Evaluating Saudi Arabia's 50% carbonated drink excise tax: Changes in prices and volume sales

Estimating the potential impact of a health tax on the demand for unhealthy food and beverages and on tax revenue in India

Foods high in fat, sugar or salt are important contributors to the rising burden of non-communicable diseases globally and in India. Health taxes (HTs) have been used by over 70 countries as an effective tool for reducing consumption of sugar sweetened beverages (SSBs). However, the potential impacts of HTs on consumption and on revenues have not been estimated in India. This paper aims to estimate the potential impact of health taxes on the demand for sugar, SSBs and foods high in fat, sugar or salt (HFSS) in India while exploring its impact on tax revenues. PE of sugar was estimated using Private Final Consumption Expenditure and Consumer Price Index data while price elasticities for SSBs and HFSS were obtained from literature. The reduction in demand was estimated for an additional 10-30% HT added to the current goods and services tax, for varying levels of price elasticities. The results show that for manufacturers of sweets and confectionaries who buy sugar in bulk and assuming a higher price elasticity of -0.70, 20% additional HT (total tax 48%) would result in 13-18% decrease in the demand for sugar used for confectionaries and sweets. For SSBs, HT of 10-30% would result in 7-30% decline in the demand of SSBs. For HFSS food products, 10-30% HT would result in 5-24% decline in the demand for HFSS products. These additional taxes would increase tax revenues for the government by 12-200% across different scenarios. Taxing unhealthy foods is likely to reduce demand, while increasing government revenues for reinvestment back into public health programmes and policies that may reduce obesity and the incidence of non-communicable diseases in India.

Soft and energy drinks consumption and associated factors in Saudi adults: a national cross-sectional study

Introduction

The consumption of soft and energy drinks poses a significant risk for non-communicable diseases, such as diabetes and heart disease. Studies in Saudi Arabia have reported elevated consumption of soft/energy drinks, but nation-wide data is not available. Therefore, this study aims to explore the prevalence of soft and energy drinks consumption and its associated factors among a representative sample of Saudi adults.

Methods

The present research is a secondary data analysis of the 2021 Sharik Diet and Health National Survey (SDHNS). Current analysis used data on socio-demographics, anthropometrics, physical activity, and soft and energy drink consumption. The frequency of soft and energy drinks consumption is assessed on a weekly basis.

Results

Of the 5,194 Saudi adults, 3,928 were analyzed. Overall, 67% consumed soft drinks weekly, while 30% consumed energy drinks weekly. In multiple logistic regression, consumption of either soft drinks or energy drinks was associated with males, a younger age, lower income, and lower physical activity. Individuals with overweight or obesity were less likely to consume energy drinks [OR (95%CI): 0.83 (0.71, 0.99) and 0.73 (0.60, 0.90), respectively] than those with healthy weight. However, education level was not associated with either soft or energy drink consumption. These findings highlight the need for targeted interventions designed to reduce soft and energy drinks consumption in Saudi adults.

A Randomized Controlled Study to Test Front-of-Pack (FOP) Nutrition Labels in the Kingdom of Saudi Arabia

One common strategy for governments to tackle the non-communicable disease (NCD) epidemic is front-of-package (FOP) nutrition labeling. The Kingdom of Saudi Arabia (KSA) is considering implementing a new FOP label that is based on either France's Nutri-Score (NS), which labels all foods (A = healthiest to E = least healthy) based on overall nutritional quality, or the Chilean warning label (WL) approach, which identifies foods to avoid based on select nutritional characteristics. Using a fully functional online grocery store, this study aimed to test these two promising FOP strategies by randomizing 656 KSA adults into one of the three versions of the store to complete a hypothetical grocery shop: no-label (control), NS, and WL. The NS was modified with a sugar percentage tag given that reducing sugar consumption is one of KSA's public health goals. We found that both modified NS labels and Chilean warning labels positively influenced food and beverage choices among KSA participants, but there were differential effects across the two labels. Relative to the control, NS improved the overall diet quality of the shopping baskets, measured by the weighted (by the number of servings) average NS point (ranging from 0, least healthy, to 55, healthiest), by 2.5 points [95% CI: 1.7, 3.4; p < 0.001], whereas results for WL were not statistically significant (0.6 points [95% CI: -0.2,1.5]). With respect to each nutritional attribute, we found that NS reduced sugar intake per serving, whereas WL was effective at decreasing energy and saturated fat intake per serving from food and beverages purchased. Our results suggest that the NS approach that identifies the healthiness of all foods using a holistic approach appears preferable if the purpose of the label is to improve overall diet quality as opposed to addressing select nutrients to avoid.

