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Cobiac LJ, Rogers NT, Adams J, Cummins S, Smith R, Mytton O, White M, Scarborough P. Impact of the UK soft drinks industry levy on health and health inequalities in children and adolescents in England: An interrupted time series analysis and population health modelling study. PLoS Med 2024; 21:e1004371. [PMID: 38547319 PMCID: PMC11008889 DOI: 10.1371/journal.pmed.1004371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 04/11/2024] [Accepted: 03/06/2024] [Indexed: 04/13/2024] Open
Abstract
BACKGROUND The soft drinks industry levy (SDIL) in the United Kingdom has led to a significant reduction in household purchasing of sugar in drinks. In this study, we examined the potential medium- and long-term implications for health and health inequalities among children and adolescents in England. METHODS AND FINDINGS We conducted a controlled interrupted time series analysis to measure the effects of the SDIL on the amount of sugar per household per week from soft drinks purchased, 19 months post implementation and by index of multiple deprivation (IMD) quintile in England. We modelled the effect of observed sugar reduction on body mass index (BMI), dental caries, and quality-adjusted life years (QALYs) in children and adolescents (0 to 17 years) by IMD quintile over the first 10 years following announcement (March 2016) and implementation (April 2018) of the SDIL. Using a lifetable model, we simulated the potential long-term impact of these changes on life expectancy for the current birth cohort and, using regression models with results from the IMD-specific lifetable models, we calculated the impact of the SDIL on the slope index of inequality (SII) in life expectancy. The SDIL was found to have reduced sugar from purchased drinks in England by 15 g/household/week (95% confidence interval: -10.3 to -19.7). The model predicts these reductions in sugar will lead to 3,600 (95% uncertainty interval: 946 to 6,330) fewer dental caries and 64,100 (54,400 to 73,400) fewer children and adolescents classified as overweight or obese, in the first 10 years after implementation. The changes in sugar purchasing and predicted impacts on health are largest for children and adolescents in the most deprived areas (Q1: 11,000 QALYs [8,370 to 14,100] and Q2: 7,760 QALYs [5,730 to 9,970]), while children and adolescents in less deprived areas will likely experience much smaller simulated effects (Q3: -1,830 QALYs [-3,260 to -501], Q4: 652 QALYs [-336 to 1,680], Q5: 1,860 QALYs [929 to 2,890]). If the simulated effects of the SDIL are sustained over the life course, it is predicted there will be a small but significant reduction in slope index of inequality: 0.76% (95% uncertainty interval: -0.9 to -0.62) for females and 0.94% (-1.1 to -0.76) for males. CONCLUSIONS We predict that the SDIL will lead to medium-term reductions in dental caries and overweight/obesity, and long-term improvements in life expectancy, with the greatest benefits projected for children and adolescents from more deprived areas. This study provides evidence that the SDIL could narrow health inequalities for children and adolescents in England.
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Affiliation(s)
- Linda J. Cobiac
- School of Medicine and Dentistry, Griffith University, Queensland, Australia
| | - Nina T. Rogers
- MRC Epidemiology Unit, University of Cambridge School of Clinical Medicine, Institute of Metabolic Science, Cambridge, United Kingdom
| | - Jean Adams
- MRC Epidemiology Unit, University of Cambridge School of Clinical Medicine, Institute of Metabolic Science, Cambridge, United Kingdom
| | - Steven Cummins
- Population Health Innovation Lab, Department of Public Health, Environments & Society, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Richard Smith
- Faculty of Health and Life Sciences, University of Exeter, Exeter, United Kingdom
| | - Oliver Mytton
- UCL Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| | - Martin White
- MRC Epidemiology Unit, University of Cambridge School of Clinical Medicine, Institute of Metabolic Science, Cambridge, United Kingdom
| | - Peter Scarborough
- Nuffield Department of Primary Care Health Sciences, University of Oxford, UK & NIHR Oxford Health Biomedical Research Centre at Oxford, Oxford, United Kingdom
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Rogers NT, Pell D, Mytton OT, Penney TL, Briggs A, Cummins S, Jones C, Rayner M, Rutter H, Scarborough P, Sharp S, Smith R, White M, Adams J. Changes in soft drinks purchased by British households associated with the UK soft drinks industry levy: a controlled interrupted time series analysis. BMJ Open 2023; 13:e077059. [PMID: 38052470 PMCID: PMC10711915 DOI: 10.1136/bmjopen-2023-077059] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 11/21/2023] [Indexed: 12/07/2023] Open
Abstract
OBJECTIVE To determine changes in household purchases of drinks 1 year after implementation of the UK soft drinks industry levy (SDIL). DESIGN Controlled interrupted time series. PARTICIPANTS Households reporting their purchasing to a market research company (average weekly n=22 091), March 2014 to March 2019. INTERVENTION A two-tiered tax levied on soft drinks manufacturers, announced in March 2016 and implemented in April 2018. Drinks with ≥8 g sugar/100 mL (high tier) are taxed at £0.24/L, drinks with ≥5 to <8 g sugar/100 mL (low tier) are taxed at £0.18/L. MAIN OUTCOME MEASURES Absolute and relative differences in the volume of, and amount of sugar in, soft drinks categories, all soft drinks combined, alcohol and confectionery purchased per household per week 1 year after implementation. RESULTS In March 2019, compared with the counterfactual, purchased volume of high tier drinks decreased by 140.8 mL (95% CI 104.3 to 177.3 mL) per household per week, equivalent to 37.8% (28.0% to 47.6%), and sugar purchased in these drinks decreased by 16.2 g (13.5 to 18.8 g), or 42.6% (35.6% to 49.6%). Purchases of low tier drinks decreased by 170.5 mL (154.5 to 186.5 mL) or 85.8% (77.8% to 93.9%), with an 11.5 g (9.1 to 13.9 g) reduction in sugar in these drinks, equivalent to 87.8% (69.2% to 106.4%). When all soft drinks were combined irrespective of levy tier or eligibility, the volume of drinks purchased increased by 188.8 mL (30.7 to 346.9 mL) per household per week, or 2.6% (0.4% to 4.7%), but sugar decreased by 8.0 g (2.4 to 13.6 g), or 2.7% (0.8% to 4.5%). Purchases of confectionery and alcoholic drinks did not increase. CONCLUSIONS Compared with trends before the SDIL was announced, 1 year after implementation, volume of all soft drinks purchased combined increased by 189 mL, or 2.6% per household per week. The amount of sugar in those drinks was 8 g, or 2.7%, lower per household per week. Further studies should determine whether and how apparently small effect sizes translate into health outcomes. TRIAL REGISTRATION NUMBER ISRCTN18042742.
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Affiliation(s)
| | | | - Oliver T Mytton
- MRC Epidemiology Unit, Cambridge, UK
- University College London Great Ormond Street Institute of Child Health, London, UK
| | - Tarra L Penney
- York University - Keele Campus, Toronto, Ontario, Canada
| | - Adam Briggs
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
- Institute for Health Policy and Clinical Practice, University of Warwick Warwick Medical School, Coventry, UK
| | - Steven Cummins
- Department of Social and Environmental Health Research, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Mike Rayner
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
- NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Harry Rutter
- University of Bath Department of Social and Policy Sciences, Bath, UK
| | - Peter Scarborough
- NIHR Oxford Biomedical Research Centre, Oxford, UK
- Nuffield Department of Population Health, Centre on Population Approaches for Non-Communicable Disease Prevention, Oxford, UK
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Amies-Cull B, Luengo-Fernandez R, Scarborough P, Wolstenholme J. NHS reference costs: a history and cautionary note. Health Econ Rev 2023; 13:54. [PMID: 37991623 PMCID: PMC10664521 DOI: 10.1186/s13561-023-00469-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 11/08/2023] [Indexed: 11/23/2023]
Abstract
Historically, the NHS did not routinely collect cost data, unlike many countries with private insurance markets. In 1998, for the first time the government mandated NHS trusts to submit estimates of their costs of service, known as reference costs. These have informed a wide range of health economic evaluations and important functions in the health service, such as setting prices.Reference costs are collected by progressively disaggregating budgets top-down into disease and treatment groups. Despite ongoing improvements to methods and guidance, these submissions continued to suffer a lack of accuracy and comparability, fundamentally undermining their credibility for critical functions.To overcome these issues, there was a long-held ambition to collect "patient-level" cost data. Patient-level costs are estimated with a combination of disaggregating budgets but also capturing the patient-level "causality of costs" bottom-up in the allocation of resources to patient episodes. These not only aim to capture more of the drivers of costs, but also improve consistency of reporting between providers.The change in methods may confer improvements to data quality, though judgement is still required and achieving consistency between trusts will take further work. Estimated costs may also change in important ways that may take many years to fully understand. We end on a cautionary note that patient-level cost methods may unlock potential, they alone contribute little to our understanding of the complexities involved with service quality or need, while that potential will require substantial investment to realise. Many healthcare resources cannot be attributed to individual patients so the very notion of "patient-level" costs may be misplaced. High hopes have been put in these new data, though much more work is now necessary to understand their quality, what they show and how their use will impact the system.
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Affiliation(s)
- Ben Amies-Cull
- Nuffield Department of Primary Care Health Sciences, Gibson Building, Woodstock Rd, Oxford, OX2 6GG, UK.
| | - Ramon Luengo-Fernandez
- Health Economics Research Centre, Richard Doll Building, University of Oxford, Old Road Campus, Oxford, OX3 7LF, UK
| | - Peter Scarborough
- Nuffield Department of Primary Care Health Sciences, Gibson Building, Woodstock Rd, Oxford, OX2 6GG, UK
| | - Jane Wolstenholme
- Health Economics Research Centre, Richard Doll Building, University of Oxford, Old Road Campus, Oxford, OX3 7LF, UK
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Scarborough P, Clark M, Cobiac L, Papier K, Knuppel A, Lynch J, Harrington R, Key T, Springmann M. Vegans, vegetarians, fish-eaters and meat-eaters in the UK show discrepant environmental impacts. Nat Food 2023:10.1038/s43016-023-00795-w. [PMID: 37474804 PMCID: PMC10365988 DOI: 10.1038/s43016-023-00795-w] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 06/12/2023] [Indexed: 07/22/2023]
Abstract
Modelled dietary scenarios often fail to reflect true dietary practice and do not account for variation in the environmental burden of food due to sourcing and production methods. Here we link dietary data from a sample of 55,504 vegans, vegetarians, fish-eaters and meat-eaters with food-level data on greenhouse gas emissions, land use, water use, eutrophication risk and potential biodiversity loss from a review of 570 life-cycle assessments covering more than 38,000 farms in 119 countries. Our results include the variation in food production and sourcing that is observed in the review of life-cycle assessments. All environmental indicators showed a positive association with amounts of animal-based food consumed. Dietary impacts of vegans were 25.1% (95% uncertainty interval, 15.1-37.0%) of high meat-eaters (≥100 g total meat consumed per day) for greenhouse gas emissions, 25.1% (7.1-44.5%) for land use, 46.4% (21.0-81.0%) for water use, 27.0% (19.4-40.4%) for eutrophication and 34.3% (12.0-65.3%) for biodiversity. At least 30% differences were found between low and high meat-eaters for most indicators. Despite substantial variation due to where and how food is produced, the relationship between environmental impact and animal-based food consumption is clear and should prompt the reduction of the latter.
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Affiliation(s)
- Peter Scarborough
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Oxford, UK.
- NIHR Oxford Health Biomedical Research Centre at Oxford, Warneford Hospital, Oxford, UK.
| | - Michael Clark
- Oxford Martin School, University of Oxford, Oxford, UK
| | - Linda Cobiac
- Griffith University, Southport, Queensland, Australia
| | - Keren Papier
- Cancer Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | | | - John Lynch
- Nature-based Solutions Initiative, Department of Biology, University of Oxford, Oxford, UK
| | - Richard Harrington
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Oxford, UK
- NIHR Oxford Health Biomedical Research Centre at Oxford, Warneford Hospital, Oxford, UK
| | - Tim Key
- Cancer Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
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Breeze PR, Squires H, Ennis K, Meier P, Hayes K, Lomax N, Shiell A, Kee F, de Vocht F, O’Flaherty M, Gilbert N, Purshouse R, Robinson S, Dodd PJ, Strong M, Paisley S, Smith R, Briggs A, Shahab L, Occhipinti J, Lawson K, Bayley T, Smith R, Boyd J, Kadirkamanathan V, Cookson R, Hernandez‐Alava M, Jackson CH, Karapici A, Sassi F, Scarborough P, Siebert U, Silverman E, Vale L, Walsh C, Brennan A. Guidance on the use of complex systems models for economic evaluations of public health interventions. Health Econ 2023; 32:1603-1625. [PMID: 37081811 PMCID: PMC10947434 DOI: 10.1002/hec.4681] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 03/13/2023] [Accepted: 03/14/2023] [Indexed: 05/03/2023]
Abstract
To help health economic modelers respond to demands for greater use of complex systems models in public health. To propose identifiable features of such models and support researchers to plan public health modeling projects using these models. A working group of experts in complex systems modeling and economic evaluation was brought together to develop and jointly write guidance for the use of complex systems models for health economic analysis. The content of workshops was informed by a scoping review. A public health complex systems model for economic evaluation is defined as a quantitative, dynamic, non-linear model that incorporates feedback and interactions among model elements, in order to capture emergent outcomes and estimate health, economic and potentially other consequences to inform public policies. The guidance covers: when complex systems modeling is needed; principles for designing a complex systems model; and how to choose an appropriate modeling technique. This paper provides a definition to identify and characterize complex systems models for economic evaluations and proposes guidance on key aspects of the process for health economics analysis. This document will support the development of complex systems models, with impact on public health systems policy and decision making.
