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

The effects of a 25% discount on fruits and vegetables: results of a randomized trial in a three-dimensional web-based supermarket

Background

Lowering the price of fruit and vegetables is a promising strategy in stimulating the purchase of those foods. However, the true effects of this strategy are not well studied and it is unclear how the money saved is spent. The aim of this study is to examine the effects of a 25% discount on fruits and vegetables on food purchases in a supermarket environment.

Methods

A randomized controlled trial with two research conditions was conducted: a control condition with regular prices (n = 52) and an experimental condition with a 25% discount on fruits and vegetables (n = 63). The experiment was carried out using a three-dimensional web-based supermarket, which is a software application in the image of a real supermarket. Data were collected in 2010 in the Netherlands. Participants received a fixed budget and were asked to buy weekly household groceries at the web-based supermarket. Differences in fruit and vegetable purchases, differences in expenditures in other food categories and differences in total calories were analyzed using independent samples t-tests and multiple linear regression models accounting for potential effect modifiers and confounders.

Results

The purchased amount of fruit plus vegetables was significantly higher in the experimental condition compared to the control condition (Δ984 g per household per week, p = .03) after appropriate adjustments. This corresponds to a 25% difference compared to the control group. Both groups had similar expenditures in unhealthier food categories, including desserts, soda, crisps, candy and chocolate. Furthermore, both groups purchased an equal number of food items and an equal amount of calories, indicating that participants in the discount condition did not spend the money they saved from the discounts on other foods than fruits and vegetables.

Conclusion

A 25% discount on fruits and vegetables was effective in stimulating purchases of those products and did neither lead to higher expenditures in unhealthier food categories nor to higher total calories purchased. Future studies in real supermarkets need to confirm these findings.

Government regulation to promote healthy food environments--a view from inside state governments

Food policy interventions are an important component of obesity-prevention strategies and can potentially drive positive changes in obesogenic environments. This study sought to identify regulatory interventions targeting the food environment, and barriers/facilitators to their implementation at the Australian state government level. In-depth interviews were conducted with senior representatives from state/territory governments, statutory authorities and non-government organizations (n =45) to examine participants' (i) suggestions for regulatory interventions for healthier food environments and (ii) support for pre-selected regulatory interventions derived from a literature review. Data were analysed using thematic and constant comparative analyses. Interventions commonly suggested by participants were regulating unhealthy food marketing; limiting the density of fast food outlets; pricing reforms to decrease fruit/vegetable prices and increase unhealthy food prices; and improved food labelling. The most commonly supported pre-selected interventions were related to food marketing and service. Primary production and retail sector interventions were least supported. The dominant themes were the need for whole-of-government and collaborative approaches; the influence of the food industry; conflicting policies/agenda; regulatory challenges; the need for evidence of effectiveness; and economic disincentives. While interventions such as public sector healthy food service policies were supported by participants, marketing restrictions and fiscal interventions face substantial barriers including a push for deregulation and private sector opposition.

Taxing sugar-sweetened beverages: a survey of knowledge, attitudes and behaviours

OBJECTIVE

To assess current beverage consumption patterns and anticipated reaction to an added 20 % tax on these products.

DESIGN

A random-digit dialled telephone interview lasting 20 min was administered to assess demographics, beverage consumption behaviours and intentions regarding consumption of sugar-sweetened beverages in the event of an additional tax on these beverages.

SETTING

Respondents were recruited throughout the USA.

SUBJECTS

The study included 592 adults.

RESULTS

Sixty-nine per cent of respondents reported consuming at least one pre-packaged sugar-sweetened beverage in the past week; those who consumed sugar-sweetened beverages averaged seven pre-packaged beverages per week. Ninety-one per cent knew that frequent consumption of soft drinks increases risk of obesity. Thirty-six per cent supported a tax on sugar-sweetened beverages with greatest support among those aged 18-24 years, those with BMI < 30 kg/m2 and those with higher levels of education (P < 0·05). Over one-third of respondents said that they would cut back on their sweetened beverage consumption in the event of an added 20 % tax on these beverages.

CONCLUSIONS

Our findings suggest that an added tax on these beverages could influence some to cut down on their consumption, reducing their risk of obesity and related illnesses.

Does access to fast food lead to super-sized pregnant women and whopper babies?

