Outcomes Following Taxation of Sugar-Sweetened Beverages: A Systematic Review and Meta-analysis

Burden of cardiometabolic disease attributable to sugar sweetened beverages consumption in North Africa and the Middle East from 1990 to 2021

Objectives

The consumption of sugar-sweetened beverages (SSBs) is recognized as a significant risk factor for chronic non-communicable diseases (NCDs). Accurate estimates of the burden of SSBs are crucial for preventing, controlling, and treating associated diseases to achieve the Third United Nations Sustainable Development Goal of reducing premature mortality from NCDs by one-third by 2030. In this study, we aim to systematically assess the regional patterns and trends in the burden of SSBs in the North Africa and the Middle East (NAME) region. By analyzing regional differences, the study identifies specific areas where SSBs consumption has a more significant impact on public health.

Methods

The study data were retrieved from the Global Burden of Disease (GBD) study 2021. This study analyzed the impact of SSBs on mortality, years lived with disability, years of life lost, and disability-adjusted life years (DALYs) in 21 countries in the NAME region from 1990 to 2021. Our analysis considered various factors, including sex, age, region, and socio-demographic index.

Results

In 2021, DALYs attributable to SSBs there were 315,312 (95% uncertainty interval, 140,854 to 503,347) in absolute terms reflecting 518.3% (424.9 to 642.2) increase over three decades. From 1990 to 2021, the age-standardized rate of DALYs attributable to SSBs increased by 118.5%, from 27.9 (11.4 to 43.9) to 61.0 (27.6 to 97.0) per 100,000 population. Qatar (246.7 [113.1 to 404.5]), Saudi Arabia (201.2 [87.1 to 314.2]), and Bahrain (180.1 [78.4 to 295.8]) had the highest age-standardized rate of DALYs. The highest attributable DALYs and mortality from SSBs consumption were due to diabetes mellitus in all countries in 1990 and 2021. In 2021, Qatar (224.7 [104.9 to 365.5]), Bahrain (167.0 [74.8 to 274.8]), and Saudi Arabia (153.1 [75.3 to 230.4]) had the three highest age-standardized rates of DALYs from diabetes mellitus attributed to SSBs.

Conclusions

NAME witnessed a substantial increase in the burden attributable to SSBs. Alarmingly, exposure to SSBs has principally contributed to the increased burden of diabetes mellitus and chronic kidney disease. Among the region's countries, exposure and attributable burden trends vary considerably. It is imperative that governments and health authorities within the NAME region work together to combat SSBs' detrimental effects. Local, socioeconomic, and educational factors need to be considered when developing prevention and treatment strategies at the individual, community, and national levels.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40200-025-01578-9.

Do nudges need a regulatory push? Comparing the effectiveness and implementation of exemplar nudge (size-based) and non-nudge (price-based) dietary interventions

Changing behaviour across populations is key to improving population health and achieving net zero by 2050, including changing diets. We examine the extent to which nudges, with the potential to contribute to such change, are being implemented alongside traditional approaches. We compare the effectiveness and extent of implementation into policy of two interventions to improve diets: size-based interventions that alter portion, package or tableware size, commonly considered a nudge; and, price-based interventions, including food-item taxes, not considered a nudge. We conducted four rapid reviews: two for systematic reviews with meta-analyses aimed to determine the effectiveness of size-based and price-based interventions, respectively; and two for reports to estimate the extent to which size-based and price-based interventions have been implemented in health or environment policies of governments, public authorities, or private sector organisations, at national or sub-national levels. Both sets of interventions were consistently found in research studies to be effective at reducing consumption and purchasing of unhealthy products, but price-based interventions have been implemented in policies far more often than size-based ones. At least 118 countries have implemented taxes on sugar sweetened beverages (SSBs), and 42 countries have implemented taxes on unhealthy foods. In contrast, we identified 20 reports of size-based interventions implemented at sub-national level, of which only one involved regulation. Explaining and reversing the lack of implementation of size-based interventions and other effective nudges merits prioritisation to help realise global ambitions to improve population health and achieve net zero by 2050.

Effectiveness of sugar taxation policies in Asia and Africa: a systematic review

Background

The prevalence of major noncommunicable diseases (NCDs) such as cardiovascular disease, cancer, and diabetes is rising rapidly in Asia and Africa. One of the major modifiable risk factors for these diseases is the consumption of free sugars, commonly found in sugary drinks. To address this issue, some countries have implemented food taxes such as taxes on sugar-sweetened beverages as part of national public health policies to reduce its intake. The review aims to assess the effects of national taxation of sugar-sweetened beverages within the continents of Asia and Africa.

Methods

Eight databases (MEDLINE (Ovid), Embase, PubMed, Cochrane, SCOPUS, Web of Science and ProQuest) were searched, and seven studies were included in this review. Only studies focused on the taxation of SSBs in Asia and Africa until 30 June 2023 and those that studied the impact of national sugar taxation among their population were included. Simulation or studies evaluating the estimation effect of taxes were excluded. All eligible records were assessed for the risk of bias using the NIH Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies, and the certainty of the evidence was reviewed.

Results

Seven studies included in this review investigated the impact of sugar tax policies in South Africa, India, Thailand, and Saudi Arabia. The interventions in these countries were implemented from 2017 to 2018 mainly for sugar-sweetened beverages. The studies provided evidence on changes in the volume of purchase, consumption, and sugar content of taxed items. Some evidence was found to suggest the positive impact of SSB taxes in reducing consumption of taxed items which ranged from 2.5% to 19% decrease. However, no study has reported on individual health outcomes.

Conclusion

There is substantial evidence of a decrease in the consumption of taxed items, but there is uncertainty about the health impact of these outcomes. Future research should prioritize longitudinal studies assessing direct health impacts of SSB taxation policies. Additionally, generalizability of the results of such fiscal policies need to be investigated in lower economic settings and thus be of significance for uniform health policy reforms.Systematic Review Registration: https://www.crd.york.ac.uk/PROSPERO/view/CRD42023427030, PROSPERO (CRD42023427030).

Evaluation of Ireland's Sugar-Sweetened Beverage Tax (SSBT)

BACKGROUND

Ireland is experiencing high levels of overweight and obesity. The adverse health impacts of excess weight include cancer, cardiovascular disease, diabetes, and dental decay, as well as a host of other conditions. In response, the Irish Government introduced a Sugar-Sweetened Beverage Tax (SSBT) in 2018.

AIMS

This research sought to explore the impact of Ireland's Sugar-Sweetened Beverage Tax.

METHOD

Euromonitor International Ltd data for the years 2010 - 2022 detailing carbonated drinkrelated sugar consumption in Ireland was examined.

RESULTS

A gradual decline in sugar consumption via carbonated soft drinks was evident before the introduction of the SSBT in Ireland. However, in the first full year since the introduction of the SSBT, there was a marked 30.2% reduction in sugar intake via carbonates through retailers and a 19.8% reduction in sugar intake via carbonates via food service venues.

CONCLUSIONS

The reduction in sugar intake via carbonates in the aftermath of the introduction of the SSBT was dramatic. However, it is unclear how much of this reduction was caused by industry reformulation of soft drinks and how much by consumers choosing lower-sugar or sugar-free soft beverages. Whatever the precise contribution of either factor, these results suggest that the SSBT has effectively reset national sugar consumption via soft drinks at a lower level.

Tackling the complexity of obesity in the US through adaptation of public health strategies

Obesity prevalence continues to rise in the US despite more than two decades of recommendations and guidelines for its prevention and management. The encouragement of individuals to adopt a healthy diet and lifestyle has remained the focus of clinical interventions and recommendations despite these efforts alone proving ineffective for long-term weight management. There are many recognized barriers to obesity prevention and management in community and clinical settings including political factors, social determinants of health, weight bias and stigma, and inequities in access to treatment and insurance coverage. We discuss these barriers in more detail and attempt to identify areas where public health and healthcare approaches can be better aligned, allowing for better advocating by public health officials to enable a more meaningful and population-level change in obesity prevention and management in the US.

Beverage consumption among adults in Newfoundland and Labrador, Canada prior to the implementation of a sugar-sweetened beverage tax

BACKGROUND

Lawmakers in Newfoundland and Labrador (NL) recently passed Canada's first sugar-sweetened beverage (SSB) tax. SSB tax evaluations rely on detailed understandings of beverage consumption patterns prior to policy implementation, but there is no recent literature about such patterns among NL residents during the pre-tax period.

METHODS

We recruited a convenience sample of NL adults ages 19 and older and measured participant characteristics via online surveys and beverage intake via previously-validated, semi-quantitative beverage frequency questionnaires. We generated inverse probability weights of sample selection using the Canadian Census as a representative reference sample. We described the weighted prevalence and intake among consumers of taxable SSBs (e.g., regular pop), non-taxable SSBs (e.g., sweetened milk), diet (non-nutritive sweetened) beverages and unsweetened beverages (including 100% juice). We explored weighted bivariate associations between consumption of beverages and sociodemographic characteristics identified as potential correlates of SSB intake.

RESULTS

The sample (n = 1233) was 65% female, 57% between ages 30-59 years, and nearly all (94%) white. More than half (57.3%) consumed taxable SSBs weekly, and 23.2% consumed non-taxable SSBs weekly. The most-consumed (highest volume) taxable SSB was regular pop (weighted mean (SD) 2.3 (3.5) L/week); the most-consumed non-taxable SSB was sweetened, flavoured milk (mean (SD) 1.2 2.0) L/week). We found independent differences in consumption patterns (prevalence, mean intake among consumers) across each beverage category. People who were younger, had fewer years of education, reported income below the poverty threshold, or reported experiencing food insecurity had a higher prevalence and mean intake among consumers of taxable SSBs. People with fewer years of education or those who reported experiencing food insecurity had a lower prevalence and mean intake among consumers of unsweetened beverages.

