other non-nutritive foods and beverages. Furthermore, both intended and unintended consequences of interventions should be closely monitored.

The consumption of ultra-processed foods according to eating out occasions

Objective:

To describe out-of-home consumption according to the purpose and extent of industrial processing and also evaluate the association between eating out and ultra-processed food consumption, taking account of variance within and between individuals.

Design:

Cross-sectional study.

Setting:

Brazil.

Participants:

The study was based on the Individual Food Intake of the Brazilian Household Budget Survey, carried out with 34 003 individuals aged 10 years or more, between May 2008 and May 2009. All food items were classified according to food processing level. The habit of eating out was evaluated through the frequency of days each individual reported eating out, described according to sociodemographic characteristics. The contribution of food energy per group and subgroup was estimated according to the frequency of eating out. In addition, multilevel modelling was employed to evaluate the association between eating out and ultra-processed food consumption.

Results:

In Brazil, culinary preparations accounted for most of the energy eaten out. However, it was possible to observe a higher contribution of ultra-processed foods, especially sugary beverages and ready-to-eat meals, as the frequency of out-of-home consumption increased. Compared with food consumption exclusively at home, eating out increased the consumption of ultra-processed foods by 0·41 percentage points within and between individuals.

Conclusion:

In Brazil, the same individual and different individuals had greater consumption of ultra-processed foods when they ate out of home compared with when they ate at home. So, it is necessary to implement public policies which discourage the out-of-home consumption of ultra-processed foods and that provide affordable and accessible less-processed food options.

Perceptions of the possible health and economic impacts of Seattle's sugary beverage tax

BACKGROUND

Taxes on sugary beverages are an emerging strategy to improve health by reducing consumption and raising revenues to support community wellbeing. However, taxes may have unintended consequences, and perceptions of these consequences may affect attitudes towards this policy.

METHODS

In June 2017, the Seattle City Council passed an ordinance imposing a tax on sugary beverages, effective January 1, 2018. Between October and December 2017, we recruited 851 adults in Seattle to complete a survey (telephone or online) about support for the tax and their perceptions of tax-related health and economic impacts. We first analyzed data for the full sample. We then tested for differences in participants' responses by household income level (< 260% Federal Poverty Level [FPL], ≥ 260% FPL) and across race/ethnicities using chi-square tests. Analyses used population weights and adjusted for multiple comparisons, using the Holm-Bonferroni Sequential Correction (p < 0.01).

RESULTS

A majority of participants supported the sugary beverage tax (59%; 95% Confidence Interval [CI]: 55, 63%) and believed that the tax would improve public health (56%; CI: 52, 60%). Most participants believed that the tax would not negatively affect small businesses (52%; CI: 48, 56%) nor result in job loss (66%; CI: 62, 70%). Most participants also perceived that the tax would not negatively impact their own finances (79%; CI: 75, 82%). However, fewer lower-income (48%; CI: 42, 53%), versus higher-income participants (61%; CI: 55, 66%), perceived that the tax would improve public health, would not result in job loss (lower-income: 58%; CI: 53, 64%; higher-income: 71%; CI: 66, 75%) and would not negatively affect their own finances (lower-income: 68%; CI: 62, 73%; higher-income: 85%; CI: 81, 88%). Compared to non-Hispanic Whites, (82%; CI: 79, 86%), a smaller proportion of non-Hispanic Blacks (63%; 95% CI: 48, 75%), and Hispanics (67%; 95% CI: 51, 79%), perceived that the tax would have negative consequences for their own family finances.

CONCLUSIONS

A majority of respondents supported the sugary beverage tax in Seattle. Lower-income participants were more concerned about potential financial consequences. Further evaluation of the extent to which unintended consequences occur is needed.

Efficacy of population-wide diabetes and obesity prevention programs: An overview of systematic reviews on proximal, intermediate, and distal outcomes and a meta-analysis of impact on BMI

We conducted an overview of systematic reviews and a meta-analysis of the impact on body mass index (BMI) of primary studies of population-wide obesity and diabetes prevention programs, in order to evaluate their efficacy. We searched eight databases for reviews of population-level programs reporting effect on diet, physical activity, BMI, or prevalence of obesity/overweight or type 2 diabetes mellitus (T2DM). Meta-analysis of primary studies within reviews reporting effect on BMI. Interventions were categorized using ANGELO framework and quality assessment using AMSTAR. Fifty-three systematic reviews were included. Primary studies were largely natural experiments or cross-sectional studies of national data. Increased price of sugar-sweetened beverages (SSBs) and fast food, decreased price of fruit and vegetables, food labelling, and grocery store interventions were associated with positive effects on diet. Park and playground renovations and point-of-choice prompts to increase stair use were associated with positive effects on physical activity. Increased price of SSBs, menu labelling, grocery store interventions, and multicomponent interventions were associated with small reductions in BMI. There was insufficient evidence of impact of any interventions on the prevalence of overweight, obesity, or T2DM. We have identified a promising suite of population-wide actions to improve diet, increase physical activity, and reduce BMI. Impact on subsequent incidence of T2DM remains speculative.

Effects of Contextual Economic Factors on Childhood Obesity

OBJECTIVES

To examine the association between changes in contextual economic factors on childhood obesity in the US.

METHODS

We combined data from 2003, 2007, and 2011/2012 National Surveys of Children's Health for 129,781 children aged 10-17 with 27 state-level variables capturing general economic conditions, labor supply, and the monetary or time costs of calorie intake, physical activity, and cigarette smoking. We employed regression models controlling for demographic factors and state and year fixed effects. We also examined heterogeneity in economic effects by household income.

RESULTS

Obesity risk increased with workforce proportion in blue-collar occupations, urban sprawl, female labor force participation, and number of convenience stores but declined with median household income, smoking ban in restaurants, and full service restaurants per capita. Most effects were specific to low income households, except for density of supercenters/warehouse clubs which was significantly associated with higher overweight/obesity risk only in higher income households.

CONCLUSIONS FOR PRACTICE

Changes in state-level economic factors related to labor supply and monetary or time cost of calorie intake may affect childhood obesity especially for children in low-income households. Policymakers should consider these effects when designing programs aimed at reducing childhood obesity.

Socio-economic inequality in unhealthy snacks consumption among adolescent students in Iran: a concentration index decomposition analysis

OBJECTIVE

The present study aimed to assess and decompose the socio-economic inequality in unhealthy snacks consumption among adolescent students in Kerman, Iran.

DESIGN

The data were obtained from a cross-sectional study. Principal component analysis was done to measure the socio-economic status (SES) of the adolescents' families and the normalized concentration index (NCI) was used to measure the inequality in unhealthy snacks consumption among adolescent students of different SES. The contributions of environmental and individual explanatory variables to inequality were assessed by decomposing the concentration index.

SETTING

Forty secondary schools of Kerman Province in Iran in 2015.

PARTICIPANTS

Eighth-grade adolescent students (n 1320).