An umbrella review of the effectiveness of fiscal and pricing policies on food and non-alcoholic beverages to improve health

Poor quality diets represent major risk factors for the global burden of disease. Modeling studies indicate a potential for diet-related fiscal and pricing policies (FPs) to improve health. There is real-world evidence (RWE) that such policies can change behavior; however, the evidence regarding health is less clear. We conducted an umbrella review of the effectiveness of FPs on food and non-alcoholic beverages in influencing health or intermediate outcomes like consumption. We considered FPs applied to an entire population within a jurisdiction and included four systematic reviews in our final sample. Quality appraisal, an examination of excluded reviews, and a literature review of recent primary studies assessed the robustness of our results. Taxes and, to some extent, subsidies are effective in changing consumption of taxed/subsidized items; however, substitution is likely to occur. There is a lack of RWE supporting the effectiveness of FPs in improving health but this does not mean that they are ineffective. FPs may be important for improving health but their design is critical. Poorly designed FPs may fail to improve health and could reduce support for such policies or be used to support their repeal. More high-quality RWE on the impact of FPs on health is needed.

Why has the taxing policy on sugar sweetened beverages not reduced their purchase in Iranian households?

Objective

This study aimed at analyzing the effectiveness of the policy of taxing Sugar-Sweetened Beverages (SSBs) on their purchases during the last decade in Iranian households.

Methods

The present mixed method study was done in 2017 in four phases: (1) A meta-review of the fiscal policies during the last decade, (2) Collecting existing data on soft drinks' production, price, and household expenditure during the last decade, (3) Conducting 19 semi-structured interviews with key informants, and (4) Facilitating a national meeting to achieve a consensus on the recommendations and future implications.

Results

Document reviews showed that based on the Permanent Provisions of National Development Plans of Iran, the Ministry of Health and Medical Education (MOHME) should announce the list of health threatening products to increase taxation for them. The government is allowed to impose taxes on domestically produced and imported SSBs. The average household expenditure on SSBs increased in the rural and urban households of Iran during 2006-2016 in spite of taxation. In the different key informants' opinion, only value-added tax (VAT) was implemented among different fiscal policies, and the other parts, including tax and tolls were debated.

Conclusion

The present research findings further proposed some suggestions for increasing the effectiveness of financial policies in reducing the prevalence of NCDs in Iran.

Changes in sugar-sweetened beverage consumption in the first two years (2018 - 2020) of San Francisco's tax: A prospective longitudinal study

BACKGROUND

Sugar sweetened beverage (SSB) taxes are a promising strategy to decrease SSB consumption, and their inequitable health impacts, while raising revenue to meet social objectives. In 2016, San Francisco passed a one cent per ounce tax on SSBs. This study compared SSB consumption in San Francisco to that in San José, before and after tax implementation in 2018.

METHODS & FINDINGS

A longitudinal panel of adults (n = 1,443) was surveyed from zip codes in San Francisco and San José, CA with higher densities of Black and Latino residents, racial/ethnic groups with higher SSB consumption in California. SSB consumption was measured at baseline (11/17-1/18), one- (11/18-1/19), and two-years (11/19-1/20) after the SSB tax was implemented in January 2018. Average daily SSB consumption (in ounces) was ascertained using the BevQ-15 instrument and modeled as both continuous and binary (high consumption: ≥6 oz (178 ml) versus low consumption: <6 oz) daily beverage intake measures. Weighted generalized linear models (GLMs) estimated difference-in-differences of SSB consumption between cities by including variables for year, city, and their interaction, adjusting for demographics and sampling source. In San Francisco, average SSB consumption in the sample declined by 34.1% (-3.68 oz, p = 0.004) from baseline to 2 years post-tax, versus San José which declined 16.5% by 2 years post-tax (-1.29 oz, p = 0.157), a non-significant difference-in-differences (-17.6%, adjusted AMR = 0.79, p = 0.224). The probability of high SSB intake in San Francisco declined significantly more than in San José from baseline to 2-years post-tax (AOR[interaction] = 0.49, p = 0.031). The difference-in-differences of odds of high consumption, examining the interaction between cities, time and poverty, was far greater (AOR[city*year 2*federal poverty level] = 0.12, p = 0.010) among those living below 200% of the federal poverty level 2-years post-tax.

CONCLUSIONS

Average SSB intake declined significantly in San Francisco post-tax, but the difference in differences between cities over time did not vary significantly. Likelihood of high SSB intake declined significantly more in San Francisco by year 2 and more so among low-income respondents.

Stakeholder perspectives on Nigeria's national sodium reduction program: Lessons for implementation and scale-up

BACKGROUND

To reduce excess dietary sodium consumption, Nigeria's 2019 National Multi-sectoral Action Plan (NMSAP) for the Prevention and Control of Non-communicable Diseases includes policies based on the World Health Organization SHAKE package. Priority actions and strategies include mandatory sodium limits in processed foods, advertising restrictions, mass-media campaigns, school-based interventions, and improved front-of-package labeling. We conducted a formative qualitative evaluation of stakeholders' knowledge, and potential barriers as well as effective strategies to implement these NMSAP priority actions.