CONCLUSIONS

Our findings align with prior studies of socioeconomic position and SSB consumption in Canada, which collectively demonstrate that, on average, those with less education and income consume more SSBs and fewer unsweetened beverages. This research provides necessary understanding of social patterning of beverage consumption in NL prior to tax implementation. Post-tax evaluations of this policy should investigate potential impacts of the tax on diet and health equity, as well as potential beverage substitutions towards other beverage categories.

Are taxes to sugar-sweetened beverages and non-essential energy dense food implemented in Mexico regressive?

INTRODUCTION

In January 2014, Mexico introduced an excise tax of $1.00 Mexican peso/liter on sugar-sweetened beverages (SSB) and an 8% tax on non-essential energy dense food (NEDF) with at least 275 kilocalories/100 grams. Fiscal policies could be regressive when taxes generate a greater financial burden for low-income households compared to higher-income households. The objective of this study was to analyze whether SSB and NEDF taxes in Mexico were regressive using a nationally representative survey.

MATERIALS AND METHODS

Information from the National Household Income and Expenditure Survey in Mexico in its 2014, 2016 and 2018 waves were used to estimate changes in expenditures on SSB and NEDF over total expenditures by income quintile and place of residence using own price elasticities, changes in prices after tax implementation and tax pass-through prices. We derived uncompensated own price elasticities using the Linear Approximation of the Almost Ideal Demand System.

RESULTS

Price elasticities -in absolute values- were higher in urban areas than in rural settings for SSB in 2014 and 2016, while the opposite was observed for NEDF. For SSB, price elasticities -in absolute values- among households in the highest income quintiles were lower than those in the lowest income quintiles. The tax paid for SSB and NEDF over total expenditures was higher among low-income households. However, the reduction in SSB expenditures over total expenditures in low-income households was higher compared to the highest income quintile. For NEDF, weekly expenditures in rural areas were lower than in urban areas for the lowest quintile, while for the highest quintile the reduction was similar.

CONCLUSIONS

Low-income households in urban and rural areas reduced the proportion spent on SSB and NEDF more compared to higher-income residents, counteracting the regressive burden of the taxes.

Personalizing product sets to individual health priorities increases the healthfulness of hypothetical food choices in US adults

Recently, the potential for dietary personalization based on genetic/phenotypic characteristics to improve health has been studied. While promising, inputs into this biology-focused personalization process are intensive and may not align with an individual's own health priorities, which drive health behaviors. Here, we examine how personalizing food suggestions based on individuals' health priorities affects the healthiness of their food choices. We conducted a pre-registered experiment examining hypothetical food choices from three food categories in six conditions: (1) control, (2) health priority prime, (3) healthy product subset, (4) health priority prime + healthy product subset, (5) health priority prime + priority subset, and (6) health priority-based personalized product suggestions. Participants in conditions 2, 4, 5, and 6 first encountered a question asking them to select their top health priority from a list of options. In conditions 5, the subset of healthy items was described as foods beneficial for the selected health priority, while in condition 6, participants immediately saw the set of foods beneficial for the selected health priority, but had the option to see all foods instead. After making food choices, participants completed a survey with questions about the choice process, health priorities, and demographic variables. We used logistic regression to analyze the impact of condition on healthiness of food choices, and ordered logistic regression to examine the impact of condition on satisfaction with choices made. The experiment and survey were completed by 4171 adults (≥ 19 years) in the US, with the sample closely matching US distribution of age, sex, education, and income characteristics. There were no significant differences in the distribution of demographic characteristics among conditions. All intervention conditions significantly increased the likelihood that an individual chose a healthy food. However, interventions that combined priming with healthy subsets were significantly more effective than single interventions. Conditions that connected the healthy subsets to individuals' health priorities were particularly effective. The adjusted odds ratio (aOR) of selecting a healthy food was 4.77 (95% CI 4.12, 5.52) relative to the control condition when participants could view a subset described as helpful for their health priority. When people immediately viewed the personalized product set, the aOR increased to 11.67 (95% CI 0.1, 13,5). Likewise, analysis of nutrient content from food choices revealed that personalization decreased saturated fat, added sugar, and sodium and increased dietary fiber, potassium, iron, and calcium. However, product choice satisfaction was significantly lower in the personalized product set, which appears to be partially due to a tendency in this condition to forego choosing a product rather than selecting an unhealthy product. Personalization of product options based on individual health priorities should be tested in real-choice environments.

Association of sugar-sweetened beverage consumption and cardiorespiratory fitness with executive function: a cross-sectional survey based on Tajik adolescents at high altitude in China

Background

Executive function has a significant impact on adolescents' academic and future achievement and is strongly associated with multiple factors. However, few studies have examined the association between sugar-sweetened beverage (SSB) consumption, cardiorespiratory fitness, and executive function. Moreover, no research studies have been found on Tajik adolescents at high altitudes in China. The present study aimed to understand the associations between SSB consumption, cardiorespiratory fitness, and executive function among Tajik adolescents in high-altitude areas of China. To accumulate information on the physical and mental health development of Tajik adolescents in high-altitude areas of China.

Methods

In this study, a cross-sectional assessment of SSB consumption, cardiorespiratory fitness, and executive function was conducted on 1,121 Tajik adolescents aged 13-15 years at high altitude in China in 2023. One-way analysis of variance (ANOVA), binary logistic regression analysis, and ordered logistic regression analysis with a generalized linear model were used to analyze the associations that existed between SSB consumption and cardiorespiratory fitness and executive function.

Results

The proportions of Tajik adolescents aged 13-15 years with SSB consumption of ≤1 time/week, 2-5 times/week, and ≥ 6 times/week were 14.6, 51.6, and 33.8%, respectively, in high-altitude areas of China. The VO2max of Tajik adolescents was (37.17 ± 5.52) ml.kg.min-1. The inhibit control function response, refreshing memory function response, and switching flexibility function response of Chinese Tajik adolescents were (19.71 ± 5.86) ms, (1114.39 ± 356.85) ms, (382.2 ± 213.4) ms. Overall, using the SSB consumption ≤1 times/w and VO2max of the Q4 group as the reference group, ordered logistic regression analysis showed that Tajik adolescents with SSB consumption ≥5 times/w and VO2max of the Q1 group experienced inhibit control function dysfunction (OR = 28.80, 95%CI: 10.23 ~ 81.07), refreshing memory function dysfunction (OR = 6.79, 95%CI: 3.19 ~ 14.43), switching flexibility function dysfunction (OR = 13.10, 95%CI: 5.59 ~ 30.70) were at increased risk (p < 0.001).

Conclusion

SSB consumption and cardiorespiratory fitness were associated with executive function in Tajik adolescents at high altitudes in China. Increased frequency of SSB consumption and decreased cardiorespiratory fitness increased the risk of executive function disorders in Tajik adolescents. In the future, SSB consumption and cardiorespiratory fitness should be effectively controlled in Tajik adolescents to improve their executive function and promote the physical and mental health of Tajik adolescents in high-altitude areas.

Dietary Guidance, Sensory, Health and Safety Considerations When Choosing Low and No-Calorie Sweeteners

The growing global focus on the adverse health conditions associated with excessive sugar consumption has prompted health and policy organizations as well as the public to take a more mindful approach to health and wellness. In response, food and beverage companies have proactively innovated and reformulated their product portfolios to incorporate low and no-calorie sweeteners (LNCSs) as viable alternatives to sugar. LNCSs offer an effective and safe approach to delivering sweetness to foods and beverages and reducing calories and sugar intake while contributing to the enjoyment of eating. The objective of this paper is to enhance the understanding of LNCSs segmentation and definitions, dietary consumption and reduction guidance, front-of-package labeling, taste and sensory perception and physiology, metabolic efficacy and impact, as well as the overall safety of LNCSs and sugar.

Affordability of sugar-sweetened beverages and nonessential energy-dense foods after taxation, Mexico, 2010-2022

Objectives

This study had two objectives: first, to estimate trends in affordability of sugar-sweetened beverages and nonessential energy-dense foods from 2010 to 2022 in Mexico, both nationally and by household income level. The second was to simulate the effects of different tax increases for these foods and beverages to observe how much their affordability would change compared with the current scenario.

Methods

We used the 2010 to 2022 rounds of the Mexican National Survey of Household Income and Expenditures. The affordability ratio was estimated as the proportion of monthly income required to purchase 16 L of sugar-sweetened beverages and 2.8 kg of nonessential energy-dense foods, amounts that reflect median monthly consumption per household. Trends in the affordability ratio and its components (e.g. income and costs) are reported. Additionally, different tax increases were simulated for 2014-2022.

Results

Nationally and among low-income households, the affordability of these foods and beverages did not show significant changes before and after the implementation of the taxes on these introduced in 2014. The simulation scenarios showed that a tax of 3 pesos/L for sugar-sweetened beverages and 32% for nonessential energy-dense foods would be effective in reducing affordability at all income levels.