Rise in the availability of fast-food restaurants has been blamed, at least partly, for the increasing obesity in the U.S. The existing studies of obesity have focused primarily on children, adolescents, and adults, and this paper extends the literature by raising a little-studied question and using nationally representative data to answer it. It examines the relationship between the supply of fast-food restaurants and weight gain of pregnant women and their newborns. I study prenatal weight gain because excessive weight gain has been linked to postpartum overweight/obesity and I study both tails of the birthweight distribution because the origin of obesity may be traced to the prenatal period and both tail outcomes have been associated with obesity later in life. I merge the 1998 and 2004 Natality Detail Files with the Area Resource File, and County Business Patterns, which provide data on the number of fast-food restaurants in the metropolitan area where the mother resides. The empirical model includes an extensive list of MSA characteristics and MSA fixed effects to control for factors that may be correlated with both health outcomes and restaurants' location decision. Results reveal that the fast-food and weight gain relationship is robust to the inclusion of these controls but these controls greatly mitigate the fast food-infant health relationship. Greater access to fast-food restaurants is positively related to mothers' probability of excessive weight gain but it does not share a statistically significant relationship with birthweight. These relationships hold in all the socioeconomic and demographic subgroups studied.

Measuring weight outcomes for obesity intervention strategies: the case of a sugar-sweetened beverage tax

Taxing unhealthy foods has been proposed as a means to improve diet and health by reducing calorie intake and raising funds to combat obesity, particularly sugar-sweetened beverages (SSBs). A growing number of studies have examined the effects of such food taxes, but few have estimated the weight-loss effects. Typically, a static model of 3500 calories for one pound of body weight is used, and the main objective of the study is to demonstrate its bias. To accomplish the objective, we estimate income-segmented beverage demand systems to examine the potential effects of a SSB tax. Elasticity estimates and a hypothetical 20 percent effective tax rate (or about 0.5 cent per ounce) are applied to beverage intake data from a nationally representative survey, and we find an average daily reduction of 34-47 calories among adults and 40-51 calories among children. The tax-induced energy reductions are translated into weight loss using both static and dynamic calorie-to-weight models. Results demonstrate that the static model significantly overestimates the weight loss from reduced energy intake by 63 percent in year one, 346 percent in year five, and 764 percent in year 10, which leads to unrealistic expectations for obesity intervention strategies. The tax is estimated to generate $5.8 billion a year in revenue and is found to be regressive, although it represents about 1 percent of household food and beverage spending.

Sugar-sweetened beverage taxes in Brazil

OBJECTIVES

We investigated whether taxing sugar-sweetened beverages (SSBs) would improve the diets of households in Brazil.

METHODS

We used household food consumption data that the Brazilian Institute of Geography and Statistics collected in 2002-2003 from a nationally representative sample of 48,470 Brazilian households. The consumption of SSBs is expressed as the total SSB calories consumed and as the SSB percentage of the total calories purchased. We investigated price elasticity with regression models, controlling for demographic variables, income, and prices of all other foods and drinks.

RESULTS

Increases in the price of SSBs led to reductions in consumption. A 1.00% increase in the price of SSBs led to a 0.85% reduction of SSB calories consumed (1.03% reduction for the poor and 0.63% for the nonpoor). Increased income had a positive effect on SSB consumption, but the effect was less than half the size of the price elasticity (0.41% increase in SSB calories consumed for every 1.00% increase in income).

CONCLUSIONS

High SSB price elasticity in Brazil indicates that a tax on purchased weight or volume would lead to reductions in SSB consumption.

Using theory to identify beliefs associated with support for policies to raise the price of high-fat and high-sugar foods

Public policies designed to dramatically raise the price of high-fat and high-sugar foods have received substantial attention from researchers and the media. Although econometric studies suggest that these policies could reduce obesity rates, they are likely to face substantial public opposition. This study used the theory of perceived responsibility and social motivation as a framework to analyze data from a politically diverse convenience sample of 500 adults in upstate New York. The authors examined associations between attribution beliefs and policy support to identify what types of scientific evidence and accompanying messages appear most likely to generate public support for price-raising policies. Results suggest that public health advocates and health communicators could benefit from an increased emphasis on advertising for unhealthy foods as a cause of obesity and the food industry's (manufacturers, advertisers, markets, and restaurants) responsibility for addressing the problem.

Simulated reductions in consumption of sugar-sweetened beverages improves diet quality in Lower Mississippi Delta adults

BACKGROUND

Although the effects of replacing sugar-sweetened beverages (SSBs) with water on energy intake and body weight have been reported, little is known about how these replacements affect diet quality.

OBJECTIVE

To simulate the effects of replacing SSBs with tap water on diet quality and total energy intake of Lower Mississippi Delta (LMD) adults.

DESIGN

Retrospective analysis of cross-sectional dietary intake data using a representative sample of LMD adults (n=1,689). Diet quality was measured using the Healthy Eating Index-2005 (HEI-2005) scores that were computed using the population ratio method. The effects of substituting SSBs with water on diet quality were simulated by replacing the targeted items' nutrient profile with tap water's profile.

RESULTS

Simulating the replacement of SSBs with tap water at 25, 50, and 100% levels resulted in 1-, 2.3-, and 3.8-point increases, respectively, in the HEI-2005 total score. Based on a mean daily intake of 2,011 kcal, 100% substitution of SSBs with tap water would result in 11% reduction in energy intake.

