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Emmert-Fees KMF, Amies-Cull B, Wawro N, Linseisen J, Staudigel M, Peters A, Cobiac LJ, O’Flaherty M, Scarborough P, Kypridemos C, Laxy M. Projected health and economic impacts of sugar-sweetened beverage taxation in Germany: A cross-validation modelling study. PLoS Med 2023; 20:e1004311. [PMID: 37988392 PMCID: PMC10662751 DOI: 10.1371/journal.pmed.1004311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 10/13/2023] [Indexed: 11/23/2023] Open
Abstract
BACKGROUND Taxes on sugar-sweetened beverages (SSBs) have been implemented globally to reduce the burden of cardiometabolic diseases by disincentivizing consumption through increased prices (e.g., 1 peso/litre tax in Mexico) or incentivizing industry reformulation to reduce SSB sugar content (e.g., tiered structure of the United Kingdom [UK] Soft Drinks Industry Levy [SDIL]). In Germany, where no tax on SSBs is enacted, the health and economic impact of SSB taxation using the experience from internationally implemented tax designs has not been evaluated. The objective of this study was to estimate the health and economic impact of national SSBs taxation scenarios in Germany. METHODS AND FINDINGS In this modelling study, we evaluated a 20% ad valorem SSB tax with/without taxation of fruit juice (based on implemented SSB taxes and recommendations) and a tiered tax (based on the UK SDIL) in the German adult population aged 30 to 90 years from 2023 to 2043. We developed a microsimulation model (IMPACTNCD Germany) that captures the demographics, risk factor profile and epidemiology of type 2 diabetes, coronary heart disease (CHD) and stroke in the German population using the best available evidence and national data. For each scenario, we estimated changes in sugar consumption and associated weight change. Resulting cases of cardiometabolic disease prevented/postponed and related quality-adjusted life years (QALYs) and economic impacts from healthcare (medical costs) and societal (medical, patient time, and productivity costs) perspectives were estimated using national cost and health utility data. Additionally, we assessed structural uncertainty regarding direct, body mass index (BMI)-independent cardiometabolic effects of SSBs and cross-validated results with an independently developed cohort model (PRIMEtime). We found that SSB taxation could reduce sugar intake in the German adult population by 1 g/day (95%-uncertainty interval [0.05, 1.65]) for a 20% ad valorem tax on SSBs leading to reduced consumption through increased prices (pass-through of 82%) and 2.34 g/day (95%-UI [2.32, 2.36]) for a tiered tax on SSBs leading to 30% reduction in SSB sugar content via reformulation. Through reductions in obesity, type 2 diabetes, and cardiovascular disease (CVD), 106,000 (95%-UI [57,200, 153,200]) QALYs could be gained with a 20% ad valorem tax and 192,300 (95%-UI [130,100, 254,200]) QALYs with a tiered tax. Respectively, €9.6 billion (95%-UI [4.7, 15.3]) and €16.0 billion (95%-UI [8.1, 25.5]) costs could be saved from a societal perspective over 20 years. Impacts of the 20% ad valorem tax were larger when additionally taxing fruit juice (252,400 QALYs gained, 95%-UI [176,700, 325,800]; €11.8 billion costs saved, 95%-UI [€6.7, €17.9]), but impacts of all scenarios were reduced when excluding direct health effects of SSBs. Cross-validation with PRIMEtime showed similar results. Limitations include remaining uncertainties in the economic and epidemiological evidence and a lack of product-level data. CONCLUSIONS In this study, we found that SSB taxation in Germany could help to reduce the national burden of noncommunicable diseases and save a substantial amount of societal costs. A tiered tax designed to incentivize reformulation of SSBs towards less sugar might have a larger population-level health and economic impact than an ad valorem tax that incentivizes consumer behaviour change only through increased prices.