Conclusions

Current taxes are not high enough to significantly reduce the affordability of these foods and beverages. For low-income households, increases in income were greater than the increases in prices, thus sugar-sweetened beverages and nonessential energy-dense foods did not become less affordable, even after taxes were introduced in 2014. Tax rates would need to increase significantly to reduce affordability, and they should be adjusted for economic growth to compensate for increases in household income.

Carbonated Beverage Consumption Among Saudi Adults Before and After Implementation of Soft Drink Tax

The prevalence of obesity in Saudi Arabia has increased dramatically, with approximately 35% of the population estimated to be obese. This study assessed the patterns of carbonated beverage consumption and the factors and attitudes influencing consumption before and after implementing new soft drink taxes among Saudi adults. A secondary analysis was conducted on two cross-sectional studies involving Saudi adults aged over 18 years. The studies were conducted in July-September 2016 (Pre taxation, n = 964) and October 2022-March 2023 (post taxation, n = 1931). Data were collected using a validated questionnaire that included sociodemographic information, consumption patterns, influencing factors, and attitudes. A chi-square test compared frequency changes between the two periods, while a linear regression model assessed the impact of taxation on consumption frequency and quantity, along with associated factors and attitudes. Daily carbonated beverage consumption increased from 6% pre-taxation to 8% post-taxation. Significant changes were observed in factors and attitudes toward consumption (P < 0.05). The perceived influence of advertising decreased significantly (-0.320, P < 0.0001), while consumption during meals at home (0.430, P < 0.0001) and while watching TV or using electronic devices (0.231, P < 0.0001) increased post-taxation. The findings indicate that despite taxation, carbonated beverage consumption did not decrease among Saudi adults. These results underscore the need for comprehensive health promotion and intervention programs to address the high consumption of sugar-sweetened beverages and mitigate their health impacts.

The relationship between perceptions toward advertising and consumption of energy-dense nutrient-poor foods among adults in the United States: results from a national survey

Introduction

Much of the research on the effects of food advertising has been focused on children and adolescents; however, adults may also be influenced. Prior research has also shown that exposure to food advertisements have impacted the consumption behaviors of adults. The purpose of this study is to explore (1) the differences in perceptions toward and trust in food advertisements between racial/ethnic population subgroups; and (2) the associations between perceptions toward food advertising and the consumption of energy-dense, nutrient poor (EDNP) foods among adults using data from a national data set (n = 1,535).

Methods

Data from the National Cancer Institute's Family Life, Activity, Sun, Health, and Eating (FLASHE) survey were utilized in this secondary data analysis study. We conducted one-way ANOVAs to evaluate demographic subgroup differences within advertising trust and perceptions, and utilized bivariate and multivariable linear regression models to examine associations between (1) the perceptions toward and trust in food advertisements between racial/ethnic population subgroups; and (2) the associations between perceptions toward food advertising and the consumption of EDNP foods, while controlling for sociodemographic factors.

Results

Results show significant differences between racial/ethnic groups on advertising perceptions (F = 8.59, p < 0.0001). Planned contrasts show that there was a statistically significant and meaningful difference (p = 0.04) between Non-Hispanic Blacks (mean = 2.85) and Non-Hispanic Whites (mean = 2.52) for trust in food advertising. Regression analyses show that as positive perceptions toward food advertising increase among adults, there is an increase in daily frequency of consumption of EDNP foods and drinks (𝛽 = 0.15, p < 0.0001). This pattern was similar for trust in food advertising (𝛽 = 0.13, p < 0.0001).

Discussion

Given that previous studies have shown that ethnic minority groups, particularly Non-Hispanic Blacks, are more likely to be exposed to unhealthy food advertisements across various types of media, such as TV, billboards, and in grocery stores, it is possible that Non-Hispanic Black adults have greater trust in food advertising because of the increased environmental exposure to advertising through various channels of communication. Numerous studies have demonstrated that exposure to food advertisements is linked to consumption of the foods found in those advertisements. Our results provide some initial empirical support for the cognitive mechanisms of how exposure to food advertising may contribute to consumption. Developing advertising literacy interventions to inoculate against the cognitive impacts of food advertising may be a viable strategy to limiting consumption of EDNP foods.

Cardiovascular disease in the Americas: the epidemiology of cardiovascular disease and its risk factors

This first article of the Series about Cardiovascular Disease in the Americas summarizes the epidemiology of CVD and its risk factors, and population-level strategies in place aimed at CVD prevention. While age-standardized CVD incidence and CV mortality rates have been decreasing across in the Americas since 1990, the annual number of CVD cases and related deaths have increased due to population growth and ageing. The burden of CVD is also slowly transitioning from high-income countries in North America to middle-income countries in Latin America and the Caribbean. Trends in CV risk factor levels have been mixed, with declines in smoking and mean cholesterol counterbalanced by higher prevalence of obesity and diabetes. Population-wide strategies aimed at controlling cardiometabolic risk factors and tobacco use have been implemented with varying degrees of success. There is a need to better implement existing CVD prevention strategies in the region.

The Experimental Beverage Marketplace: Feasibility and preliminary validation of a tool to experimentally study sugar-sweetened beverage taxes and beverage purchasing

Sugar sweetened-beverage (SSB) consumption contributes to poor diet quality and diet-related chronic diseases. One effective public health strategy to reduce SSB consumption is to tax SSB. Laboratory approaches can complement existing methods to improve understanding of how taxes on SSB influence purchasing. In this study we sought to develop and validate an experimental marketplace that presents participants with beverages typically available at grocery stores. Participants who drink SSB (n = 73) hypothetically shopped for beverages for their household with a 40% SSB tax and with no tax (order counterbalanced). Relative to the no tax condition, SSB purchasing was lower in the tax condition. We also found that self-reported beverage expenditures were correlated with experimental marketplace beverage expenditures. Most participants noticed the tax and agreed that the experimental marketplace was easy to use. Using an experimental marketplace is a promising way to explore SSB tax design to improve public policy. We present ideas for future studies that can include real and hypothetical outcomes.

A systematic review and meta-analysis of visual cues and primes for nudging consumption-related behaviours

Healthy diets are crucial for maintaining overall well-being and reducing risk of health complications. Visual cues and primes are popular implicit nudging techniques for promoting healthier consumption habits. The present review and meta-analysis was conducted and reported according to PRISMA guidelines. It aimed to evaluate the effectiveness of these cues and primes for nudging consumption-related behaviours. Six electronic databases were comprehensively searched for experimental studies on the use of non-marketing-based visual cues/primes on food/beverage consumption. Sixty-six studies from 52 articles were included, resulting in 205 comparisons categorised into seven groups for separate analyses: (1) healthy food- and (2) body-related nudges, and (3) unhealthy food- and (4) body-related nudges, versus neutral controls; (5) mixed-health food- and (6) body-related comparisons; and (7) nudges not inherently health-related. Overall, nudges effectively influenced consumption-related behaviours. Healthier food- and body-nudges encouraged healthier behaviours relative to neutral controls and less healthy nudges, and unhealthy food-nudges, relative to neutral controls. Non-health-related nudges influenced behaviours in the expected direction, relative to comparison/control conditions. Nudge effectiveness, especially for unhealthy food-nudges, was moderated by participant age and weight, nudge timing (prime/cue) outcome measure (intake/choice), health (mixed/healthy/unhealthy), and whether the outcome was real or hypothetical. A range of participant, nudge, and outcome-related mechanisms proposed to underlie nudge effectiveness were also identified. Findings supported the efficacy of visual cues and primes for eliciting changes in consumption-related behaviours, indicating they may be effective for encouraging healthier consumption, when the right nudges are used. Results also indicated that different forms of nudges may be more appropriate in different circumstances (e.g., for different types of participants or food-related outcomes). Further research is needed to thoroughly comprehend the mechanisms underlying these nudges and their effectiveness.

The association between the health promotion levy and employment in South Africa: an interrupted time series analysis

BACKGROUND

The production and consumption of sugar-sweetened beverages (SSBs) have been increasing over the past years, globally. However, there is overwhelming evidence linking SSBs to the rising prevalence in obesity and its comorbidities. In South Africa, the prevalence of overweight and obesity is high and is among the highest in Sub-Saharan Africa. In response to rising prevalence in obesity and its comorbidities, on 1 April 2018 the South African government introduced an SSB tax, known as the Health Promotion Levy (HPL). However, the levy has been opposed by the sugar industry, claiming that it leads to jobs losses. Against this backdrop, this study seeks to investigate the association between the HPL and employment in the sugar industry.

METHODS

We employed single-group interrupted time series analyses using the Quarterly Labour Force Survey data from Statistics South Africa.

RESULTS

Our results show that the HPL has not been associated with job losses (or generation) in the sugar-related industries in South Africa. These findings are consistent with the findings on the effects of SSB taxes on employment in other jurisdictions.

CONCLUSIONS

Considering that the HPL does not impede employment, and the overwhelming evidence on the effectiveness of SSB taxes, together with the relatively low tax burden, it is imperative that the government raises the HPL from the current 8% of the retail price to the WHO-recommended 20% threshold. The government should also consider expanding the HPL to fruit juices. Such strategies are important in encouraging people to reduce the intake of SSBs, while enabling the government to raise additional revenue for the fiscus.