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Affiliation(s)
- Penny R. Breeze
- School of Health and Related ResearchUniversity of SheffieldSheffieldUK
| | - Hazel Squires
- School of Health and Related ResearchUniversity of SheffieldSheffieldUK
| | - Kate Ennis
- British Medical Journal Technology Appraisal GroupLondonUK
| | - Petra Meier
- MRC/CSO Social and Public Health Sciences UnitUniversity of GlasgowScotlandUK
| | - Kate Hayes
- School of Health and Related ResearchUniversity of SheffieldSheffieldUK
| | - Nik Lomax
- School of GeographyUniversity of LeedsLeedsUK
| | - Alan Shiell
- Department of Public HealthLaTrobe UniversityMelbourneAustralia
| | - Frank Kee
- Centre for Public HealthQueen's University BelfastBelfastUK
| | - Frank de Vocht
- Population Health SciencesBristol Medical SchoolUniversity of BristolBristolUK
- NIHR Applied Research Collaboration West (ARC West)BristolUK
| | - Martin O’Flaherty
- Department of Public Health, Policy and SystemsUniversity of LiverpoolLiverpoolUK
| | | | - Robin Purshouse
- Department of Automatic Control and Systems EngineeringUniversity of SheffieldSheffieldUK
| | | | - Peter J Dodd
- School of Health and Related ResearchUniversity of SheffieldSheffieldUK
| | - Mark Strong
- School of Health and Related ResearchUniversity of SheffieldSheffieldUK
| | | | - Richard Smith
- College of Medicine and HealthUniversity of ExeterExeterUK
| | - Andrew Briggs
- London School of Hygiene & Tropical MedicineLondonUK
| | - Lion Shahab
- Department of Behavioural Science and HealthUCLLondonUK
| | - Jo‐An Occhipinti
- Brain and Mind CentreUniversity of SydneyNew South WalesCamperdownAustralia
| | - Kenny Lawson
- Brain and Mind CentreUniversity of SydneyNew South WalesCamperdownAustralia
| | | | - Robert Smith
- School of Health and Related ResearchUniversity of SheffieldSheffieldUK
| | - Jennifer Boyd
- School of Health and Related ResearchUniversity of SheffieldSheffieldUK
- MRC/CSO Social and Public Health Sciences UnitUniversity of GlasgowGlasgowUK
| | | | | | | | | | - Amanda Karapici
- NIHR SPHRLondon School of Hygiene and Tropical MedicineLondonUK
| | - Franco Sassi
- Centre for Health Economics & Policy InnovationImperial College Business SchoolLondonUK
| | - Peter Scarborough
- Nuffield Department of Population HealthUniversity of OxfordOxfordshireOxfordUK
| | - Uwe Siebert
- Department of Public Health, Health Services Research and Health Technology AssessmentUMIT TIROL ‐ University for Health Sciences and TechnologyHall in TirolTyrolAustria
- Division of Health Technology Assessment and BioinformaticsONCOTYROL ‐ Center for Personalized Cancer MedicineInnsbruckAustria
- Center for Health Decision ScienceDepartments of Epidemiology and Health Policy & ManagementHarvard T.H. Chan School of Public HealthMassachusettsBostonUSA
- Program on Cardiovascular Research, Institute for Technology Assessment and Department of RadiologyMassachusetts General HospitalHarvard Medical SchoolMassachusettsBostonUSA
| | - Eric Silverman
- MRC/CSO Social and Public Health Sciences UnitUniversity of GlasgowGlasgowUK
| | - Luke Vale
- Health Economics GroupPopulation Health Sciences InstituteNewcastle UniversityNewcastleUK
| | - Cathal Walsh
- Health Research Institute and MACSIUniversity of LimerickLimerickIreland
| | - Alan Brennan
- School of Health and Related ResearchUniversity of SheffieldSheffieldUK
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Clark M, Springmann M, Rayner M, Scarborough P, Hill J, Tilman D, Macdiarmid JI, Fanzo J, Bandy L, Harrington RA. Reply to Muzzioli et al.: Communicating nutrition and environmental information to food system stakeholders. Proc Natl Acad Sci U S A 2023; 120:e2302165120. [PMID: 37068226 PMCID: PMC10151584 DOI: 10.1073/pnas.2302165120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2023] Open
Affiliation(s)
- Michael Clark
- Nuffield Department of Population Health, University of Oxford, Oxford OX3 7LF, UK
- Oxford Martin School, University of Oxford, Oxford OX1 3BD, UK
- Department of Zoology, Interdisciplinary Centre of Conservation Science, University of Oxford, Oxford OX1 3SZ, UK
- Smith School of Enterprise and Environment, University of Oxford, Oxford OX1 3QY, UK
| | - Marco Springmann
- Nuffield Department of Population Health, University of Oxford, Oxford OX3 7LF, UK
- Oxford Martin School, University of Oxford, Oxford OX1 3BD, UK
| | - Mike Rayner
- Nuffield Department of Population Health, University of Oxford, Oxford OX3 7LF, UK
| | - Peter Scarborough
- Nuffield Department of Population Health, University of Oxford, Oxford OX3 7LF, UK
- National Institutes for Health and Care Research (NIHR) Biomedical Research Centre at Oxford, University of Oxford, Oxford OX3 7LF, UK
- Nuffield Department of Primary Care, University of Oxford, Oxford OX2 6GG, UK
| | - Jason Hill
- Department of Bioproducts and Bioengineering, University of Minnesota, St Paul, MN 55108
| | - David Tilman
- Department of Ecology, Evolution, and Behavior, University of Minnesota, St Paul, MN 55108
- Bren School of Environmental Science & Management, University of California, Santa Barbara, CA 93117
| | | | - Jessica Fanzo
- Nitze School of Advanced International Studies, Johns Hopkins University, Washington, D.C. 20036
- Global Food Ethics and Policy Program, Johns Hopkins University, Baltimore, MD 21205
| | - Lauren Bandy
- Nuffield Department of Population Health, University of Oxford, Oxford OX3 7LF, UK
- Nuffield Department of Primary Care, University of Oxford, Oxford OX2 6GG, UK
| | - Richard A Harrington
- Nuffield Department of Population Health, University of Oxford, Oxford OX3 7LF, UK
- National Institutes for Health and Care Research (NIHR) Biomedical Research Centre at Oxford, University of Oxford, Oxford OX3 7LF, UK
- Nuffield Department of Primary Care, University of Oxford, Oxford OX2 6GG, UK
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Hartmann-Boyce J, Theodoulou A, Oke JL, Butler AR, Bastounis A, Dunnigan A, Byadya R, Cobiac LJ, Scarborough P, Hobbs FR, Sniehotta FF, Jebb SA, Aveyard P. Long-Term Effect of Weight Regain Following Behavioral Weight Management Programs on Cardiometabolic Disease Incidence and Risk: Systematic Review and Meta-Analysis. Circ Cardiovasc Qual Outcomes 2023; 16:e009348. [PMID: 36974678 PMCID: PMC10106109 DOI: 10.1161/circoutcomes.122.009348] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 01/13/2023] [Indexed: 03/29/2023]
Abstract
BACKGROUND Behavioral weight management programs (BWMPs) enhance weight loss in the short term, but longer term cardiometabolic effects are uncertain as weight is commonly regained. We assessed the impact of weight regain after BWMPs on cardiovascular risk factors, diabetes, and cardiovascular disease. METHODS Trial registries, 11 databases, and forward-citation searching (latest search, December 19) were used to identify articles published in English, from any geographical region. Randomized trials of BWMPs in adults with overweight/obesity reporting cardiometabolic outcomes at ≥12 months at and after program end were included. Differences between more intensive interventions and comparator groups were synthesized using mixed-effects, meta-regression, and time-to-event models to assess the impact of weight regain on cardiovascular disease incidence and risk. RESULTS One hundred twenty-four trials reporting on ≥1 cardiometabolic outcomes with a median follow-up of 28 (range, 11-360) months after program end were included. Median baseline participant body mass index was 33 kg/m2; median age was 51 years. Eight and 15 study arms (7889 and 4202 participants, respectively) examined the incidence of cardiovascular disease and type 2 diabetes, respectively, with imprecise evidence of a lower incidence for at least 5 years. Weight regain in BWMPs relative to comparators reduced these differences. One and 5 years after program end, total cholesterol/HDL (high-density lipoprotein) ratio was 1.5 points lower at both times (82 studies; 19 003 participants), systolic blood pressure was 1.5 mm mercury and 0.4 mm lower (84 studies; 30 836 participants), and HbA1c (%) 0.38 lower at both times (94 studies; 28 083 participants). Of the included studies, 22% were judged at high risk of bias; removing these did not meaningfully change results. CONCLUSIONS Despite weight regain, BWMPs reduce cardiometabolic risk factors with effects lasting at least 5 years after program end and dwindling with weight regain. Evidence that they reduce the incidence of cardiovascular disease or diabetes is less certain. Few studies followed participants for ≥5 years. REGISTRATION URL: https://www.crd.york.ac.uk/PROSPERO/; Unique identifier: CRD42018105744.
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Affiliation(s)
- Jamie Hartmann-Boyce
- Nuffield Department of Primary Care Health Sciences (J.H.-B., A.T., A.R.B., A.B., R.B., F.D.R.H., S.A.J., P.A.), University of Oxford, United Kingdom
| | - Annika Theodoulou
- Nuffield Department of Primary Care Health Sciences (J.H.-B., A.T., A.R.B., A.B., R.B., F.D.R.H., S.A.J., P.A.), University of Oxford, United Kingdom
| | - Jason L. Oke
- NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, United Kingdom (J.L.O.)
| | - Ailsa R. Butler
- Nuffield Department of Primary Care Health Sciences (J.H.-B., A.T., A.R.B., A.B., R.B., F.D.R.H., S.A.J., P.A.), University of Oxford, United Kingdom
| | - Anastasios Bastounis
- Nuffield Department of Primary Care Health Sciences (J.H.-B., A.T., A.R.B., A.B., R.B., F.D.R.H., S.A.J., P.A.), University of Oxford, United Kingdom
- Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, United Kingdom (A.B.)
| | - Anna Dunnigan
- Oxford University Hospitals NHS Foundation Trust, United Kingdom (A.D.)
- Royal Free London NHS Foundation Trust, United Kingdom (A.D.)
| | - Rimu Byadya
- Nuffield Department of Primary Care Health Sciences (J.H.-B., A.T., A.R.B., A.B., R.B., F.D.R.H., S.A.J., P.A.), University of Oxford, United Kingdom
- United Nations World Food Programme, Cox’s Bazar, Bangladesh, India (R.B.)
| | - Linda J. Cobiac
- Nuffield Department of Population Health, Centre on Population Approaches for Non-Communicable Disease Prevention (L.J.C.), University of Oxford, United Kingdom
| | - Peter Scarborough
- Nuffield Department of Population Health, Oxford Biomedical Research Centre (P.S.), University of Oxford, United Kingdom
| | - F.D. Richard Hobbs
- Nuffield Department of Primary Care Health Sciences (J.H.-B., A.T., A.R.B., A.B., R.B., F.D.R.H., S.A.J., P.A.), University of Oxford, United Kingdom
| | - Falko F. Sniehotta
- Faculty of Medical Sciences, Population Health Sciences Institute, Newcastle University, United Kingdom (F.F.S.)
| | - Susan A. Jebb
- Nuffield Department of Primary Care Health Sciences (J.H.-B., A.T., A.R.B., A.B., R.B., F.D.R.H., S.A.J., P.A.), University of Oxford, United Kingdom
| | - Paul Aveyard
- Nuffield Department of Primary Care Health Sciences (J.H.-B., A.T., A.R.B., A.B., R.B., F.D.R.H., S.A.J., P.A.), University of Oxford, United Kingdom
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Hartmann-Boyce J, Cobiac LJ, Theodoulou A, Oke JL, Butler AR, Scarborough P, Bastounis A, Dunnigan A, Byadya R, Hobbs FDR, Sniehotta FF, Amies-Cull B, Aveyard P, Jebb SA. Weight regain after behavioural weight management programmes and its impact on quality of life and cost effectiveness: Evidence synthesis and health economic analyses. Diabetes Obes Metab 2023; 25:526-535. [PMID: 36239137 PMCID: PMC10092406 DOI: 10.1111/dom.14895] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 09/26/2022] [Accepted: 10/09/2022] [Indexed: 02/02/2023]
Abstract
AIMS We used data from a recent systematic review to investigate weight regain after behavioural weight management programmes (BWMPs, sometimes referred to as lifestyle modification programmes) and its impact on quality-of-life and cost-effectiveness. MATERIALS AND METHODS Trial registries, databases and forward-citation searching (latest search December 2019) were used to identify randomized trials of BWMPs in adults with overweight/obesity reporting outcomes at ≥12 months, and after programme end. Two independent reviewers screened records. One reviewer extracted data and a second checked them. The differences between intervention and control groups were synthesized using mixed-effect, meta-regression and time-to-event models. We examined associations between weight difference and difference in quality-of-life. Cost-effectiveness was estimated from a health sector perspective. RESULTS In total, 155 trials (n > 150 000) contributed to analyses. The longest follow-up was 23 years post-programme. At programme end, intervention groups achieved -2.8 kg (95%CI -3.2 to -2.4) greater weight loss than controls. Weight regain after programme end was 0.12-0.32 kg/year greater in intervention relative to control groups, with a between-group difference evident for at least 5 years. Quality-of-life increased in intervention groups relative to control at programme end and thereafter returned to control as the difference in weight between groups diminished. BWMPs with this initial weight loss and subsequent regain would be cost-effective if delivered for under £560 (£8.80-£3900) per person. CONCLUSIONS Modest rates of weight regain, with persistent benefits for several years, should encourage health care practitioners and policymakers to offer obesity treatments that cost less than our suggested thresholds as a cost-effective intervention to improve long-term weight management. REGISTRATION The review is registered on PROSPERO, CRD42018105744.
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Affiliation(s)
- Jamie Hartmann-Boyce
- Radcliffe Primary Care Building, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Linda J Cobiac
- School of Medicine and Dentistry, Griffith University, Brisbane, Queensland, Australia
| | - Annika Theodoulou
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Jason L Oke
- NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Ailsa R Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Peter Scarborough
- NIHR Oxford Biomedical Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Anastasios Bastounis
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Nottingham, UK
| | - Anna Dunnigan
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Royal Free London NHS Foundation Trust, London, UK
| | - Rimu Byadya
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- United Nations World Food Programme, Cox's Bazar, Bangladesh
| | - F D Richard Hobbs
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Falko F Sniehotta
- Faculty of Medical Sciences, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Ben Amies-Cull
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Paul Aveyard
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Susan A Jebb
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Emmert-Fees KMF, Felea A, Kypridemos C, Scarborough P, Laxy M. Impact of Sugar-Sweetened Beverage Taxation Scenarios in Germany: A Comparative Modelling Study. Eur J Public Health 2022. [DOI: 10.1093/eurpub/ckac129.340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Objectives
Taxing sugar-sweetened beverages (SSBs) is recommended to reduce the burden of obesity, cardiovascular disease (CVD) and type 2 diabetes (T2DM). The objective of this study was to quantify the potential long-term health and economic impact of different SSBs taxation scenarios in Germany using simulation models with different granularity.
Methods
We used a multi-state life table Markov cohort (MSLT) and a microsimulation (IMPACT) model to simulate the impact of different SSB taxation assumptions and scenarios on CVD and T2DM in the German population aged 20 years and older over 20 years. Data sources included official population counts, anthropometric and dietary intake data from national surveys and published meta-analyses. Change in beverage consumption by sex and age under different taxation scenarios was estimated using de-novo national price elasticities and changes in body weight were based on an energy equilibrium model. We projected incremental disability-adjusted life years (DALYs) and healthcare costs, comparing results between both models.
Results
Preliminary results from the MSLT model show that a 20% SSB excise tax in Germany could lead to moderate body weight reductions across all age-sex groups. Over 20 years, the tax would reduce healthcare costs by €753 million [95% CI: 527; 1,021] and save 24,380 DALYs [18,460; 33,900] from T2DM alone. Health and economic gains largely depend on the relevance of substitution effects, tax amount and taxed beverage categories. Results including CVD and comparisons with the IMPACT model are work-in-progress.
Conclusions
We show that SSBs taxation in Germany has the potential to reduce healthcare costs and improve population health. The impact of any SSB tax depends on its implementation scenario, which behavioural assumptions hold, and the obesity-related disease outcomes considered for its evaluation. Further research should compare various obesity prevention approaches to support health policy priority setting.
Key messages
• Taxation of sugar-sweetened beverages can reduce healthcare costs and improve population health in Germany.
• The estimated health and economic impact of sugar-sweetened beverage taxation critically depends on tax design and behavioural modelling assumptions.
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Affiliation(s)
- KMF Emmert-Fees
- Institute of Health Economics and Health Care, Helmholtz Zentrum München , Neuherberg, Germany
- Department of Sport and Health Sciences, Technical University of Munich , Munich, Germany
| | - A Felea
- Institute of Health Economics and Health Care, Helmholtz Zentrum München , Neuherberg, Germany
| | - C Kypridemos
- Department of Public Health, Policy and Systems, University of Liverpool , Liverpool, UK
| | - P Scarborough
- Nuffield Department of Population Health, University of Oxford , Oxford, UK
| | - M Laxy
- Institute of Health Economics and Health Care, Helmholtz Zentrum München , Neuherberg, Germany
- Department of Sport and Health Sciences, Technical University of Munich , Munich, Germany
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11
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Scarborough P, Benchea M, Bell K, Bennardo M. 278 Piloting and evaluating the impact of specialist, online exercise programs on self-reported measures of health and exercise perceptions in adults with cystic fibrosis. J Cyst Fibros 2022. [DOI: 10.1016/s1569-1993(22)00968-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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12
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Sims J, Milton K, Foster C, Scarborough P. A profile of children's physical activity data from the 2012 and 2015 health survey for England. BMC Public Health 2022; 22:1785. [PMID: 36127714 PMCID: PMC9490976 DOI: 10.1186/s12889-022-14150-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 05/30/2022] [Indexed: 11/22/2022] Open
Abstract
Background Low childhood physical activity levels constitute an important modifiable risk for adult non-communicable disease incidence and subsequent socio-economic burden, but few publications have explored age and sex related patterns within the UK population. The aims were to profile child physical activity data from the Health Survey for England from 2012 (1,732 respondents) and 2015 (5,346 respondents). Methods Reported physical activity episodes were converted to metabolic equivalents with reference to child-specific compendiums. Physical activity levels were aggregated for each domain, and again to produce total physical activity estimates. Contributions from each domain to total physical activity were explored, stratifying for age, sex, socio-economic deprivation, ethnicity, and weight status. Further analyses were run stratifying for physical activity levels. Few differences were detected between the survey iterations. Results Boys reported higher absolute levels of physical activity at all ages and across all domains. For boys and girls, informal activity reduces with age. For boys this reduction is largely mitigated by increased formal sport, but this is not the case for girls. Absolute levels of school activity and active travel remained consistent regardless of total physical activity, thereby comprising an increasingly important proportion of total physical activity for less active children. Conclusions We recommend a specific focus on establishing and maintaining girl’s participation in formal sport thorough their teenage years, and a recognition and consolidation of the important role played by active travel and school-based physical activity for the least active children.