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Affiliation(s)
- Karl M. F. Emmert-Fees
- Professorship of Public Health and Prevention, School of Medicine and Health, Technical University of Munich, Munich, Germany
- Institute for Medical Information Processing, Biometry, and Epidemiology, Pettenkofer School of Public Health LMU Munich, Munich, Germany
- Institute of Epidemiology, Helmholtz Zentrum München, Research Center for Environmental Health, Neuherberg, Germany
| | - Ben Amies-Cull
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
- Oxford Health Biomedical Research Centre, National Institute of Health and Care Research, Oxford, United Kingdom
| | - Nina Wawro
- Institute of Epidemiology, Helmholtz Zentrum München, Research Center for Environmental Health, Neuherberg, Germany
| | - Jakob Linseisen
- Epidemiology, University of Augsburg, University Hospital Augsburg, Augsburg, Germany
| | - Matthias Staudigel
- TUM School of Management, Technical University of Munich, Munich, Germany
| | - Annette Peters
- Institute of Epidemiology, Helmholtz Zentrum München, Research Center for Environmental Health, Neuherberg, Germany
| | - Linda J. Cobiac
- School of Medicine and Dentistry, Griffith University, Southport, Australia
| | - Martin O’Flaherty
- Department of Public Health, Policy & Systems, University of Liverpool, Liverpool, United Kingdom
| | - Peter Scarborough
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
- Oxford Health Biomedical Research Centre, National Institute of Health and Care Research, Oxford, United Kingdom
| | - Chris Kypridemos
- Department of Public Health, Policy & Systems, University of Liverpool, Liverpool, United Kingdom
| | - Michael Laxy
- Professorship of Public Health and Prevention, School of Medicine and Health, Technical University of Munich, Munich, Germany
- Institute of Epidemiology, Helmholtz Zentrum München, Research Center for Environmental Health, Neuherberg, Germany
- German Center for Diabetes Research (DZD), Neuherberg, Germany
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Reyes-Sánchez F, Basto-Abreu A, Torres-Álvarez R, Carnalla-Cortés M, Reyes-García A, Swinburn B, Meza R, Rivera JA, Popkin B, Barientos-Gutiérrez T. Caloric reductions needed to achieve obesity goals in Mexico for 2030 and 2040: A modeling study. PLoS Med 2023; 20:e1004248. [PMID: 37363878 DOI: 10.1371/journal.pmed.1004248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 05/25/2023] [Indexed: 06/28/2023] Open
Abstract
BACKGROUND In Mexico, obesity prevalence among adults increased from 23% in 2000 to 36% in 2018, approximately. Mexico has not defined short- or long-term obesity goals, obscuring the level of effort required to achieve a relevant impact. We aimed to explore potential obesity goals for 2030 and 2040 in Mexico and to estimate the required caloric reductions to achieve them. METHODS AND FINDINGS We obtained anthropometric and demographic information on the Mexican adult population (age ≥20 years) from the Health and Nutrition Surveys conducted in 2000, 2006, 2012, 2016, and 2018 (n = 137,907). Each survey wave is cross-sectional, multistage, and representative of the Mexican population at the national, regional, and urban/rural levels. Obesity prevalence was projected for 2030 and 2040 by combining population projections of energy intake by socioeconomic status (SES) with a weight-change microsimulation model taking into account individual-level information on sex, age, physical activity, and initial body weight and height. If current trends continue, Mexico's obesity prevalence is expected to increase from 36% (95% CI 35% to 37%) in 2018 to 45% (uncertainty interval [UI] 41% to 48%) in 2030 and to 48% (UI 41% to 55%) in 2040. Based on expert opinion, we identified 3 obesity goals scenarios: (1) plausible (38% in 2030 and 36% in 2040); (2) intermediate (33% in 2030 and 29% in 2040); and (3) ideal based on the average prevalence of Organization for Economic Co-operation and Development countries (OECD; 19%). We estimated the caloric reductions needed to achieve the goal scenarios using the microsimulation model. Obesity was projected to increase more rapidly in the low SES (around 34% in 2018 to 48% (UI 41% to 55%) in 2040), than in the middle (around 38% to 52% (UI 45% to 56%)), or high SES group (around 36% to 45% (UI 36% to 54%)). Caloric reductions of 40 (UI 13 to 60), 75 (UI 49 to 95), and 190 (UI 163 to 215) kcal/person/day would be needed to reach the plausible, intermediate, and the ideal (OECD) average scenarios for 2030, respectively. To reach the 2040 goals, caloric reductions of 74 (UI 28 to 114), 124 (UI 78 to 169), and 209 (UI 163 to 254) kcal/person/day would be required, respectively. Study limitations include assuming a constant and sedentary physical activity level, not considering cohort-specific differences that could occur in the future, and assuming the same caloric trends under no intervention and the obesity goal scenarios. CONCLUSIONS To reach the 3 obesity goals in 2040, caloric reductions between 74 and 209 kcal/day/person would be needed in Mexico. A package of new and stronger interventions should be added to existing efforts such as food taxes and warning labels on non-nutritious food.