Consumption responses to sweetened beverage taxes by household income in four U.S. cities

Taxes on sweetened beverages have become an important policy response to growing obesity rates and the prevalence of type 2 diabetes in the U.S. and other nations. Since 2015, eight U.S. cities have implemented these taxes, but so far direct evidence of their impacts on household purchasing behavior is scarce. Of particular interest to many researchers and policy makers is the response of lower-income consumers to these taxes, both because they have higher sweetened beverage consumption on average and because of concerns that sweetened beverage taxes are regressive. This project investigates the income-stratified household response to SSB taxes using a data set containing the purchasing behavior of approximately 400 households in the cities of Seattle, San Francisco, Oakland, and Philadelphia, all of which have recently introduced beverage taxes. Using doubly-robust estimation of dynamic and heterogeneous treatment effects relative to a propensity-matched set of households in three comparison cities, we find that households in taxed cities experience increased prices and reduce their purchases of those beverages, with no evidence of cross-border shopping. We further find differential tax impacts by income level, with lower-income households (households with income <200% of the federal poverty line for their size) reducing their purchases of taxed beverages by nearly 50% - more than double the 18% reduction found in higher-income households (households with income >400% of the federal poverty line for their size). Our finding that lower-income households decrease their consumption more than twice as much as higher-income households suggests that these taxes may reduce health disparities and promote population health.

Sugar-sweetened beverages: taxation evidence from seven European countries and recommendations for implementation in other EU regions

OBJECTIVES

Higher-than-recommended sugar consumption (< 10% of total energy intake; WHO) leads to negative health impacts and the development of serious diseases. Sugar-sweetened beverages (SSBs) proved to be among the leading sources of free sugar intake, as they contain large amounts of added sugar. Our article aims to propose tax measures that will help change consumer behaviour and reduce SSBs consumption.

METHODS

For a comparison of the forms of taxation, the experience of seven countries (Denmark, France, Hungary, Italy, Poland, Catalonia - Spain, and the UK) were analysed. The evolution of sugar consumption, consumption of sweetened drinks and obesity before and after the introduction and/or abolition of the sugar tax were reviewed.

RESULTS

States that implemented a tax on SSBs were able to reduce SSBs consumption in the first year after the tax was introduced when states with a sugar-content-based tax have implemented it more effectively than states with a volume-based tax. Based on this finding, we propose basic design assumptions for the tax that can be used in European countries that have not yet introduced the tax. Progressive taxation divides beverages into 3 bands. The basic assumption is to encourage the desired consumer behaviour, i.e., consumption of SSBs with lower sugar content. The proposed tax design is applied to the conditions of the Czech Republic as a model case study.

CONCLUSIONS

The results of our study suggest that SSBs taxation could be an effective policy intervention to improve population health by reducing the health impacts of SSBs among children and adolescents, although further studies are needed to prove the causality of the described associations.

Epidemiology of cardiometabolic health in Latin America and strategies to address disparities

In Latin America and the Caribbean (LAC), sociodemographic context, socioeconomic disparities and the high level of urbanization provide a unique entry point to reflect on the burden of cardiometabolic disease in the region. Cardiovascular diseases are the main cause of death in LAC, precipitated by population growth and ageing together with a rapid increase in the prevalence of cardiometabolic risk factors, predominantly obesity and diabetes mellitus, over the past four decades. Strategies to address this growing cardiometabolic burden include both population-wide and individual-based initiatives tailored to the specific challenges faced by different LAC countries, which are heterogeneous. The implementation of public policies to reduce smoking and health system approaches to control hypertension are examples of scalable strategies. The challenges faced by LAC are also opportunities to foster innovative approaches to combat the high burden of cardiometabolic diseases such as implementing digital health interventions and team-based initiatives. This Review provides a summary of trends in the epidemiology of cardiometabolic diseases and their risk factors in LAC as well as context-specific disease determinants and potential solutions to improve cardiometabolic health in the region.

An Inventory of Proposed and Enacted Sugar-Sweetened Beverage Policies at the State, Local, and Tribal Levels in the United States, 2014‒2023

Objectives. To inventory and describe trends in proposal and enactment of US sugar-sweetened beverage (SSB) policies at state, local, and Tribal levels, 2014-2023. Methods. We systematically searched 6 policy databases in 2021 (updated May 2023) using SSB-related search terms, identifying additional policies through snowball and online searches and a survey of food-policy experts. We reviewed 10 821 policies for inclusion and quantitatively coded included policies. Results. The inventory included 400 (321 unique [i.e., excluding companion]) policies meeting criteria: 335 (256 unique) state-, 63 local-, and 2 Tribal-level policies. From 2014 to 2023, 11% of unique state-, 92% of local-, and 100% of Tribal-level proposed policies were enacted. Across jurisdictions, the most frequently proposed policies related to excise taxes, restaurant children's meals, nutrition standards, and the Supplemental Nutrition Assistance Program, while the largest proportions of enacted policies related to restaurant children's meals, nutrition standards, education, and procurement. More policies were proposed and enacted in California and New York than other states, and in 2017 (proposed) and 2016 (enacted). Conclusions. This comprehensive inventory of US SSB policies provides information to inform future SSB policy development and diffusion. (Am J Public Health. 2024;114(12):1344-1353. https://doi.org/10.2105/AJPH.2024.307855).

Watered down: a cross-case political economy analysis of sugar-sweetened beverage taxes in Vanuatu and Fiji

Taxes on sugar-sweetened beverages (SSBs) in Vanuatu and Fiji are praised for their alignment with the World Health Organization's noncommunicable diseases Best Buy policy recommendations. SSB taxes also intersect with economic, trade and commercial interests as well as complex domestic and international power dynamics. Yet, to date, the role of these broader interests and power dynamics in shaping SSB tax adoption in Vanuatu and Fiji has remained underexamined. Drawing on Bourdieu's forms of capital and triangulating interview (n = 50), document (n = 461) and observational data, this cross-case political economy analysis sought to understand where forms of power reside, how they manifest, and what impact they have on the alignment between SSB tax in Vanuatu and Fiji and national and global goals and priorities. Three interconnected themes emerged from the analysis: the influence of domestic industry actors in a context of shifting fiscal and trade incentives; the pivotal agenda-setting role of pro-tax multisectoral coalitions and the way political instability lent importance to informal policy processes. Findings evidence the varying influence of economic, social, and cultural capitals across the policy cycle and showcase the way in which actors strategically deployed, lost or re-imagined their capitals to secure policy influence. Importantly, cultural capital was essential to leveraging influence across the policy cycle and more inward-facing systems favoured the protection of domestic actors and industries, including their economic capital. From a health perspective, these political forces ultimately culminated in weaker or 'watered down' SSB taxes in both Vanuatu and Fiji.

Lifestyle interventions for cardiometabolic health

Unhealthy lifestyle behaviors such as poor diets and physical inactivity account for most of the cardiometabolic disease (CMD) burden, including type 2 diabetes and cardiovascular diseases. Much of this burden is mediated by the effects of unhealthy lifestyle behaviors on overweight and obesity, and disproportionally impacts certain population groups-including those from disadvantaged socioeconomic backgrounds. Combined lifestyle interventions (CLIs), which target multiple behaviors, have the potential to prevent CMD, but their implementation, reach and effectiveness in routine practice are often limited. Considering the increasing availability of effective but expensive pharmaceutical options for weight loss, we review the short-term and long-term benefits and cost-effectiveness of CLIs on overweight, obesity and associated CMDs, in controlled studies and in routine care. Against the backdrop of changing living environments, we discuss the effective components of CLIs and the many challenges associated with implementing them. Finally, we outline future directions for research and implications for policy and practice to improve lifestyle behaviors and cardiometabolic health at the population level.

The impact of culturally-informed messages to reduce sugar-sweetened beverage consumption: An experiment among Black women in the United States

OBJECTIVE

Sugar-sweetened beverage (i.e., sugary drink) consumption is associated with chronic health issues that disproportionately affect Black women. Culturally-informed (CI) health campaigns may be more effective among Black women than campaigns designed for general audiences. This study assesses the effects of a CI campaign on consumption intentions, comparing these effects to general audience and control campaigns.

METHODS

We conducted an online between-persons randomized experiment with a national convenience sample of 502 Black women in February 2023. Participants were randomly assigned to view a CI, general audience, or control campaign. Outcomes were intentions to decrease sugary drink consumption (primary outcome; range 1-7), knowledge of (range 0-4) and perceived susceptibility to health harms (range 1-5) and sharing intentions (range 0-3).

RESULTS

The CI campaign had significantly higher perceived cultural relevance (M = 4.61) than the general audience (M = 3.64) or control (M = 3.66; p's<0.05) campaigns. Consumption intentions did not differ by campaign condition (F = 0.03, p>0.05). There was no main effect of campaign condition on knowledge or perceived susceptibility (p's>0.05), though findings were moderated by body size. Based on body size, women reported less perceived susceptibility or knowledge when exposed to the CI campaign, compared to either the control or general audience campaign. Sharing intentions did not differ by campaign condition.

CONCLUSIONS

Future research should continue to examine the role of refining message content over a longer duration to understand whether the anticipated impact of CI messages can be achieved in the context of sugary drink consumption among Black women.

De-normalizing sugar-sweetened beverage consumption: effects of tax measures on social norms and attitudes in the California Bay Area

BACKGROUND

Social norms can influence individual health behaviors. Shifts in social norms for smoking were critical for the effectiveness of tobacco control efforts such as excise taxes. Sugar-sweetened beverage (SSB) excise taxes have been implemented in municipalities across the United States to reduce SSB intake and improve health. We sought to identify trends in social norms and attitudes about healthfulness of sugar-sweetened beverage (SSB) consumption in the California Bay Area and examine whether social norms and attitudes changed following SSB taxes.