METHODS

From January 2021 to February 2021, key informant interviews (n = 23) and focus group discussions (n = 5) were conducted with regulators, food producers, consumers, food retailers and restaurant managers, academia, and healthcare workers in Nigeria. Building on RE-AIM and the Consolidated Framework for Implementation Research, we conducted directed content qualitative analysis to identify anticipated implementation outcomes, barriers, and facilitators to implementation of the NMSAP sodium reduction priority actions.

RESULTS

Most stakeholders reported high appropriateness of the NMSAP because excess dietary sodium consumption is common in Nigeria and associated with high hypertension prevalence. Participants identified multiple barriers to adoption and acceptability of implementing the priority actions (e.g., poor population knowledge on the impact of excess salt intake on health, potential profit loss, resistance to change in taste) as well as facilitators to implementation (e.g., learning from favorable existing smoking reduction and advertising strategies). Key strategies to strengthen NMSAP implementation included consumer education, mandatory and improved front-of-package labeling, legislative initiatives to establish maximum sodium content limits in foods and ingredients, strengthening regulation and enforcement of food advertising restrictions, and integrating nutrition education into school curriculum.

CONCLUSION

We found that implementation and scale-up of the Nigeria NMSAP priority actions are feasible and will require several implementation strategies ranging from community-focused education to strengthening current and planned regulation and enforcement, and improvement of front-of-package labeling quality, consistency, and use.

Systematic review on fiscal policy interventions in nutrition

Introduction

Both the World Health Organization and the Lancet Series on Adolescent nutrition recommend that governments adopt fiscal policies to combat diet-related non-communicable diseases (NCDs). However, rigorous, systematic evidence regarding the effects of these interventions is lacking.

Methods

We synthesize the available evidence regarding the impacts of taxes and subsidies that directly affect consumer prices on availability and accessibility of foods and beverages, purchasing behavior, diet quality, health and well-being outcomes as well as considerations for implementation, sustainability and equity.

Results

Our initial search returned 2,113 de-duplicated studies, and ultimately 24 impact evaluations and two systematic reviews met final eligibility criteria and represented unique evaluations. Our meta-analysis of these studies suggests that taxes may decrease purchases of taxed beverages (SMD = -0.14 [95% CI: -0.29 to -0.07], n = 15). Results should be interpreted cautiously due to considerable heterogeneity (Q(14) = 335.19, p = 0.01,τ ^ 2 = 0.03 , I 2 = 95.82%).

Discussion

The evidence base is too limited to draw conclusions about the effects of taxes on beverages and calorie-dense foods on purchases, or on the effects of subsidies on purchasing or diet quality. Overall, the evidence base is inconclusive on whether fiscal policies can meaningfully influence the availability and accessibility of foods and beverages, diet quality, and health outcomes. Policymakers implementing fiscal policies should consider information campaigns on health benefits and health risks associated with certain food and beverage consumption. For taxes, exposure to health information may amplify signaling effects of taxes and reduce avoidance behaviors, such as cross-border shopping. Future evaluations should diversify data sources to better understand impacts on diet and health outcomes.

Prevalence, risk factors, and interventions for obesity in Saudi Arabia: A systematic review

Saudi Arabia (SA) has a reported obesity prevalence greater than the global average. Here, we systematically review firstly the prevalence and associated factors (59 studies) and secondly the pharmacological, lifestyle, and surgical interventions for obesity (body mass index, >30 kg/m² ) in SA (29 studies) between December 2020 and March 2021 in PubMed, Medline, Embase, PsycINFO, and Cochrane. Peer-reviewed articles in Arabic and English on human adults (aged >18 years) were searched. Among the eight largest studies with sample sizes over 10,000 people, the maximum-reported obesity prevalence was 35.6%, with notable variations in gender and geographic region. Diet, specifically the move towards Western diet and heavy consumption of sugary beverages, and high levels of inactivity are major contributing factors to obesity. The reported obesity-risk polymorphisms are not specific. Bariatric surgery is underrepresented, and in general, there is a lack of nationally coordinated studies on weight loss interventions. In particular, the systematic review did not find a body of research on psychological interventions. There is no trial data for the use of GLP-1 analogs in SA, despite their widespread use. These findings can help policymakers, and practitioners prioritize future research efforts to reduce obesity prevalence in SA.

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

IMPORTANCE

More than 45 countries and several local jurisdictions have implemented sugar-sweetened beverage (SSB) taxes to improve nutrition and population health, and evidence on their outcomes to date is essential to inform policy discussions. Responding to this need, the World Health Organization commissioned a systematic literature review on the outcomes of fiscal policies, including SSB taxes.

OBJECTIVE

To assess the associations of implemented SSB taxes with prices, sales, consumption, diet, body weight, product changes, unintended consequences, health, and pregnancy outcomes.

DATA SOURCES

Searches of 8 bibliographic databases (Business Source Complete, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, CINAHL, EconLit, PsycINFO, PubMed, and Scopus) were performed from database inception through June 1, 2020, with no language or setting restrictions. Grey literature was assessed using 14 sources and government websites.

STUDY SELECTION

The review included primary studies of implemented SSB taxes.