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Affiliation(s)
| | - Ana Basto-Abreu
- National Institute of Public Health, Population Health Research Center, Cuernavaca, Mexico
| | - Rossana Torres-Álvarez
- Department of Epidemiology, University of Michigan-Ann Arbor, Michigan, United States of America
| | - Martha Carnalla-Cortés
- National Institute of Public Health, Population Health Research Center, Cuernavaca, Mexico
| | - Alan Reyes-García
- National Institute of Public Health, Population Health Research Center, Cuernavaca, Mexico
| | - Boyd Swinburn
- School of Population Health, University of Auckland, Auckland, New Zealand
- GLOBE (Global Obesity Centre), Deakin University, Melbourne, Victoria, Australia
| | - Rafael Meza
- Department of Epidemiology, University of Michigan-Ann Arbor, Michigan, United States of America
| | - Juan A Rivera
- National Institute of Public Health, Population Health Research Center, Cuernavaca, Mexico
| | - Barry Popkin
- Department of Nutrition at the Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
- Department of Nutrition, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
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Ahrens W, Brenner H, Flechtner-Mors M, Harrington JM, Hebestreit A, Kamphuis CBM, Kelly L, Laxy M, Luszczynska A, Mazzocchi M, Murrin C, Poelman MP, Steenhuis I, Roos G, Steinacker JM, van Lenthe F, Zeeb H, Zukowska J, Lakerveld J, Woods CB. Dietary behaviour and physical activity policies in Europe: learnings from the Policy Evaluation Network (PEN). Eur J Public Health 2022; 32:iv114-iv125. [PMID: 36444106 PMCID: PMC9706119 DOI: 10.1093/eurpub/ckac148] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
The European Policy Evaluation Network (PEN), initiated in autumn 2018, aimed at advancing the evidence base for public policies impacting dietary behaviour, physical activity and sedentary behaviours in Europe. This is needed because non-communicable diseases-the leading cause of global mortality-are substantially caused by physical inactivity and unhealthy dietary behaviours, which in turn are driven by upstream factors that have not yet been addressed effectively by prevention approaches. Thus, successful policy interventions are required that target entire populations and tackle the 'causes of the causes'. To advance our knowledge on the effective implementation of policies and their impact in terms of improving health behaviours, PEN focused on five research tasks: (i) Adaptation and implementation of a Food Environment Policy Index (Food-EPI) and development of a Physical Activity Environment Policy Index (PA-EPI); (ii) Mapping of health-related indicators needed for policy evaluation and facilitating a harmonized pan-European approach for surveillance to assess the impact of policy interventions; (iii) Refining quantitative methods to evaluate the impact of public policies; (iv) Identifying key barriers and facilitators of implementation of policies; and (v) Advance understanding the equity impact of the development, implementation and evaluation of policies aimed at promoting physical activity and a healthy diet. Finally, and in order to provide concrete evidence for policymaking, existing exemplary policies, namely sugar-sweetened beverages taxation, active transport policies and school policies on nutrition and physical activity were assessed in consideration of these five tasks. At the end of the PEN project's formal runtime, considerable advancements have been made. Here, we present an overview of the most important learnings and outputs.
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Affiliation(s)
- Wolfgang Ahrens
- Correspondence: Wolfgang Ahrens, Department of Epidemiological Methods and Etiological Research, Leibniz Institute for Prevention Research and Epidemiology – BIPS, Achterstrasse 30, 28359 Bremen, Germany, Tel: +49 421 218 56822, e-mail:
| | - Hermann Brenner
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Marion Flechtner-Mors
- Division of Sports and Rehabilitation Medicine, Department of Medicine, University Hospital Ulm, Ulm, Germany
| | - Janas M Harrington
- HRB Centre for Health and Diet Research, School of Public Health, University College Cork, Cork, Ireland
| | - Antje Hebestreit
- Leibniz Institute for Prevention Research and Epidemiology – BIPS, Bremen, Germany
| | - Carlijn B M Kamphuis
- Department of Interdisciplinary Social Science, Utrecht University, Utrecht, the Netherlands
| | - Liam Kelly
- Department of Physical Education and Sport Sciences, Faculty of Education and Health Sciences, Physical Activity for Health Research Cluster, Health Research Institute, University of Limerick, Limerick, Ireland
| | - Michael Laxy
- Technical University of Munich, Professorship of Public Health and Prevention, Munich, Germany
| | | | - Mario Mazzocchi
- Department of Statistical Sciences, University of Bologna, Bologna, Italy
| | - Celine Murrin
- School of Public Health, Physiotherapy and Sports Science, University College Dublin, Belfield, Dublin, Ireland
| | - Maartje P Poelman
- Chair Group Consumption and Healthy Lifestyles, Wageningen University & Research, Wageningen, The Netherlands
| | - Ingrid Steenhuis
- Department of Health Sciences, Faculty of Science and Amsterdam Public Health Research Institute De Boelelaan 1085, VU University Amsterdam, Amsterdam, The Netherlands
| | - Gun Roos
- Consumption Research Norway, Oslo Metropolitan University, Oslo, Norway
| | - Jürgen M Steinacker
- Division of Sports and Rehabilitation Medicine, Department of Medicine, University Hospital Ulm, Ulm, Germany
| | - Frank van Lenthe
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands,Department of Human Geography and Public Health, Utrecht University, Utrecht, The Netherlands
| | - Hajo Zeeb
- Leibniz Institute for Prevention Research and Epidemiology – BIPS, Bremen, Germany,Health Sciences Bremen, University of Bremen, Bremen, Germany
| | - Joanna Zukowska
- Faculty of Civil and Environmental Engineering, Gdansk University of Technology, Gdansk, Poland
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