METHODS

Data came from annual (2016-2019, 2021) cross-sectional surveys (n = 9128) in lower-income neighborhoods in Oakland, San Francisco, Berkeley, and Richmond. We assessed overall trends and compared pre-post tax changes in Oakland and San Francisco with comparison cities.

RESULTS

We observed a 28% reduction in social norms for SSB consumption (people's perceptions of peers' consumption) and variable reductions in attitudes about the healthfulness of SSBs. Relative to comparison cities, post-tax, perceptions of peers' consumption of sports drinks declined in Oakland; attitudes about the healthfulness of sugar-sweetened fruit drinks declined in San Francisco.

CONCLUSIONS

Among lower-income populations, social norms and attitudes towards the healthfulness of SSBs meaningfully declined over time, with smaller tax-related effects. SSB taxes as well as the local media attention they generate appear to affect people's perceptions of SSBs. Pairing SSB taxes with messaging campaigns may be more effective in de-normalizing SSB consumption.

Prevention and control of cardiovascular disease in "real-world" settings: sustainable implementation of effective policies

Global progress in addressing cardiovascular diseases (CVD) has been insufficient to attain the nine WHO non-communicable disease (NCD) targets and the Sustainable Development Goal (SDG) target of reducing premature NCD mortality by one-third by 2030. Progress has been slowest in low- and middle-income countries (LMIC) where addressing the CVD burden is a foremost development imperative. This review examines the reasons for this situation to propose a way forward. First, we review policy instruments to address behavioral and metabolic risk factors of CVD and health system interventions to improve cardiovascular outcomes. Second, we illustrate the financial, health workforce, health system challenges, and weak national capacity that impede the implementation of these policy instruments. Third, we discuss how LMIC might move forward despite these challenges by (a) giving due consideration to contextual and other factors that determine the success of policy implementation (b) including affordable, high-impact interventions as the core of the universal health coverage health benefit package with primary health care as the foundation and (c) by taking note of the WHO guidance provided in the 2023-2030 implementation roadmap for the Global Action Plan for prevention and control of NCD.

Offline to online: a systematic mapping review of evidence to inform nutrition-related policies applicable to online food delivery platforms

BACKGROUND

Online food delivery (OFD) platforms offer easy access to an abundance of energy-dense and nutrient-poor takeaway foods and may exacerbate existing unhealthy food environments. Efforts to improve population diets include a range of policy recommendations focused on improving the healthiness of food environments; however, the way in which such policies may apply to OFD platforms is not clear. This paper aimed to synthesise the existing evidence to inform nutrition-related policies applicable to OFD platforms for population health and well-being. A secondary aim was to scan existing nutrition-related policies in Australia and internationally, which have the potential to be applicable to OFD platforms.

METHODS

Seven electronic databases including Medline, Embase, CINAHL, Business Source Ultimate, Scopus, Web of Science, and Proquest were searched from January 2010 to October 2023. Evidence from studies was mapped to five existing policy domains outlined by the Healthy Food Environment Policy Index (Food-EPI) including (i) food labelling; (ii) food promotion; (iii) food composition and nutritional quality; (iv) food retail; and (v) food pricing. Relevant data sources were searched for currently implemented nutrition-related government policies that may have relevance to OFD platforms.

RESULTS

A total of 2012 records were screened, and 43 studies were included. There were 70 relevant study outcomes across the included studies, which addressed one or more of the 5 domains. Of these, 21 were relevant to 'Food Promotion' (30%), 18 to 'Food Retail' (26%), 15 to 'Food Composition (21%), 11 to 'Food Prices' (16%), and six to 'Food Labelling' (9%). Three existing policies from international jurisdictions (England, Singapore, EU) included OFD platforms, of which one was a voluntary measure. Several existing policies under food labelling have the potential to be amended to include OFD platforms under regulatory definitions.

CONCLUSION

OFD platforms have emerged as a disruptor to how people acquire their food and have yet to be widely included in existing nutrition-related policies. Advancing the evidence base to support the design of effective policy actions and mitigate the potential negative health impacts of OFD platforms will support efforts to improve population diets.

Associations of the Philadelphia sweetened beverage tax with changes in adult body weight: an interrupted time series analysis

Background

Sweetened beverage taxes are associated with large decreases in sugar-sweetened beverage sales, but their effects on weight outcomes are unclear. We examined associations of the 2017 Philadelphia beverage tax with changes in adult weight outcomes.

Methods

We obtained electronic health record data on adults 18-65 years old in Philadelphia (intervention) and other areas of Pennsylvania and New Jersey (control) from 2014 to 2019. Controlled interrupted time series models compared post-tax changes in trends of body mass index (BMI, primary outcome) and obesity prevalence (secondary outcome). A panel sample comprised 175,675 adults with at least one BMI measure in both the pre-tax (2014-2016) and post-tax (2017-2019) periods. A cross-sectional sample comprised 587,121 adults with at least one BMI measure from 2014 to 2019.

Findings

Before tax implementation, Philadelphia panel patients had a mean BMI of 30.4 kg/m2 and an obesity prevalence of 44.5%. After implementation, in the panel sample, there was a -0.03 kg/m2 (95% CI: -0.07, 0.02) per quarter decrease in BMI vs. control, implying a -0.32 kg/m2 (-0.85, 0.20) change at the end of the 3-year study period. In the cross-sectional sample, there was a -0.05 kg/m2 (95% CI: -0.09, -0.01) per quarter decrease in BMI vs. control, implying a -0.60 kg/m2 (-1.04, -0.16) change at the end of the study period. Results for obesity prevalence were consistent with the BMI results.

Interpretation

There was some limited evidence of a decrease in BMI and obesity prevalence in Philadelphia 3 years after beverage tax implementation. Replication of these results is needed.

Funding

National Institutes of Health.

Protecting whose welfare? A document analysis of competition regulatory decisions in four jurisdictions across three harmful consumer product industries

BACKGROUND AND METHODS

Competition regulation has a strong influence on the relative market power of firms. As such, competition regulation can complement industry-specific measures designed to address harms associated with excessive market power in harmful consumer product industries. This study aimed to examine, through a public health lens, assessments and decisions made by competition authorities in four jurisdictions (Australia, South Africa, the United States (US), and the European Union (EU)) involving three harmful consumer product industries (alcoholic beverages, soft drinks, tobacco). We analysed legal case documents, sourced from online public registers and dating back as far as the online records extended, using a narrative approach. Regulatory decisions and harms described by the authorities were inductively coded, focusing on the affected group(s) (e.g., consumers) and the nature of the harms (e.g., price increases) identified.

RESULTS

We identified 359 cases published by competition authorities in Australia (n = 202), South Africa (n = 44), the US (n = 27), and the EU (n = 86). Most cases (n = 239) related to mergers and acquisitions (M&As). Competition authorities in Australia, the US, and the EU were found to make many decisions oriented towards increasing the affordability and accessibility of alcohol beverages, soft drinks, and tobacco products. Such decisions were very often made despite the presence of consumption-reduction public health policies. In comparison, South Africa's competition authorities routinely considered broader issues, including 'Black Economic Empowerment' and potential harms to workers.

CONCLUSION

Many of the competition regulatory decisions assessed likely facilitated the concentration of market power in the industries we explored. Nevertheless, there appears to be potential for competition regulatory frameworks to play a more prominent role in promoting and protecting the public's health through tighter regulation of excessive market power in harmful consumer product industries.

The Role of Food and Beverage Environments in Child Health and Weight-Related Behaviors

This article explores how food and beverage environments influence child health and obesity risk and addresses institutional settings, retail environments, food assistance programs, and food and beverage industry marketing. It emphasizes social determinants of health, evidence-based interventions, and policy recommendations to promote healthier food options and reduce inequities. Pediatric health care providers play a critical role in addressing the need for systemic changes to eliminate inequities in food environments and the systems that support these inequities.

US trade policy and public health: heterogeneous effects from the North American Free Trade Agreement

OBJECTIVE

To investigate the causal link between the North American Free Trade Agreement (NAFTA) unrestricted sugar trade agreement signed in 2008 between the USA and Mexico and the diabetes prevalence across all fifty US states.

DESIGN

A quasi-experimental research design to investigate the causal effect of the NAFTA unrestricted sugar trade agreement on diabetes prevalence. Our study utilises a comprehensive panel dataset spanning from 2000 to 2016, comprising 1054 observations. To conduct our analysis, we applied both the difference-in-differences and event-study methodologies.

SETTING

All the states in the USA.

PARTICIPANTS

The fifty states in the USA.

RESULTS

After the enactment of the NAFTA sugar trade agreement between the USA and Mexico in 2008, most states witnessed an increase in diabetes prevalence. The annual impacts displayed significant variation among states, with percentage increases spanning from 0·50 to 2·28 %.

CONCLUSIONS

States with a higher percentage of their population living below the poverty line, a larger Black resident population and a lower proportion of high school graduates had more significant increases in diabetes prevalence attributed to the NAFTA sugar trade agreement.