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Affiliation(s)
- Jamie Sims
- Department of Population Health, University of Oxford, Nuffield, Old Road Campus, OX3 7LF, Oxford, UK. .,Department of Sport, Health Sciences and Social Work, Oxford Brooks University, Headington Campus, OX3 0BP, Oxford, UK.
| | - Karen Milton
- Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich, NR4 7TJ, UK
| | - Charlie Foster
- School for Policy Studies, Social Science Complex, 8 Priory Road, Bristol, BS8 1TZ, UK
| | - Peter Scarborough
- Department of Population Health, University of Oxford, Nuffield, Old Road Campus, OX3 7LF, Oxford, UK
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13
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Scarborough P, Kaur A, Cobiac LJ. Forecast of myocardial infarction incidence, events and prevalence in England to 2035 using a microsimulation model with endogenous disease outcomes. PLoS One 2022; 17:e0270189. [PMID: 35771859 PMCID: PMC9246106 DOI: 10.1371/journal.pone.0270189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 06/07/2022] [Indexed: 11/18/2022] Open
Abstract
Background Models that forecast non-communicable disease rates are poorly designed to predict future changes in trend because they are based on exogenous measures of disease rates. We introduce microPRIME, which forecasts myocardial infarction (MI) incidence, events and prevalence in England to 2035. microPRIME can forecast changes in trend as all MI rates emerge from competing trends in risk factors and treatment. Materials and methods microPRIME is a microsimulation of MI events within a sample of 114,000 agents representative of England. We simulate 37 annual time points from 1998 to 2035, where agents can have an MI event, die from an MI, or die from an unrelated cause. The probability of each event is a function of age, sex, BMI, blood pressure, cholesterol, smoking, diabetes and previous MI. This function does not change over time. Instead population-level changes in MI rates are due to competing trends in risk factors and treatment. Uncertainty estimates are based on 450 model runs that use parameters calibrated against external measures of MI rates between 1999 and 2011. Findings Forecasted MI incidence rates fall for men and women of different age groups before plateauing in the mid 2020s. Age-standardised event rates show a similar pattern, with a non-significant upturn by 2035, larger for men than women. Prevalence in men decreases for the oldest age groups, with peaks of prevalence rates in 2019 for 85 and older at 25.8% (23.3–28.3). For women, prevalence rates are more stable. Prevalence in over 85s is estimated as 14.5% (12.6–16.5) in 2019, and then plateaus thereafter. Conclusion We may see an increase in event rates from MI in England for men before 2035 but increases for women are unlikely. Prevalence rates may fall in older men, and are likely to remain stable in women over the next decade and a half.
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Affiliation(s)
- Peter Scarborough
- Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
- National Institute of Health and Care Research Biomedical Research Centre at Oxford, Oxford, United Kingdom
- * E-mail:
| | - Asha Kaur
- Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Linda J. Cobiac
- Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
- Griffith University, Queensland, Australia
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14
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Amies-Cull B, Wolstenholme J, Cobiac L, Scarborough P. Estimating BMI distributions by age and sex for local authorities in England: a small area estimation study. BMJ Open 2022; 12:e060892. [PMID: 35732379 PMCID: PMC9226908 DOI: 10.1136/bmjopen-2022-060892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES Rates of overweight and obesity vary across England, but local rates have not been estimated for over 10 years. We aimed to produce new small area estimates of body mass index (BMI) by age and sex for each lower tier and unitary local authority in England, to provide up-to-date and more detailed estimates for the use of policy-makers and academics working in non-communicable disease risk and health inequalities. DESIGN We used generalised linear modelling to estimate the relationship between BMI with social/demographic markers in a cross-sectional survey, then used this model to impute a BMI for each adult in locally-representative populations. These groups were then disaggregated by 5-year age group, sex and local authority group. SETTING The Health Survey for England 2018 (cross-sectional BMI data for England) and Census microdata 2011 (locally representative). PARTICIPANTS A total of 6174 complete cases aged 16 and over were included. OUTCOME MEASURES Modelled group-level BMI as mean and SD of log-BMI. Extensive internal validation was performed, against the original data and external validation against the National Diet and Nutrition Survey and Active Lives Survey and previous small area estimates. RESULTS In 94% of age-sex are groups, mean BMI was in the overweight or obese ranges. Older and more deprived areas had the highest overweight and obesity rates, which were particularly in coastal areas, the West Midlands, Yorkshire and the Humber. Validation showed close concordance with previous estimates by local area and demographic groups. CONCLUSION This work updated previous estimates of the distribution of BMI in England and contributes considerable additional detail to our understanding of the local epidemiology of overweight and obesity. Raised BMI now affects the vast majority of demographic groups by age, sex and area in England, regardless of geography or deprivation.
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Affiliation(s)
- Ben Amies-Cull
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Jane Wolstenholme
- HERC, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Linda Cobiac
- School of Medicine, Griffith University, Nathan, Queensland, Australia
| | - Peter Scarborough
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
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15
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Forde H, Boyland EJ, Scarborough P, Smith R, White M, Adams J. Exploring the potential impact of the proposed UK TV and online food advertising regulations: a concept mapping study. BMJ Open 2022; 12:e060302. [PMID: 35715182 PMCID: PMC9207937 DOI: 10.1136/bmjopen-2021-060302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
OBJECTIVES In July 2020 the UK Government announced an intention to restrict advertisements for products high in fat, salt or sugar on live broadcast, catch-up and on-demand television before 21:00 hours; and paid for online advertising. As no other jurisdiction has implemented similar regulations, there is no empirical evidence about how they might perturb the food system. To guide the regulations' implementation and evaluation, we aimed to develop a concept map to hypothesise their potential consequences for the commercial food system, health and society. METHODS We used adapted group concept mapping in four virtual workshops with food marketing and regulation experts across academia, civil society, government organisations, and industry (n=14), supported by Miro software. We merged concepts derived from the four workshops to develop a master map and then invited feedback from participants via email to generate a final concept map. RESULTS The concept map shows how the reactions of stakeholders to the regulations may reinforce or undermine the impact on the commercial food system, health and society. The map shows adaptations made by stakeholders that could reinforce, or undermine, positive impacts on public health. It also illustrates potential weaknesses in the design and implementation of the regulations that could result in little substantial difference to public health. CONCLUSIONS Prior to the regulations' initial implementation or subsequent iterations, they could be altered to maximise the potential for reinforcing adaptations, minimise the potential for undermining adaptations and ensure they cover a wide range of advertising opportunities and foods. The concept map will also inform the design of an evaluation of the regulations and could be used to inform the design and evaluation of similar regulations elsewhere.
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Affiliation(s)
| | - Emma J Boyland
- Department of Psychology, Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Peter Scarborough
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
- NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Richard Smith
- Institute of Health Research, University of Exeter Medical School, Exeter, UK
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Stanford G, Scarborough P, von Berg K, Ward N, Hauser J. ePS2.06 “It’s good to talk” – development of a virtual international physiotherapy discussion forum. J Cyst Fibros 2022. [DOI: 10.1016/s1569-1993(22)00294-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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17
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Renzella J, Fernando S, Kalupahana B, Rayner M, Scarborough P, Townsend N. Assessing the social validity of a brief dietary survey for Sri Lankan adults with a focus on gender: a qualitative study. BMC Nutr 2021; 7:79. [PMID: 34802458 PMCID: PMC8607623 DOI: 10.1186/s40795-021-00481-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 10/26/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND As the World Health Organization urges countries to strengthen their noncommunicable disease monitoring and surveillance activities, setting-specific innovations are emerging. Diet - a key, modifiable risk factor for chronic diseases - is particularly challenging to capture reliably. By socially validating self-report dietary survey tools, we may be able to increase the accuracy and representativeness of data for improved population health outcomes. The purpose of this study was to explore the factors that impact Sri Lankan Brief Dietary Survey (a newly developed tool) and 24-h Dietary Recall participation, engagement, and social validity among Sri Lankan adults. METHODS We conducted semi-structured interviews with 93 participants (61 women and 32 men) in three Sri Lankan districts (Colombo, Kalutara, and Trincomalee). Interview data were analysed thematically and are presented as non-hierarchical thematic networks. RESULTS Participants identified a number of factors that influenced their survey participation and engagement. These included the time of day interviews occur, recall ease, level of commitment required, perceived survey value, emotional response to surveys, and interviewer positionality. Many of these factors were gendered, however, both female and male participants expressed a preference for engaging with socially valid research that they felt justified their personal investment in data collection. When explicitly asked to share ideas about how to improve the surveys, many participants opted not to provide suggestions as they felt they lacked the appropriate expertise. CONCLUSIONS Our findings have implications for the accuracy and equity of dietary surveillance activities, and ultimately the appropriateness and effectiveness of programmes and policies informed by these data. Only through understanding how and why the target population engages with dietary research can we develop socially valid methods that assess and address the dietary risks of individuals and groups that are underrepresented by current conventions.
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Affiliation(s)
- Jessica Renzella
- Nuffield Department of Population Health, University of Oxford, BDI Building, Old Road Campus, Oxford, OX3 7FZ, UK.
| | - Santhushya Fernando
- Sri Jayewardenepura General Hospital and Post Graduate Training Centre, Colombo, Sri Lanka
| | | | - Mike Rayner
- Nuffield Department of Population Health, University of Oxford, BDI Building, Old Road Campus, Oxford, OX3 7FZ, UK
| | - Peter Scarborough
- NIHR Biomedical Research Centre at Oxford and Nuffield Department of Population Health, University of Oxford, Oxford, UK
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Springmann M, Clark MA, Rayner M, Scarborough P, Webb P. The global and regional costs of healthy and sustainable dietary patterns: a modelling study. Lancet Planet Health 2021; 5:e797-e807. [PMID: 34715058 PMCID: PMC8581186 DOI: 10.1016/s2542-5196(21)00251-5] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 08/18/2021] [Accepted: 08/20/2021] [Indexed: 05/12/2023]
Abstract
BACKGROUND Adoption of healthy and sustainable diets could be essential for safe-guarding the Earth's natural resources and reducing diet-related mortality, but their adoption could be hampered if such diets proved to be more expensive and unaffordable for some populations. Therefore, we aimed to estimate the costs of healthy and sustainable diets around the world. METHODS In this modelling study, we used regionally comparable food prices from the International Comparison Program for 150 countries. We paired those prices with estimates of food demand for different dietary patterns that, in modelling studies, have been associated with reductions in premature mortality and environmental resource demand, including nutritionally balanced flexitarian, pescatarian, vegetarian, and vegan diets. We used estimates of food waste and projections of food demand and prices to specify food system and socioeconomic change scenarios up to 2050. In the full cost accounting, we estimated diet-related health-care costs by pairing a comparative risk assessment of dietary risks with cost-of-illness estimates, and we estimated climate change costs by pairing the diet scenarios with greenhouse gas emission footprints and estimates of the social cost of carbon. FINDINGS Compared with the cost of current diets, the healthy and sustainable dietary patterns were, depending on the pattern, up to 22-34% lower in cost in upper-middle-income to high-income countries on average (when considering statistical means), but at least 18-29% more expensive in lower-middle-income to low-income countries. Reductions in food waste, a favourable socioeconomic development scenario, and a fuller cost accounting that included the diet-related costs of climate change and health care in the cost of diets increased the affordability of the dietary patterns in our future projections. When these measures were combined, the healthy and sustainable dietary patterns were up to 25-29% lower in cost in low-income to lower-middle-income countries, and up to 37% lower in cost on average, for the year 2050. Variants of vegetarian and vegan dietary patterns were generally most affordable, and pescatarian diets were least affordable. INTERPRETATION In high-income and upper-middle-income countries, dietary change interventions that incentivise adoption of healthy and sustainable diets can help consumers in those countries reduce costs while, at the same time, contribute to fulfilling national climate change commitments and reduce public health spending. In low-income and lower-middle-income countries, healthy and sustainable diets are substantially less costly than western diets and can also be cost-competitive in the medium-to-long term, subject to beneficial socioeconomic development and reductions in food waste. A fuller accounting of the costs of diets would make healthy and sustainable diets the least costly option in most countries in the future. FUNDING Global Panel on Agriculture and Food Systems for Nutrition and Wellcome Trust.
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Affiliation(s)
- Marco Springmann
- Oxford Martin Programme on the Future of Food and WHO Collaborating Centre on Population Approaches for Non-Communicable Disease Prevention, Nuffield Department of Population Health, University of Oxford, Oxford, UK.
| | - Michael A Clark
- Oxford Martin Programme on the Future of Food and WHO Collaborating Centre on Population Approaches for Non-Communicable Disease Prevention, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Mike Rayner
- Oxford Martin Programme on the Future of Food and WHO Collaborating Centre on Population Approaches for Non-Communicable Disease Prevention, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Peter Scarborough
- Oxford Martin Programme on the Future of Food and WHO Collaborating Centre on Population Approaches for Non-Communicable Disease Prevention, Nuffield Department of Population Health, University of Oxford, Oxford, UK; NIHR Biomedical Research Centre, John Radcliffe Hospital, Oxford, UK
| | - Patrick Webb
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA, USA
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Saha S, Nordström J, Scarborough P, Thunström L, Gerdtham UG. In search of an appropriate mix of taxes and subsidies on nutrients and food: A modelling study of the effectiveness on health-related consumption and mortality. Soc Sci Med 2021; 287:114388. [PMID: 34520938 DOI: 10.1016/j.socscimed.2021.114388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 07/21/2021] [Accepted: 09/07/2021] [Indexed: 10/20/2022]
Abstract
Taxes and subsidies on foods and nutrients have the potential to promote healthier diets and thereby reduce mortality. In this study, we examine the effects of such policy instruments on Swedish public health. Specifically, we estimate the effects of food and nutrient taxes and subsidies on mortality averted and postponed in Sweden, using both demand system estimations and simulation models. We evaluate different Value Added Tax (VAT) reforms. The VAT is raised on food products that are particularly rich in saturated fat or salt and lowered on fruit and vegetables. Our models predict that an increase in the current VAT of 12% on food, to 25% VAT on products rich in saturated fat plus a 0% VAT on fruits and vegetables would result in almost 1100 deaths (95% CI: -832; -1363) averted or postponed in a year in Sweden, while the combination of a 34.4% VAT on products rich in saturated fat and a -10.4% VAT (i.e. a subsidy) on fruits and vegetables would result in almost 2100 (95% CI: -1572; -2311) deaths averted or postponed corresponding to a 4.8% reduction in diet-related annual death. Most of the deaths averted or delayed from this reform would be deaths from coronary heart disease (-1,148, 95% CI: -728; -1586), followed by stroke -641 (95% CI: -408; -887) and diet-related cancer deaths (-288, 95% CI: -11; -435). We find that health-related food taxes and subsidies improve dietary habits as well as reduce the mortality of the Swedish population. However, the effect of these reforms on different socioeconomic classes and which reforms provide the best value for money, i.e., cost-effectiveness of these reforms needs to be established first before implementation.
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Affiliation(s)
- Sanjib Saha
- Health Economics Unit, Department of Clinical Science (Malmö), Lund University, Lund, Sweden.
| | - Jonas Nordström
- Lund University School of Economics and Management, Agrifood Economics Centre, Lund, Sweden; Department of Food and Resource Economics, University of Copenhagen, Copenhagen, Denmark; School of Technology and Business Studies, Dalarna University, Sweden.
| | - Peter Scarborough
- Nuffield Department of Population Health & NIHR Biomedical Research Centre at Oxford, University of Oxford, Oxford, United Kingdom.
| | - Linda Thunström
- Department of Economics, University of Wyoming, Laramie, WY, United States.
| | - Ulf-G Gerdtham
- Health Economics Unit, Department of Clinical Science (Malmö), Lund University, Lund, Sweden; Department of Economics, Lund University, Lund, Sweden.
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Komarek AM, Dunston S, Enahoro D, Godfray HCJ, Herrero M, Mason-D’Croz D, Rich KM, Scarborough P, Springmann M, Sulser TB, Wiebe K, Willenbockel D. Income, consumer preferences, and the future of livestock-derived food demand. Glob Environ Change 2021; 70:102343. [PMID: 34857999 PMCID: PMC7612057 DOI: 10.1016/j.gloenvcha.2021.102343] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
In recent decades there has been a sustained and substantial shift in human diets across the globe towards including more livestock-derived foods. Continuing debates scrutinize how these dietary shifts affect human health, the natural environment, and livelihoods. However, amidst these debates there remain unanswered questions about how demand for livestock-derived foods may evolve over the upcoming decades for a range of scenarios for key drivers of change including human population, income, and consumer preferences. Future trends in human population and income in our scenarios were sourced from three of the shared socioeconomic pathways. We used scenario-based modeling to show that average protein demand for red meat (beef, sheep, goats, and pork), poultry, dairy milk, and eggs across the globe would increase by 14% per person and 38% in total between the year 2020 and the year 2050 if trends in income and population continue along a mid-range trajectory. The fastest per person rates of increase were 49% in South Asia and 55% in sub-Saharan Africa. We show that per person demand for red meat in high-income countries would decline by 2.8% if income elasticities of demand (a partial proxy for consumer preferences, based on the responsiveness of demand to income changes) in high-income countries decline by 100% by 2050 under a mid-range trajectory for per person income growth, compared to their current trajectory. Prices are an important driver of demand, and our results demonstrate that the result of a decline in red meat demand in high-income countries is strongly related to rising red meat prices, as projected by our scenario-based modeling. If the decline in the income elasticity of demand occurred in all countries rather than only in high-income countries, then per person red meat demand in high-income countries would actually increase in 2050 by 8.9% because the income elasticity-driven decline in global demand reduces prices, and the effect of lower prices outweighs the effect of a decline in the income elasticity of demand. Our results demonstrate the importance of interactions between income, prices, and the income elasticity of demand in projecting future demand for livestock-derived foods. We complement the existing literature on food systems and global change by providing quantitative evidence about the possible space for the future demand of livestock-derived foods, which has important implications for human health and the natural environment.