DATA EXTRACTION AND SYNTHESIS

The review followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. For prices, sales and consumption, results were meta-analyzed using a 3-level random-effects model. Study quality was assessed at the outcome level.

MAIN OUTCOMES AND MEASURES

Tax pass-through rate for prices, percentage reduction in SSB demand, and price elasticity of demand for sales and consumption. Heterogeneity was assessed using τ2 and the I2 statistic.

RESULTS

A total of 86 articles were eligible, with 62 studies contributing to the meta-analysis. The overall tax pass-through rate was 82% (95% CI, 66% to 98%; P < .001, I2 = 99%), suggesting tax undershifting. The demand for SSBs was highly sensitive to tax-induced price increases, with the price elasticity of demand of -1.59 (95% CI, -2.11 to -1.08; P < .001; I2 = 100%) and a mean reduction in SSB sales of 15% (95% CI, -20% to -9%; P < .001; I2 = 100%). There was no evidence of substitution to untaxed beverages, and changes in SSB consumption were not significant. The narrative synthesis found reformulation and reduced sugar content of taxed beverages for tiered taxes, cross-border shopping in most studies of local-level taxes, and no negative changes in employment. Data on the heterogeneity of SSB tax outcomes across subpopulations were limited.

CONCLUSIONS AND RELEVANCE

In this systematic review and meta-analysis of implemented SSB taxes worldwide, SSB taxes were associated with higher prices and lower sales of taxed beverages.

Adolescent Obesity Prevention in Saudi Arabia: Co-identifying Actionable Priorities for Interventions

Background

Childhood obesity is a serious issue in the Kingdom of Saudi Arabia, but there is no known community intervention. The aim of the study was to use a participatory approach to obtain the perspectives of students, school staff and Ministry of Education (MoE) representatives and parents on important and feasible intervention opportunities for school-based obesity prevention for adolescent girls.

Method

The study was conducted in two intermediate schools for girls (13–15 years old) in Jeddah that were purposefully identified with the support of the MoE. Group concept mapping, a mixed method approach, was conducted with 19 adults which included staff from the MoE and schools, school canteen suppliers and mothers. Adults generated statements in response to two prompts (P); P1 “The factors influencing adolescent obesity in Saudi are...” and P2 “The content of school-based programmes should focus on....” Photovoice-enhanced concept mapping was used with students (n = 15 students) to capture adolescent perspectives on what influences their dietary and physical activity habits. Students generated statements' using their own photographs. Stakeholders, both adult and students, sorted the statements into themes and rated each statement for relative importance and feasibility. Multidimensional scaling and hierarchical cluster analyses were used to produce concept maps with the input from students and adults.

Result

Adults generated 35 statements in response to P1 and identified five themes that influenced adolescent obesity including “Home Environment,” “Lifestyle,” “School Environment,” “Community,” “Biology.” They generated 42 statements in relation to P2 and identified four themes including “Ministry of Education Support,” “School Environment,” “Public health programmes” and “Wider environmental influences.” Students generated 42 statements from 39 pictures. They identified five themes that influenced their dietary and physical activity habits—“Role of Government,” “School Environment,” “Home Environment,” “Retail Environment” and “Cultural Practices.” Both groups identified several common important and feasible actions with a strong emphasis on improving the school environment, in particular food provision, with MoE support. Exemplar corresponding statements from adults were “Offer healthy foods in the canteen,” “Remove chocolates and sweets” and “Educate children about healthy foods” and from students were “Offer fruit and vegetables in the canteen,” “Remove chocolates from the canteen,” “Healthy meals should not expensive.” Lack of correspondence related to students' emphasis on access to both healthy foods and physical activity in schools and the wider environment (e.g. retail environments), while adults emphasized school-based education and food provision. After further consultations, both stakeholder groups agreed on improving access to healthy foods in the canteen.

Conclusions

Students and school and MoE staff jointly agreed that a canteen-based intervention was important and feasible to improve dietary habits and thus help to prevent obesity among adolescent girls. This was the first time a participatory approach was used with students for intervention development in Saudi Arabia. A co-development approach may have value to improve their school food environments.

Tax awareness and perceived cost of sugar-sweetened beverages in four countries between 2017 and 2019: findings from the international food policy study

BACKGROUND

The public health benefits of sugar-sweetened beverage (SSB) taxes often rely on, among other things, changes to consumer purchases. Thus, perceived cost of SSBs and signalling effects-via awareness of the tax-may impact the effectiveness of SSB taxes on consumer purchases.

OBJECTIVE

The study sought to examine perceived cost of SSBs, tax awareness, and changes in beverage purchasing over time and across four countries with and without SSB taxes.

METHODS

The study used data from the 2017, 2018 and 2019 waves of the International Food Policy Study. Annual cross-sectional online surveys were conducted in Australia, Mexico, UK and US, which captured perceived cost of SSBs relative to non-SSBs in all countries (with Australia as a no-tax comparator), and measures of tax awareness and participants' reported changes in beverage purchasing in response to SSB taxes in Mexico (tax implemented in 2014), UK (tax implemented in 2018) and US (subnational taxes since 2015). Logistic regression models evaluated the measures across years and socio-demographic groups.