Proportion and number of cancer cases and deaths attributable to potentially modifiable risk factors in the United States, 2019

In 2018, the authors reported estimates of the number and proportion of cancers attributable to potentially modifiable risk factors in 2014 in the United States. These data are useful for advocating for and informing cancer prevention and control. Herein, based on up-to-date relative risk and cancer occurrence data, the authors estimated the proportion and number of invasive cancer cases (excluding nonmelanoma skin cancers) and deaths, overall and for 30 cancer types among adults who were aged 30 years and older in 2019 in the United States, that were attributable to potentially modifiable risk factors. These included cigarette smoking; second-hand smoke; excess body weight; alcohol consumption; consumption of red and processed meat; low consumption of fruits and vegetables, dietary fiber, and dietary calcium; physical inactivity; ultraviolet radiation; and seven carcinogenic infections. Numbers of cancer cases and deaths were obtained from data sources with complete national coverage, risk factor prevalence estimates from nationally representative surveys, and associated relative risks of cancer from published large-scale pooled or meta-analyses. In 2019, an estimated 40.0% (713,340 of 1,781,649) of all incident cancers (excluding nonmelanoma skin cancers) and 44.0% (262,120 of 595,737) of all cancer deaths in adults aged 30 years and older in the United States were attributable to the evaluated risk factors. Cigarette smoking was the leading risk factor contributing to cancer cases and deaths overall (19.3% and 28.5%, respectively), followed by excess body weight (7.6% and 7.3%, respectively), and alcohol consumption (5.4% and 4.1%, respectively). For 19 of 30 evaluated cancer types, more than one half of the cancer cases and deaths were attributable to the potentially modifiable risk factors considered in this study. Lung cancer had the highest number of cancer cases (201,660) and deaths (122,740) attributable to evaluated risk factors, followed by female breast cancer (83,840 cases), skin melanoma (82,710), and colorectal cancer (78,440) for attributable cases and by colorectal (25,800 deaths), liver (14,720), and esophageal (13,600) cancer for attributable deaths. Large numbers of cancer cases and deaths in the United States are attributable to potentially modifiable risk factors, underscoring the potential to substantially reduce the cancer burden through broad and equitable implementation of preventive initiatives.

Exploring the sugar-sweetened beverage tax (SSBT) pass-through rate in the Irish hospitality sector

BACKGROUND

The World Health Organization (WHO) supports the use of Sugar-Sweetened Beverage Taxes (SSBTs) as a fiscal lever to help reduce sugar consumption and tackle obesity. Obesity is associated with a range of adverse health outcomes. In response to increasing levels of obesity in Ireland, an SSBT was introduced in 2018. Previous research in Ireland has noted that the pass-through rate of the SSBT in retail (off-site consumption) settings was poor. However, to date, no research has examined the SSBT pass-through rate in hospitality (on-site consumption) venues in Ireland.

METHODS

This research examines the SSBT pass-through rate on Coca-Cola versus diet versions of Coca-Cola in a convenience sample of 100 hospitality venues in two provincial Irish cities.

RESULTS

Wilcoxon signed rank test analysis revealed that regular Coca-Cola was significantly more expensive compared to the price charged for diet versions of Coca-Cola. However, in 85.6% of cases the same price was charged for both full-sugar and sugar-free drinks. The mean pass-through rate of the SSBT was 33.8%.

CONCLUSION

The effective functioning of the SSBT is premised on persistent price differences between soft drink prices based on sugar content. However, this is barely evident in the hospitality sector in Ireland. A number of recommendations are suggested, including both increasing the SSBT, and increasing it annually in line with inflation.

The implications of policy modeling assumptions for the projected impact of sugar-sweetened beverage taxation on body weight and type 2 diabetes in Germany

BACKGROUND

Evaluating sugar-sweetened beverage (SSB) taxation often relies on simulation models. We assess how assumptions about the response to SSB taxation affect the projected body weight change and subsequent health and economic impacts related to type 2 diabetes mellitus (T2DM) using Germany as an example.

METHODS

In the main analysis, we estimated changes in energy intake by age and sex under a 20% value-added tax on SSBs in Germany using marginal price elasticities (PE) and applied an energy equilibrium model to predict body weight changes. We then quantified the impact of several assumption modifications: SSB own-PE adjusted for consumption (M1)/based on alternative meta-analysis (M2); SSB consumption adjusted for underreporting (M3); substitution via marginal (M4a) or adjusted (M4b) cross-PE/as % of calorie change (M4c). We also assessed scenarios with alternative tax rates of 10% (S1) or 30% (S2) and including fruit juice (S3). We calculated overweight and obesity rates per modification and scenario. We simulated the impact on T2DM, associated healthcare costs, and disability-adjusted life years (DALYs) over the lifetime of the 2011 German adult population with a Markov model. Data included official demographics, national surveys, and meta-analyses.

RESULTS

A 20% value-added tax in Germany could reduce the number of men and women with obesity by 210,800 [138,800; 294,100] and 80,800 [45,100; 123,300], respectively. Over the population's lifetime, this would lead to modest T2DM-related health and economic impacts (76,700 DALYs [42,500; 120,600] averted; €2.37 billion [1.33; 3.71] costs saved). Policy impacts varied highly across modifications (all in DALYs averted): (M1) 94,800 [51,500; 150,700]; (M2) 164,200 [99,500; 243,500]; (M3) 52,600 [22,500; 91,100]; (M4a) -18,100 [-111,500; 68,300]; (M4b) 25,800 [-31,400; 81,500]; (M4c) 46,700 [25,300; 77,200]. The variability in policy impact related to modifications was similar to the variability between alternative policy scenarios (all in DALYs averted): (S1) 26,400 [9,300; 47,600]; (S2) 126,200 [73,600; 194,500]; (S3) 342,200 [234,200; 430,400].

CONCLUSIONS

Predicted body weight reductions under SSB taxation are sensitive to assumptions by researchers often needed due to data limitations. Because this variability propagates to estimates of health and economic impacts, the resulting structural uncertainty should be considered when using results in decision-making.

Dynamics of combatting market-driven epidemics: Insights from U.S. reduction of cigarette, sugar, and prescription opioid consumption

Misuse and overconsumption of certain consumer products have become major global risk factors for premature deaths, with their total costs in trillions of dollars. Progress in reducing such deaths has been slow and difficult. To address this challenge, this review introduces the definition of market-driven epidemics (MDEs), which arise when companies aggressively market products with proven harms, deny these harms, and resist mitigation efforts. MDEs are a specific within the broader landscape of commercial determinants of health. We selected three illustrative MDE products reflecting different consumer experiences: cigarettes (nicotine delivery product), sugar (food product), and prescription opioids (medical product). Each met the MDE case definition with proven adverse health impacts, well-documented histories, longitudinal product consumption and health impact data, and sustained reduction in product consumption. Based on these epidemics, we describe five MDE phases: market expansion, evidence of harm, corporate resistance, mitigation, and market adaptation. From the peak of consumption to the most recent data, U.S. cigarette sales fell by 82%, sugar consumption by 15%, and prescription opioid prescriptions by 62%. For each, the consumption tipping point occurred when compelling evidence of harm, professional alarm, and an authoritative public health voice and/or public mobilization overcame corporate marketing and resistance efforts. The gap between suspicion of harm and the consumption tipping point ranged from one to five decades-much of which was attributable to the time required to generate sufficient evidence of harm. Market adaptation to the reduced consumption of target products had both negative and positive impacts. To our knowledge, this is the first comparative analysis of three successful efforts to change the product consumption patterns and the associated adverse health impacts of these products. The MDE epidemiological approach of shortening the latent time to effective mitigation provides a new method to reduce the impacts of harmful products.

An Evaluation of Healthy Hydration Recommendations for 93 Countries with Sugary Beverage Tax Legislation Globally, 2000-2023

Adequate water intake is essential for human health. Sugary beverage taxes are a best buy policy to reduce obesity and diet-related non-communicable diseases. Food-based dietary guidelines (FBDGs) promote healthy dietary patterns. The study purpose was to evaluate national FBDGs for countries with sugary beverage tax legislation (2000-2023) to promote water and discourage sugary beverage consumption. We developed a coding framework to conduct a content analysis of FBDG documents, and used six indicators to identify messages and images to assign healthy hydration recommendation (HHR) scores from 0-12 to compare FBDGs across countries and six regions. Results showed 93 countries with sugary beverage tax legislation of which 58 countries (62%) had published FBDGs (1998-2023). Of 58 FBDGs reviewed, 48 (83%) had complementary recommendations that encouraged water and discouraged sugary beverages. Of 93 countries, 13 (14%) had the highest HHR scores (11-12); 22, (24%) had high HHR scores (9-10); 20 (21%) had medium HHR scores (4-8); 3 (3%) had low HHR scores (0-3); and 35 (38%) countries had no FBDGs. To reduce health risks for populations, governments must ensure policy coherence to optimize sugary beverage tax impacts by developing FBDGs that encourage water and discourage sugary beverages complementary to national policies.

Redesigning Pharmacy to Improve Public Health Outcomes: Expanding Retail Spaces for Digital Therapeutics to Replace Consumer Products That Increase Mortality and Morbidity Risks

United States healthcare outcomes, including avoidable mortality rates, are among the worst of high-income countries despite the highest healthcare spending per capita. While community pharmacies contribute to chronic disease management and preventive medicine, they also offer consumer products that increase mortality risks and the prevalence of cardiovascular diseases, diabetes, cancer, and depression. To resolve these contradictions, our perspective article describes opportunities for major pharmacy chains (e.g., CVS Pharmacy and Walgreens) to introduce digital health aisles dedicated to prescription and over-the-counter digital therapeutics (DTx), together with mobile apps and wearables that support disease self-management, wellness, and well-being. We provide an evidence-based rationale for digital health aisles to replace spaces devoted to sugar-sweetened beverages and other unhealthy commodities (alcohol, tobacco) that may increase risks for premature death. We discuss how digital health aisles can serve as marketing and patient education resources, informing customers about commercially available DTx and other technologies that support healthy lifestyles. Since pharmacy practice requires symbiotic balancing between profit margins and patient-centered, value-based care, replacing health-harming products with health-promoting technologies could positively impact prevention of chronic diseases, as well as the physical and mental health of patients and caregivers who visit neighborhood pharmacies in order to pick up medicines.