RESULTS

The data of 1242 adolescent students were completed for the current study. Unhealthy snacks consumption was unequally distributed among adolescent students and was concentrated mainly among the high-SES adolescents (NCI = 0·179; 95 % CI 0·056, 0·119). The decomposition showed that higher SES (62 %) and receiving pocket money allowance (31 %), as environmental variables, had the highest positive contributions to the measured inequality in unhealthy snacks consumption. Taste and sensory perception (7 %) as well as cost sensitivity (5 %), as individual variables, followed them in terms of their contribution importance.

CONCLUSIONS

It is highly suggested that both environmental and individual factors should be addressed at different settings including schools, families and suppliers of unhealthy snacks. These findings can help future health promotion strategies in Iran to tackle the observed inequality in unhealthy snacks consumption.

Attitudes and perceptions among urban South Africans towards sugar-sweetened beverages and taxation

OBJECTIVE

A tax on sugar-sweetened beverages (SSB) was introduced in South Africa in April 2018. Our objective was to document perceptions and attitudes among urban South Africans living in Soweto on factors that contribute to their SSB intake and on South Africa's use of a tax to reduce SSB consumption.

DESIGN

We conducted six focus group discussions using a semi-structured guide.

SETTING

The study was conducted in Soweto, Johannesburg, South Africa, 3 months before South Africa's SSB tax was implemented.

PARTICIPANTS

Adults aged 18 years or above living in Soweto (n 57).

RESULTS

Participants reported frequent SSB consumption and attributed this to habit, addiction, advertising and wide accessibility of SSB. Most of the participants were not aware of the proposed SSB tax; when made aware of the tax, their responses included both beliefs that it would and would not result in reduced SSB intake. However, participants indicated cynicism with regard to the government's stated motivation in introducing the tax for health rather than revenue reasons.

CONCLUSIONS

While an SSB tax is a policy tool that could be used with other strategies to reduce people's high level of SSB consumption in Soweto, our findings suggest a need to complement the SSB tax with a multipronged behaviour change strategy. This strategy could include both environmental and individual levers to reduce SSB consumption and its associated risks.

Following in the footsteps of tobacco and alcohol? Stakeholder discourse in UK newspaper coverage of the Soft Drinks Industry Levy

OBJECTIVE

In politically contested health debates, stakeholders on both sides present arguments and evidence to influence public opinion and the political agenda. The present study aimed to examine whether stakeholders in the Soft Drinks Industry Levy (SDIL) debate sought to establish or undermine the acceptability of this policy through the news media and how this compared with similar policy debates in relation to tobacco and alcohol industries.

DESIGN

Quantitative and qualitative content analysis of newspaper articles discussing sugar-sweetened beverage (SSB) taxation published in eleven UK newspapers between 1 April 2015 and 30 November 2016, identified through the Nexis database. Direct stakeholder citations were entered in NVivo to allow inductive thematic analysis and comparison with an established typology of industry stakeholder arguments used by the alcohol and tobacco industries.

SETTING

UK newspapers.

PARTICIPANTS

Proponents and opponents of SSB tax/SDIL cited in UK newspapers.

RESULTS

Four hundred and ninety-one newspaper articles cited stakeholders' (n 287) arguments in relation to SSB taxation (n 1761: 65 % supportive and 35 % opposing). Stakeholders' positions broadly reflected their vested interests. Inconsistencies arose from: changes in ideological position; insufficient clarity on the nature of the problem to be solved; policy priorities; and consistency with academic rigour. Both opposing and supportive themes were comparable with the alcohol and tobacco industry typology.

CONCLUSIONS

Public health advocates were particularly prominent in the UK newspaper debate surrounding the SDIL. Advocates in future policy debates might benefit from seeking a similar level of prominence and avoiding inconsistencies by being clearer about the policy objective and mechanisms.

Inter-brand competition in the convenience store industry, store density and healthcare utilization

We investigate the impact of access to convenience stores and competition between convenience store chains on the use of medical care in Taiwan. Using insurance claims from 0.85 million individuals and administrative data on store sales, we find that greater store density and more inter-brand competition reduced expenditures on outpatient medical services and prescription drugs. In support of these findings, we demonstrate that convenience store competition was associated with greater consumption of healthy foods and lower obesity rates. Our estimates suggest that the rise in convenience store competition from 2002 to 2012 reduced outpatient expenditures in Taiwan by 0.44 percent and prescription drug expenditures by 0.85 percent.

Legal and Administrative Feasibility of a Federal Junk Food and Sugar-Sweetened Beverage Tax to Improve Diet

OBJECTIVES

To evaluate legal and administrative feasibility of a federal "junk" food (including sugar-sweetened beverages [SSBs]) tax to improve diet.

METHODS

To assess food definitions and administration models, we systematically searched (1) PubMed (through May 15, 2017) for articles defining foods subject to taxes, and legal and legislative databases as well as online for (2) US federal, state, and tribal junk food tax bills and laws (January 1, 2012-February 28, 2017); SSB taxes (January 1, 2014-February 28, 2017); and international junk food tax laws (as of February 28, 2017); and (3) federal taxing mechanisms and administrative methods (as of February 28, 2017).

RESULTS

Articles recommend taxing foods by product category, broad nutrient criteria, specific nutrients or calories, or a combination. US junk food tax bills (n = 6) and laws (n = 3), international junk food laws (n = 2), and US SSB taxes (n = 10) support taxing foods using category-based (n = 8), nutrient-based (n = 1), or combination (n = 12) approaches. Federal taxing mechanisms (particularly manufacturer excise taxes on alcohol) and administrative methods provide informative models.

CONCLUSIONS

From legal and administrative perspectives, a federal junk food tax appears feasible based on product categories or combination category-plus-nutrient approaches, using a manufacturer excise tax, with additional support for sugar and graduated tax strategies.

Nutrient profiling and food prices: what is the cost of choosing healthier products?

BACKGROUND

The Health Star Rating (HSR) is a front-of-pack label designed to help Australian consumers identify healthier packaged foods. Price is an important determinant of food choice and yet no previous studies have examined the relationship between HSR and price. In the present study, we investigated whether (i) healthier packaged food products, as determined by HSR, are more expensive than less healthy alternatives and (ii) products displaying the HSR are more expensive than similar products that do not.

METHODS

Prices of three packaged foods categories (breakfast cereals, cereal-based bars and fruit juices) and nutrient data (to calculate HSR) were obtained from shopping receipts of approximately 1600 Australians between June 2014 and September 2016. Associations between HSR and price [per energy ($/100 kJ) and per unit ($/100 g)] for products of comparable package sizes were assessed by linear regression and the results are presented as differences in average price over the theoretical maximum range of HSR from 0.5 to 5 stars.

RESULTS

The HSR of products was not consistently related to price. Small positive associations were observed for juice ($0.08/100 mL; P = 0.03) and for cereal-based bars ($0.04/100 kJ; P = 0.02). No other associations between HSR and price were observed (P ≥ 0.23). Products that displayed the HSR were no more expensive on average than products that received a similar HSR but did not display the HSR (P ≥ 0.16).

