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

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.

Consumption of Sugar-Sweetened Beverages by Polish Young Adults: A Preliminary Study on the Importance of Sugar Tax Familiarity and Health Effects

Consumption of sugar-sweetened beverages (SSBs) contributes to the risk of developing overweight and obesity in children and adults. Thus, reducing free sugar is a globally recognized public health priority. The implementation of a sugar tax is one way of achieving this goal. This study aimed to investigate the relationship between familiarity with the sugar tax and its importance in reducing obesity, the perceived health consequences of SSBs, situations and reasons for consumption, and the frequency of SSB consumption. A cross-sectional study was conducted in May 2022 among 216 Polish adults (age 18-45). Hierarchical cluster analysis was used to identify three homogeneous clusters with regard to the perceived health consequences of consuming SSBs. A logistic regression model was used to verify the relationship between the frequency of SSB consumption (dependent variable) and other variables. Respondents with higher familiarity with the sugar tax (OR: 0.594; 95% CI: 0.42-0.85) and those in the "Unaware of disease" (OR: 0.437; 95% CI: 0.18-0.94) and "Disease-conscious" (OR: 0.484; 95% CI: 0.24-0.97) clusters were less likely to consume SSBs at least once per week than those in the "Moderately disease-conscious" cluster. Both the place of SSB consumption (i.e., restaurant-OR: 1.847; 95% CI: 1.14-3.64, work or university-OR: 3.217; 95% CI: 1.51-6.88, family home-OR: 2.877; 95% CI: 1.50-5.53) as well as a preference for their taste (OR: 4.54; 95% CI: 1.66-12.45) increased the chance of consuming SSBs at least once a week. In conclusion, it is necessary to continue educating the public about the health consequences of SSB consumption. The use of legislative measures (i.e., sugar tax) also contributes to reducing SSB consumption and can thus counteract the increasing obesity rate.

Self-reported decreases in the purchases of selected unhealthy foods resulting from the implementation of warning labels in Mexican youth and adult population

BACKGROUND

Front-of-package nutritional warning labels (WLs) are designed to facilitate identification and selection of healthier food choices. We assessed self-reported changes in purchasing different types of unhealthy foods due to WLs in Mexico and the association between the self-reported reductions in purchases of sugary beverages and intake of water and sugar-sweetened beverages.

METHODS

Data came from 14 to 17 year old youth (n = 1,696) and adults ≥ 18 (n = 7,775) who participated in the Mexican arm of the 2020-2021 International Food Policy Study, an annual repeat cross-sectional online survey. Participants self-reported whether the WLs had influenced them to purchase less of each of nine unhealthy food categories due to WLs. Among adults, a 23-item Beverage Frequency Questionnaire was used derive past 7-day intake of water and sugary beverages analyzed to determine the relationship between self-reported reductions in purchasing sugary drinks due to the WLs. Multilevel mixed-effects logistic regression models were fitted to estimate the percentage of participants who self-reported reducing purchases within each food group, and overall. Sociodemographic characteristics associated with this reduction were investigated as well.

RESULTS

Overall, 44.8% of adults and 38.7% of youth reported buying less of unhealthy food categories due to the implementation of WL, with the largest proportion reporting decreased purchases of cola, regular and diet soda. A greater impact of WLs on the reported purchase of unhealthy foods was observed among the following socio-demographic characteristics: females, individuals who self-identified as indigenous, those who were overweight, individuals with lower educational levels, those with higher nutrition knowledge, households with children, and those with a significant role in household food purchases. In addition, adults who reported higher water intake and lower consumption of sugary beverages were more likely to report reduced purchases of sugary drinks due to the WLs. Adults who reported greater water intake and lower sugary beverages intake were significantly more likely to report buying fewer sugary drinks due to the WLs.

CONCLUSION

Our findings suggest that implementation of WLs has reduced perceived purchases of unhealthy foods in Mexico. These results underscore the potential positive impact of the labeling policy particularly in subpopulations with lower levels of education and among indigenous adults.

Impact of the Philadelphia Beverage Tax on Perceived Beverage Healthfulness, Tax Awareness, and Tax Opinions

OBJECTIVE

To assess the impact of the Philadelphia Beverage Tax on perceived beverage healthfulness, and awareness and opinions of the tax.