Sugar-sweetened beverage intake and chronic low back pain

Background

The consumption of sugar-sweetened beverages (SSBs) has become a major public health problem globally. However, no studies have specifically examined the relationship between SSB intake and chronic low back pain (CLBP). Therefore, the present study aimed to investigate the relationship between SSB intake and the risk of CLBP.

Methods

This cross-sectional study enrolled participants aged 20 to 69 from the National Health and Nutrition Examination Survey. CLBP was defined as persistent LBP for a consecutive three-month period. Furthermore, SSB intake was assessed and calculated based on dietary recall interviews. Moreover, survey-weighted logistic regression models were employed to evaluate the association between SSB intake and the risk of CLBP, while the restricted cubic spline (RCS) analysis was used to determine whether there were nonlinear associations between SSB intake and CLBP risk. In addition, subgroup analysis was performed using stratification and interaction analysis for all covariates.

Results

A total of 4,146 participants (mean age: 43.405 years) were enrolled in the final analysis. The results of survey-weighted logistic regression models showed that SSB consumption was significantly associated with an increased risk of CLBP among individuals aged 20 to 69 years. Moreover, the results of subgroup analysis and interaction analysis demonstrated that the association between SSB intake and the risk of CLBP was modified by smoking status and hypertension. Specifically, the SSB intake-associated CLBP risk was more pronounced among current smokers or individuals with hypertension.

Conclusion

Reduction of SSB consumption might contribute to the prevention of CLBP for individuals aged 20 to 69 years. Moreover, current smokers or individuals with hypertension should be more vigilant about the SSB intake-associated CLBP risk. Nevertheless, caution should be exercised when interpreting the results of this study, as further research is necessary to explore the association between SSB consumption and CLBP, given the limitations of the current study.

Promoting Healthier Purchases: Ultraprocessed Food Taxes and Minimally Processed Foods Subsidies for the Low Income

INTRODUCTION

Fiscal policies can shift relative food prices to encourage the purchase and consumption of minimally processed foods while discouraging the purchase and consumption of unhealthy ultraprocessed foods, high in calories and nutrients of concern (sodium, sugar, and saturated fats), especially for low-income households.

METHODS

The 2017-2018 packaged food purchase data among U.S. households were used to derive household income- and composition-specific demand elasticities across 22 food and beverage categories. Policy simulations, conducted in 2022-2023, assessed the impact of national taxes on unhealthy ultraprocessed food and beverage purchases, both separately and alongside subsidies for minimally processed foods and beverages targeted to low-income households. Resultant nutritional implications are reported on the basis of changes in purchased calories and nutrients of concern. In addition, financial implications for both households and the federal government are projected.

RESULTS

A sugar-based tax on sugar-sweetened beverages would lower both volume and calories purchased with the largest impact on low-income households without children. Meanwhile, targeted subsidies would increase fruit, vegetable, and healthier drink purchases without substantially increasing calories. Under tax simulations, low-income households would make larger reductions in their absolute volume and calorie purchases of taxed foods and beverages than their higher-income counterparts, suggesting that these policies, if implemented, could help narrow nutritional disparities.

CONCLUSIONS

Levying national taxes on unhealthy ultraprocessed foods/beverages and offering targeted subsidies for minimally processed foods/beverages could promote healthier food choices among low-income households. Such policies have the potential to benefit low-income households financially and at a relatively low cost for the federal government annually.

The impact of the UK soft drink industry levy on the soft drink marketplace, 2017-2020: An interrupted time series analysis with comparator series

BACKGROUND

In April 2018, the UK government implemented a levy on soft drinks importers and manufacturers, tiered according to the amount of sugar in drinks. The stated aim was to encourage manufacturers to reduce sugar and portion sizes. Previous evidence suggests that the policy has been successful in reducing sugar in drinks in the short-term since implementation, but their sustained effects have not been explored. This study aimed to assess the impact of the soft drink industry levy (SDIL) on sugar levels, price, portion size and use of non-sugar sweeteners in the medium-term.

METHODS AND FINDINGS

Product data from 30 November 2017 to 14 March 2020 from one major UK retail supermarket were analysed (112,452 observations, 126 weekly time points). We used interrupted time series analysis, to assess the impact of the soft-drink industry levy (SDIL) on levy-eligible soft drinks, with exempt drinks (i.e. 100% fruit juices, milks, flavoured milks) acting as a comparator series. At the point of implementation of the SDIL (April 2018) there was a step change in the proportion of eligible drinks with sugar content below the SDIL levy threshold (5g per 100ml) (+0.08, 95%CI: +0.04, +0.12), with a similar sized decrease in the proportion in the highest levy category (> = 8g sugar per 100ml) (-0.06, 95%CI: -0.10, -0.03). Between April 2018 and March 2020, the proportion of eligible drinks below the SDIL levy threshold continued to gradually increase (p = 0.003), while those in the highest levy category decreased (p = 0.007). There was a step change in price of eligible drinks in the higher levy category at the point of implementation of +£0.049 (95%CI: +£0.034, +£0.065) per 100mL (for comparison, the levy is set at £0.024 per 100mL for this group). Trends in price for the high levy category were not altered by the SDIL. In the no levy category, there was a step change in price at the implementation (+£0.012 per 100mL, 95%CI: +£0.008, +£0.023), followed by a second step change in October 2018 (-£0.018p per 100mL, 95%CI: -£0.033, -£0.001p). The volume of products in the higher levy group decreased at the time of the implementation (-305mL on average including multipacks, 95%CI: -511, -99). The change in trend for the product volume of drinks in the higher levy group between April 2018 and March 2020 was in the increasing direction (+704mL per year, 95%CI: -95, 1504), but it did not meet our threshold for statistical significance (p = 0.084). There were no changes observed in the volume of lower levy drinks or no levy drinks. There was a step change in the proportion of drinks with non-sugar sweeteners at the implementation of the SDIL (+0.04, 95%CI: +0.02, +0.06).

CONCLUSION

These results suggest that the SDIL was successful in [1] producing reductions in sugar levels that were maintained over the medium term up to March 2020 and [2] a reduction in product volume for higher tier drinks that may be diminishing over time. Our results also show that the SDIL was associated with a maintained price differential between high and low sugar drinks.

Food Systems Interventions for Nutrition: Lessons from 6 Program Evaluations in Africa and South Asia

Although there is growing global momentum behind food systems strategies to improve planetary and human health-including nutrition-there is limited evidence of what types of food systems interventions work. Evaluating these types of interventions is challenging due to their complex and dynamic nature and lack of fit with standard evaluation methods. In this article, we draw on a portfolio of 6 evaluations of food systems interventions in Africa and South Asia that were intended to improve nutrition. We identify key methodological challenges and formulate recommendations to improve the quality of such studies. We highlight 5 challenges: a lack of evidence base to justify the intervention, the dynamic and multifaceted nature of the interventions, addressing attribution, collecting or accessing accurate and timely data, and defining and measuring appropriate outcomes. In addition to more specific guidance, we identify 6 cross-cutting recommendations, including a need to use multiple and diverse methods and flexible designs. We also note that these evaluation challenges present opportunities to develop new methods and highlight several specific needs in this space.

Outcomes of sugar reduction policies, United Kingdom of Great Britain and Northern Ireland

Poor diets are the major cause of death and disease globally, driving high levels of obesity and noncommunicable diseases. Cheap, heavily marketed, ultra-processed, energy-dense and nutrient-poor food and drinks that are high in fat, sugar and salt play a major role. The high-sugar content of these products leads to consumption levels much higher than recommended. The World Health Organization recommends that sugar intake should be reduced to just 5% of energy intake by using fiscal policies and food and drink reformulation strategies. Over the previous decade, the government of the United Kingdom of Great Britain and Northern Ireland has implemented several policies aimed at reducing sugar intake. We compare the soft drinks industry levy and the sugar reduction programme, examining how differences in policy design and process may have influenced the outcomes. Success has been mixed: the mandatory levy achieved a reduction in total sugar sales of 34.3%, and the voluntary reduction programme only achieved a 3.5% reduction in sugar levels of key contributors to sugar intake (despite a target of 20%). Both policies can be improved to enhance their impact, for example, by increasing the levy and reducing the sugar content threshold in the soft drinks industry levy, and by setting more stringent subcategory specific targets in the sugar reduction programme. We also recommend that policy-makers should consider applying a similar levy to other discretionary products that are key contributors to sugar intake. Both approaches provide valuable learnings for future policy in the United Kingdom and globally.

Association of sugary drinks, carbonated beverages, vegetable and fruit juices, sweetened and black coffee, and green tea with subsequent depression: A five-year cohort study

BACKGROUND & AIMS

Evidence on the impact of beverage consumption on depression is limited in the Asian population. Specifically, there is little information available on vegetable and fruit juices, while whole vegetables and fruits are reportedly protective against depression. Furthermore, evidence is scarce in differentiating the impacts of sweetened and black coffee. We aimed to examine the association of the consumption of total sugary drinks, carbonated beverages, vegetable and fruit juices, sweetened and black coffee, and green tea with subsequent depression in a general population sample.