CONCLUSIONS

In summary, the findings of the present study suggest that healthier packaged food products were not consistently more expensive than less healthy products and also that price is unlikely to be a barrier for consumers to use the HSR to select healthier packaged foods.

Assessing the impact of the Barbados sugar-sweetened beverage tax on beverage sales: an observational study

BACKGROUND

The World Health Organization has advocated for sugar-sweetened beverage (SSB) taxes as part of a broader non-communicable disease prevention strategy, and these taxes have been recently introduced in a wide range of settings. However, much is still unknown about how SSB taxes operate in various contexts and as a result of different tax designs. In 2015, the Government of Barbados implemented a 10% ad valorem (value-based) tax on SSBs. It has been hypothesized that this tax structure may inadvertently encourage consumers to switch to cheaper sugary drinks. We aimed to assess whether and to what extent there has been a change in sales of SSBs following implementation of the SSB tax.

METHODS

We used electronic point of sale data from a major grocery store chain and applied an interrupted time series (ITS) design to assess grocery store SSB and non-SSB sales from January 2013 to October 2016. We controlled for the underlying time trend, seasonality, inflation, tourism and holidays. We conducted sensitivity analyses using a cross-country control (Trinidad and Tobago) and a within-country control (vinegar). We included a post-hoc stratification by price tertile to assess the extent to which consumers may switch to cheaper sugary drinks.

RESULTS

We found that average weekly sales of SSBs decreased by 4.3% (95%CI 3.6 to 4.9%) compared to expected sales without a tax, primarily driven by a decrease in carbonated SSBs sales of 3.6% (95%CI 2.9 to 4.4%). Sales of non-SSBs increased by 5.2% (95%CI 4.5 to 5.9%), with bottled water sales increasing by an average of 7.5% (95%CI 6.5 to 8.3%). The sensitivity analyses were consistent with the uncontrolled results. After stratifying by price, we found evidence of substitution to cheaper SSBs.

CONCLUSIONS

This study suggests that the Barbados SSB tax was associated with decreased sales of SSBs in a major grocery store chain after controlling for underlying trends. This finding was robust to sensitivity analyses. We found evidence to suggest that consumers may have changed their behaviour in response to the tax by purchasing cheaper sugary drinks, in addition to substituting to untaxed products. This has important implications for the design of future SSB taxes.

Healthy Food Options at Dollar Discount Stores Are Equivalent in Quality and Lower in Price Compared to Grocery Stores: An Examination in Las Vegas, NV

Food deserts indicate limited access to and affordability of healthy foods. One potential mediator is the availability of healthy food in non-traditional outlets such as dollar-discount stores, stores selling produce at the fixed $1 price. The purpose of this study was to compare availability, quality, price differences in 'healthier' versus 'regular' food choices, price per each food item, and summary score in dollar-discount stores to grocery stores in Las Vegas using the NEMS-S; a protocol consisting of three subscores-availability, quality, price of healthier versus regular food, and a summary score. A 25% sample of grocery stores (n = 40) and all dollar-discount stores (n = 14) were evaluated. t-tests showed that dollar-discount stores were less likely to price healthy options lower than their unhealthy alternatives (mean (M) = 1.0 vs. M = 2.5; p < 0.001) and had reduced availability (M = 20.50 vs. M = 23.80; p < 0.001) compared to grocery stores. The quality of produce did not differ (M = 5.93 vs. M = 6.00; p = 0.34). Price comparisons revealed that 84.2% of produce and 89.5% of other food items were significantly less expensive at the dollar-discount stores, with only two items being more expensive. While dollar-discount stores did have lower availability, they provided quality fresh and healthy foods which were usually less expensive. Findings indicate that dollar discount stores may be an existing community asset, and considering them as such may aid in efforts to strengthen the overall food system. Practitioners should consider dollar discount stores when assessing the community food environment and designing and implementing outreach programs, as they may bridge some disparities in access.

The Association Between Food Prices and the Blood Glucose Level of US Adults With Type 2 Diabetes

Objectives. We estimated the association between the price of healthy and less-healthy food groups and blood sugar among US adults with type 2 diabetes.

Methods. We linked 1999–2006 National Health and Nutrition Examination Survey health information to food prices contained in the Quarterly Food-at-Home Price Database. We regressed blood sugar levels on food prices from the previous calendar quarter, controlling for market region and a range of other covariates. We also examined whether the association between food prices and blood sugar varies among different income groups.

Results. The prices of produce and low-fat dairy foods were associated with blood sugar levels of people with type 2 diabetes. Specifically, higher prices for produce and low-fat dairy foods were associated with higher levels of glycated hemoglobin and fasting plasma glucose 3 months later. Food prices had a greater association with blood sugar for low-income people than for higher-income people, and in the expected direction.

Conclusions. Higher prices of healthy foods were associated with increased blood sugar among people with type 2 diabetes. The association was especially pronounced among low-income people with type 2 diabetes.

The impact of rising food prices on obesity in women: a longitudinal analysis of 31 low-income and middle-income countries from 2000 to 2014

OBJECTIVES

To examine whether changes in food prices are associated with changes in obesity prevalence among women in developing countries, and assess effect modification by individual socioeconomic status (SES).

METHODS

Longitudinal study of country-level food price inflation temporally and geographically linked to anthropometric data on non-pregnant adult women (n = 295,984) in 31 low-income and middle-income countries over the 2000-2014 time period, using separate multivariable multilevel growth models of five SES indicators. Post-estimation analysis computed the relationship between food price inflation and predicted mean probabilities of being obese, by SES.

RESULTS

Rising food price inflation was strongly associated with women's obesity prevalence, and SES consistently modified the relationship. Regardless of indicator used, higher food price inflation was positively associated with obesity among women in top SES categories, but was flat or negative among women in low SES categories, averaging over time. The SES differences were widest across educational strata and were most pronounced when food price inflation was highest. Overall, for every 1-unit increase in food price inflation, predicted mean obesity prevalence was between 0.02 and 0.06 percentage points greater in women of high SES compared to low SES women.

CONCLUSION

There is a strong link between food price inflation and obesity in adult women in developing countries which is clearly modified by individuals' SES. Greater food price inflation was associated with greater obesity prevalence only among women in higher SES groups, who may be net food buyers most at risk of obesity in low-income and middle-income countries.

Comparative evidence of the consumption from fast-food restaurants between normal-weight and obese Saudi schoolchildren

OBJECTIVE

To provide an in-depth analysis of the relationship between obesity and fast-food consumption by comparing urban obese and normal-weight Saudi Arabian children.

DESIGN

A multicentre cross-sectional study was conducted from December 2015 to March 2016. Participants were divided into two groups (normal weight and obese) and further stratified by sex. Groups were randomly selected using a multistage stratified cluster-sampling technique. A self-paced questionnaire was used to collect data relating to food consumption. Weight height and waist circumference were measured and bioelectrical impedance analysis was performed in all children.