CONCLUSIONS

Replacing SSBs with water could substantially improve the diet quality of the LMD adult population and potentially lead to significant weight loss overtime. Prioritizing intervention efforts to focus on the replacement of SSBs with energy-free drinks may be the most efficacious approach for conveying potentially substantial health benefits in this and similar disadvantaged populations.

Maternal obesity trends in Egypt 1995-2005

According to the World Health Organization (WHO), 46% of adult females in Egypt are obese. This research was aimed at documenting obesity trends and identifying the populations most at risk for obesity. Using data from the 1995 and 2005 Egyptian Demographic and Health Surveys a linear model was employed to seek associations between household wealth, urban/rural residence, governorate of residence, employment status, parity and age and increases in body mass index (BMI) among married Egyptian women between the ages of 15-49. Between 1995 and 2005, the mean BMI of women of reproductive age in Egypt increased from 26.31 to 28.52. Although there was an overall trend towards greater obesity between 1995 and 2005, older women residing in rural, poor households became obese at a faster rate than younger women residing in richer, urban households. Studies have shown that household wealth is a key determinant of food consumption patterns. Rising obesity rates among the poor in developed countries are linked to the relatively cheap price of high-calorie, nutrient-poor foods. One factor that may be contributing to the rapid increases in obesity among the rural poor in Egypt is the subsidisation of high-energy, low-nutritive value foods that form a larger part of the diet of poor, rural populations.

Economic instruments for obesity prevention: results of a scoping review and modified Delphi survey

BACKGROUND

Comprehensive, multi-level approaches are required to address obesity. One important target for intervention is the economic domain. The purpose of this study was to synthesize existing evidence regarding the impact of economic policies targeting obesity and its causal behaviours (diet, physical activity), and to make specific recommendations for the Canadian context.

METHODS

Arksey and O'Malley's (2005) methodological framework for conducting scoping reviews was adopted for this study and this consisted of two phases: 1) a structured literature search and review, and 2) consultation with experts in the research field through a Delphi survey and an in-person expert panel meeting in April 2010.

RESULTS

Two key findings from the scoping review included 1) consistent evidence that weight outcomes are responsive to food and beverage prices. The debate on the use of food taxes and subsidies to address obesity should now shift to how best to address practical issues in designing such policies; and 2) very few studies have examined the impact of economic instruments to promote physical activity and clear policy recommendations cannot be made at this time. Delphi survey findings emphasised the relatively modest impact any specific economic instrument would have on obesity independently. Based on empirical evidence and expert opinion, three recommendations were supported. First, to create and implement an effective health filter to review new and current agricultural polices to reduce the possibility that such policies have a deleterious impact on population rates of obesity. Second, to implement a caloric sweetened beverage tax. Third, to examine how to implement fruit and vegetable subsidies targeted at children and low income households.

CONCLUSIONS

In terms of economic interventions, shifting from empirical evidence to policy recommendation remains challenging. Overall, the evidence is not sufficiently strong to provide clear policy direction. Additionally, the nature of the experiments needed to provide definitive evidence supporting certain policy directions is likely to be complex and potentially unfeasible. However, these are not reasons to take no action. It is likely that policies need to be implemented in the face of an incomplete evidence base.

Overweight and obesity in eastern mediterranean region: prevalence and possible causes

The objective of this paper was to explore the prevalence of overweight and obesity among various age groups as well as discuss the possible factors that associated with obesity in the Eastern Mediterranean Region (EMR). A systematic review of published papers between 1990 and 2011 was carried out. Obesity reached an alarming level in all age groups of the EMR countries. The prevalence of overweight among preschool children(<5 years) ranged from 1.9% to 21.9%, while the prevalence of overweight and obesity among school children ranged from 7% to 45%. Among adults the prevalence of overweight and obesity ranged from 25% to 81.9%. Possible factors determining obesity in this region include: nutrition transition, inactivity, urbanization, marital status, a shorter duration of breastfeeding, frequent snacking, skipping breakfast, a high intake of sugary beverages, an increase in the incidence of eating outside the home, long periods of time spent viewing television, massive marketing promotion of high fat foods, stunting, perceived body image, cultural elements and food subsidize policy. A national plan of action to overcome obesity is urgently needed to reduce the economic and health burden of obesity in this region.

Public policy versus individual rights and responsibility: an economist's perspective

Interventions to reduce childhood obesity entail ethical considerations. Although a rationale exists for government to intervene in a way that limits individual rights while protecting the public's health, a clear economic rationale also exists. The markets for goods and services that contribute to obesity are characterized by multiple failures that create an economic rationale for government to intervene (eg, consumers' lack of accurate information regarding obesogenic foods and beverages). If effective public policies for reducing obesity and its consequences are to be developed and implemented, individual rights and government interests must be balanced.