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Affiliation(s)
- Adam M. Komarek
- International Food Policy Research Institute, Washington DC, USA
- The University of Queensland, School of Agriculture and Food Sciences, Gatton, Qld 4343 Australia
- Corresponding author at: The University of Queensland, School of Agriculture and Food Sciences, Gatton, Qld 4343 Australia. (A.M. Komarek)
| | - Shahnila Dunston
- International Food Policy Research Institute, Washington DC, USA
| | - Dolapo Enahoro
- Policies, Institutions and Livelihoods Program, International Livestock Research Institute (ILRI), P.O. Box 30709, Nairobi 00100, Kenya
| | - H. Charles J. Godfray
- Oxford Martin Programme on the Future of Food, Oxford Martin School, University of Oxford, 34 Broad Street, Oxford OX1 3BD, UK
- Department of Zoology, University of Oxford, South Parks Road, Oxford OX1 3PS, UK
| | - Mario Herrero
- Department of Zoology, University of Oxford, South Parks Road, Oxford OX1 3PS, UK
- Commonwealth Scientific and Industrial Research Organisation, Australia
| | - Daniel Mason-D’Croz
- Department of Zoology, University of Oxford, South Parks Road, Oxford OX1 3PS, UK
| | - Karl M. Rich
- Policies, Institutions and Livelihoods Program, International Livestock Research Institute (ILRI), P.O. Box 30709, Nairobi 00100, Kenya
- Oklahoma State University, Ferguson College of Agriculture, Department of Agricultural Economics, Stillwater, OK 74078, USA
| | - Peter Scarborough
- Oxford Martin Programme on the Future of Food, Oxford Martin School, University of Oxford, 34 Broad Street, Oxford OX1 3BD, UK
- Nuffield Department of Population Health, University of Oxford, Old Road Campus, Headington, Oxford OX3 7LF, UK
| | - Marco Springmann
- Oxford Martin Programme on the Future of Food, Oxford Martin School, University of Oxford, 34 Broad Street, Oxford OX1 3BD, UK
- Nuffield Department of Population Health, University of Oxford, Old Road Campus, Headington, Oxford OX3 7LF, UK
| | | | - Keith Wiebe
- International Food Policy Research Institute, Washington DC, USA
| | - Dirk Willenbockel
- Institute of Development Studies, University of Sussex, Brighton, UK
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21
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Hartmann-Boyce J, Theodoulou A, Oke JL, Butler AR, Scarborough P, Bastounis A, Dunnigan A, Byadya R, Hobbs FDR, Sniehotta FF, Jebb SA, Aveyard P. Association between characteristics of behavioural weight loss programmes and weight change after programme end: systematic review and meta-analysis. BMJ 2021; 374:n1840. [PMID: 34404631 PMCID: PMC8369384 DOI: 10.1136/bmj.n1840] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To determine if the characteristics of behavioural weight loss programmes influence the rate of change in weight after the end of the programme. DESIGN Systematic review and meta-analysis. DATA SOURCES Trial registries, 11 electronic databases, and forward citation searching (from database inception; latest search December 2019). Randomised trials of behavioural weight loss programmes in adults with overweight or obesity, reporting outcomes at ≥12 months, including at the end of the programme and after the end of the programme. REVIEW METHODS Studies were screened by two independent reviewers with discrepancies resolved by discussion. 5% of the studies identified in the searches met the inclusion criteria. One reviewer extracted the data and a second reviewer checked the data. Risk of bias was assessed with Cochrane's risk of bias tool (version 1). The rate of change in weight was calculated (kg/month; converted to kg/year for interpretability) after the end of the programme in the intervention versus control groups by a mixed model with a random intercept. Associations between the rate of change in weight and prespecified variables were tested. RESULTS Data were analysed from 249 trials (n=59 081) with a mean length of follow-up of two years (longest 30 years). 56% of studies (n=140) had an unclear risk of bias, 21% (n=52) a low risk, and 23% (n=57) a high risk of bias. Regain in weight was faster in the intervention versus the no intervention control groups (0.12-0.32 kg/year) but the difference between groups was maintained for at least five years. Each kilogram of weight lost at the end of the programme was associated with faster regain in weight at a rate of 0.13-0.19 kg/year. Financial incentives for weight loss were associated with faster regain in weight at a rate of 1-1.5 kg/year. Compared with programmes with no meal replacements, interventions involving partial meal replacements were associated with faster regain in weight but not after adjustment for weight loss during the programme. Access to the programme outside of the study was associated with slower regain in weight. Programmes where the intensity of the interaction reduced gradually were also associated with slower regain in weight in the multivariable analysis, although the point estimate suggested that the association was small. Other characteristics did not explain the heterogeneity in regain in weight. CONCLUSION Faster regain in weight after weight loss was associated with greater initial weight loss, but greater initial weight loss was still associated with reduced weight for at least five years after the end of the programme, after which data were limited. Continued availability of the programme to participants outside of the study predicted a slower regain in weight, and provision of financial incentives predicted faster regain in weight; no other clear associations were found. STUDY REGISTRATION PROSPERO CRD42018105744.
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Affiliation(s)
- Jamie Hartmann-Boyce
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Annika Theodoulou
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Jason L Oke
- NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Ailsa R Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Peter Scarborough
- Oxford Biomedical Research Centre, Nuffield Department of Population Health, University of Oxford, Big Data Institute, Oxford, UK
| | - Anastasios Bastounis
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Nottingham, UK
| | - Anna Dunnigan
- Royal Free Hospital, Royal Free London NHS Foundation Trust, London, UK
| | - Rimu Byadya
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- United Nations World Food Programme, Cox's Bazar, Bangladesh
| | - F D Richard Hobbs
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Falko F Sniehotta
- Faculty of Medical Sciences, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
- Faculty of Behavioural, Management, and Social Sciences, University of Twente, Enschede, Netherlands
| | - Susan A Jebb
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Paul Aveyard
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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22
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Pinho-Gomes AC, Kaur A, Scarborough P, Rayner M. Are the Eatwell Guide and Nutrient Profiling Models Consistent in the UK? Nutrients 2021; 13:2732. [PMID: 34444892 PMCID: PMC8401171 DOI: 10.3390/nu13082732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 07/26/2021] [Accepted: 08/06/2021] [Indexed: 11/24/2022] Open
Abstract
A nutrient profiling model (NPM) was developed in 2005 in the UK to regulate the marketing of foods to children. It was revised in 2018, but the new version has not been finalised. The Eatwell Guide (EWG) is the UK's official food-based dietary guidelines. The aim of this study was to evaluate the agreement between the 2005 and 2018 versions of the NPM and the EWG. Using recent National Diet and Nutrition Surveys, we estimated the healthiness of individual diets based on an EWG dietary score and a NPM dietary index. We then compared the percentage of agreement and Cohen's kappa for each combination of the EWG score and NPM index across the range of observed values for the 2005 and 2018 versions. A total of 3028 individual diets were assessed. Individuals with a higher (i.e., healthier) EWG score consumed a diet with, on average, a lower (i.e., healthier) NPM index both for the 2005 and 2018 versions. Overall, there was good agreement between the EWG score and the NPM dietary index at assessing the healthiness of representative diets of the UK population, when a low cut-off for the NPM dietary index was used, irrespective of the version. This suggests that dietary advice to the public is broadly aligned with NPM-based food policies and vice-versa.
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Affiliation(s)
- Ana-Catarina Pinho-Gomes
- Faculty of Life Sciences & Medicine, School of Population Health & Environmental Sciences, King’s College London, London WC2R 2LS, UK;
- The George Institute for Global Health, London W12 0BZ, UK
- Nuffield Department of Population Health, University of Oxford, Oxford OX3 7LF, UK; (A.K.); (P.S.)
| | - Asha Kaur
- Nuffield Department of Population Health, University of Oxford, Oxford OX3 7LF, UK; (A.K.); (P.S.)
| | - Peter Scarborough
- Nuffield Department of Population Health, University of Oxford, Oxford OX3 7LF, UK; (A.K.); (P.S.)
| | - Mike Rayner
- Nuffield Department of Population Health, University of Oxford, Oxford OX3 7LF, UK; (A.K.); (P.S.)
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23
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Bandy LK, Hollowell S, Harrington R, Scarborough P, Jebb S, Rayner M. Assessing the healthiness of UK food companies' product portfolios using food sales and nutrient composition data. PLoS One 2021; 16:e0254833. [PMID: 34347807 PMCID: PMC8336824 DOI: 10.1371/journal.pone.0254833] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 07/04/2021] [Indexed: 12/04/2022] Open
Abstract
Background The provision and over-consumption of foods high in energy, saturated fat, free sugars or salt are important risk factors for poor diet and ill-health. In the UK, policies seek to drive improvement through voluntary reformulation of single nutrients in key food groups. There has been little consideration of the overall progress by individual companies. This study assesses recent changes in the nutrient profile of brands and products sold by the top 10 food and beverage companies in the UK. Methods The FSA/Ofcom nutrient profile model was applied to the nutrient composition data for all products manufactured by the top 10 food and beverage companies and weighted by volume sales. The mean nutrient profiling score, on a scale of 1–100 with thresholds for healthy products being 62 for foods and 68 for drinks, was used to rank companies and food categories between 2015 and 2018, and to calculate the proportion of individual products and sales that are considered by the UK Government to be healthy. Results Between 2015 and 2018 there was little change in the sales-weighted nutrient profiling score of the top 10 companies (49 to 51; p = 0.28) or the proportion of products classified as healthy (46% to 48%; p = 0.23). Of the top five brands sold by each of the ten companies, only six brands among ten companies improved their nutrient profiling score by 20% or more. The proportion of total volume sales classified as healthy increased from 44% to 51% (p = 0.07) driven by an increase in the volume sales of bottled water, low/no calorie carbonates and juices, but after removing soft drinks, the proportion of foods classified as healthy decreased from 7% to 6% (p = 33). Conclusions The UK voluntary reformulation policies, setting targets for reductions in calories, sugar and salt, do not appear to have led to significant changes in the nutritional quality of foods, though there has been progress in soft drinks where the soft drink industry levy also applies. Further policy action is needed to incentivise companies to make more substantive changes in product composition to support consumers to achieve a healthier diet.
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Affiliation(s)
- Lauren Kate Bandy
- Nuffield Department of Population Health, University of Oxford, Oxford, England
- * E-mail:
| | - Sven Hollowell
- Nuffield Department of Population Health, University of Oxford, Oxford, England
| | - Richard Harrington
- Nuffield Department of Population Health, Centre on Population Approaches for NCD Prevention, University of Oxford, Oxford, England
| | - Peter Scarborough
- Nuffield Department of Population Health, University of Oxford, Oxford, England
| | - Susan Jebb
- Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, University of Oxford, Oxford, England
| | - Mike Rayner
- Nuffield Department of Population Health, University of Oxford, Oxford, England
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Piernas C, Cook B, Stevens R, Stewart C, Hollowell J, Scarborough P, Jebb SA. Estimating the effect of moving meat-free products to the meat aisle on sales of meat and meat-free products: A non-randomised controlled intervention study in a large UK supermarket chain. PLoS Med 2021; 18:e1003715. [PMID: 34264943 PMCID: PMC8321099 DOI: 10.1371/journal.pmed.1003715] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 07/29/2021] [Accepted: 06/29/2021] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Reducing meat consumption could bring health and environmental benefits, but there is little research to date on effective interventions to achieve this. A non-randomised controlled intervention study was used to evaluate whether prominent positioning of meat-free products in the meat aisle was associated with a change in weekly mean sales of meat and meat-free products. METHODS AND FINDINGS Weekly sales data were obtained from 108 stores: 20 intervention stores that moved a selection of 26 meat-free products into a newly created meat-free bay within the meat aisle and 88 matched control stores. The primary outcome analysis used a hierarchical negative binomial model to compare changes in weekly sales (units) of meat products sold in intervention versus control stores during the main intervention period (Phase I: February 2019 to April 2019). Interrupted time series analysis was also used to evaluate the effects of the Phase I intervention. Moreover, 8 of the 20 stores enhanced the intervention from August 2019 onwards (Phase II intervention) by adding a second bay of meat-free products into the meat aisle, which was evaluated following the same analytical methods. During the Phase I intervention, sales of meat products (units/store/week) decreased in intervention (approximately -6%) and control stores (-5%) without significant differences (incidence rate ratio [IRR] 1.01 [95% CI 0.95-1.07]. Sales of meat-free products increased significantly more in the intervention (+31%) compared to the control stores (+6%; IRR 1.43 [95% CI 1.30-1.57]), mostly due to increased sales of meat-free burgers, mince, and sausages. Consistent results were observed in interrupted time series analyses where the effect of the Phase II intervention was significant in intervention versus control stores. CONCLUSIONS Prominent positioning of meat-free products into the meat aisle in a supermarket was not effective in reducing sales of meat products, but successfully increased sales of meat-free alternatives in the longer term. A preregistered protocol (https://osf.io/qmz3a/) was completed and fully available before data analysis.
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Affiliation(s)
- Carmen Piernas
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Brian Cook
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Richard Stevens
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Cristina Stewart
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Jennifer Hollowell
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Peter Scarborough
- Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Susan A Jebb
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
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Abstract
BACKGROUND Obesity is a leading risk for poor health outcomes in England. We examined best- and worst-case scenarios for the future trajectory of the obesity epidemic. METHODS Taking the last 27 years of Health Survey for England data, we determined both position and shape of the adult body mass index (BMI) distribution and projected these parameters 20 years forward in time. For the best-case scenario, we fitted linear models, allowing for a quadratic relationship between the outcome variable and time, to reflect a potential reversal in upwards trends. For the worst-case scenario, we fitted non-linear models that applied an exponential function to reflect a potential flattening of trends over time. Best-fitting models were identified using Monte Carlo cross-validation on 1991-2014 data, and predictions of population prevalence across five BMI categories were then validated using 2015-17 data. RESULTS Both linear and non-linear models showed a close fit to observed data (mean absolute error <2%). In the best-case scenario, the proportion of the population at increased risk (BMI≥25kg/m2) is predicted to fall from 66% in 2017 to 53% (95% confidence interval: 41% to 64%) in 2035. In the worst-case scenario, this proportion is likely to remain relatively stable overall- 64% (37% to 90%) in 2035 -but with an increasing proportion of the population at highest risk (BMI≥35kg/m2). CONCLUSIONS While obesity prediction depends on chosen modelling methods, even under optimistic assumptions it is likely that the majority of the English population will still be at increased risk of disease due to their weight until at least 2035, without greater allocation of resources to effective interventions.
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Affiliation(s)
- Linda J. Cobiac
- Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
- * E-mail:
| | - Peter Scarborough
- Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
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26
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Bandy LK, Scarborough P, Harrington RA, Rayner M, Jebb SA. The sugar content of foods in the UK by category and company: A repeated cross-sectional study, 2015-2018. PLoS Med 2021; 18:e1003647. [PMID: 34003863 PMCID: PMC8171925 DOI: 10.1371/journal.pmed.1003647] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 06/02/2021] [Accepted: 05/07/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Consumption of free sugars in the UK greatly exceeds dietary recommendations. Public Health England (PHE) has set voluntary targets for industry to reduce the sales-weighted mean sugar content of key food categories contributing to sugar intake by 5% by 2018 and 20% by 2020. The aim of this study was to assess changes in the sales-weighted mean sugar content and total volume sales of sugar in selected food categories among UK companies between 2015 and 2018. METHODS AND FINDINGS We used sales data from Euromonitor, which estimates total annual retail sales of packaged foods, for 5 categories-biscuits and cereal bars, breakfast cereals, chocolate confectionery, sugar confectionery, and yoghurts-for 4 consecutive years (2015-2018). This analysis includes 353 brands (groups of products with the same name) sold by 99 different companies. These data were linked with nutrient composition data collected online from supermarket websites over 2015-2018 by Edge by Ascential. The main outcome measures were sales volume, sales-weighted mean sugar content, and total volume of sugar sold by category and company. Our results show that between 2015 and 2018 the sales-weighted mean sugar content of all included foods fell by 5.2% (95% CI -9.4%, -1.4%), from 28.7 g/100 g (95% CI 27.2, 30.4) to 27.2 g/100 g (95% CI 25.8, 28.4). The greatest change seen was in yoghurts (-17.0% [95% CI -26.8%, -7.1%]) and breakfast cereals (-13.3% [95% CI -19.2%, -7.4%]), with only small reductions in sugar confectionery (-2.4% [95% CI -4.2%, -0.6%]) and chocolate confectionery (-1.0% [95% CI -3.1, 1.2]). Our results show that total volume of sugars sold per capita fell from 21.4 g/d (95% CI 20.3, 22.7) to 19.7 g/d (95% CI 18.8, 20.7), a reduction of 7.5% (95% CI -13.1%, -2.8%). Of the 50 companies representing the top 10 companies in each category, 24 met the 5% reduction target set by PHE for 2018. The key limitations of this study are that it does not encompass the whole food market and is limited by its use of brand-level sales data, rather than individual product sales data. CONCLUSIONS Our findings show there has been a small reduction in total volume sales of sugar in the included categories, primarily due to reductions in the sugar content of yoghurts and breakfast cereals. Additional policy measures may be needed to accelerate progress in categories such as sugar confectionery and chocolate confectionery if the 2020 PHE voluntary sugar reduction targets are to be met.