SETTING

Capital of Saudi Arabia, Riyadh.

SUBJECTS

Children aged 9·00-11·99 years (n 1023).

RESULTS

Compared with normal-weight groups, intake frequency of fast food/week was higher among the obese groups (P<0·001), irrespective of fast-food consumption outside (P<0·001) or inside (P<0·001) the home; and larger portion sizes were preferred in obese groups (P<0·001). Families eating fast-food meals together was a protective factor against obesity (OR; 95 % CI: 2·67; 1·44, 4·96, P<0·001), with similar results for families ordering from a 'healthy meals menu' for their children (1·90; 1·24, 2·90, P=0·002). Taste of fast foods (P=0·021), child-friendly menu (P=0·020) and meal cost (P<0·001) were identified as main reasons why parents took their children to fast-food restaurants; these data were replicated for parents with obese boys, but not girls.

CONCLUSIONS

Development of effective interventions to reduce fast-food consumption in Saudi Arabian schoolchildren requires greater research-based evidence of fast-food consumption habits and practices associated with increased childhood obesity.

Does the cost of a meal influence the portion size effect?

Serving larger portions leads to increased intake, but little is known about how the cost of a meal affects this response. Therefore, we tested whether the amount of money paid for a meal influenced the portion size effect at a lunch served in a controlled restaurant-style setting. In a crossover design, 79 adults (55 women; 24 men) came to the lab once a week for 4 weeks to eat a main dish of pasta with side dishes. Across weeks, the meal was varied in two factors: portion size of the main dish (400 g or 600 g) and cost of the meal (US$8 or $16). At discharge subjects completed questionnaires that assessed behaviors thought to influence the response to portion size and cost. Results showed that the portion size of the main dish had a significant effect on meal intake (P < 0.0001). The weight of food consumed at the meal increased by 18 ± 2% (mean ± SEM 83 ± 11 g) and energy intake increased by 20 ± 2% (133 ± 16 kcal) when the larger portion was served. These effects of portion size did not differ across the two levels of cost (both interactions P > 0.37) nor did meal cost have significant effects on meal intake (both P > 0.24). Subject scores for satiety responsiveness did, however, influence the effect of portion size on food intake (P = 0.0007). Serving larger portions led to increased intake in subjects with lower satiety responsiveness scores (P < 0.0001), but did not affect intake in those with higher scores. In summary, the effect of portion size on intake in a restaurant-style setting was not influenced by meal cost but was attenuated in individuals higher in satiety responsiveness.

Sugar-Sweetened Beverage, Obesity, and Type 2 Diabetes in Children and Adolescents: Policies, Taxation, and Programs

PURPOSE OF REVIEW

Obesity has grown at an alarming rate in children and adolescents. Concurrently, consumption on sugar-sweetened beverages (SSBs) also rose significantly. This review provides an overview of obesity and type 2 diabetes mellitus (T2DM) related to SSBs and current policies restricting SSBs in schools, school-based interventions, and taxation on reducing SSB intake and obesity. We also discuss challenges of and future steps for these initiatives.

RECENT FINDINGS

Clinical and epidemiological studies suggest a strong association between SSB intake and obesity and T2DM. School food policies have been initiated at federal, state, and local levels. School-based interventions have shown positive effects on SSB intake and obesity reduction. Taxation on SSBs is promising in combating obesity and in generating revenue. Challenges towards compliance and implementation of the policies and programs exist. The relationship between SSB and obesity and T2DM is a complex problem which requires comprehensive solutions. Continued efforts in restricting SSBs in schools are needed. Intervention programs should be tailored to age, gender, language, and culture and involve participation from families and local communities. Taxation can reduce SSB consumption by direct economic incentive, earmarking revenues to support healthy foods, and sending negative message. However, a higher tax rate may be necessary to have a measurable effect on weight.

Understanding the risk and protective factors associated with obesity amongst Libyan adults - a qualitative study

Background

There are a range of multifaceted behavioural and societal factors that combine to contribute to the causes of obesity. However, it is not yet known how particularly countries’ cultural norms are contributing to the global obesity epidemic. Despite obesity reaching epidemic proportions in Libya, since the discovery of oil in 1959, there is a lack of information about obesity in Libyan adults. This study sought to explore the views of key informants about the risk and protective factors associated with obesity among Libyan men and women.

Methods

A series of qualitative semi-structured interviews were conducted with Libyan healthcare professionals and community leaders.

Results

Eleven main themes (risk and protective factors) were identified, specifically: socio-demographic and biological factors, socioeconomic status, unhealthy eating behaviours, knowledge about obesity, social-cultural influences, Libya’s healthcare facilities, physical activity and the effect of the neighbourhood environment, sedentary behaviour, Libyan food-subsidy policy, and suggestions for preventing and controlling obesity.

Conclusions

Key recommendations are that an electronic health information system needs to be implemented and awareness about obesity and its causes and consequences needs to be raised among the public in order to dispel the many myths and misconceptions held by Libyans about obesity. The current political instability within Libya is contributing to a less-active lifestyle for the population due to security concerns and the impact of curfews. Our findings have implications for Libyan health policy and highlight the urgent need for action towards mitigating against the obesity epidemic in Libya.

Seattle's minimum wage ordinance did not affect supermarket food prices by food processing category

OBJECTIVE

To examine the impacts of Seattle's minimum wage ordinance on food prices by food processing category.

DESIGN

Supermarket food prices were collected for 106 items using a University of Washington Center for Public Health Nutrition market basket at affected and unaffected supermarket chain stores at three times: March 2015 (1-month pre-policy enactment), May 2015 (1-month post-policy enactment) and May 2016 (1-year post-policy enactment). Food items were categorized into four food processing groups, from minimally to ultra-processed. Data were analysed across time using a multilevel, linear difference-in-differences model at the store and price level stratified by level of food processing.

SETTING

Six large supermarket chain stores located in Seattle ('intervention') affected by the policy and six same-chain but unaffected stores in King County ('control'), Washington, USA.

SUBJECTS

One hundred and six food and beverage items.

RESULTS

The largest change in average price by food item was +$US 0·53 for 'processed foods' in King County between 1-month post-policy and 1-year post-policy enactment (P < 0·01). The smallest change was $US 0·00 for 'unprocessed or minimally processed foods' in Seattle between 1-month post-policy and 1-year post-policy enactment (P = 0·94). No significant changes in averaged chain prices were observed across food processing level strata in Seattle v. King County stores at 1-month or 1-year post-policy enactment.

CONCLUSIONS

Supermarket food prices do not appear to be differentially impacted by Seattle's minimum wage ordinance by level of the food's processing. These results suggest that the early implementation of a city-level minimum wage policy does not alter supermarket food prices by level of food processing.