The economics of childhood obesity

In the past few decades, obesity rates among American children have skyrocketed. Although many factors have played a part in this unhealthy increase, this paper focuses on how economic policies may be contributing to our children's growing girth and how these policies might be altered to reverse this trend. It examines the economic causes and consequences of obesity, the rationales for government intervention, the cost-effectiveness of various policies, and the need for more research funding.

An economic analysis of community-level fast food prices and individual-level fast food intake: a longitudinal study

BACKGROUND

While dietary intake is shaped by cost, there is minimal research on the association between community-level food prices and dietary intake.

METHODS

We used nationally representative, longitudinal data to examine how community-level food price variation was associated with individual-level fast food intake by race/ethnicity and income across waves II (1996) and III (2001-2002) of the National Longitudinal Study of Adolescent Health (n=11,088) from 158 baseline and 363 follow-up US counties.

RESULTS

Negative binomial regression models predicting the number of fast food meals per week show strong relationships between fast food consumption and prices of fast food and soda that varied by gender and race/ethnicity. We found relatively stronger association between food prices and fast food intake for males and relatively greater price sensitivity for soda versus burgers. In the group with strongest associations (black males), a 20% increase in the price of soda was associated with a decrease of 0.25 visits to a fast food restaurant per week.

CONCLUSIONS

Economic incentives may be an effective mechanism to address fast food intake in an age group at high risk for obesity.

Regional price differences and food consumption frequency among elementary school children

OBJECTIVE

Food prices may affect diet and weight gain among youth and lead to geographic disparities in obesity. This paper examines the association between regional prices and consumption frequency of fruit/vegetables and snack items among elementary school children in the USA.

STUDY DESIGN

Observational study using individual-level survey data of fifth-grade children (average age 11 years) and regional food prices based on store visits in 2004.

METHODS

Dependent variables are self-reported consumption frequency in fifth grade; primary explanatory variables are metropolitan area food prices relative to cost of living. Multivariate regression analysis.

RESULTS

Price variation across metropolitan areas exists, and lower real prices for vegetables and fruits predict significantly higher intake frequency. Higher dairy prices predict lower frequency of milk consumption, while higher meat prices predict increased milk consumption. Similar price effects were not found for fast food or soft drink consumption.

DISCUSSION

The geographic variation in food prices across the USA is sufficiently large to affect dietary patterns among youth for fruit, vegetables and milk. The price variation is either too small to affect children's consumption frequency of fast food or soft drinks, or the consumption of these foods is less price sensitive.

Using the tax system to promote physical activity: critical analysis of Canadian initiatives

In Canada, tax incentives have been recently introduced to promote physical activity and reduce rates of obesity. The most prominent of these is the federal government's Children's Fitness Tax Credit, which came into effect in 2007. We critically assess the potential benefits and limitations of using tax measures to promote physical activity. Careful design could make these measures more effective, but any tax-based measures have inherent limitations, and the costs of such programs are substantial. Therefore, it is important to consider whether public funds are better spent on other strategies that could instead provide direct public funding to address environmental and systemic factors.

Estimating the potential of taxes on sugar-sweetened beverages to reduce consumption and generate revenue

OBJECTIVE

Beverage taxes came into light with increasing concerns about obesity, particularly among youth. Sugar-sweetened beverages have become a target of anti-obesity initiatives with increasing evidence of their link to obesity. Our paper offers a method for estimating revenues from an excise tax on sugar-sweetened beverages that governments of various levels could direct towards obesity prevention.

MODEL

We construct a model projecting beverage consumption and tax revenues based on best available data on regional beverage consumption, historic trends and recent estimates of the price elasticity of sugar-sweetened beverage demand.

RESULTS

The public health impact of beverage taxes could be substantial. An estimated 24% reduction in sugar-sweetened beverage consumption from a penny-per-ounce sugar-sweetened beverage tax could reduce daily per capita caloric intake from sugar-sweetened beverages from the current 190-200 cal to 145-150 cal, if there is no substitution to other caloric beverages or food. A national penny-per-ounce tax on sugar-sweetened beverages could generate new tax revenue of $79 billion over 2010-2015.

CONCLUSION

A modest tax on sugar-sweetened beverages could both raise significant revenues and improve public health by reducing obesity. To the extent that at least some of the tax revenues get invested in obesity prevention programs, the public health benefits could be even more pronounced.

Preventing diabetes and obesity in American Indian communities: the potential of environmental interventions

Obesity, diabetes, and other diet-related chronic diseases persist in American Indians at rates that are significantly higher than those in other ethnic minority populations. Environmental interventions to improve diet and increase physical activity have the potential to improve these health outcomes, but relatively little work has taken place in American Indian communities. We reviewed the experiences and findings of the following 3 case studies of intervention trials in American Indian communities: the Pathways trial, which was a school-based trial that focused on children; the Apache Healthy Stores program, which was a food-store program that focused on food preparers and shoppers; and the Zhiwaapenewin Akino'maagewin trial, which was a multiinstitutional trial for First Nations adults that worked with food stores, elementary schools, and health and social services agencies. All 3 trials showed mixed success. Important lessons were learned, including the need to focus on supply and demand, institutional and multilevel approaches, and the identification of institutional bases to sustain programs.