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Affiliation(s)
- Lauren K. Bandy
- Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
- * E-mail:
| | - Peter Scarborough
- Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Richard A. Harrington
- Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Mike Rayner
- Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Susan A. Jebb
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
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Pell D, Mytton O, Penney TL, Briggs A, Cummins S, Penn-Jones C, Rayner M, Rutter H, Scarborough P, Sharp SJ, Smith RD, White M, Adams J. Changes in soft drinks purchased by British households associated with the UK soft drinks industry levy: controlled interrupted time series analysis. BMJ 2021; 372:n254. [PMID: 33692200 PMCID: PMC7944367 DOI: 10.1136/bmj.n254] [Citation(s) in RCA: 74] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/15/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To determine changes in household purchases of drinks and confectionery one year after implementation of the UK soft drinks industry levy (SDIL). DESIGN Controlled interrupted time series analysis. PARTICIPANTS Members of a panel of households reporting their purchasing on a weekly basis to a market research company (average weekly number of participants n=22 183), March 2014 to March 2019. INTERVENTION A two tiered tax levied on manufacturers of soft drinks, announced in March 2016 and implemented in April 2018. Drinks with ≥8 g sugar/100 mL (high tier) are taxed at £0.24/L and drinks with ≥5 to <8 g sugar/100 mL (low tier) are taxed at £0.18/L. Drinks with <5 g sugar/100 mL (no levy) are not taxed. MAIN OUTCOME MEASURES Absolute and relative differences in the volume of, and amount of sugar in, soft drinks categories, all soft drinks combined, alcohol, and confectionery purchased per household per week one year after implementation of the SDIL compared with trends before the announcement of the SDIL. RESULTS In March 2019, compared with the counterfactual estimated from pre-announcement trends, purchased volume of drinks in the high levy tier decreased by 155 mL (95% confidence interval 240.5 to 69.5 mL) per household per week, equivalent to 44.3% (95% confidence interval 59.9% to 28.7%), and sugar purchased in these drinks decreased by 18.0 g (95% confidence interval 32.3 to 3.6 g), or 45.9% (68.8% to 22.9%). Purchases of low tier drinks decreased by 177.3 mL (225.3 to 129.3 mL) per household per week, or 85.9% (95.1% to 76.7%), with a 12.5 g (15.4 to 9.5 g) reduction in sugar in these drinks, equivalent to 86.2% (94.2% to 78.1%). Despite no overall change in volume of no levy drinks purchased, there was an increase in sugar purchased of 15.3 g (12.6 to 17.9 g) per household per week, equivalent to 166.4% (94.2% to 238.5%). When all soft drinks were combined, the volume of drinks purchased did not change, but sugar decreased by 29.5 g (55.8 to 3.1 g), or 9.8% (17.9% to 1.8%). Purchases of confectionery and alcoholic drinks did not change. CONCLUSIONS Compared with trends before the SDIL was announced, one year after implementation, the volume of soft drinks purchased did not change. The amount of sugar in those drinks was 30 g, or 10%, lower per household per week-equivalent to one 250 mL serving of a low tier drink per person per week. The SDIL might benefit public health without harming industry. TRIAL REGISTRATION ISRCTN18042742.
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Affiliation(s)
- David Pell
- Centre for Diet and Activity Research, MRC Epidemiology Unit, University of Cambridge School of Clinical Medicine, Institute of Metabolic Science, Cambridge CB2 0QQ, UK
| | - Oliver Mytton
- Centre for Diet and Activity Research, MRC Epidemiology Unit, University of Cambridge School of Clinical Medicine, Institute of Metabolic Science, Cambridge CB2 0QQ, UK
| | - Tarra L Penney
- Centre for Diet and Activity Research, MRC Epidemiology Unit, University of Cambridge School of Clinical Medicine, Institute of Metabolic Science, Cambridge CB2 0QQ, UK
- Faculty of Health, School of Kinesiology and Health Science, Toronto, Canada
| | - Adam Briggs
- Centre on Population Approaches for Non-Communicable Disease Prevention, Nuffield Department of Population Health, University of Oxford, Oxford, UK
- Warwick Medical School, University of Warwick, Division of Health Sciences, Coventry, UK
| | - Steven Cummins
- Population Health Innovation Lab, Department of Public Health, Environment and Society, London School of Hygiene and Tropical Medicine, London, UK
| | - Catrin Penn-Jones
- Centre for Diet and Activity Research, MRC Epidemiology Unit, University of Cambridge School of Clinical Medicine, Institute of Metabolic Science, Cambridge CB2 0QQ, UK
| | - Mike Rayner
- Centre on Population Approaches for Non-Communicable Disease Prevention, Nuffield Department of Population Health, University of Oxford, Oxford, UK
- National Institute of Health Research Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Headington, Oxford, UK
| | - Harry Rutter
- Department of Social and Policy Sciences, University of Bath, Bath, UK
| | - Peter Scarborough
- Centre on Population Approaches for Non-Communicable Disease Prevention, Nuffield Department of Population Health, University of Oxford, Oxford, UK
- National Institute of Health Research Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Headington, Oxford, UK
| | - Stephen J Sharp
- Centre for Diet and Activity Research, MRC Epidemiology Unit, University of Cambridge School of Clinical Medicine, Institute of Metabolic Science, Cambridge CB2 0QQ, UK
| | - Richard D Smith
- College of Medicine and Health, University of Exeter, Exeter, UK
| | - Martin White
- Centre for Diet and Activity Research, MRC Epidemiology Unit, University of Cambridge School of Clinical Medicine, Institute of Metabolic Science, Cambridge CB2 0QQ, UK
| | - Jean Adams
- Centre for Diet and Activity Research, MRC Epidemiology Unit, University of Cambridge School of Clinical Medicine, Institute of Metabolic Science, Cambridge CB2 0QQ, UK
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Renzella J, Fernando S, Kalupahana B, Townsend N, Rayner M, Wickramasinghe K, Katulanda P, Scarborough P. Relative validity of a brief dietary survey to assess food intake and adherence to national dietary guidelines among Sri Lankan adults. BMC Nutr 2020; 6:68. [PMID: 33292681 PMCID: PMC7690106 DOI: 10.1186/s40795-020-00391-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 10/23/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Suboptimal diet is the leading cause of global morbidity and mortality. Addressing this problem requires context-specific solutions informed by context-specific data collected by context-specific tools. This study aimed to assess the relative validity of a newly developed brief dietary survey to estimate food intake and adherence to the Food Based Dietary Guidelines for Sri Lankans. METHODS Between December 2018 and February 2019, we interviewed 94 Sri Lankan adults living in Colombo (Western Province), Kalutara (Western Province), and Trincomalee (Eastern Province). We assessed the relative validity of the Sri Lankan Brief Dietary Survey (SLBDS) with Wilcoxon rank-sum tests, Spearman's Rho correlation coefficients, Bland-Altman plots, and Cohen's kappa tests using a 24-h Dietary Recall (24DR) as reference. RESULTS Ninety-four adults (40.7 years ±12.6; 66% female) completed both surveys during the same interview. With the exception of 'Fish, pulses, meat and eggs' food group median intake, which was underestimated by the SLBDS compared to the 24DR, there was no strong evidence of difference between median intakes reported by the two methods. Correlation coefficients were highest for 'Milk and dairy products' (0.84) at the food group level and for 'dosa', 'hoppers', 'milk rice', and 'dried fish' (1.00) among individual food and beverages. Visual exploration of Bland-Altman plots showed acceptable agreement between the SLBDS and 24DR, with the SLBDS tending to overestimate consumption as the number of servings of 'Rice, bread, other cereals and yams' and 'Vegetables' consumed increased and slightly underestimate consumption as the number of servings of 'Fish, pulses, meat and eggs', 'Milk and dairy products', and 'Nuts' increased. Kappa values ranged from from 0.59 (95% CI: 0.32-0.86) for 'Vegetables' to 0.81 (95% CI: 0.66-0.96) for 'Fruit' indicating a moderate to strong level of agreement. CONCLUSIONS Having been developed for and relatively validated with the study population in question, our study shows that the SLBDS can be used as a fit for purpose research tool. Additional research is needed to assess SLBDS test-retest reliability and to validate further the reporting of salt, oil, and coconut intake.
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Affiliation(s)
- J. Renzella
- Centre on Population Approaches for NCD Prevention, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - S. Fernando
- Sri Jayewardenepura General Hospital and Post Graduate Training Centre, Colombo, Sri Lanka
| | | | - N. Townsend
- Department of Health, University of Bath, Bath, UK
| | - M. Rayner
- Centre on Population Approaches for NCD Prevention, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - K. Wickramasinghe
- WHO European Office for Prevention and Control of Non-communicable Diseases, WHO Regional Office for Europe, Moscow, Russia
| | - P. Katulanda
- Department of Clinical Medicine, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | - P. Scarborough
- NIHR Biomedical Research Centre at Oxford and Centre on Population Approaches for NCD Prevention, Nuffield Department of Population Health, University of Oxford, Oxford, UK
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Renzella J, Fernando S, Kalupahana B, Scarborough P, Rayner M, Townsend N. Food labour, consumption hierarchies, and diet decision-making in Sri Lankan households: a qualitative study. BMC Nutr 2020; 6:64. [PMID: 33292762 PMCID: PMC7678094 DOI: 10.1186/s40795-020-00389-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 10/15/2020] [Indexed: 11/29/2022] Open
Abstract
Background Sri Lanka faces the double burden of over- and undernutrition. To tackle this dual challenge, double duty interventions that improve the quality of the Sri Lankan diet in line with national dietary guidelines have been suggested. The success of these interventions depends upon an understanding of the context-specific factors that impact their uptake within the population. The purpose of this study was threefold: explore household responsibility for food-related labour; understand food decision-making influences; and investigate consumption hierarchies that might impact the distribution of intervention benefits. Methods We conducted face-to-face semi-structured interviews with 93 Sri Lankan adults residing in urban Colombo (n = 56), and urban and rural sectors in Kalutara (n = 29) and Trincomalee (n = 8). Interview data were analysed thematically. Results Findings from this study suggest that women in Sri Lanka continue to shoulder the burden of food-related labour disproportionately to men but that this responsibility is not always a proxy for dietary decision-making power. While men are often absent from the kitchen, their role in food purchasing and payment is prominent in many households. Despite these observed gender differences in food labour and provisioning, “traditional” age- and gender-based consumption hierarchies with negative nutrition consequences for women and children are not common, indicating that Sri Lankan ‘table culture’ may be changing. Conclusion Dietary interventions with the aim of influencing day-to-day practice should be developed with an awareness of who is responsible for, who is able to perform, and who influences targeted behaviours. Supplementary information Supplementary information accompanies this paper at 10.1186/s40795-020-00389-w.
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Affiliation(s)
- J Renzella
- Centre on Population Approaches for NCD Prevention, Nuffield Department of Population Health, University of Oxford, Oxford, UK.
| | - S Fernando
- Sri Jayewardenepura General Hospital and Post Graduate Training Centre, Colombo, Sri Lanka
| | | | - P Scarborough
- NIHR Biomedical Research Centre at Oxford and Centre on Population Approaches for NCD Prevention, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - M Rayner
- Centre on Population Approaches for NCD Prevention, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - N Townsend
- Department of Health, University of Bath, Bath, UK
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Rogers NT, Pell D, Penney TL, Mytton O, Briggs A, Cummins S, Rayner M, Rutter H, Scarborough P, Sharp SJ, Smith RD, White M, Adams J. Anticipatory changes in British household purchases of soft drinks associated with the announcement of the Soft Drinks Industry Levy: A controlled interrupted time series analysis. PLoS Med 2020; 17:e1003269. [PMID: 33180869 PMCID: PMC7660521 DOI: 10.1371/journal.pmed.1003269] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Accepted: 09/18/2020] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Sugar-sweetened beverage (SSB) consumption is positively associated with obesity, type 2 diabetes, and cardiovascular disease. The World Health Organization recommends that member states implement effective taxes on SSBs to reduce consumption. The United Kingdom Soft Drinks Industry Levy (SDIL) is a two-tiered tax, announced in March 2016 and implemented in April 2018. Drinks with ≥8 g of sugar per 100 ml (higher levy tier) are taxed at £0.24 per litre, drinks with ≥5 to <8 g of sugar per 100 ml (lower levy tier) are taxed at £0.18 per litre, and drinks with <5 g sugar per 100 ml (no levy) are not taxed. Milk-based drinks, pure fruit juices, drinks sold as powder, and drinks with >1.2% alcohol by volume are exempt. We aimed to determine if the announcement of the SDIL was associated with anticipatory changes in purchases of soft drinks prior to implementation of the SDIL in April 2018. We explored differences in the volume of and amount of sugar in household purchases of drinks in each levy tier at 2 years post announcement. METHODS AND FINDINGS We used controlled interrupted time series to compare observed changes associated with the announcement of the SDIL to the counterfactual scenario of no announcement. We used data from Kantar Worldpanel, a commercial household purchasing panel with approximately 30,000 British members that includes linked nutritional data on purchases. We conducted separate analyses for drinks liable for the SDIL in the higher, lower, and no-levy tiers controlling with household purchase volumes of toiletries. At 2 years post announcement, there was no difference in volume of or sugar from purchases of higher-levy-tier drinks compared to the counterfactual of no announcement. In contrast, a reversal of the existing upward trend in volume (ml) of and amount of sugar (g) in purchases of lower-levy-tier drinks was seen. These changes led to a -96.1 ml (95% confidence interval [CI] -144.2 to -48.0) reduction in volume and -6.4 g (95% CI -9.8 to -3.1) reduction in sugar purchased in these drinks per household per week. There was a reversal of the existing downward trend in the amount of sugar in household purchases of the no-levy drinks but no change in volume purchased. At 2 years post announcement, these changes led to a 6.1 g (95% CI 3.9-8.2) increase in sugar purchased in these drinks per household per week. There was no evidence that volume of or amount of sugar in purchases of all drinks combined was different from the counterfactual. This is an observational study, and changes other than the SDIL may have been responsible for the results reported. Purchases consumed outside of the home were not accounted for. CONCLUSIONS The announcement of the UK SDIL was associated with reductions in volume and sugar purchased in lower-levy-tier drinks before implementation. These were offset by increases in sugar purchased from no-levy drinks. These findings may reflect reformulation of drinks from the lower levy to no-levy tier with removal of some but not all sugar, alongside changes in consumer attitudes and beliefs. TRIAL REGISTRATION ISRCTN Registry ISRCTN18042742.