Using evidence-informed policies to tackle overweight and obesity in Chile

Overweight and obesity are a global epidemic with rates having risen to alarming levels in both developed and developing countries. Chile has been no exemption, with sharp increases in obesity prevalence, especially among school-age children. This paper describes the policy actions and strategies implemented to tackle this major public health concern in Chile over the last 10 years, and highlights the main challenges and nuances of the process. Chile has taken policy action that includes front-of-package labelling, advertising regulations, and school-food restrictions. New policies focus on the social determinants of health as they relate to food environments and people’s behavior. These actions are not only suitable to the current context in Chile, but are also supported by the best available scientific evidence. Moreover, the implementation of these policies has produced a broad debate involving public institutions and the food industry, with discussions issues ranging from property rights to trade barriers. Despite some differences among stakeholders, a valuable political consensus has been achieved, and several international organizations are eager to evaluate the impact of these pioneer initiatives in Latin America.

Do high vs. low purchasers respond differently to a nonessential energy-dense food tax? Two-year evaluation of Mexico's 8% nonessential food tax

It is unclear whether response to a nonessential food tax varies across time or for high vs. low-consuming households. The objective is to examine whether the effect of Mexico's 2014 8% nonessential energy-dense foods tax increased in the second year post-implementation and whether it differentially affected households by pre-tax purchasing pattern. We used longitudinal data on Mexican household food purchases (n=6089 households) from 2012 to 2015. Households were classified based on median pre-tax purchases: low untaxed/low taxed ("low"), low untaxed/high taxed ("unhealthy"), high untaxed/low taxed ("healthy"), and high untaxed/high taxed ("high") purchasers. Fixed effects models tested whether observed post-tax purchases differed from the counterfactual, or what would have been expected based on pre-tax trends. Post-tax declines in the % taxed food purchases increased from -4.8% in year one to -7.4% in year two, yielding a 2-year mean decline of 6.0% beyond the counterfactual (p<0.01). Post-tax change in % taxed food purchases varied by pre-tax purchasing level. Healthy purchasers showed no post-tax change in % taxed food purchases beyond the counterfactual, while unhealthy, low and high purchasers decreased (-12.3%, -5.3% and -4.4%, respectively) (p<0.01). The positive effect of Mexico's junk food tax continued in the second year, and households with greater preferences for taxed foods showed a larger decline in taxed food purchases.

State-of-the-art for food taxes to promote public health

The use of taxes to promote healthy nutritional behaviour has gained ground in the past decade. The present paper reviews existing applications of fiscal instruments in nutrition policy and derives some perspectives and recommendations from the experiences gained with these instruments. Many countries in different parts of the world have experiences with the taxation of sugar-sweetened beverages, in some cases in combination with taxes on unhealthy food commodities such as confectionery or high-fat foods. These tax schemes have many similarities, but also differ in their definitions of tax objects and in the applied tax rates. Denmark has been the only country in the world to operate a tax on saturated fat content in foods, from 2011 to 2012. Most of the existing food tax schemes have been introduced from fiscal motivations, with health promotion as a secondary objective, but a few have been introduced with health promotion as the primary objective. The diversity in experiences from existing tax schemes can provide valuable insights for future use of fiscal instruments to promote healthy nutrition, in terms of designing effective and efficient tax or subsidy instruments, and in terms of smooth and politically viable implementation of the instruments.

Neighborhood Prices of Healthier and Unhealthier Foods and Associations with Diet Quality: Evidence from the Multi-Ethnic Study of Atherosclerosis

It is known that the price of food influences the purchasing and consumption decisions of individuals; however, little work has examined if the price of healthier food relative to unhealthier food in an individual’s neighborhood is associated with overall dietary quality while using data from multiple regions in the United States. Cross-sectional person-level data came from The Multi-Ethnic Study of Atherosclerosis (exam 5, 2010–2012, n = 2765); a food frequency questionnaire assessed diet. Supermarket food/beverage prices came from Information Resources Inc. (n = 794 supermarkets). For each individual, the average price of select indicators of healthier foods (vegetables, fruits, dairy) and unhealthier foods (soda, sweets, salty snacks), as well as their ratio, was computed for supermarkets within three miles of the person’s residential address. Logistic regression estimated odds ratios of a high-quality diet (top quintile of Healthy Eating Index 2010) associated with healthy-to-unhealthy price ratio, adjusted for individual and neighborhood characteristics. Sensitivity analyses used an instrumental variable (IV) approach. Healthier foods cost nearly twice as much as unhealthier foods per serving on average (mean healthy-to-unhealthy ratio = 1.97 [SD 0.14]). A larger healthy-to-unhealthy price ratio was associated with lower odds of a high-quality diet (OR = 0.76 per SD increase in the ratio, 95% CI = [0.64–0.9]). IV analyses largely confirmed these findings although—as expected with IV adjustment—confidence intervals were wide (OR = 0.82 [0.57–1.19]). Policies to address the large price differences between healthier and unhealthy foods may help improve diet quality in the United States.

Pricing Strategies to Encourage Availability, Purchase, and Consumption of Healthy Foods and Beverages: A Systematic Review

Introduction

Food pricing policies to promote healthy diets, such as taxes, price manipulations, and food subsidies, have been tested in different settings. However, little consensus exists about the effect of these policies on the availability of healthy and unhealthy foods, on what foods consumers buy, or on the impact of food purchases on consumer health outcomes. We conducted a systematic review of studies of the effect of food-pricing interventions on retail sales and on consumer purchasing and consumption of healthy foods and beverages.

Methods

We used MEDLINE, Embase, PsycINFO, Web of Science, ClinicalTrials.gov, and the Cochrane Library to conduct a systematic search for peer-reviewed articles related to studies of food pricing policies. We selected articles that were published in English from January 2000 through December 2016 on the following types of studies: 1) real-world experimental studies (randomized controlled trials, quasi-experimental studies, and natural experiments); 2) population studies of people or retail stores in middle-income and high-income countries; 3) pricing interventions alone or in combination with other strategies (price promotions, coupons, taxes, or cash-back rebates), excluding studies of vending-machine or online sales; and 4) outcomes studies at the retail (stocking, sales) and consumer (purchasing, consumption) levels. We selected 65 articles representing 30 studies for review.

Results

Sixteen pricing intervention studies that sought to improve access to healthy food and beverage options reported increased stocking and sales of promoted food items. Most studies (n = 23) reported improvement in the purchasing and consumption of healthy foods or beverages or decreased purchasing and consumption of unhealthy foods or beverages. Most studies assessed promotions of fresh fruits and vegetables (n = 20); however, these foods may be hard to source, have high perishability, and raise concerns about safety and handling. Few of the pricing studies we reviewed discouraged purchasing and consumption of unhealthy foods (n = 6). Many studies we reviewed had limitations, including lack of formative research, process evaluation, or psychosocial and health assessments of the intervention’s impact; short intervention duration; or no assessment of food substitutions or the effects of pricing interventions on food purchasing and diets.