A review of the literature on policies directed at the youth consumption of sugar sweetened beverages

Sugar sweetened beverages (SSB) constitute a large percentage of energy consumed by youth. This paper reviews the literature on school nutrition policies and price interventions directed at youth SSB consumption. In addition to considering the direct effect of policies on SSB consumption, we provide an overview of the literature on how SSB consumption affects total energy intake (TEI) and BMI, as well as on how TEI affects BMI. By considering each of these links, we attempted to gauge the effect of policies directed at SSB consumption, as well as highlight areas that merit future research. We found that school nutrition and price policies reduce SSB consumption and that reduced SSB consumption is associated with a reduction in energy intake that can influence BMI. Policies directed at SSB consumption can play an important role in reducing youth overweight and obesity.

From neighborhood design and food options to residents' weight status

This study examined associations of accessibility, availability, price, and quality of food choices and neighborhood urban design with weight status and utilitarian walking. To account for self-selection bias, data on adult residents of a middle-to-high-income neighborhood were used. Participants kept a 2-day activity/travel diary and self-reported socio-demographics, height, and weight. Geographic Information Systems data were used to objectively quantify walking-related aspects of urban design, and number of and distance to food outlets within respondents' 1km residential buffers. Food outlets were audited for availability, price, and quality of healthful food choices. Number of convenience stores and in-store healthful food choices were positively related to walking for errands which, in turn, was predictive of lower risk of being overweight/obese. Negative associations with overweight/obesity unexplained by walking were found for number of grocery stores and healthful food choices in sit-down restaurants. Aspects of urban form and food environment were associated with walking for eating purposes which, however, was not predictive of overweight/obesity. Access to diverse destinations, food outlets and healthful food choices may promote pedestrian activity and contribute to better weight regulation. Accessibility and availability of healthful food choices may lower the risk of overweight/obesity by providing opportunities for healthier dietary patterns.

Food prices are associated with dietary quality, fast food consumption, and body mass index among U.S. children and adolescents

Food prices are expected to affect dietary intakes, however, previous findings are mixed and few are based on nationally representative data. We examined the associations of price indices of fast foods (FF-PI) and fruits and vegetables (FV-PI) with dietary intakes and BMI among U.S. children and adolescents using data from the Continuing Survey of Food Intakes by Individuals (CSFII; 1994-1998) for 6759 children (2-9 y) and 1679 adolescents (10-18 y). FF-PI and FV-PI were linked to individuals' CSFII dietary data through city-level geocodes. Main outcomes included intakes of selected nutrients and food groups, a fast food consumption index (FF-CI), diet quality using the 2005 Healthy Eating Index (HEI), and BMI. Among children (2-9 y), a higher FF-PI (by $1) was associated with intakes of lower FF-CI (β ± SE: -0.9 ± 0.3 count/d), higher HEI (6.6 ± 2.5), higher intakes of fiber (2.7 ± 0.7 g/d), calcium (225.7 ± 52.3 mg/d), dairy (172.5 ± 36.2 g/d), and fruits and vegetables (113.3 ± 23.4 cup equivalents/d). FV-PI was inversely related to fiber intake (β ± SE: -3.3 ± 1.5 g/d) and positively associated with BMI (4.3 ± 1.2 kg/m(2)). Less consistent findings were ascribed to FV-PI and among adolescents (10-18 y). Significant associations were almost equally balanced between low and high family income groups, with some significant interactions between food prices and family income observed, particularly among children (2-9 y). Our findings suggest that among U.S. children aged 2-9 y, higher FF-PI is associated with better dietary quality, whereas higher FV-PI is linked to higher BMI and lower fiber intake. Associations varied by family income in children for many dietary intake variables.

Effect of food prices on the prevalence of obesity among young adults

OBJECTIVE

To examine the extent to which various food prices were associated with the obesity status of young adults.

STUDY DESIGN

Retrospective cohort study of 6537 men and 5324 women in the USA using panel data from the Monitoring the Future Surveys (1992-2003), which were merged with two food-at-home and one food-away-from-home price measures from the American Chamber of Commerce Researchers Association.

METHODS

Longitudinal individual random effect and fixed effect models were estimated.

RESULTS

This study found that food prices did not have a significant effect on the prevalence of obesity among young female adults. For young adult men, an individual random effect estimator suggested that a 10% increase in the price of fast food was associated with a 13.2% decrease in the probability of obesity, but this effect lost its economic and statistical significance once individual fixed effects were controlled for in the estimation.