DESIGN

Natural experiment SETTING: Small independent stores in Philadelphia (n = 61) and Baltimore (untaxed control site; n = 65) PARTICIPANTS: Shoppers in Philadelphia (n = 2,731) and Baltimore (n = 4,600) pre- and post-tax implementation.

MAIN OUTCOME MEASURES

Perceptions of 4 beverages (unhealthy vs healthy/neutral), tax awareness, and tax opinions (oppose vs favor/neutral).

ANALYSIS

Mixed-effects linear probability models estimated changes in perceived beverage healthfulness in Philadelphia, relative to Baltimore, following a difference-in-differences approach. Mixed-effects linear probability models estimated pre-post changes in tax awareness and opinions in Philadelphia-only.

RESULTS

The probability of perceiving taxed beverages as unhealthy increased 2-years post-tax relative to Baltimore (regular soda: 5.7% [95% confidence interval (CI), 0.9-10.6], P = 0.02; diet soda: 7.7% [95% CI, 1.5-13.8], P < 0.001; sports drinks: 6.4% [95% CI, 0.4-12.4], P = 0.04), with similar changes at 1-year post-tax, whereas perceived healthfulness of untaxed 100% fruit juice did not change. Tax awareness was high at baseline (72%) and increased post-implementation; however, the probability of opposing the tax (22%) also increased over time.

CONCLUSIONS AND IMPLICATIONS

Decreases in the perceived healthfulness of taxed beverages suggest the tax had a health-signaling effect. Consumer awareness and health education efforts could complement tax policies to enhance understanding of health risks.

Taxing sugar-sweetened beverages: Knowledge, beliefs and where should the money go?

Background

The Sugar-Sweetened Beverage (SSB) industry consciously and subconsciously influences consumers to buy its products. Countering unhealthy messaging and behaviour could be tackled through the SSB levy and allocation of revenue toward healthy lifestyle programs. Given the limited information in the UAE on demographic and consumer knowledge and beliefs and allocation of SSB levy, we conducted a study to explore this further. The study objectives were to a) explore the association between demographic factors (nationality, income and education) with knowledge and beliefs for SSB and b) explore participants' views on allocating SSB levy toward healthy lifestyle programs.

Methods

A cross-sectional study of adults in the United Arab Emirates.

Results

The findings suggest knowledge was high for Sugar-Sweetened Beverages (SSB), obesity, and diabetes (1,231, 96.1%), and there was a high awareness of SSB tax (1,066, 83.2%). Knowledge and beliefs about Sugar-Sweetened Beverages were statistically significant for two demographic factors. There was support for the tax revenue to be spent on government programs and greater support for spending to be directed toward specific healthy lifestyle programs such as school health programmes (514, 39.8%), children's diet and nutrition programmes (497, 38.5%), physical activity programmes (480, 37.2%), among others.

Conclusions

The findings shed light on the influence demographic factors have on knowledge and beliefs, public health gaps and potential areas for SSB levy expenditure. Further research is needed to understand how best to implement healthy lifestyle programs within the community to optimise coverage, cost-effectiveness, and health outcomes.

Understanding Whether Price Tag Messaging Can Amplify the Benefits of Taxes: An Online Experiment

INTRODUCTION

Excise taxes on unhealthy products like sugary drinks and tobacco can reduce purchases of these products. However, little research has investigated whether messages at the point of purchase, such as enhanced price tags, can increase the effects of taxes by heightening psychological reactions. This study aimed to examine whether including messages about taxes on price tags could amplify the benefits of excise taxes on unhealthy products.

METHODS

In 2022, an online study recruited 1,013 U.S. parents to view seven price tag messages (e.g., "includes a 19% sugary drink tax") and a control (i.e., standard price tag with the tax included in the price) displayed in random order alongside sugary drinks. Participants were randomly assigned to view a caution-symbol icon or no icon on price tags. Analyses were conducted in 2023.

RESULTS

All seven messages discouraged parents from buying sugary drinks for their children compared to control (average differential effects [ADEs] ranged from 0.28 to 0.48, all p<0.001). All messages led to greater attention to the price tag (ADEs ranged from 0.24 to 0.41, all p<0.001) and greater consideration of the cost of sugary drinks (ADEs ranged from 0.31 to 0.50, all p<0.001). Icons elicited higher cost consideration than text-only price tags (ADE=0.15, p<0.010), but not discouragement (p=0.061) or attention (p=0.079).