Conclusion

Pricing interventions generally increased stocking, sales, purchasing, and consumption of promoted foods and beverages. Additional studies are needed to differentiate the potential impact of selected pricing strategies and policies over others.

Deal or no deal? The prevalence and nutritional quality of price promotions among U.S. food and beverage purchases

OBJECTIVE

This study examines trends in the prevalence of price promotions among packaged food and beverage purchases, differences in prevalence by household race/ethnicity or income, and the association between price promotions and the nutritional profile of purchases.

DESIGN

This cross-sectional study utilizes a dataset of 90 million purchases from 38,744 (2008) to 45,042 (2012) US households in 2008-2012. Chi-square tests were used to examine whether the proportion of purchases with price promotions changed over time or differed by household race/ethnicity or income. T-tests were used to compare purchased products' nutritional profiles.

RESULTS

Prevalence of price promotions among packaged food and beverage purchases increased by 8% and 6%, respectively, from 2008 to 2012, with both reaching 34% by 2012. Higher-income households had greater proportions of purchases with price promotions than lower-income households. Asian households had the highest proportion of purchases with any price promotion, followed by non-Hispanic whites. While total price-promoted packaged food purchases had higher mean energy, total sugar, and saturated fat densities than purchases with no price promotions, absolute differences were small.

CONCLUSIONS

Prevalence of price promotions among US household purchases increased from 2008 to 2012 and was greater for higher-income households. No clear associations emerged between presence of price promotions and nutritional quality of purchases.

A free lunch or a walk back home? The school food environment and dietary behaviours among children and adolescents in Ghana

Food environments can play an important roles in shaping nutrition and health outcomes. One such environment that has potential to affect youth is the school food environment. In contrast to higher-income countries, however, there is a critical evidence gap on the role of school food environments on children and adolescents in low- and middle-income countries. This mixed-methods study contributes to filling this gap by investigating the role of school food environments on dietary behaviours of children and adolescents in Ghana. It draws on data from household and school questionnaires as well as focus group discussions collected as part of the baseline for an impact evaluation of the Ghana School Feeding Programme (GSFP). Multi-level regression models were fitted with random intercepts at the individual, household and community levels. Excerpts from the focus group discussions provided a deeper understanding of quantitative findings. Children and adolescents who received free school meals provided by the GSFP or who lived further away from school were less likely to go home for lunch. More than half of sampled schools reported offering foods for sale by independent vendors, the most common being meals followed by confectionery, fruit and sugar-sweetened beverages. Predictors of bringing money to school to buy food included non-receipt of free school meals, adolescence, greater commuting distance from home, household asset score, and urban location. Policy efforts focusing on the school food environment may contribute to healthy dietary behaviours for children and adolescents with positive impacts over the lifecourse.

Are Big Food’s corporate social responsibility strategies valuable to communities? A qualitative study with parents and children

Objective

Recent studies have identified parents and children as two target groups whom Big Food hopes to positively influence through its corporate social responsibility (CSR) strategies. The current preliminary study aimed to gain an in-depth understanding of parents and children’s awareness and interpretation of Big Food’s CSR strategies to understand how CSR shapes their beliefs about companies.

Design

Community-based qualitative semi-structured interviews.

Setting

New South Wales, Australia.

Subjects

Parents (n 15) and children aged 8–12 years (n 15).

Results

Parents and children showed unprompted recognition of CSR activities when shown McDonald’s and Coca-Cola brand logos, indicating a strong level of association between the brands and activities that target the settings of children. When discussing CSR strategies some parents and most children saw value in the activities, viewing them as acts of merit or worth. For some parents and children, the companies’ CSR activities were seen as a reflection of the company’s moral attributes, which resonated with their own values of charity and health. For others, CSR strategies were in conflict with companies’ core business. Finally, some also viewed the activities as harmful, representing a deceit of the public and a smokescreen for the companies’ ultimately unethical behaviour.

Conclusions

A large proportion of participants valued the CSR activities, signalling that denormalising CSR to sever the strong ties between the community and Big Food will be a difficult process for the public health community. Efforts to gain public acceptance for action on CSR may need greater levels of persuasion to gain public support of a comprehensive and restrictive approach.

Improving food environments and tackling obesity: A realist systematic review of the policy success of regulatory interventions targeting population nutrition

Background

This systematic review (PROSPERO: CRD42015025276) employs a realist approach to investigate the effect of “real-world” policies targeting different aspects of the food environment that shape individual and collective nutrition.

Objectives

We were interested in assessing intermediate outcomes along the assumed causal pathway to “policy success”, in addition to the final outcome of changed consumption patterns.

Data sources

We performed a search of 16 databases through October 2015, with no initial restriction by language.

Study eligibility criteria

We included all publications that reported the effect of statutory provisions aimed at reducing the consumption of energy-dense foods and beverages in the general population. We allowed all methodological approaches that contained some measure of comparison, including studies of implementation progress.

Study appraisal and synthesis methods

We reviewed included studies using the appraisal tools for pre-post and observational studies developed by the National Heart, Lung, and Blood Institute. Given the considerable heterogeneity in interventions assessed, study designs employed, and outcome measures reported, we opted for a narrative synthesis of results.

Results and implications

Results drawn from 36 peer-reviewed articles and grey literature reports demonstrated that isolated regulatory interventions can improve intermediate outcomes, but fail to affect consumption at clinically significant levels. The included literature covered six different types of interventions, with 19 studies reporting on calorie posting on chain restaurant menus. The large majority of the identified interventions were conducted in the US. Early results from recent taxation measures were published after the review cut-off date but these suggested more favorable effects on consumption levels. Nevertheless, the evidence assessed in this review suggests that current policies are generally falling short of anticipated health impacts.

Public Attitudes and Support for a Sugar-Sweetened Beverage Tax in America's Heartland

BACKGROUND

Policy and environmental strategies are part of a comprehensive approach to obesity prevention. We investigated the association between public attitudes about how the environment influences health and support for a sugar-sweetened beverage (SSB) tax in Kansas.

METHOD

We collected data via a 2014 representative dual-frame (cellular and landline) telephone survey of 2,203 adult Kansans regarding healthy eating policy support and beliefs about obesity causes and solutions.

RESULTS

A significant proportion of Kansas adults (40%) support an SSB tax. Support was significantly stronger among females, young people, and liberals. Causal and responsibility attributions of obesity were significantly associated with policy support. Individuals who attribute more responsibility for the solution to the obesity epidemic to environmental factors were more likely to support a tax, regardless of their political affiliation.

CONCLUSIONS

Messaging that focuses on the role of the environment in creating opportunities for health may be useful in framing discussions around SSB taxes.