CONCLUSIONS

Overall, the results imply that observed time-varying individual characteristics, such as working status, marital status and school enrolment status, may over-ride the effect of changes in food prices for young adults. More research employing longitudinal data is necessary to determine if food subsidies or taxes, particularly soft drink and fast food taxes or subsidies for fruit and vegetables, could be effective policy measures to curtail the increasing prevalence of obesity among young adults.

Lifestyle changes and reduction of colon cancer incidence in Europe: A scenario study of physical activity promotion and weight reduction

BACKGROUND

Across Europe, there are over 300,000 new cases of colorectal cancer annually. Major risk factors include excess body weight (usually expressed by a high body mass index, BMI) and physical inactivity (PA). In this study we modelled the potential long-term effects on colon cancer incidence of changes in prevalence of excess body weight and physical inactivity in seven European countries across Europe with adequate data.

METHODS

We addressed the impact of interventions aimed at preventing weight gain and increasing physical activity on colon cancer incidence using the Prevent model as refined in the FP-6 Eurocadet project. Relative risk (RR) estimates were derived from meta-analyses; sex- and country-specific prevalences of BMI and PA were determined from survey data. Models were made for Czech Republic, Denmark, France, Latvia, the Netherlands, Spain and the United Kingdom.

RESULTS

In a hypothetical scenario in which a whole population had obtained an ideal weight distribution in the year 2009, up to 11 new cases per 100,000 person-years would be avoided by 2040. The population attributable fractions (PAF) for excess weight were much higher for males (between 13.5% and 18.2%) than for females (2.3-4.6%). In contrast, using the optimum scenario where everybody in Europe would adhere to the recommended guideline of at least 30 min of moderate PA 5d per week, the PAFs for PA in various countries were substantially greater in women (4.4-21.2%) than in men (3.2-11.6%). Sensitivity analyses were performed assuming underreporting of BMI by using self-reports (difference of 5 and 0.8 percent-points in males and females, respectively), using different risk estimates (between 5.8 and 11.5 percent-points difference for BMI for men and women, respectively, and up to 11.6 percent-points difference for PA for women).

INTERPRETATION

Changes in lifestyle can indeed result in large health benefits, including for colon cancer. Two interesting patterns emerged: for colon cancer, achieving optimum BMI levels in the population appears to offer the greatest health benefits in population attributable fractions in males, while increased physical activity might offer the greatest fraction of avoidable cancers in females. These observations suggest a sex-specific strategy to colon cancer prevention.

The costs of food at home and away from home and consumption patterns among U.S. adolescents

PURPOSE

This study examined the associations of prices of food at home groceries, prices of fast food away from home and the availability of food stores and restaurants with the number of days over the past week that adolescents consumed fruit and fruit juices, vegetables, meat, nonmeat protein, dairy, grains, and sweets.

METHODS

Individual-level data on adolescents were drawn from the Child Development Supplement of the Panel Study of Income Dynamics combined at the zip code level with external economic contextual data. Multivariate regression analyses were used to estimate the associations between food consumption categories and the economic contextual factors. Regressions were also estimated by households' poverty status.

RESULTS

Fast food and food at home prices were not significantly associated with any of the food consumption categories in the full sample. However, among poor adolescents, higher fast food prices were associated with higher levels of nonmeat protein consumption. Food store outlet availability was found to have very small significant associations with some food consumption categories but no significant associations were found for restaurant outlets.

CONCLUSIONS

Food away from home prices, such as fast food prices and supermarket and grocery store availability, were associated with some food consumption categories among low-income youths and related policies deserve further examination.

An integrated approach to preventing cardiovascular disease: community-based approaches, health system initiatives, and public health policy

Cardiovascular disease (CVD) is largely the product of interactions among modifiable risk factors that are common in developed nations and increasingly of concern in developing countries. Hypertension is an important precursor to the development of CVD, and although detection and treatment rates have improved in recent years in some jurisdictions, effective strategies and policies supporting a shift in distribution of risk factors at the population level remain paramount. Challenges in managing cardiovascular health more effectively include factors at the patient, provider, and system level. Strategies to reduce hypertension and CVD should be population based, incorporate multilevel, multicomponent, and socioenvironmental approaches, and integrate community resources with public health and clinical care. There is an urgent need to improve monitoring and management of risk factors through community-wide, primary care-linked initiatives, increase the evidence base for community-based prevention strategies, further develop and evaluate promising program components, and develop new approaches to support healthy lifestyle behaviors in diverse age, socioeconomic, and ethnocultural groups. Policy and system changes are critical to reduce risk in populations, including legislation and public education to reduce dietary sodium and trans-fatty acids, food pricing policies, and changes to health care delivery systems to explicitly support prevention and management of CVD.