RESULTS

Perceived cost of SSBs relative to non-SSBs was higher in Mexico (all three years) and the UK (2018 and 2019 following tax implementation) than Australia and the US. Tax awareness was higher in UK than Mexico, and decreased over time among Mexican respondents. Patterns of reported beverage purchasing changes in response to the tax were similar across Mexico, UK and US, with the largest changes reported by Mexican respondents. Respondents with characteristics corresponding to lower socioeconomic status were less likely to be aware of an SSB tax, but more likely to perceive SSBs to cost more than non-SSBs and report changes in purchasing in response to the tax, where there was one.

CONCLUSIONS

This study suggests that in countries where a national SSB tax was present (Mexico, UK), perceived cost of SSBs and tax awareness were higher compared to countries with no SSB tax (Australia) or subnational SSB taxes (US), respectively, and suggests that perceived cost and tax awareness represent distinct constructs. Improving the 'signalling effect' of existing SSB taxes may be warranted, particularly in tax settings where consumer behaviour change is a policy objective.

Determinants of Sugar-Sweetened Beverage Consumption Among the Saudi Adults: Findings From a Nationally Representative Survey

Background

Saudi Arabia is the fifth largest consumer of calories from sugar-sweetened beverages (SSBs) in the world. However, there is a knowledge gap to understand factors that could potentially impact SSB consumption in Saudi Arabia. This study is aimed to examine the determinants of SSBs in Saudi Arabia.

Methods

The participants of this study were from the Saudi Health Interview Survey (SHIS) of 2013, recruited from all regions of Saudi Arabia. Data of a total of 10,118 survey respondents were utilized in this study who were aged 15 years and older. Our study used two binary outcome variables: weekly SSB consumption (no vs. any amount) and daily SSB consumption (non-daily vs. daily). After adjusting for survey weights, multivariate logistic regression models were applied to assess the association of SSB consumption and study variables.

Results

About 71% of the respondents consumed SSB at least one time weekly. The higher likelihood of SSB consumption was reported among men, young age group (25–34 years), people with lower income (<3,000 SR), current smokers, frequent fast-food consumers, and individuals watching television for longer hours (≥4 h). Daily vegetable intake reduced the likelihood of SSB consumption by more than one-third.

Conclusions

Three out of four individuals aged 15 years and over in Saudi Arabia consume SSB at least one time weekly. A better understanding of the relationship between SSB consumption and demographic, socioeconomic, and behavioral factors is necessary for the reduction of SSB consumption. The findings of this study have established essential population-based evidence to inform public health efforts to adopt effective strategies to reduce the consumption of SSB in Saudi Arabia. Interventions directed toward education on the adverse health effect associated with SSB intake are needed.

The economic burden of overweight and obesity in Saudi Arabia

CONTEXT

The prevalence of overweight and obesity in Saudi Arabia has been rising. Although the health burden of excess weight is well established, little is known about the economic burden.

AIMS

To assess the economic burden-both direct medical costs and the value of absenteeism and presenteeism-resulting from overweight and obesity in Saudi Arabia.

SETTINGS AND DESIGN

The cost of overweight and obesity in Saudi Arabia was estimated from a societal perspective using an epidemiologic approach.

METHODS AND MATERIALS

Data were obtained from previously published studies and secondary databases.

STATISTICAL ANALYSIS USED

Overweight/obesity-attributable costs were calculated for six major noncommunicable diseases; sensitivity analyses were conducted for key model parameters.

RESULTS

The impact of overweight and obesity for these diseases is found to directly cost a total of $3.8 billion, equal to 4.3 percent of total health expenditures in Saudi Arabia in 2019. Estimated overweight and obesity-attributable absenteeism and presenteeism costs a total of $15.5 billion, equal to 0.9 percent of GDP in 2019.

CONCLUSIONS

Even when limited to six diseases and a subset of total indirect costs, results indicate that overweight and obesity are a significant economic burden in Saudi Arabia. Future studies should identify strategies to reduce the health and economic burden resulting from excess weight in Saudi Arabia.

South Africa's Health Promotion Levy on Pricing and Acquisition of Beverages in Local Spazas and Supermarkets

OBJECTIVE

In response to concern over rising sugar-sweetened beverage (SSB) consumption, in April 2018, South Africa became the first Sub-Saharan African country to implement an SSB tax. We assess changes in pricing and acquisition of beverages from local supermarkets and small stores among 18-39 year old adults living in one township in the Western Cape, before and after tax implementation. This study is among the first evaluations of an SSB tax on the local food environment in a low-income township.

DESIGN

Store beverage pricing and participant surveys were cross-sectional, analyzed 1 month before and 11 months after implementation of the tax (March 2018 and March 2019).

SETTING

Langa, Western Cape, South Africa.