CONCLUSIONS

Messaging on price tags could make excise taxes more effective. Policymakers should consider requiring messaging on price tags when implementing taxes.

Lifestyle management of hypertension: International Society of Hypertension position paper endorsed by the World Hypertension League and European Society of Hypertension

Hypertension, defined as persistently elevated systolic blood pressure (SBP) >140 mmHg and/or diastolic blood pressure (DBP) at least 90 mmHg (International Society of Hypertension guidelines), affects over 1.5 billion people worldwide. Hypertension is associated with increased risk of cardiovascular disease (CVD) events (e.g. coronary heart disease, heart failure and stroke) and death. An international panel of experts convened by the International Society of Hypertension College of Experts compiled lifestyle management recommendations as first-line strategy to prevent and control hypertension in adulthood. We also recommend that lifestyle changes be continued even when blood pressure-lowering medications are prescribed. Specific recommendations based on literature evidence are summarized with advice to start these measures early in life, including maintaining a healthy body weight, increased levels of different types of physical activity, healthy eating and drinking, avoidance and cessation of smoking and alcohol use, management of stress and sleep levels. We also discuss the relevance of specific approaches including consumption of sodium, potassium, sugar, fibre, coffee, tea, intermittent fasting as well as integrated strategies to implement these recommendations using, for example, behaviour change-related technologies and digital tools.

Self-reported decreases in the purchases of selected unhealthy foods resulting from the implementation of warning labels in Mexican youth and adult population

Background

Front-of-package nutritional warning labels (WLs) are designed to facilitate identification and selection of healthier food choices. We assessed self-reported changes in purchasing different types of unhealthy foods due to WLs in Mexico and the association between the self-reported reductions in purchases of sugary beverages and intake of water and sugar-sweetened beverages.

Methods

Data came from 14-17 year old youth (n=1,696) and adults ≥18 (n=7,775) who participated in the Mexican arm of the 2020-2021 International Food Policy Study, an annual repeat cross-sectional online survey. Participants self-reported whether the WLs had influenced them to purchase less of each of ten unhealthy food categories due to WLs. Among adults, a 23-item Beverage Frequency Questionnaire was used derive past 7-day intake of water and sugary beverages analyzed to determine the relationship between self-reported reductions in purchasing sugary drinks due to the WLs. Multilevel mixed-effects logistic regression models were fitted to estimate the percentage of participants who self-reported reducing purchases within each food group, and overall. Sociodemographic characteristics associated with this reduction were investigated as well.

Results

Overall, 44.8% of adults and 38.7% of youth reported buying less of unhealthy food categories due to the implementation of WL, with the largest proportion reporting decreased purchases of cola, regular and diet soda. A greater impact of WLs on the reported purchase of unhealthy foods was observed among the following socio-demographic characteristics: females, individuals who self-identified as indigenous, those who were overweight, individuals with lower educational levels, those with higher nutrition knowledge, households with children, and those with a significant role in household food purchases. In addition, adults who reported higher water intake and lower consumption of sugary beverages were more likely to report reduced purchases of sugary drinks due to the WLs. Adults who reported greater water intake and lower sugary beverages intake were significantly more likely to report buying fewer sugary drinks due to the WLs.

Conclusion

Our findings suggest that implementation of WLs has reduced purchases of unhealthy foods in Mexico. These results underscore the positive impact of the labeling policy particularly in subpopulations with lower levels of education and among indigenous adults.

Evaluating the relative impact of multiple healthy food choice interventions on choice process variables and choices

Fiscal tools-taxes and/or subsidies-are increasingly used to address diet-related health problems. However, some studies have found that these tools are markedly more effective if attention is drawn to the tax or subsidy, suggesting that the price change alone may go unnoticed in the complex food environments that consumers face. Interventions that prompt individuals to consider health during choice show promise for promoting healthy food choices in both simple laboratory settings and complex, real-world markets. In this pre-registered study, I examine the impact of dietary fiber health prompts and/or dietary fiber subsidies on the per-serving fiber content of foods chosen, the documented set of products considered, and (self-reported) nutrition information use by participants in an online supermarket setting. Participants were randomized to one of four conditions: 1) control, 2) subsidy, 3) fiber prompt, and 4) fiber prompt + subsidy. Results show that both the prompt and prompt + subsidy conditions significantly increase fiber content of foods chosen (with the latter having a larger effect). While all three interventions influence the probability of using nutrition information during food choice and affect the set of products that respondents consider relative to the control condition, the effects were larger for the prompt and prompt + subsidy conditions. A multiple mediation analysis illustrates that both direct and indirect (through the set of products considered and the use of fiber information during choice) pathways lead to the significant overall increase in fiber content of selected foods.