The global context for public health nutrition taxation

OBJECTIVE

To assess critically the scope for public health nutrition taxation within the framework of the global tax reform agenda.

DESIGN

Review of the tax policy literature for global policy priorities relevant to public health nutrition taxation; critical analysis of proposals for public health nutrition taxation judged against the global agenda for tax reform.

SETTING

The global tax reform agenda shapes decisions of tax policy makers in all countries. By understanding this agenda, public health nutritionists can make feasible taxation proposals and thus improve the development, uptake and implementation of recommendations for nutrition-related taxation.

RESULTS

The priorities of the global tax reform agenda relevant to public health nutrition taxation are streamlining of taxes, adoption of value-added tax (VAT), minimisation of excise taxes (except to correct for externalities) and removal of import taxes in line with trade liberalisation policies. Proposals consistent with the global tax reform agenda have included excise taxes, extension of VAT to currently exempted (unhealthy) foods and tariff reductions for healthy foods.

CONCLUSIONS

Proposals for public health nutrition taxation should (i) use existing types and rates of taxes where possible, (ii) use excise taxes that specifically address externalities, (iii) avoid differential VAT on foods and (iv) use import taxes in ways that comply with trade liberalisation priorities.

Economic contextual factors, food consumption, and obesity among U.S. adolescents

Adolescents have poor dietary behaviors and high overweight prevalence. Economic contextual factors such as food prices and food store and restaurant availability are hypothesized and increasingly being explored empirically as contributors to the obesity epidemic. Evidence showed that healthful compared with less healthful foods increasingly cost more and that fast food restaurants are increasingly available. In addition, racial, ethnic, and socioeconomic disparities have been documented in access to food outlets, particularly chain supermarkets, and such disparities have been shown to be increasing recently. Empirical evidence based on nationally representative U.S. adolescent data revealed that lower fruit and vegetable prices, higher fast food prices, and greater supermarket availability were related to higher fruit and vegetable consumption and lower BMI, in particular for BMI among teens who are overweight or at risk for overweight and who are low- to middle-socioeconomic status. The availability of fast food restaurants was not associated with youth BMI. Overall, this research implies that pricing interventions of taxes on energy-dense foods such as fast food and/or subsidies to healthful foods such as fruits and vegetables and policy efforts to improve access to supermarkets may help to improve adolescent weight outcomes.

Perceptions on the use of pricing strategies to stimulate healthy eating among residents of deprived neighbourhoods: a focus group study

Background

Pricing strategies are mentioned frequently as a potentially effective tool to stimulate healthy eating, mainly for consumers with a low socio-economic status. Still, it is not known how these consumers perceive pricing strategies, which pricing strategies are favoured and what contextual factors are important in achieving the anticipated effects.

Methods

We conducted seven focus groups among 59 residents of deprived neighbourhoods in two large Dutch cities. The focus group topics were based on insights from Rogers' Diffusion of Innovations Theory and consisted of four parts: 1) discussion on factors in food selection; 2) attitudes and perceptions towards food prices; 3) thinking up pricing strategies; 4) attitudes and perceptions regarding nine pricing strategies that were nominated by experts in a former Delphi Study. Analyses were conducted with Atlas.ti 5.2 computer software, using the framework approach.

Results

Qualitative analyses revealed that this group of consumers consider price to be a core factor in food choice and that they experience financial barriers against buying certain foods. Price was also experienced as a proficient tool to stimulate healthier food choices. Yet, consumers indicated that significant effects could only be achieved by combining price with information and promotion techniques. In general, pricing strategies focusing on encouraging healthy eating were valued to be more helpful than pricing strategies which focused on discouraging unhealthy eating. Suggested high reward strategies were: reducing the price of healthier options of comparable products (e.g., whole meal bread) compared to unhealthier options (e.g., white bread); providing a healthy food discount card for low-income groups; and combining price discounts on healthier foods with other marketing techniques such as displaying cheap and healthy foods at the cash desk.

Conclusion

This focus group study provides important new insights regarding the use of pricing strategies to stimulate healthy eating. The observed perceptions and attitudes of residents of deprived neighbourhoods can be integrated into future experimental studies and be used to reveal if and how pricing strategies are effective in stimulating healthy eating.

The effect of fiscal policy on diet, obesity and chronic disease: a systematic review

OBJECTIVE

To assess the effect of food taxes and subsidies on diet, body weight and health through a systematic review of the literature.

METHODS

We searched the English-language published and grey literature for empirical and modelling studies on the effects of monetary subsidies or taxes levied on specific food products on consumption habits, body weight and chronic conditions. Empirical studies were dealing with an actual tax, while modelling studies predicted outcomes based on a hypothetical tax or subsidy.