PARTICIPANTS

Surveyed participants were residents of Langa between 18-39 years old (N=2,693 in 2018 and N=2,520 in 2019).

RESULTS

Prices of taxed SSBs increased significantly among small shops and supermarkets between 2018 and 2019. There were non-significant decreases in prices of untaxed beverages in small shops, but prices of untaxed beverages increased in supermarkets. Across all store types, there was a 9 percentage point decrease in the probability of purchasing regular soda weekly pre/post-implementation. Reductions in purchasing were larger in small shops than supermarkets.

CONCLUSIONS

We found some differential impacts of the levy on pricing and acquisition of beverages by retailer type in one low-income township. As other Sub-Saharan African countries consider similar fiscal policies to curb soda consumption, obesity and related diseases, this work can be used to understand the implications of these policies in the retail setting.

A Comparative Policy Analysis of the Adoption and Implementation of Sugar-Sweetened Beverage Taxes (2016-2019) in 16 Countries

Taxes on sugar-sweetened beverages (SSBs) are recommended as part of comprehensive policy action to prevent diet-related non-communicable diseases (NCDs), but have been adopted by only one quarter of World Health Organization (WHO) Member States. This paper presents a comparative policy analysis of recent SSB taxes (2016–19) in 16 countries. This study aimed to analyse the characteristics and patterns of factors influencing adoption and implementation of SSB taxes and policy learning between countries, to draw lessons for future SSB taxes. The data collection and analysis were informed by an analytical framework that drew on ‘diffusion of innovation’ and theories of policy learning. Qualitative data were collected from policy documents and media, in addition to national statistics. Qualitative data were thematically analysed and a narrative synthesis approach was used for integrated case study analysis. We found adaptation and heterogeneity in the approaches used for SSB taxation with a majority of countries adopting excise taxes, and consistent health framing in media and policy documents. Common public frames supporting the taxes included reducing obesity/NCDs and raising revenue (government actors) and subsequent health system savings (non-government actors). Opposing frames focused on regressivity and incoherence with other economic policy (government actors) and posited that taxes have limited health benefits and negative economic impacts on the food industry (industry). Evident ‘diffusion networks’ included the WHO, predominantly in middle-income countries, and some regional economic bodies. We found indications of policy learning in the form of reference to other countries’ taxes, particularly countries with membership in the same economic bodies and with shared borders. The study suggests that adoption of SSB taxation could be enhanced through strategic engagement by health actors with the policy-making process, consideration of the economic context, use of consistent health frames by cross-sector coalitions, and robust evaluation and reporting of SSB taxation.

The Effect of Price Changes and Teaspoon Labelling on Intention to Purchase Sugar-Sweetened Beverages: A Discrete Choice Experiment

INTRODUCTION

Childhood obesity is a major public health concern and sugar-sweetened beverages (SSBs) are a known contributor. SSB taxation and food labelling have been proposed as policies to reduce consumption by changing purchasing behaviours. The study aimed to analyse caregivers' preferences on commonly purchased SSBs in Australia and to determine the effect of price increases and teaspoon labelling on their purchasing intentions.

METHODS

We used a discrete choice experiment (DCE) to obtain data about choices between SSB and non-SSB alternatives. 563 caregivers, who had young children aged 3-7 years, completed the experiment online. 286 were randomly allocated to receive choice sets with plain labelling while 277 were assigned to teaspoon labelling. Each participant completed nine choice scenarios where they chose between six SSB and non-SSB beverage options or a no-beverage option, with beverage prices varying between scenarios. While hypothetical, price and teaspoon labelling for sugar content for each beverage was obtained from an informal market survey. Responses from the DCE were modelled using random parameters logit within a random utility theory framework. Household income and children's consumption volumes of soft drink were used to explore preference heterogeneity.

RESULTS

Using mixed logit as the final model, we found that higher reduction in intended purchases was observed for soft drink and fruit drink in teaspoon labelling than it was in plain labelling. Participants exposed to teaspoon labelling intended to purchase less of flavoured milk and fruit juice compared to those exposed to plain labelling. Compared to baseline prices, a hypothetical 20% increase in SSB prices and the presentation of 'teaspoons of sugar' labelling were predicted to reduce intentional SSB purchases and increase intentional non-SSB purchases. Within each labelling group, there were no significant differences of intentional purchases between the highest and the lowest income quintile, high and low consumers of soft drinks. However, compared to plain labelling, teaspoon labelling was predicted to strongly influence intentional purchases of SSBs and non-SSBs.

CONCLUSION

This study suggests that a policy to increase SSB price and include teaspoon labelling would lead to a reduced consumption of SSBs and increased consumption of non-SSBs.