The 'sugar tax' in Bermuda: a mixed methods study of general population and key stakeholder perceptions

Background

Taxes on discretionary foods and sugar-sweetened beverages have emerged as a strategy for health promotion. Between 2018–2019, the Bermuda government introduced a phased tax on imported sugar-sweetened beverages, confectionery, products containing cocoa and pure sugar, and eliminated import duties on select healthy food items. The aim of this study was to conduct an mixed methods evaluation of perceptions of the tax among the general population and key stakeholders.

Methods

We conducted a survey of the general population (N = 400), and semi-structured interviews with key informants (N = 14) from the government, food and beverage, and health sectors to understand awareness, acceptability, and perceived impact of the tax after implementation. Survey data was analysed using thematic analysis, summary statistics, and Chi-squared tests. Key informant interviews were analysed using the framework method.

Results

General population respondents had high awareness of the sugar tax (94%) but low awareness of the healthy food subsidy (32%). Most respondents (67%) felt the tax was not an appropriate way to motivate healthier consumption due to beliefs the tax would not be effective (44%), and because of the high price of healthy food (20%). However, nearly half (48%) reported consuming fewer taxed products, primarily for health reasons but also motivated by price increases. Key informants indicated there was high awareness but limited understanding of the tax policy. Informants expressed support for taxation as a health promotion strategy, conditional on policy implementation. The lack of clear price differentiation between taxed and un-taxed products and the absence of accompanying health education were key factors believed to affect the impact of the tax. No informants were aware of use of tax revenues for health purposes and tax revenue was reportedly re-directed to other priorities after implementation.

Conclusions

There was high awareness, but limited acceptability of the Bermuda sugar tax as implemented. Clarity in the tax policy, appropriateness of the tax mechanism, and use of revenue in alignment with the tax aim are critical components for acceptance. The absence of complementary education and health promotion affected acceptance and may limit potential health impacts. The lessons learned in Bermuda can inform similar policies in other settings.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13945-9.

Daily Fluid Intake Behaviors and Associated Health Effects Among Australian and United States Populations

Minimal data exist exploring intercontinental differences in fluid intake (FI) beliefs and behaviors and the impact on fluid intake practices (i.e., fluid intake volume, beverage type, and timing of fluid intake). Therefore, this study explored the impact that FI beliefs and behaviors had on FI practices among emerging adults living in the United States (USA) and Australia (AUS). A total of 489 individuals (74.5% female; USA, 79.4%; age, 25 ± 6 years completed a 23-item survey between November 2020 and June 2021). Participants detailed their FI practices. FI beliefs were evaluated to determine their contribution to FI behaviors across the day. Multinomial and multiple linear regression analyses explored the association of daily FI beliefs and behaviors across multiple domains. Independent sample t-tests and chi-square analyses were conducted to compare FI practices, beliefs, and behaviors between individuals in the USA and AUS. FI behaviors were significantly different between countries, with the USA more likely to consume fluids to meet a total target volume (β = 1.150, p = 0.036) and consume fluid at the same time as structured daily activities (β = 0.773, p = 0.046) compared to FI alongside food intake. However, there were no differences in the types of beverage consumed (juice, sugar-sweetened beverages, tea, and coffee), total fluid volume, and physical activity (PA) between countries (p &gt; 0.05). Beverage consumption was higher among USA than AUS residents for water, beer, and wine (p &lt; 0.05). Total fluid consumption was greater among males (3,189 ± 2,407 ml) than females (2,215 ± 1,132 ml; β = 3.61, p &lt; 0.001), individuals who regularly consumed fluid during the day to meet a targeted volume (β = 1,728.5, p &lt; 0.001), and those who regularly consumed fluid as a habitual behavior (β = 3.97, p &lt; 0.001) compared to those individuals who only consumed fluid alongside mealtimes (β = 1,041.7, p &lt; 0.001). FI behaviors differed between the USA and AUS; however, total volume consumed, type of beverage consumed, and FI beliefs were similar. FI practices and behaviors appear to be individualized and context-specific among the studied populations.