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Affiliation(s)
- Nina T. Rogers
- MRC Epidemiology Unit, University of Cambridge School of Clinical Medicine, Institute of Metabolic Science, Cambridge Biomedical Campus, Cambridge, United Kingdom
- * E-mail:
| | - David Pell
- MRC Epidemiology Unit, University of Cambridge School of Clinical Medicine, Institute of Metabolic Science, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Tarra L. Penney
- MRC Epidemiology Unit, University of Cambridge School of Clinical Medicine, Institute of Metabolic Science, Cambridge Biomedical Campus, Cambridge, United Kingdom
- Faculty of health, School of Kinesiology & Health Science, Keele Campus, Toronto, Canada
| | - Oliver Mytton
- MRC Epidemiology Unit, University of Cambridge School of Clinical Medicine, Institute of Metabolic Science, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Adam Briggs
- Centre on Population Approaches for Non-Communicable Disease Prevention, Nuffield Department of Population Health, University of Oxford, Headington, Oxford, United Kingdom
- Warwick Medical School, University of Warwick, Division of Health Sciences, Coventry, United Kingdom
| | - Steven Cummins
- Population Health Innovation Lab, Department of Public Health, Environment and Society, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Mike Rayner
- National Institute of Health Research Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Headington, Oxford, United Kingdom
| | - Harry Rutter
- Department of Social and Policy Sciences, University of Bath, Claverton Down, Bath, United Kingdom
| | - Peter Scarborough
- Centre on Population Approaches for Non-Communicable Disease Prevention, Nuffield Department of Population Health, University of Oxford, Headington, Oxford, United Kingdom
- National Institute of Health Research Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Headington, Oxford, United Kingdom
| | - Stephen J. Sharp
- MRC Epidemiology Unit, University of Cambridge School of Clinical Medicine, Institute of Metabolic Science, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Richard D. Smith
- College of Medicine and Health, University of Exeter, Medical School Building, St Luke’s Campus, Exeter, United Kingdom
| | - Martin White
- MRC Epidemiology Unit, University of Cambridge School of Clinical Medicine, Institute of Metabolic Science, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Jean Adams
- MRC Epidemiology Unit, University of Cambridge School of Clinical Medicine, Institute of Metabolic Science, Cambridge Biomedical Campus, Cambridge, United Kingdom
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Springmann M, Spajic L, Clark MA, Poore J, Herforth A, Webb P, Rayner M, Scarborough P. The healthiness and sustainability of national and global food based dietary guidelines: modelling study. BMJ 2020; 370:m2322. [PMID: 32669369 PMCID: PMC7362232 DOI: 10.1136/bmj.m2322] [Citation(s) in RCA: 154] [Impact Index Per Article: 38.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/20/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To analyse the health and environmental implications of adopting national food based dietary guidelines (FBDGs) at a national level and compared with global health and environmental targets. DESIGN Modelling study. SETTING 85 countries. PARTICIPANTS Population of 85 countries. MAIN OUTCOME MEASURES A graded coding method was developed and used to extract quantitative recommendations from 85 FBDGs. The health and environmental impacts of these guidelines were assessed by using a comparative risk assessment of deaths from chronic diseases and a set of country specific environmental footprints for greenhouse gas emissions, freshwater use, cropland use, and fertiliser application. For comparison, the impacts of adopting the global dietary recommendations of the World Health Organization and the EAT-Lancet Commission on Healthy Diets from Sustainable Food Systems were also analysed. Each guideline's health and sustainability implications were assessed by modelling its adoption at both the national level and globally, and comparing the impacts to global health and environmental targets, including the Action Agenda on Non-Communicable Diseases, the Paris Climate Agreement, the Aichi biodiversity targets related to land use, and the sustainable development goals and planetary boundaries related to freshwater use and fertiliser application. RESULTS Adoption of national FBDGs was associated with reductions in premature mortality of 15% on average (95% uncertainty interval 13% to 16%) and mixed changes in environmental resource demand, including a reduction in greenhouse gas emissions of 13% on average (regional range -34% to 35%). When universally adopted globally, most of the national guidelines (83, 98%) were not compatible with at least one of the global health and environmental targets. About a third of the FBDGs (29, 34%) were incompatible with the agenda on non-communicable diseases, and most (57 to 74, 67% to 87%) were incompatible with the Paris Climate Agreement and other environmental targets. In comparison, adoption of the WHO recommendations was associated with similar health and environmental changes, whereas adoption of the EAT-Lancet recommendations was associated with 34% greater reductions in premature mortality, more than three times greater reductions in greenhouse gas emissions, and general attainment of the global health and environmental targets. As an example, the FBDGs of the UK, US, and China were incompatible with the climate change, land use, freshwater, and nitrogen targets, and adopting guidelines in line with the EAT-Lancet recommendation could increase the number of avoided deaths from 78 000 (74 000 to 81 000) to 104 000 (96 000 to 112 000) in the UK, from 480 000 (445 000 to 516 000) to 585 000 (523 000 to 646 000) in the USA, and from 1 149 000 (1 095 000 to 1 204 000) to 1 802 000 (1 664 000 to 1 941 000) in China. CONCLUSIONS This analysis suggests that national guidelines could be both healthier and more sustainable. Providing clearer advice on limiting in most contexts the consumption of animal source foods, in particular beef and dairy, was found to have the greatest potential for increasing the environmental sustainability of dietary guidelines, whereas increasing the intake of whole grains, fruits and vegetables, nuts and seeds, and legumes, reducing the intake of red and processed meat, and highlighting the importance of attaining balanced energy intake and weight levels were associated with most of the additional health benefits. The health results were based on observational data and assuming a causal relation between dietary risk factors and health outcomes. The certainty of evidence for these relations is mostly graded as moderate in existing meta-analyses.
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Affiliation(s)
- Marco Springmann
- Oxford Martin Programme on the Future of Food and Nuffield Department of Population Health, University of Oxford, Oxford OX3 7LF, UK
| | - Luke Spajic
- School of Medicine, University of Adelaide, Adelaide, SA, Australia
| | - Michael A Clark
- Oxford Martin Programme on the Future of Food and Nuffield Department of Population Health, University of Oxford, Oxford OX3 7LF, UK
| | - Joseph Poore
- Department of Zoology and School of Geography and the Environment, University of Oxford, Oxford, UK
| | - Anna Herforth
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Patrick Webb
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA, USA
| | - Mike Rayner
- Oxford Martin Programme on the Future of Food and Nuffield Department of Population Health, University of Oxford, Oxford OX3 7LF, UK
| | - Peter Scarborough
- Oxford Martin Programme on the Future of Food, NIHR Biomedical Research Centre at Oxford, and Nuffield Department of Population Health, University of Oxford, Oxford, UK
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Blakely T, Nghiem N, Genc M, Mizdrak A, Cobiac L, Mhurchu CN, Swinburn B, Scarborough P, Cleghorn C. Modelling the health impact of food taxes and subsidies with price elasticities: The case for additional scaling of food consumption using the total food expenditure elasticity. PLoS One 2020; 15:e0230506. [PMID: 32214329 PMCID: PMC7098589 DOI: 10.1371/journal.pone.0230506] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 03/03/2020] [Indexed: 11/24/2022] Open
Abstract
Background Food taxes and subsidies are one intervention to address poor diets. Price elasticity (PE) matrices are commonly used to model the change in food purchasing. Usually a PE matrix is generated in one setting then applied to another setting with differing starting consumptions and prices of foods. This violates econometric assumptions resulting in likely mis-estimation of total food consumption. In this paper we demonstrate this problem, canvass possible options for rescaling all consumption after applying a PE matrix, and illustrate the use of a total food expenditure elasticity (TFEe; the expenditure elasticity for all food combined given the policy-induced change in the total price of food). We use case studies of: NZ$2 per 100g saturated fat (SAFA) tax, NZ$0.4 per 100g sugar tax, and a 20% fruit and vegetable (F&V) subsidy. Methods We estimated changes in food purchasing using a NZ PE matrix applied conventionally, and then with TFEe adjustment. Impacts were quantified for pre- to post-policy changes in total food expenditure and health adjusted life years (HALYs) for the total NZ population alive in 2011 over the rest of their lifetime using a multistate lifetable model. Results Two NZ studies gave TFEe’s of 0.68 and 0.83, with international estimates ranging from 0.46 to 0.90 (except a UK outlier of 0.04). Without TFEe adjustment, total food expenditure decreased with the tax policies and increased with the F&V subsidy–implausible directions of shift given economic theory and the external TFEe estimates. After TFEe adjustment, HALY gains reduced by a third to a half for the two taxes and reversed from an apparent health loss to a health gain for the F&V subsidy. With TFEe adjustment, HALY gains (in 1000’s) were: 1,805 (95% uncertainty interval 1,337 to 2,340) for the SAFA tax; 1,671 (1,220 to 2,269) for the sugar tax; and 953 (453 to 1,308) for the F&V subsidy. Conclusions If PE matrices are applied in settings beyond where they were derived, additional scaling is likely required. We suggest that the TFEe is a useful scalar, but we also encourage other researchers to examine this issue and propose alternative options.
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Affiliation(s)
- Tony Blakely
- Population Interventions Unit, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
- Burden of Disease Epidemiology, Equity and Cost Effectiveness Programme, Department of Public Health, University of Otago, Wellington, New Zealand
- * E-mail:
| | - Nhung Nghiem
- Burden of Disease Epidemiology, Equity and Cost Effectiveness Programme, Department of Public Health, University of Otago, Wellington, New Zealand
| | - Murat Genc
- Department of Economics, University of Otago, Dunedin, New Zealand
| | - Anja Mizdrak
- Burden of Disease Epidemiology, Equity and Cost Effectiveness Programme, Department of Public Health, University of Otago, Wellington, New Zealand
| | - Linda Cobiac
- Nuffield Department of Population Health, Oxford University, Oxford, United Kingdom
| | - Cliona Ni Mhurchu
- National Institute of Health Innovation, University of Auckland, Auckland, New Zealand
| | - Boyd Swinburn
- School of Population Health, University of Auckland, Auckland, New Zealand
| | - Peter Scarborough
- Nuffield Department of Population Health, Oxford University, Oxford, United Kingdom
| | - Christine Cleghorn
- Burden of Disease Epidemiology, Equity and Cost Effectiveness Programme, Department of Public Health, University of Otago, Wellington, New Zealand
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Abstract
BACKGROUND The consumption of free sugars in the UK is more than double the guideline intake for adults and close to triple for children, with soft drinks representing a significant proportion. The aim of this study was to assess how individual soft drink companies and consumers have responded to calls to reduce sugar consumption, including the soft drink industry levy (SDIL), between 2015 and 2018. METHODS This was an annual cross-sectional study using nutrient composition data of 7377 products collected online, paired with volume sales data for 195 brands offered by 57 companies. The main outcome measures were sales volume, sugar content and volume of sugars sold by company and category, expressed in total and per capita per day terms. RESULTS Between 2015 and 2018, the volume of sugars sold per capita per day from soft drinks declined by 30%, equivalent to a reduction of 4.6 g per capita per day. The sales-weighted mean sugar content of soft drinks fell from 4.4 g/100 ml in 2015 to 2.9 g/100 ml in 2018. The total volume sales of soft drinks that are subject to the SDIL (i.e. contain more than 5 g/100 ml of sugar) fell by 50%, while volume sales of low- and zero-sugar (< 5 g/100 ml) drinks rose by 40%. CONCLUSION Action by the soft drinks industry to reduce sugar in products and change their product portfolios, coupled with changes in consumer purchasing, has led to a significant reduction in the total volume and per capita sales of sugars sold in soft drinks in the UK. The rate of change accelerated between 2017 and 2018, which also implies that the implementation of the SDIL acted as an extra incentive for companies to reformulate above and beyond what was already being done as part of voluntary commitments to reformulation, or changes in sales driven by consumer preferences.
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Affiliation(s)
- L K Bandy
- Centre on Population Approaches for NCD Prevention, Nuffield Department of Population Health, University of Oxford, BDI Building, Old Road Campus, Oxford, OX3 7FZ, UK.
| | - P Scarborough
- Centre on Population Approaches for NCD Prevention, Nuffield Department of Population Health, University of Oxford, BDI Building, Old Road Campus, Oxford, OX3 7FZ, UK
| | - R A Harrington
- Centre on Population Approaches for NCD Prevention, Nuffield Department of Population Health, University of Oxford, BDI Building, Old Road Campus, Oxford, OX3 7FZ, UK
| | - M Rayner
- Centre on Population Approaches for NCD Prevention, Nuffield Department of Population Health, University of Oxford, BDI Building, Old Road Campus, Oxford, OX3 7FZ, UK
| | - S A Jebb
- Nuffield Department of Primary Health Care Sciences, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, University of Oxford, Woodstock Road, Oxford, OX2 6GG, UK
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Labonté ME, Emrich TE, Scarborough P, Rayner M, L’Abbé MR. Traffic light labelling could prevent mortality from noncommunicable diseases in Canada: A scenario modelling study. PLoS One 2019; 14:e0226975. [PMID: 31881069 PMCID: PMC6934336 DOI: 10.1371/journal.pone.0226975] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 12/09/2019] [Indexed: 11/24/2022] Open
Abstract
Background Traffic-light labelling (TLL) is a promising front-of-pack system to help consumers make informed dietary choices. It has been shown that adopting TLL in Canada, through an optimistic scenario of avoiding, if possible, foods with red traffic lights, could effectively reduce Canadians’ intakes of energy, total fat, saturated fat, and sodium by 5%, 13%, 14% and 6%, respectively. However, the potential health impact of adopting TLL has not been determined in the North American context. Objective This study modelled the potential impact of adopting TLL on mortality from noncommunicable diseases (NCDs) in Canada, due to the previously predicted improved nutrient intakes. Methods Investigators used data from adults (n = 19,915) in the 2004 nationally representative Canadian Community Health Survey (CCHS)-Cycle 2.2. Nutrient amounts in foods consumed by CCHS respondents were profiled using the 2013 United Kingdom’s TLL criteria. Whenever possible, foods assigned at least one red light (non-compliant foods) were replaced with similar, but compliant, foods identified from a Canadian brand-specific food database. Respondents’ nutrient intakes were calculated under the original CCHS scenario and the counterfactual TLL scenario, and entered in the Preventable Risk Integrated ModEl (PRIME) to estimate the health impact of adopting TLL. The primary outcome was the number of deaths attributable to diet-related NCDs that could be averted or delayed based on the TLL scenario compared with the baseline scenario. Results PRIME estimated that 11,715 deaths (95% CI 10,500–12,865) per year due to diet-related NCDs, among which 72% are specifically related to cardiovascular diseases, could be prevented if Canadians avoided foods labelled with red traffic lights. The reduction in energy intakes would by itself save 10,490 deaths (9,312–11,592; 90%). Conclusions This study, although depicting an idealistic scenario, suggests that TLL (if used to avoid red lights when possible) could be an effective population-wide intervention to improve NCD outcomes in Canada.
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Affiliation(s)
- Marie-Eve Labonté
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Teri E. Emrich
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Peter Scarborough
- Nuffield Department of Population Health, University of Oxford, Oxford, Oxfordshire, United Kingdom
| | - Mike Rayner
- Nuffield Department of Population Health, University of Oxford, Oxford, Oxfordshire, United Kingdom
| | - Mary R. L’Abbé
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- * E-mail:
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Kelly B, Vandevijvere S, Ng S, Adams J, Allemandi L, Bahena‐Espina L, Barquera S, Boyland E, Calleja P, Carmona‐Garcés IC, Castronuovo L, Cauchi D, Correa T, Corvalán C, Cosenza‐Quintana EL, Fernández‐Escobar C, González‐Zapata LI, Halford J, Jaichuen N, Jensen ML, Karupaiah T, Kaur A, Kroker‐Lobos MF, Mchiza Z, Miklavec K, Parker W, Potvin Kent M, Pravst I, Ramírez‐Zea M, Reiff S, Reyes M, Royo‐Bordonada MÁ, Rueangsom P, Scarborough P, Tiscornia MV, Tolentino‐Mayo L, Wate J, White M, Zamora‐Corrales I, Zeng L, Swinburn B. Global benchmarking of children's exposure to television advertising of unhealthy foods and beverages across 22 countries. Obes Rev 2019; 20 Suppl 2:116-128. [PMID: 30977265 PMCID: PMC6988129 DOI: 10.1111/obr.12840] [Citation(s) in RCA: 106] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 01/13/2019] [Accepted: 01/17/2019] [Indexed: 12/23/2022]
Abstract
Restricting children's exposures to marketing of unhealthy foods and beverages is a global obesity prevention priority. Monitoring marketing exposures supports informed policymaking. This study presents a global overview of children's television advertising exposure to healthy and unhealthy products. Twenty-two countries contributed data, captured between 2008 and 2017. Advertisements were coded for the nature of foods and beverages, using the 2015 World Health Organization (WHO) Europe Nutrient Profile Model (should be permitted/not-permitted to be advertised). Peak viewing times were defined as the top five hour timeslots for children. On average, there were four times more advertisements for foods/beverages that should not be permitted than for permitted foods/beverages. The frequency of food/beverages advertisements that should not be permitted per hour was higher during peak viewing times compared with other times (P < 0.001). During peak viewing times, food and beverage advertisements that should not be permitted were higher in countries with industry self-regulatory programmes for responsible advertising compared with countries with no policies. Globally, children are exposed to a large volume of television advertisements for unhealthy foods and beverages, despite the implementation of food industry programmes. Governments should enact regulation to protect children from television advertising of unhealthy products that undermine their health.