Potential effect of real-world junk food and sugar-sweetened beverage taxes on population health, health system costs and greenhouse gas emissions in New Zealand: a modelling study

Poor diet is a major risk factor for excess weight gain and obesity-related diseases, including cardiovascular diseases, type 2 diabetes mellitus, osteoarthritis and several cancers. This paper aims to assess the potential impacts of real-world food and beverage taxes on change in dietary risk factors, health gains (in quality-adjusted life years (QALYs)), health system costs and greenhouse gas (GHG) emissions as if they had all been implemented in New Zealand (NZ). Ten taxes or tax packages were modelled. A proportional multistate life table model was used to predict resultant QALYs and costs over the remaining lifespan of the NZ population alive in 2011, as well as GHG emissions. QALYs ranged from 12.5 (95% uncertainty interval (UI) 10.2 to 15.0; 3% discount rate) per 1000 population for the import tax on sugar-sweetened beverages (SSB) in Palau to 143 (95% UI 118 to 171) per 1000 population for the excise duties on saturated fat, chocolate and sweets in Denmark, while health expenditure savings ranged from 2011 NZ$245 (95% UI 188 to 310; 2020 US$185) per capita to NZ$2770 (95% UI 2140 to 3480; US$2100) per capita, respectively. The modelled taxes resulted in decreases in GHG emissions from baseline diets, ranging from −0.2% for the tax on SSB in Barbados to −2.8% for Denmark’s tax package. There is strong evidence for the implementation of food and beverage tax packages in NZ or similar high-income settings.

The Association between Obesity and Chronic Conditions: Results from a Large Electronic Health Records System in Saudi Arabia

This cross-sectional study aimed to estimate the prevalence of obesity and its association with diabetes and hypertension among beneficiaries in the National Guard Health Affairs system of Saudi Arabia. We included individuals aged 17 years and older, and patients were classified as diabetic or hypertensive if they had any visit during the 4 years where the primary diagnosis was one of those conditions or they were taking diabetes or hypertension medications. The association between obesity (body mass index ≥30) and diabetes and hypertension were evaluated using a multiple logistic regression model, adjusting for age, gender, nationality, and region. A total of 616,092 individuals were included. The majority were Saudi nationals (93.1%). Approximately 68% of the population were either obese (38.9%) or overweight (29.30%). Obesity was more prevalent among Saudi nationals (39.8% vs. 26.7%, p < 0.01) and females (45.3% vs. 31.2%, p < 0.01). Obesity was independently associated with diabetes mellitus (OR = 2.24, p < 0.01) and hypertension (OR = 2.15, p < 0.01). The prevalence of obesity in the study population was alarming and more pronounced among women. Our findings call for efforts to intensify preventive measures to reduce obesity and associated conditions. Using electronic records to examine the impact of interventions to reduce obesity and chronic conditions may help monitor and improve population health.

Saudi Arabia's Healthy Food Strategy: Progress & Hurdles in the 2030 Road

The Kingdom of Saudi Arabia (KSA) is a leading country worldwide in the prevalence of non-communicable diseases (NCDs), which alone can explain 73% of mortality in the country. In response to the heavy burden of NCDs, the Saudi Food and Drug Authority (SFDA), in collaboration with other government entities, developed a healthy food strategy (HFS) aimed at enhancing healthy lifestyles and reducing the intake of salt, sugar, saturated fatty acids (SSF) and trans fatty acids (TFA). The objectives of the HFS, to facilitate consumers' identification of SSF and reduce the SSF and TFA content in food items, were addressed in collaboration with key stakeholders in the public and private sectors of the food industry. These reforms included voluntary and mandatory schemes to display nutrition information in food and beverage establishments, display allergens on food menus, encourage the adoption of front of pack nutrient labels (FoPNLs) on food products, ban the use of partially hydrogenated oils and establish limits for sodium composition in breads and selected food products. This manuscript contextualizes the HFS and presents the results of monitoring initiatives undertaken by the SFDA to assess compliance with these reforms.

Do taxes on unhealthy foods and beverages influence food purchases?

PURPOSE OF REVIEW

Interest in taxes on unhealthy foods and beverages as a public health tool has increased in recent years. This paper aimed to summarise recent evidence of the impact of taxes on unhealthy foods and beverages on food purchases, and discuss opportunities to advance knowledge and policy impact.

RECENT FINDINGS

Evaluations of taxes on unhealthy foods and beverages have shown reductions in purchases of targeted unhealthy products and nutrients. Similarly, data from multiple sources demonstrate that as prices of unhealthy foods and beverages increase, purchase volume decreases. However, studies indicate potential for substitution to non-taxed unhealthy foods, which needs to be factored into taxation design. Taxes on unhealthy foods and beverages are a promising strategy to improve population diets. Further research is required to understand food industry responses to tax implementation, as well as the impact of taxes on population and planetary health outcomes.

The impact of seven major noncommunicable diseases on direct medical costs, absenteeism, and presenteeism in Gulf Cooperation Council countries

AIMS

To estimate the current burden of seven major noncommunicable diseases on direct medical costs, absenteeism, and presenteeism in the six countries in the Gulf Cooperation Council: Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and the United Arab Emirates.