METHODS

We studied individuals without a history of cancer, myocardial infarction, stroke, diabetes, or depression at baseline in 2011-2016, with a five-year follow-up. We used Poisson regression models and the g-formula, thereby calculating the risk difference (RD) for depression. Multiple sensitivity analyses were conducted. Missing data were handled using random forest imputation. We also examined effect heterogeneity based on sex, age, and body mass index by analyzing the relative excess risk due to interaction and the ratio of risk ratios.

RESULTS

In total, 94,873 individuals were evaluated, and 80,497 completed the five-year follow-up survey for depression. Of these, 18,172 showed depression. When comparing the high consumption group with the no consumption group, the fully adjusted RD (95% CI) was 3.6% (2.8% to 4.3%) for total sugary drinks, 3.5% (2.1% to 4.7%) for carbonated beverages, 2.3% (1.3% to 3.4%) for vegetable juice, 2.4% (1.1% to 3.6%) for 100% fruit juice, and 2.6% (1.9% to 3.5%) for sweetened coffee. In contrast, the fully adjusted RD (95% CI) was -1.7% (-2.6% to -0.7%) for black coffee. The fully adjusted RD for green tea did not reach statistical significance. The results were robust in multiple sensitivity analyses. We did not find substantial effect heterogeneity based on sex, age, and body mass index.

CONCLUSIONS

Total sugary drinks, carbonated beverages, vegetable and fruit juices, and sweetened coffee may increase the risk of depression, whereas black coffee may decrease it.

Economic Evaluations of Obesity-Targeted Sugar-Sweetened Beverage (SSB) Taxes-A Review to Identify Methodological Issues

INTRODUCTION

Economic evaluations of public health interventions like sugar-sweetened beverage (SSB) taxes face difficulties similar to those previously identified in other public health areas. This stems from challenges in accurately attributing effects, capturing outcomes and costs beyond health, and integrating equity effects. This review examines how these challenges were addressed in economic evaluations of SSB taxes.

METHODS

A systematic review was conducted to identify economic evaluations of SSB taxes focused on addressing obesity in adults, published up to February 2021. The methodological challenges examined include measuring effects, valuing outcomes, assessing costs, and incorporating equity.

RESULTS

Fourteen economic evaluations of SSB taxes were identified. Across these evaluations, estimating SSB tax effects was uncertain due to a reliance on indirect evidence that was less robust than evidence from randomised controlled trials. Health outcomes, like quality-adjusted life years, along with a healthcare system perspective for costs, dominated the evaluations of SSB taxes, with a limited focus on broader non-health consequences. Equity analyses were common but employed significantly different approaches and exhibited varying degrees of quality.

CONCLUSION

Addressing the methodological challenges remains an issue for economic evaluations of public health interventions like SSB taxes, suggesting the need for increased attention on those issues in future studies. Dedicated methodological guidelines, in particular addressing the measurement of effect and incorporation of equity impacts, are warranted.

A sustainable and healthy diet: Personality, motives, and sociodemographics

Background

Sustainable and healthy food choices have usually been studied by investigating either consumer choices concerning one product or product group. To investigate dietary patterns are more complex but may be more useful to promote dietary changes among consumers.

Objectives

To identify existing dietary patterns, and to investigate the importance of personality traits, food choice motives, and sociodemographic variables in adopting these patterns.

Methods

A food frequency questionnaire and principal component analysis were used to identify dietary patterns. The importance of food choice motives, sociodemographics, and personality traits were investigated by using ordinary least squares. The personality traits were measured by the Big Five model, and food choice motives were measured by a set of twelve food values.

Results

Three patterns were found and labelled as sustainable, traditional, and unsustainable. The sustainable pattern was positively associated with respondents who were younger, married, females, and having higher income and education. It was also positively associated with openness to experience, conscientiousness, and perceived environmental impact, and it was negatively associated with convenience and price.

Value

The results may be used to target consumer groups for information and marketing activities.

U.S. food policy to address diet-related chronic disease

Poor diet is the leading cause of mortality in the U.S. due to the direct relationship with diet-related chronic diseases, disproportionally affects underserved communities, and exacerbates health disparities. Evidence-based policy solutions are greatly needed to foster an equitable and climate-smart food system that improves health, nutrition and reduces chronic disease healthcare costs. To directly address epidemic levels of U.S. diet-related chronic diseases and nutritional health disparities, we conducted a policy analysis, prioritized policy options and implementation strategies, and issued final recommendations for bipartisan consideration in the 2023-24 Farm Bill Reauthorization. Actional recommendations include: sugar-sweetened beverage taxation, Supplemental Nutrition Assistance Program (SNAP) fruit and vegetable subsidy expansion, replacement of ultra-processed foods (UPF) with sustainable, diverse, climate-smart agriculture and food purchasing options, and implementing "food is medicine."

The relationship between the price and demand of alcohol, tobacco, unhealthy food, sugar-sweetened beverages, and gambling: an umbrella review of systematic reviews

BACKGROUND

The WHO highlight alcohol, tobacco, unhealthy food, and sugar-sweetened beverage (SSB) taxes as one of the most effective policies for preventing and reducing the burden of non-communicable diseases. This umbrella review aimed to identify and summarise evidence from systematic reviews that report the relationship between price and demand or price and disease/death for alcohol, tobacco, unhealthy food, and SSBs. Given the recent recognition as gambling as a public health problem, we also included gambling.

METHODS

The protocol for this umbrella review was pre-registered (PROSPERO CRD42023447429). Seven electronic databases were searched between 2000-2023. Eligible systematic reviews were those published in any country, including adults or children, and which quantitatively examined the relationship between alcohol, tobacco, gambling, unhealthy food, or SSB price/tax and demand (sales/consumption) or disease/death. Two researchers undertook screening, eligibility, data extraction, and risk of bias assessment using the ROBIS tool.

RESULTS

We identified 50 reviews from 5,185 records, of which 31 reported on unhealthy food or SSBs, nine reported on tobacco, nine on alcohol, and one on multiple outcomes (alcohol, tobacco, unhealthy food, and SSBs). We did not identify any reviews on gambling. Higher prices were consistently associated with lower demand, notwithstanding variation in the size of effect across commodities or populations. Reductions in demand were large enough to be considered meaningful for policy.

CONCLUSIONS

Increases in the price of alcohol, tobacco, unhealthy food, and SSBs are consistently associated with decreases in demand. Moreover, increasing taxes can be expected to increase tax revenue. There may be potential in joining up approaches to taxation across the harm-causing commodities.

Sweetened Beverage Tax Implementation and Change in Body Mass Index Among Children in Seattle

Importance

Sweetened beverage taxes have been associated with reduced purchasing of taxed beverages. However, few studies have assessed the association between sweetened beverage taxes and health outcomes.

Objective

To evaluate the association between the Seattle sweetened beverage tax and change in body mass index (BMI) among children.

Design, Setting, and Participants

In this longitudinal cohort study, anthropometric data were obtained from electronic medical records of 2 health care systems (Kaiser Permanente Washington [KP] and Seattle Children's Hospital Odessa Brown Children's Clinic [OBCC]). Children were included in the study if they were aged 2 to 18 years (between January 1, 2014, and December 31, 2019); had at least 1 weight measurement every year between 2015 and 2019; lived in Seattle or in urban areas of 3 surrounding counties (King, Pierce, and Snohomish); had not moved between taxed (Seattle) and nontaxed areas; received primary health care from KP or OBCC; did not have a recent history of cancer, bariatric surgery, or pregnancy; and had biologically plausible height and BMI (calculated as weight in kilograms divided by height in meters squared). Data analysis was conducted between August 5, 2022, and March 4, 2024.

Exposure

Seattle sweetened beverage tax (1.75 cents per ounce on sweetened beverages), implemented on January 1, 2018.

Main Outcomes and Measures

The primary outcome was BMIp95 (BMI expressed as a percentage of the 95th percentile; a newly recommended metric for assessing BMI change) of the reference population for age and sex, using the Centers for Disease Control and Prevention growth charts. In the primary (synthetic difference-in-differences [SDID]) model used, a comparison sample was created by reweighting the comparison sample to optimize on matching to pretax trends in outcome among 6313 children in Seattle. Secondary models were within-person change models using 1 pretax measurement and 1 posttax measurement in 22 779 children and fine stratification weights to balance baseline individual and neighborhood-level confounders.

Results

The primary SDID analysis included 6313 children (3041 female [48%] and 3272 male [52%]). More than a third of children (2383 [38%]) were aged 2 to 5 years); their mean (SE) age was 7.7 (0.6) years. With regard to race and ethnicity, 789 children (13%) were Asian, 631 (10%) were Black, 649 (10%) were Hispanic, and 3158 (50%) were White. The primary model results suggested that the Seattle tax was associated with a larger decrease in BMIp95 for children living in Seattle compared with those living in the comparison area (SDID: -0.90 percentage points [95% CI, -1.20 to -0.60]; P < .001). Results from secondary models were similar.

Conclusions and Relevance

The findings of this cohort study suggest that the Seattle sweetened beverage tax was associated with a modest decrease in BMIp95 among children living in Seattle compared with children living in nearby nontaxed areas who were receiving care within the same health care systems. Taken together with existing studies in the US, these results suggest that sweetened beverage taxes may be an effective policy for improving children's BMI. Future research should test this association using longitudinal data in other US cities with sweetened beverage taxes.