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Affiliation(s)
- Bridget Kelly
- Early Start, School of Health and SocietyUniversity of WollongongWollongongNew South WalesAustralia
| | | | - SeeHoe Ng
- Faculty of Health SciencesNational University of MalaysiaBangiMalaysia
| | - Jean Adams
- Centre for Diet & Activity Research, MRC Epidemiology UnitUniversity of CambridgeCambridgeUK
| | - Lorena Allemandi
- Fundación InterAmericana del Corazón–Argentina (FIC Argentina)Buenos AiresArgentina
| | - Liliana Bahena‐Espina
- Nutrition and Health Research Center (CINyS)Instituto Nacional de Salud Pública (INSP)CuernavacaMexico
| | - Simon Barquera
- Nutrition and Health Research Center (CINyS)Instituto Nacional de Salud Pública (INSP)CuernavacaMexico
| | - Emma Boyland
- Department of Psychological SciencesUniversity of LiverpoolLiverpoolUK
| | - Paul Calleja
- Malta College of Arts, Science and Technology (MCAST)PaolaMalta
| | - Isabel Cristina Carmona‐Garcés
- School of Nutrition and Dietetics, University of Antioquia, Health Education and Nutrition Education Interdisciplinary Research Group (GIIESEN)MedellínColombia
| | - Luciana Castronuovo
- Fundación InterAmericana del Corazón–Argentina (FIC Argentina)Buenos AiresArgentina
| | - Daniel Cauchi
- Department of Public HealthUniversity of MaltaMsidaMalta
| | - Teresa Correa
- School of CommunicationDiego Portales UniversitySantiagoChile
| | - Camila Corvalán
- Institute of Nutrition and Food Technology (INTA)University of ChileSantiagoChile
| | - Emma Lucia Cosenza‐Quintana
- INCAP Research Center for Prevention of Chronic DiseasesInstitute of Nutrition of Central America and PanamaGuatemala CityGuatemala
| | | | - Laura I. González‐Zapata
- School of Nutrition and Dietetics, University of Antioquia, Social and Economic Determinants of Health and Nutrition Research GroupMedellínColombia
| | - Jason Halford
- Department of Psychological SciencesUniversity of LiverpoolLiverpoolUK
| | - Nongnuch Jaichuen
- International Health Policy ProgramMinistry of Public HealthNonthaburiThailand
| | | | - Tilakavati Karupaiah
- Faculty of Health SciencesNational University of MalaysiaBangiMalaysia
- School of Biosciences, Faculty of Health and Medical SciencesTaylor's UniversitySubang JayaMalaysia
| | - Asha Kaur
- Centre on Population Approaches for Non‐communicable Disease Prevention, Nuffield Department of Population HealthUniversity of OxfordOxfordUK
| | - María F. Kroker‐Lobos
- INCAP Research Center for Prevention of Chronic DiseasesInstitute of Nutrition of Central America and PanamaGuatemala CityGuatemala
| | - Zandile Mchiza
- School of Public Health, Faculty of Community and Health SciencesUniversity of the Western CapeBellvilleSouth Africa
| | | | - Whadi‐ah Parker
- Population Health, Health Systems and InnovationsHuman Science Research CouncilCape TownSouth Africa
| | - Monique Potvin Kent
- School of Epidemiology and Public Health, Faculty of MedicineUniversity of OttawaOttawaOntarioCanada
| | | | - Manuel Ramírez‐Zea
- INCAP Research Center for Prevention of Chronic DiseasesInstitute of Nutrition of Central America and PanamaGuatemala CityGuatemala
| | - Sascha Reiff
- Department for Policy in HealthMinistry for HealthVallettaMalta
| | - Marcela Reyes
- Institute of Nutrition and Food Technology (INTA)University of ChileSantiagoChile
| | | | | | - Peter Scarborough
- NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust and Centre on Population Approaches for Non‐communicable Disease Prevention, Nuffield Department of Population HealthUniversity of OxfordOxfordUK
| | | | - Lizbeth Tolentino‐Mayo
- Nutrition and Health Research Center (CINyS)Instituto Nacional de Salud Pública (INSP)CuernavacaMexico
| | - Jillian Wate
- Pacific Research Centre for the Prevention of Obesity and Non‐communicable DiseasesFiji National UniversitySuvaFiji
| | - Martin White
- Centre for Diet & Activity Research, MRC Epidemiology UnitUniversity of CambridgeCambridgeUK
| | - Irina Zamora‐Corrales
- INCAP Research Center for Prevention of Chronic DiseasesInstitute of Nutrition of Central America and PanamaGuatemala CityGuatemala
- School of Public HealthUniversity of Costa RicaSan PedroCosta Rica
| | - Lingxia Zeng
- School of Public HealthXi'an Jiaotong University Health Science CenterXi'anPR China
| | - Boyd Swinburn
- School of Population HealthUniversity of AucklandAucklandNew Zealand
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Briggs ADM, Wolstenholme J, Scarborough P. Estimating the cost-effectiveness of salt reformulation and increasing access to leisure centres in England, with PRIMEtime CE model validation using the AdViSHE tool. BMC Health Serv Res 2019; 19:489. [PMID: 31307459 PMCID: PMC6631881 DOI: 10.1186/s12913-019-4292-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Accepted: 06/23/2019] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND PRIMEtime CE is a multistate life table model that can directly compare the cost effectiveness of public health interventions affecting diet and physical activity levels, helping to inform decisions about how to spend finite resources. This paper estimates the costs and health outcomes in England of two scenarios: reformulating salt and expanding subsidised access to leisure centres. The results are used to help validate PRIMEtime CE, following the steps outlined in the Assessment of the Validation Status of Health-Economic decision models (AdViSHE) tool. METHODS The PRIMEtime CE model estimates the difference in quality adjusted life years (QALYs) and difference in NHS and social care costs of modelled interventions compared with doing nothing. The salt reformulation scenario models how salt consumption would change if food producers met the 2017 UK Food Standards Agency salt reformulation targets. The leisure centre scenario models change in physical activity levels if the Birmingham Be Active scheme (where swimming pools and gym access is free to residents during defined periods) was rolled out across England. The AdViSHE tool was developed by health economic modellers and divides model validation into five parts: validation of the conceptual model, input data validation, validation of computerised model, operational validation, and other validation techniques. PRIMEtime CE is discussed in relation to each part. RESULTS Salt reformulation was dominant compared with doing nothing, and had a 10-year return on investment of £1.44 (£0.50 to £2.94) for every £1 spent. By contrast, over 10 years the Be Active expansion would cost £727,000 (£514,000 to £1,064,000) per QALY. PRIMEtime CE has good face validity of its conceptual model and has robust input data. Cross-validation produces mixed results and shows the impact of model scope, input parameters, and model structure on cost-per-QALY estimates. CONCLUSIONS This paper illustrates how PRIMEtime CE can be used to compare the cost-effectiveness of two different public health measures affecting diet and physical activity levels. The AdViSHE tool helps to validate PRIMEtime CE, identifies some of the key drivers of model estimates, and highlights the challenges of externally validating public health economic models against independent data.
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Affiliation(s)
- Adam D. M. Briggs
- Centre on Population Approaches for Non-Communicable Disease Prevention, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Headington, Oxford, OX3 7LF UK
| | - Jane Wolstenholme
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Peter Scarborough
- Centre on Population Approaches for Non-Communicable Disease Prevention and NIHR Biomedical Research Centre at Oxford, Nuffield Department of Population Health, University of Oxford, Oxford, UK
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Briggs ADM, Cobiac LJ, Wolstenholme J, Scarborough P. PRIMEtime CE: a multistate life table model for estimating the cost-effectiveness of interventions affecting diet and physical activity. BMC Health Serv Res 2019; 19:485. [PMID: 31307442 PMCID: PMC6633614 DOI: 10.1186/s12913-019-4237-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Accepted: 06/10/2019] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Non-communicable diseases are the leading cause of death in England, and poor diet and physical inactivity are two of the principle behavioural risk factors. In the context of increasingly constrained financial resources, decision makers in England need to be able to compare the potential costs and health outcomes of different public health policies aimed at improving these risk factors in order to know where to invest so that they can maximise population health. This paper describes PRIMEtime CE, a multistate life table cost-effectiveness model that can directly compare interventions affecting multiple disease outcomes. METHODS The multistate life table model, PRIMEtime Cost Effectiveness (PRIMEtime CE), is developed from the Preventable Risk Integrated ModEl (PRIME) and the PRIMEtime model. PRIMEtime CE uses routinely available data to estimate how changing diet and physical activity in England affects morbidity and mortality from heart disease, stroke, diabetes, liver disease, and cancers either directly or via raised blood pressure, cholesterol, and body weight. RESULTS Model outcomes are change in quality adjusted life years, and change in English National Health Service and social care costs. CONCLUSION This paper describes PRIMEtime CE and highlights its main strengths and limitations. The model can be used to compare any number of public policies affecting diet and physical activity, allowing decision makers to understand how they can maximise population health with limited financial resources.
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Affiliation(s)
- Adam D. M. Briggs
- Centre on Population Approaches for Non-Communicable Disease Prevention and NIHR Biomedical Research Centre at Oxford, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Headington, Oxford, OX3 7LF UK
| | - Linda J. Cobiac
- Centre on Population Approaches for Non-Communicable Disease Prevention and NIHR Biomedical Research Centre at Oxford, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Headington, Oxford, OX3 7LF UK
| | - Jane Wolstenholme
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Peter Scarborough
- Centre on Population Approaches for Non-Communicable Disease Prevention and NIHR Biomedical Research Centre at Oxford, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Headington, Oxford, OX3 7LF UK
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Abstract
OBJECTIVES Traditional methods for creating food composition tables struggle to cope with the large number of products and the rapid pace of change in the food and drink marketplace. This paper introduces foodDB, a big data approach to the analysis of this marketplace, and presents analyses illustrating its research potential. DESIGN foodDB has been used to collect data weekly on all foods and drinks available on six major UK supermarket websites since November 2017. As of June 2018, foodDB has 3 193 171 observations of 128 283 distinct food and drink products measured at multiple timepoints. METHODS Weekly extraction of nutrition and availability data of products was extracted from the webpages of the supermarket websites. This process was automated with a codebase written in Python. RESULTS Analyses using a single weekly timepoint of 97 368 total products in March 2018 identified 2699 ready meals and pizzas, and showed that lower price ready meals had significantly lower levels of fat, saturates, sugar and salt (p<0.001). Longitudinal analyses of 903 pizzas revealed that 10.8% changed their nutritional formulation over 6 months, and 29.9% were either discontinued or new market entries. CONCLUSIONS foodDB is a powerful new tool for monitoring the food and drink marketplace, the comprehensive sampling and granularity of collection provides power for revealing analyses of the relationship between nutritional quality and marketing of branded foods, timely observation of product reformulation and other changes to the food marketplace.
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Affiliation(s)
- Richard Andrew Harrington
- Nuffield Department of Population Health, University of Oxford Nuffield Department of Population Health, Oxford, UK
| | - Vyas Adhikari
- Nuffield Department of Population Health, University of Oxford Nuffield Department of Population Health, Oxford, UK
| | - Mike Rayner
- Nuffield Department of Population Health, University of Oxford Nuffield Department of Population Health, Oxford, UK
| | - Peter Scarborough
- Nuffield Department of Population Health, University of Oxford Nuffield Department of Population Health, Oxford, UK
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Seminog OO, Scarborough P, Wright FL, Rayner M, Goldacre MJ. Determinants of the decline in mortality from acute stroke in England: linked national database study of 795 869 adults. BMJ 2019; 365:l1778. [PMID: 31122927 PMCID: PMC6529851 DOI: 10.1136/bmj.l1778] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/26/2019] [Indexed: 01/19/2023]
Abstract
OBJECTIVES To study trends in stroke mortality rates, event rates, and case fatality, and to explain the extent to which the reduction in stroke mortality rates was influenced by changes in stroke event rates or case fatality. DESIGN Population based study. SETTING Person linked routine hospital and mortality data, England. PARTICIPANTS 795 869 adults aged 20 and older who were admitted to hospital with acute stroke or died from stroke. MAIN OUTCOME MEASURES Stroke mortality rates, stroke event rates (stroke admission or stroke death without admission), and case fatality within 30 days after stroke. RESULTS Between 2001 and 2010 stroke mortality rates decreased by 55%, stroke event rates by 20%, and case fatality by 40%. The study population included 358 599 (45%) men and 437 270 (55%) women. Average annual change in mortality rate was -6.0% (95% confidence interval -6.2% to -5.8%) in men and -6.1% (-6.3% to -6.0%) in women, in stroke event rate was -1.3% (-1.4% to -1.2%) in men and -2.1% (-2.2 to -2.0) in women, and in case fatality was -4.7% (-4.9% to -4.5%) in men and -4.4% (-4.5% to -4.2%) in women. Mortality and case fatality but not event rate declined in all age groups: the stroke event rate decreased in older people but increased by 2% each year in adults aged 35 to 54 years. Of the total decline in mortality rates, 71% was attributed to the decline in case fatality (78% in men and 66% in women) and the remainder to the reduction in stroke event rates. The contribution of the two factors varied between age groups. Whereas the reduction in mortality rates in people younger than 55 years was due to the reduction in case fatality, in the oldest age group (≥85 years) reductions in case fatality and event rates contributed nearly equally. CONCLUSIONS Declines in case fatality, probably driven by improvements in stroke care, contributed more than declines in event rates to the overall reduction in stroke mortality. Mortality reduction in men and women younger than 55 was solely a result of a decrease in case fatality, whereas stroke event rates increased in the age group 35 to 54 years. The increase in stroke event rates in young adults is a concern. This suggests that stroke prevention needs to be strengthened to reduce the occurrence of stroke in people younger than 55 years.
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Affiliation(s)
- Olena O Seminog
- Unit of Health-Care Epidemiology, Big Data Institute, Nuffield Department of Population Health, NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford OX3 7LF, UK
| | - Peter Scarborough
- Centre on Population Approaches for Non-communicable Disease Prevention, Nuffield Department of Population Health, NIHR Biomedical Research Centre at Oxford, University of Oxford, Oxford, UK
| | - F Lucy Wright
- Unit of Health-Care Epidemiology, Big Data Institute, Nuffield Department of Population Health, NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford OX3 7LF, UK
| | - Mike Rayner
- Centre on Population Approaches for Non-communicable Disease Prevention, Nuffield Department of Population Health, NIHR Biomedical Research Centre at Oxford, University of Oxford, Oxford, UK
| | - Michael J Goldacre
- Unit of Health-Care Epidemiology, Big Data Institute, Nuffield Department of Population Health, NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford OX3 7LF, UK
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Abstract
OBJECTIVE To estimate the impact of the UK government's sugar reduction programme on child and adult obesity, adult disease burden, and healthcare costs. DESIGN Modelling study. SETTING Simulated scenario based on National Diet and Nutrition Survey waves 5 and 6, England. PARTICIPANTS 1508 survey respondents were used to model weight change among the population of England aged 4-80 years. MAIN OUTCOME MEASURES Calorie change, weight change, and body mass index change were estimated for children and adults. Impact on non-communicable disease incidence, quality adjusted life years, and healthcare costs were estimated for adults. Changes to disease burden were modelled with the PRIMEtime-CE Model, based on the 2014 population in England aged 18-80. RESULTS If the sugar reduction programme was achieved in its entirety and resulted in the planned sugar reduction, then the calorie reduction was estimated to be 25 kcal/day (1 kcal=4.18 kJ=0.00418 MJ) for 4-10 year olds (95% confidence interval 23 to 26), 25 kcal/day (24 to 28) for 11-18 year olds, and 19 kcal/day (17 to 20) for adults. The reduction in obesity could represent 5.5% of the baseline obese population of 4-10 year olds, 2.2% of obese 11-18 year olds, and 5.5% of obese 19-80 year olds. A modelled 51 729 quality adjusted life years (95% uncertainty interval 45 768 to 57 242) were saved over 10 years, including 154 550 (132 623 to 174 604) cases of diabetes and relating to a net healthcare saving of £285.8m (€332.5m, $373.5m; £249.7m to £319.8m). CONCLUSIONS The UK government's sugar reduction programme could reduce the burden of obesity and obesity related disease, provided that reductions in sugar levels and portion sizes do not prompt unanticipated changes in eating patterns or product formulation.