MATERIALS AND METHODS

We used data from pre-existing datasets and the literature. We identified seven major noncommunicable diseases for which data were available: coronary heart disease, stroke, type-2 diabetes mellitus, breast cancer, colon cancer, chronic obstructive pulmonary disease, and asthma. We estimated the per unit cost (the annual cost of treating each illness for one person) of each disease, multiplied per unit cost by disease prevalence counts to generate disease-specific costs, and then summed across diseases. We calculated the cost of absenteeism and presenteeism by multiplying the gross domestic product per person in the labor force by the loss in productivity from each disease due to absenteeism and presenteeism, respectively, and the prevalence in the labor force of each disease.

RESULTS

We estimate that the direct medical costs of seven major noncommunicable diseases in Gulf Cooperation Council countries are $16.7 billion (2019 International $), equal to 0.6% of gross domestic product. We estimate that absenteeism and presenteeism due to these seven noncommunicable diseases cost 0.5 and 2.2% of gross domestic product, respectively.

LIMITATIONS

Our study does not capture all noncommunicable diseases and does not capture all types of indirect costs. Our cost estimates are particularly sensitive to our assumptions regarding type-2 diabetes mellitus.

CONCLUSION

The economic burden of noncommunicable diseases in Gulf Cooperation Council countries is substantial, suggesting that successful preventive interventions have the potential to improve both population health and reduce costs. Further research is needed to capture a broader array of noncommunicable diseases and to develop more precise estimates.

The ethics of excise taxes on sugar-sweetened beverages

Sugar-sweetened beverage (SSB) taxation has emerged as a priority policy for promoting health and funding investments in communities most affected by diet-related disease. There are now 8 U.S. jurisdictions and over 40 countries that have implemented SSB taxes. Evaluations show that these policies reduce SSB consumption and purchasing while raising revenues to fund public health, education, and equity. However, there have been few analyses of the ethical considerations of SSB taxation. Using a framework for evaluating the ethics of public health interventions, this paper considers the ethical aspects of SSB excise taxes with respect to: physical health, psychosocial well-being, equality, informed choice, liberty, social and cultural values, and responsibility. Available evidence suggests there is a strong ethical case for levying SSB excise taxes on manufacturers and distributors. SSB excise taxes reduce consumption and purchasing of SSBs and are expected to meaningfully reduce obesity and diet-related morbidity and mortality. Because SSB taxes are specific to a product and its manufacturers, they are unlikely to harm psychosocial health by stigmatizing people who are overweight. SSB excise taxes should lead to greater equality because the health and social benefits are progressive (i.e., low-income individuals are likely to accrue the largest benefits from the tax, even more so when revenues are spent on health and social equity). Meanwhile, the average consumer cost burden that would result if distributors raise SSB prices in reponse to the tax is minimally regressive. Regarding liberty, SSB taxes do not eliminate the option of buying SSBs, but if SSB distributors raise SSB prices, it becomes somewhat more expensive to continue purchasing the same amount of SSBs. Meanwhile, the taxes expand beverage options by funding drinking water availability and prompting industry to expand offerings of unsweetened drinks and SSBs containing less sugar. Furthermore, by averting poor health, SSB taxes should expand overall freedom to pursue one's goals. Informed choice could be facilitated by seeing a higher SSB shelf price (which indicates a drink contains added sugar) and exposure to nutrition education funded with tax revenues. SSB taxation is unlikely to negatively interfere with social or cultural values because taxation would not eliminate having SSBs for special occasions, and SSBs are not a staple of traditional diets. Lastly, SSB taxation attributes responsibility for health in a manner that reflects industry's contribution to obesity and the multisectoral solutions that are needed to prevent diet-related disease.

Brown sugar, how come you taste so good? The impact of a soda tax on prices and consumption

Increasing obesity-related problems and rising healthcare expenditures have led governments in developed countries to consider the introduction of soda taxes. We study a recent such tax, implemented in Portugal in February 2017 -one of the first soda taxes worldwide that increases with sugar content (0.08 euros per liter for drinks with less than 80 g of sugar per liter, and 0.16 euros per liter for drinks with 80 g or more sugar per liter, plus VAT). We use extremely detailed panel data from one of the two largest retailers in the country, covering the period between February 2015 and January 2018. We take advantage of the tax breakdown by sugar levels to examine how soda prices and quantities purchased reacted. For identification, we rely on difference-in-differences models with various vectors of fixed effects, comparing each group of products to water. For drinks with more than 80 g of sugar per liter, results indicate almost full price pass-through to the consumer. For drinks with less than 80 g of sugar per liter, price pass-through surpassed 100%. Regarding consumption, our findings suggest stockpiling behavior in the quarter when the tax was approved and before it was actually implemented. In the implementation period, there are no significant changes in quantities purchased for most beverages vis-à-vis water, with the exception of soda drinks with comparatively low levels of sugar. This suggests that benefits of the soda tax in terms of reducing sugar intake are mainly due to reformulation, as producers reduced the sugar content of some drinks to fall below the 80 g per liter threshold.