FINDINGS

Twenty-four studies met the inclusion criteria: 13 were from the peer-reviewed literature and 11 were published on line. There were 8 empirical and 16 modelling studies. Nine studies assessed the impact of taxes on food consumption only, 5 on consumption and body weight, 4 on consumption and disease and 6 on body weight only. In general, taxes and subsidies influenced consumption in the desired direction, with larger taxes being associated with more significant changes in consumption, body weight and disease incidence. However, studies that focused on a single target food or nutrient may have overestimated the impact of taxes by failing to take into account shifts in consumption to other foods. The quality of the evidence was generally low. Almost all studies were conducted in high-income countries.

CONCLUSION

Food taxes and subsidies have the potential to contribute to healthy consumption patterns at the population level. However, current evidence is generally of low quality and the empirical evaluation of existing taxes is a research priority, along with research into the effectiveness and differential impact of food taxes in developing countries.

The impact of food prices on consumption: a systematic review of research on the price elasticity of demand for food

In light of proposals to improve diets by shifting food prices, it is important to understand how price changes affect demand for various foods. We reviewed 160 studies on the price elasticity of demand for major food categories to assess mean elasticities by food category and variations in estimates by study design. Price elasticities for foods and nonalcoholic beverages ranged from 0.27 to 0.81 (absolute values), with food away from home, soft drinks, juice, and meats being most responsive to price changes (0.7-0.8). As an example, a 10% increase in soft drink prices should reduce consumption by 8% to 10%. Studies estimating price effects on substitutions from unhealthy to healthy food and price responsiveness among at-risk populations are particularly needed.

Expert views on most suitable monetary incentives on food to stimulate healthy eating

BACKGROUND

Pricing strategies are an important component in the marketing mix and may also be useful in stimulating healthier food choices. However, due to competing interests and feasibility problems, the introduction of pricing strategies is complicated. For successfully introducing food pricing strategies, it is essential to explore incentives that are not only promising but also realizable and being approved by different sectors.

METHODS

We aimed to assemble a list of pricing strategies by exploring expert views using the Delphi method. Subjects included experts from academia, industry, retail, agriculture, policymakers, consumers and non-governmental organizations. Data were collected in three rounds. In round one, experts designed promising pricing strategies. Based on a time-budget model incorporating Sleep, Leisure, Occupation, Transportation and Home-based activities, these strategies were in the subsequent rounds judged on several criteria. Results were analysed using median and interquartile deviations scores.

RESULTS

We found fair consensus levels among experts and a varied list of promising pricing strategies. The panel agreed on the potential success of offering small presents, providing price-cuts on healthy foods and discounting healthier foods more frequently. Also, it was found that experts gave higher rates to pricing strategies for which the implementation responsibilities could be placed elsewhere.

CONCLUSION

The resulted list of promising monetary incentives is an essential first step for the future design of pricing strategies. Following this study, it is important to determine how to make solid agreements on responsibility and implementation issues. Also, consumer perceptions regarding the proposed pricing strategies should be studied.

Public health benefits of strategies to reduce greenhouse-gas emissions: food and agriculture

Agricultural food production and agriculturally-related change in land use substantially contribute to greenhouse-gas emissions worldwide. Four-fifths of agricultural emissions arise from the livestock sector. Although livestock products are a source of some essential nutrients, they provide large amounts of saturated fat, which is a known risk factor for cardiovascular disease. We considered potential strategies for the agricultural sector to meet the target recommended by the UK Committee on Climate Change to reduce UK emissions from the concentrations recorded in 1990 by 80% by 2050, which would require a 50% reduction by 2030. With use of the UK as a case study, we identified that a combination of agricultural technological improvements and a 30% reduction in livestock production would be needed to meet this target; in the absence of good emissions data from Brazil, we assumed for illustrative purposes that the required reductions would be the same for our second case study in São Paulo city. We then used these data to model the potential benefits of reduced consumption of livestock products on the burden of ischaemic heart disease: disease burden would decrease by about 15% in the UK (equivalent to 2850 disability-adjusted life-years [DALYs] per million population in 1 year) and 16% in São Paulo city (equivalent to 2180 DALYs per million population in 1 year). Although likely to yield benefits to health, such a strategy will probably encounter cultural, political, and commercial resistance, and face technical challenges. Coordinated intersectoral action is needed across agricultural, nutritional, public health, and climate change communities worldwide to provide affordable, healthy, low-emission diets for all societies.

Food Systems and Public Health Disparities

The United States has set a national goal to eliminate health disparities. This article emphasizes the importance of food systems in generating and exacerbating health disparities in the United States and suggests avenues for reducing them. It presents a conceptual model showing how broad food system conditions interplay with community food environments-and how these relationships are filtered and refracted through prisms of social disparities to generate and exacerbate health disparities. Interactions with demand factors in the social environment are described. The article also highlights the separate food systems pathway to health disparities via environmental and occupational health effects of agriculture.