The effects of policy actions to improve population dietary patterns and prevent diet-related non-communicable diseases: scoping review

Poor diet generates a bigger non-communicable disease (NCD) burden than tobacco, alcohol and physical inactivity combined. We reviewed the potential effectiveness of policy actions to improve healthy food consumption and thus prevent NCDs. This scoping review focused on systematic and non-systematic reviews and categorised data using a seven-part framework: price, promotion, provision, composition, labelling, supply chain, trade/investment and multi-component interventions. We screened 1805 candidate publications and included 58 systematic and non-systematic reviews. Multi-component and price interventions appeared consistently powerful in improving healthy eating. Reformulation to reduce industrial trans fat intake also seemed very effective. Evidence on food supply chain, trade and investment studies was limited and merits further research. Food labelling and restrictions on provision or marketing of unhealthy foods were generally less effective with uncertain sustainability. Increasingly strong evidence is highlighting potentially powerful policies to improve diet and thus prevent NCDs, notably multi-component interventions, taxes, subsidies, elimination and perhaps trade agreements. The implications for policy makers are becoming clearer.

Global Trends in the Affordability of Sugar-Sweetened Beverages, 1990–2016

Introduction

The objective of this study was to quantify changes in the affordability of sugar-sweetened beverages, a product implicated as a contributor to rising rates of obesity worldwide, as a function of product price and personal income.

Methods

We used international survey data in a retrospective analysis of 40 high-income and 42 low-income and middle-income countries from 1990 to 2016. Prices of sugar-sweetened beverages were from the Economist Intelligence Unit’s World Cost of Living Survey. Income and inflation data were from the International Monetary Fund’s World Economic Outlook Database. The measure of affordability was the average annual percentage change in the relative-income price of sugar-sweetened beverages, which is the annual rate of change in the proportion of per capita gross domestic product needed to purchase 100 L of Coca-Cola in each country in each year of the study.

Results

In 79 of 82 countries, the proportion of income needed to purchase sugar-sweetened beverages declined on average (using annual measures) during the study period. This pattern, described as an increase in the affordability of sugar-sweetened beverages, indicated that sugar-sweetened beverages became more affordable more rapidly in low-income and middle-income countries than in high-income countries, a fact largely attributable to the higher rate of income growth in those countries than to a decline in the real price of sugar-sweetened beverages.

Conclusion

Without deliberate policy action to raise prices, sugar-sweetened beverages are likely to become more affordable and more widely consumed around the world.

Store-directed price promotions and communications strategies improve healthier food supply and demand: impact results from a randomized controlled, Baltimore City store-intervention trial

Objective

Small food store interventions show promise to increase healthy food access in under-resourced areas. However, none have tested the impact of price discounts on healthy food supply and demand. We tested the impact of store-directed price discounts and communications strategies, separately and combined, on the stocking, sales and prices of healthier foods and on storeowner psychosocial factors.

Design

Factorial design randomized controlled trial.

Setting

Twenty-four corner stores in low-income neighbourhoods of Baltimore City, MD, USA.

Subjects

Stores were randomized to pricing intervention, communications intervention, combined pricing and communications intervention, or control. Stores that received the pricing intervention were given a 10–30% price discount by wholesalers on selected healthier food items during the 6-month trial. Communications stores received visual and interactive materials to promote healthy items, including signage, taste tests and refrigerators.

Results

All interventions showed significantly increased stock of promoted foods υ. control. There was a significant treatment effect for daily unit sales of healthy snacks (β = 6·4, 95% CI 0·9, 11·9) and prices of healthy staple foods (β = −0·49, 95% CI −0·90, −0·03) for the combined group υ. control, but not for other intervention groups. There were no significant intervention effects on storeowner psychosocial factors.

Conclusions

All interventions led to increased stock of healthier foods. The combined intervention was effective in increasing sales of healthier snacks, even though discounts on snacks were not passed to the consumer. Experimental research in small stores is needed to understand the mechanisms by which store-directed price promotions can increase healthy food supply and demand.

Rebates to Incentivize Healthy Nutrition Choices in the Supplemental Nutrition Assistance Program

Price incentives, or rebates, have been proposed as one promising strategy for improving diet quality among Supplemental Nutrition Assistance Program participants. This paper explores the existing evidence on effectiveness of rebates in this program. In particular, this paper considers findings from a recent RCT of Supplemental Nutrition Assistance Program rebates, the U.S. Department of Agriculture Healthy Incentives Pilot, in the context of the broader literature on rebate strategies. The paper concludes that rebates have a moderate impact on food intake, at moderate cost relative to alternative interventions. There is further evidence that implicit promotional effects may contribute to impacts of rebate interventions, beyond the impacts of price effects alone. However, existing studies on complementary effects of explicit promotion have been limited by relatively small sample sizes and correspondingly low power to detect differences. This appears to be a promising area for future research.

Food and beverage price discounts to improve health in remote Aboriginal communities: mixed method evaluation of a natural experiment

OBJECTIVE

Retrospectively evaluate food price discounts in remote Aboriginal community stores.

METHODS

Four price discount strategies of 10% were designed in 2010, aiming to influence grocery, fruit, vegetables and diet soft-drink sales. This natural experiment across a group of stores was evaluated using an explanatory, sequential mixed method design through analysis of store point-of-sale, document, observation and interview data. The outcome was measured by change in: 1) percentage of grocery sales to total food and beverage; 2) fruit and vegetable sales; and 3) diet soft-drink sales. Qualitative data enabled the interpretation of outcomes through understanding perceived success and benefits, and enablers and barriers to implementation.

RESULTS

Eighteen community stores and 54 informants participated. While targeted price discounts were considered important to improving health, no discernible effect was evident, due to inadequate design and communication of discount promotion, and probably inadequate magnitude of discount.

CONCLUSIONS

Strategy impact on food and beverage sales was limited by promotion and magnitude of discount. Implication for Public Health: This study demonstrates key factors and commitment required to design, communicate, implement and monitor strategies to improve health in this challenging remote retail context. Evaluation of natural experiments can contribute evidence to policy-making.

Taxing sugar-sweetened beverages: impact on overweight and obesity in Germany

BACKGROUND

Consumption of sugar-sweetened beverages (SSBs) increases the risk of overweight and obesity. Taxing SSBs could decrease daily energy consumption and body weight. This model-based study evaluated the impact of a 20% SSB-sales tax on overweight and obesity in the context of Germany.

METHODS

The population aged 15-79 years was modelled. Taxation was assumed to affect energy consumption via demand elasticities, which affected weight and BMI. Model-based analysis was performed to estimate the tax impact on BMI in different age, gender and income groups.

RESULTS

Implementing a 20% SSB tax reduced energy consumption mainly in younger age groups, males, and those with low income. Taxation decreased the mean BMI in younger groups, with the largest decrease in those aged 20-29 years, while effects in groups 60 years or above were minimal. In absolute terms, taxation was estimated to avoid 1,028,000 (-3% relative reduction) overweight individuals and 479,000 obese individuals (-4%). Overweight decreased the most in males aged 20-29 years (408,000 fewer cases /-22%), the same applied for obesity (204,000/-22%).

CONCLUSIONS

An SSB tax could have significant impact on overweight and obesity, which could translate into substantial reductions of morbidity and mortality.

Effect of Meat Price on Race and Gender Disparities in Obesity, Mortality and Quality of Life in the US: A Model-Based Analysis

INTRODUCTION

There are large differences in the burden and health implications of obesity by race and gender in the US. It is unclear to what extent policies modifying caloric consumption change the distribution of the burden of obesity and related health outcomes. Meat is a large component of the American diet. We investigate how changing meat prices (that may result from policies or from exogenous factors that reduce supply) might impact the burden of obesity by race and gender.

METHODS

We construct a microsimulation model that evaluates the 15-year body-mass index (BMI) and mortality impact of changes in meat price (5, 10, 25, and 50% increase) in the US adult population stratified by age, gender, race, and BMI.

RESULTS

Under each price change evaluated, relative to the status quo, white males, black males, and black females are expected to realize more dramatic reduction in 2030 obesity prevalence than white females. Life expectancy gains are also projected to differ by subpopulation, with black males far less likely to benefit from an increase in meat prices than other groups.

CONCLUSIONS

Changing meat prices has considerable potential to affect population health differently by race and gender. In designing interventions that alter the price of foods to consumers, it is not sufficient to assess health effects based solely on the population as a whole, since differential effects across subpopulations may be substantial.

Young adults' responses to alternative messages describing a sugar-sweetened beverage price increase

OBJECTIVE

Many jurisdictions in the USA and globally are considering raising the prices of sugar-sweetened beverages (SSB) through taxes as a strategy to reduce their consumption. The objective of the present study was to identify whether the rationale provided for an SSB price increase affects young adults' behavioural intentions and attitudes towards SSB.

DESIGN

Participants were randomly assigned to receive one of eight SSB price increase rationales. Intentions to purchase SSB and attitudes about the product and policy were measured.

SETTING

A forty-six-item cross-sectional Internet survey.

SUBJECTS

Undergraduate students (n 494) at a large US Midwestern university.

RESULTS

Rationale type was significantly associated with differences in participants' purchasing intentions for the full sample (F 7,485=2·53, P=0·014). Presenting the rationale for an SSB price increase as a user fee, an effort to reduce obesity, a strategy to offset health-care costs or to protect children led to lower SSB purchasing intentions compared with a message with no rationale. Rationale type was also significantly associated with differences in perceptions of soda companies (F 7,485=2·10, P=0·043); among low consumers of SSB, messages describing the price increase as a user fee or tax led to more negative perceptions of soda companies.

CONCLUSIONS

The rationale attached to an SSB price increase could influence consumers. However, these message effects may depend on individuals' level of SSB consumption.

Can policy ameliorate socioeconomic inequities in obesity and obesity-related behaviours? A systematic review of the impact of universal policies on adults and children

This systematic review examined the impact of universal policies on socioeconomic inequities in obesity, dietary and physical activity behaviours among adults and children. PRISMA-Equity guidelines were followed. Database searches spanned from 2004 to August 2015. Eligible studies assessed the impact of universal policies on anthropometric, dietary or physical activity-related outcomes in adults or children according to socioeconomic position. Thirty-six studies were included. Policies were classified as agentic, agento-structural or structural, and their impact on inequities was rated as positive, neutral, negative or mixed according to the dominant associations observed. Most policies had neutral impacts on obesity-related inequities regardless of whether they were agentic (60% neutral), agento-structural (68% neutral) or structural (67% neutral). The proportion of positive impacts was similar across policy types (10% agentic, 18% agento-structural and 11% structural), with some differences for negative impacts (30% agentic, 14% agento-structural and 22% structural). The majority of associations remained neutral when stratified by participant population, implementation level and socioeconomic position measures and by anthropometric and behavioural outcomes. Fiscal measures had consistently neutral or positive impacts on inequities. Findings suggest an important role for policy in addressing obesity in an equitable manner and strengthen the case for implementing a broad complement of policies spanning the agency-structure continuum.

Earmarking and the political support of fat taxes

An unhealthy good causes health issues in the long run. It creates a misperceived utility loss and increases health care costs. Conversely, a healthy good provides misperceived utility gains and reduces health care costs. Individuals differ in income and in their degree of misperception; they vote over a fat tax according to their misperceived utility. A fraction of the tax proceeds is "earmarked" to reduce health insurance premiums; the remainder finances a subsidy on the healthy good. This earmarking rule is determined to maximize welfare, anticipating the induced political equilibrium. The equilibrium fat tax is always lower than the utilitarian level. This is not necessarily true with a Rawlsian objective. The determination of the earmarking rule is complex. Even in the utilitarian case, it is not just used to boost political support for the fat tax. Instead, it may involve a tradeoff between fat tax and healthy good subsidy.

Obesity and Smoking: can we Kill Two Birds with one Tax?

The debate on tobacco and fat taxes often treats smoking and eating as independent behaviors. However, the available evidence shows that they are interdependent, which implies that policies against smoking or obesity may have larger scope than expected. To address this issue, we propose a dynamic rational model where eating, smoking, and physical exercise are simultaneous choices that jointly affect body weight and addiction to smoking. Focusing on direct and cross-price effects, we study the impact of tobacco and food taxes, and we show that in both cases a single policy tool can reduce both smoking and body weight. Copyright © 2015 John Wiley & Sons, Ltd.

Effects of Taxing Sugar-Sweetened Beverages on Caries and Treatment Costs

Caries increment is affected by sugar-sweetened beverage (SSB) consumption. Taxing SSBs could reduce sugar consumption and caries increment. The authors aimed to estimate the impact of a 20% SSB sales tax on caries increment and associated treatment costs (as well as the resulting tax revenue) in the context of Germany. A model-based approach was taken, estimating the effects for the German population aged 14 to 79 y over a 10-y period. Taxation was assumed to affect beverage-associated sugar consumption via empirical demand elasticities. Altered consumption affected caries increments and treatment costs, with cost estimates being calculated under the perspective of the statutory health insurance. National representative consumption and price data were used to estimate tax revenue. Microsimulations were performed to estimate health outcomes, costs, and revenue impact in different age, sex, and income groups. Implementing a 20% SSB sales tax reduced sugar consumption in nearly all male groups but in fewer female groups. The reduction was larger among younger than older individuals and among those with low income. Taxation reduced caries increment and treatment costs especially in younger (rather than older) individuals and those with low income. Over 10 y, mean (SD) net caries increments at the population level were 82.27 (1.15) million and 83.02 (1.08) million teeth at 20% and 0% SSB tax, respectively. These generated treatment costs of 2.64 (0.39) billion and 2.72 (0.35) billion euro, respectively. Additional tax revenue was 37.99 (3.41) billion euro over the 10 y. In conclusion and within the limitations of this study's perspective, database, and underlying assumptions, implementing a 20% sales tax on SSBs is likely to reduce caries increment, especially in young low-income males, thereby also reducing inequalities in the distribution of caries experience. Taxation would also reduce treatment costs. However, these reductions might be limited in the total population.