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Affiliation(s)
- Ben Amies-Cull
- Centre for Population Approaches to Non-Communicable Disease Prevention, Big Data Institute, University of Oxford, Headington, Oxford OX3 7FZ, UK
- Centre for Primary Care, University of Manchester, Manchester, UK
| | - Adam D M Briggs
- Centre for Population Approaches to Non-Communicable Disease Prevention, Big Data Institute, University of Oxford, Headington, Oxford OX3 7FZ, UK
| | - Peter Scarborough
- Centre for Population Approaches to Non-Communicable Disease Prevention, Big Data Institute, University of Oxford, Headington, Oxford OX3 7FZ, UK
- National Institute of Health Research Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Headington, Oxford, UK
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Harrington RA, Scarborough P, Hodgkins C, Raats MM, Cowburn G, Dean M, Doherty A, Foster C, Juszczak E, Ni Mhurchu C, Winstone N, Shepherd R, Timotijevic L, Rayner M. A Pilot Randomized Controlled Trial of a Digital Intervention Aimed at Improving Food Purchasing Behavior: The Front-of-Pack Food Labels Impact on Consumer Choice Study. JMIR Form Res 2019; 3:e9910. [PMID: 30958277 PMCID: PMC6482590 DOI: 10.2196/formative.9910] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Revised: 12/05/2018] [Accepted: 12/30/2018] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Most food in the United Kingdom is purchased in supermarkets, and many of these purchases are routinely tracked through supermarket loyalty card data. Using such data may be an effective way to develop remote public health interventions and to measure objectively their effectiveness at changing food purchasing behavior. OBJECTIVE The Front-of-pack food Labels: Impact on Consumer Choice (FLICC) study is a pilot randomized controlled trial of a digital behavior change intervention. This pilot trial aimed to collect data on recruitment and retention rates and to provide estimates of effect sizes for the primary outcome (healthiness of ready meals and pizzas purchased) to inform a larger trial. METHODS The intervention consisted of a website where participants could access tailored feedback on previous purchases of ready meals and pizzas, set goals for behavior change, and model and practice the recommended healthy shopping behavior using traffic light labels. The control consisted of Web-based information on traffic light labeling. Participants were recruited via email from a list of loyalty card holders held by the participating supermarket. All food and drink purchases for the participants for the 6 months before recruitment, during the 6-week intervention period, and during a 12-week washout period were transferred to the research team by the participating supermarket. Healthiness of ready meals and pizzas was measured using a predeveloped scale based solely on the traffic light colors on the foods. Questionnaires were completed at recruitment, end of the intervention, and end of washout to estimate the effect of the intervention on variables that mediate behavior change (eg, belief and intention formation). RESULTS We recruited 496 participants from an initial email to 50,000 people. Only 3 people withdrew from the study, and purchase data were received for all other participants. A total of 208 participants completed all 3 questionnaires. There was no difference in the healthiness of purchased ready meals and pizzas between the intervention and control arms either during the intervention period (P=.32) or at washout (P=.59). CONCLUSIONS Although the FLICC study did not find evidence of an impact of the intervention on food purchasing behavior, the unique methods used in this pilot trial are informative for future studies that plan to use supermarket loyalty card data in collaboration with supermarket partners. The experience of the trial showcases the possibilities and challenges associated with the use of loyalty card data in public health research. TRIAL REGISTRATION ISRCTN Registry ISRCTN19316955; http://www.isrctn.com/ISRCTN19316955 (Archived by WebCite at http://www.webcitation.org/76IVZ9WjK). INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) RR2-10.1186/s40814-015-0015-1.
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Affiliation(s)
- Richard A Harrington
- Centre on Population Approaches for Non-Communicable Disease Prevention, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Peter Scarborough
- Centre on Population Approaches for Non-Communicable Disease Prevention, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Charo Hodgkins
- Food, Consumer Behaviour and Health Research Centre, Faculty of Health & Medical Sciences, University of Surrey, Guildford, United Kingdom
| | - Monique M Raats
- Food, Consumer Behaviour and Health Research Centre, Faculty of Health & Medical Sciences, University of Surrey, Guildford, United Kingdom
| | - Gill Cowburn
- Centre on Population Approaches for Non-Communicable Disease Prevention, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Moira Dean
- Institute for Global Food Security, School of Biological Sciences, Queen's University Belfast, Belfast, United Kingdom
| | - Aiden Doherty
- Big Data Institute, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Charlie Foster
- Centre for Exercise, Nutrition and Health Sciences, School for Policy Studies, University of Bristol, Bristol, United Kingdom
| | - Edmund Juszczak
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Cliona Ni Mhurchu
- National Institute for Health Innovation, School of Population Health, University of Auckland, Auckland, New Zealand
| | - Naomi Winstone
- Department of Higher Education, University of Surrey, Guildford, United Kingdom
| | - Richard Shepherd
- Food, Consumer Behaviour and Health Research Centre, Faculty of Health & Medical Sciences, University of Surrey, Guildford, United Kingdom
| | - Lada Timotijevic
- Food, Consumer Behaviour and Health Research Centre, Faculty of Health & Medical Sciences, University of Surrey, Guildford, United Kingdom
| | - Mike Rayner
- Centre on Population Approaches for Non-Communicable Disease Prevention, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
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Cobiac LJ, Scarborough P. Modelling the health co-benefits of sustainable diets in the UK, France, Finland, Italy and Sweden. Eur J Clin Nutr 2019; 73:624-633. [PMID: 30755710 PMCID: PMC6484724 DOI: 10.1038/s41430-019-0401-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Revised: 10/02/2018] [Accepted: 01/18/2019] [Indexed: 12/19/2022]
Abstract
Background/Objectives It is not known if diets lower in greenhouse gas (GHG) emissions are also healthier. We evaluated the population health implications of changing to more sustainable diets in the UK, France, Finland, Italy and Sweden. Subjects/Methods We developed a life table model to simulate mortality and morbidity from diet-related diseases over the lifetime of the current population. Populating the model with locally available data for each country, we simulated the impact of country-specific dietary scenarios that had been optimised to meet dietary recommendations and reduce GHG emissions. Outcome measures included a change in disease-specific deaths, life expectancy and disability-adjusted life years (DALYs). Results Diets that meet nutritional recommendations lead to substantial improvements in population health, ranging from 0.19 (95% uncertainty interval: 0.18–0.21) DALYs per person in Italy up to 0.89 (0.80–0.98) DALYs per person in Finland. Simultaneously reducing GHG emissions does not reduce the size of this impact, and in some cases produces additional health benefits. If sustainable diets can be maintained throughout adulthood, life expectancy would increase by between 2.3 (1.6–3.2) and 6.8 (5.5–8.5) months by country. However, results are sensitive to assumptions about how quickly changes in diet can influence disease, and future trends in disease. Conclusions Modelling the health impact of diets that are both nutritional and low in GHG emissions shows the potential for significant co-benefits in health and sustainability from dietary changes. Future work is needed to find effective interventions to deliver healthy sustainable diets.
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Affiliation(s)
- Linda J Cobiac
- Centre on Population Approaches for Non-Communicable Disease Prevention, Big Data Institute, Nuffield Department of Population Health, University of Oxford, Oxford, UK.
| | - Peter Scarborough
- Centre on Population Approaches for Non-Communicable Disease Prevention, Big Data Institute, Nuffield Department of Population Health, University of Oxford, Oxford, UK
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Kaur A, Scarborough P, Rayner M. Regulating health and nutrition claims in the UK using a nutrient profile model: an explorative modelled health impact assessment. Int J Behav Nutr Phys Act 2019; 16:18. [PMID: 30732626 PMCID: PMC6367824 DOI: 10.1186/s12966-019-0778-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 01/30/2019] [Indexed: 11/26/2022] Open
Abstract
Background Health-related claims (HRCs) are statements found on food packets that convey the nutritional quality of a food (nutrition claims) and/or its impact on a health outcome (health claims). The EU stated that HRCs should be regulated such that they can only appear on foods that meet a specified nutrient profile (NP). A NP model has been proposed, but not agreed by the European Commission. Methods To model the impact of HRCs on health impacts in the UK, we built a front-end model to a pre-established non-communicable-disease (NCD) scenario model, the Preventable Risk Integrated ModEl (PRIME) by combining data from a meta-analysis examining the impact of HRCs on dietary choices and a survey of pre-packaged foods examining the prevalence of HRCs and the nutritional quality of foods that carry them. These data are used to model the impact of regulating HRCs on the nutritional quality of the diet and PRIME is used to model the health outcomes associated with these changes. Two scenarios are modelled: regulating HRCs with a NP model (the FSANZ NPSC and a draft EU model) so that only foods that pass the model are eligible to carry HRCs, and reformulating HRC-carrying foods that fail the model. Results Regulating the use of HRCs with a NP model (the FSANZ NPSC) would have unclear impacts on population health and could potentially lead to less healthy diets. This is because HRCs are currently more likely to be found on products with a better nutritional profile and restricting their use could shift consumers to less healthy diets. Two hundred fifty-eight additional deaths (95% Uncertainty Intervals [UI] -6509, 8706) were predicted if foods did not change in their nutrient composition. If all foods that currently carry HRCs were reformulated to meet the NP model criteria then there would be a positive impact of using the model: (4374 deaths averted (95%UI -2569, 14,009)). The largest contributor to the uncertainty is the underpowered estimates of nutritional quality of foods with and without claims. Conclusions Regulating HRCs could result in negative health impacts, however the wide uncertainty intervals from this analysis demonstrate that a larger health impact assessment is necessary. Electronic supplementary material The online version of this article (10.1186/s12966-019-0778-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Asha Kaur
- Centre on Population Approaches for Non-Communicable Disease Prevention, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Headington, Oxford, OX3 7LF, UK.
| | - Peter Scarborough
- Centre on Population Approaches for Non-Communicable Disease Prevention, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Headington, Oxford, OX3 7LF, UK
| | - Mike Rayner
- Centre on Population Approaches for Non-Communicable Disease Prevention, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Headington, Oxford, OX3 7LF, UK
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Wilson N, Tucker A, Heath D, Scarborough P. Licence to swill: James Bond's drinking over six decades. Med J Aust 2018; 209:495-500. [PMID: 30521444 DOI: 10.5694/mja18.00947] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2018] [Accepted: 09/14/2018] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To describe the patterns of alcohol use in James Bond movies over six decades. DESIGN Film content analysis. SETTING Wide range of international locations in 24 James Bond movies (Eon Productions series, 1962-2015). MAIN OUTCOME MEASURES Drinking episodes for Bond and major female characters; alcohol product placement in films; peak estimated blood alcohol concentrations; features relevant to DSM-5 criteria for alcohol use disorder. RESULTS Bond has drunk heavily and consistently across six decades (109 drinking events; mean, 4.5 events per movie). His peak blood alcohol level was estimated to have been 0.36 g/dL, sufficient to kill some people. We classified him as having severe alcohol use disorder, as he satisfied six of 11 DSM-5 criteria for this condition. Chronic risks for Bond include frequently drinking prior to fights, driving vehicles (including in chases), high stakes gambling, operating complex machinery or devices, contact with dangerous animals, extreme athletic performance, and sex with enemies, sometimes with guns or knives in the bed. Notable trends during the study period included a decline in using alcohol as a weapon (P = 0.023) and an increase in the number of alcohol products in his environment (for alcohol-related product placement: P < 0.001), but his martini consumption has been steady. Drinking by lead female characters and a random selection of 30 of his sexual partners was fairly stable over time, but also occasionally involved binges. CONCLUSIONS James Bond has a severe chronic alcohol problem. He should consider seeking professional help and find other strategies for managing on-the-job stress.
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Affiliation(s)
- Nick Wilson
- University of Otago, Wellington, New Zealand
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45
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Springmann M, Mason-D’Croz D, Robinson S, Wiebe K, Godfray HCJ, Rayner M, Scarborough P. Health-motivated taxes on red and processed meat: A modelling study on optimal tax levels and associated health impacts. PLoS One 2018; 13:e0204139. [PMID: 30399152 PMCID: PMC6219766 DOI: 10.1371/journal.pone.0204139] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Accepted: 09/03/2018] [Indexed: 01/04/2023] Open
Abstract
Background The consumption of red and processed meat has been associated with increased mortality from chronic diseases, and as a result, it has been classified by the World Health Organization as carcinogenic (processed meat) and probably carcinogenic (red meat) to humans. One policy response is to regulate red and processed meat consumption similar to other carcinogens and foods of public health concerns. Here we describe a market-based approach of taxing red and processed meat according to its health impacts. Methods We calculated economically optimal tax levels for 149 world regions that would account for (internalize) the health costs associated with ill-health from red and processed meat consumption, and we used a coupled modelling framework to estimate the impacts of optimal taxation on consumption, health costs, and non-communicable disease mortality. Health impacts were estimated using a global comparative risk assessment framework, and economic responses were estimated using international data on health costs, prices, and price elasticities. Findings The health-related costs to society attributable to red and processed meat consumption in 2020 amounted to USD 285 billion (sensitivity intervals based on epidemiological uncertainty (SI), 93–431), three quarters of which were due to processed meat consumption. Under optimal taxation, prices for processed meat increased by 25% on average, ranging from 1% in low-income countries to over 100% in high-income countries, and prices for red meat increased by 4%, ranging from 0.2% to over 20%. Consumption of processed meat decreased by 16% on average, ranging from 1% to 25%, whilst red meat consumption remained stable as substitution for processed meat compensated price-related reductions. The number of deaths attributable to red and processed meat consumption decreased by 9% (222,000; SI, 38,000–357,000), and attributable health costs decreased by 14% (USD 41 billion; SI, 10–57) globally, in each case with greatest reductions in high and middle-income countries. Interpretation Including the social health cost of red and processed meat consumption in the price of red and processed meat could lead to significant health and environmental benefits, in particular in high and middle-income countries. The optimal tax levels estimated in this study are context-specific and can complement the simple rules of thumb currently used for setting health-motivated tax levels.
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Affiliation(s)
- Marco Springmann
- Oxford Martin Programme on the Future of Food, University of Oxford, Oxford, United Kingdom
- Centre on Population Approaches for Non-Communicable Disease Prevention, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
- * E-mail:
| | - Daniel Mason-D’Croz
- Environment and Production Technology Division, International Food Policy Research Institute (IFPRI), Washington, DC, United States of America
- Agriculture and Food, Commonwealth Scientific and Industrial Research Organisation (CSIRO), St Lucia, Queensland, Australia
| | - Sherman Robinson
- Environment and Production Technology Division, International Food Policy Research Institute (IFPRI), Washington, DC, United States of America
| | - Keith Wiebe
- Environment and Production Technology Division, International Food Policy Research Institute (IFPRI), Washington, DC, United States of America
| | - H. Charles J. Godfray
- Oxford Martin Programme on the Future of Food, University of Oxford, Oxford, United Kingdom
- Department of Zoology, University of Oxford, Oxford, United Kingdom
| | - Mike Rayner
- Oxford Martin Programme on the Future of Food, University of Oxford, Oxford, United Kingdom
- Centre on Population Approaches for Non-Communicable Disease Prevention, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Peter Scarborough
- Oxford Martin Programme on the Future of Food, University of Oxford, Oxford, United Kingdom
- Centre on Population Approaches for Non-Communicable Disease Prevention, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
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Springmann M, Sacks G, Ananthapavan J, Scarborough P. Carbon pricing of food in Australia: an analysis of the health, environmental and public finance impacts. Aust N Z J Public Health 2018; 42:523-529. [DOI: 10.1111/1753-6405.12830] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Revised: 04/01/2018] [Accepted: 07/01/2018] [Indexed: 01/04/2023] Open
Affiliation(s)
- Marco Springmann
- Nuffield Department of Population Health; University of Oxford, United Kingdom of Great Britain and Northern Ireland
| | - Gary Sacks
- Global Obesity Centre; Deakin University; Victoria
| | - Jaithri Ananthapavan
- Global Obesity Centre; Deakin University; Victoria
- Deakin Health Economics; Deakin University; Victoria
| | - Peter Scarborough
- Nuffield Department of Population Health; University of Oxford, United Kingdom of Great Britain and Northern Ireland
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Springmann M, Wiebe K, Mason-D'Croz D, Sulser TB, Rayner M, Scarborough P. Health and nutritional aspects of sustainable diet strategies and their association with environmental impacts: a global modelling analysis with country-level detail. Lancet Planet Health 2018; 2:e451-e461. [PMID: 30318102 PMCID: PMC6182055 DOI: 10.1016/s2542-5196(18)30206-7] [Citation(s) in RCA: 321] [Impact Index Per Article: 53.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 09/05/2018] [Accepted: 09/13/2018] [Indexed: 05/03/2023]
Abstract
BACKGROUND Sustainable diets are intended to address the increasing health and environmental concerns related to food production and consumption. Although many candidates for sustainable diets have emerged, a consistent and joint environmental and health analysis of these diets has not been done at a regional level. Using an integrated health and environmental modelling framework for more than 150 countries, we examined three different approaches to sustainable diets motivated by environmental, food security, and public health objectives. METHODS In this global modelling analysis, we combined analyses of nutrient levels, diet-related and weight-related chronic disease mortality, and environmental impacts for more than 150 countries in three sets of diet scenarios. The first set, based on environmental objectives, replaced 25-100% of animal-source foods with plant-based foods. The second set, based on food security objectives, reduced levels of underweight, overweight, and obesity by 25-100%. The third set, based on public health objectives, consisted of four energy-balanced dietary patterns: flexitarian, pescatarian, vegetarian, and vegan. In the nutrient analysis, we calculated nutrient intake and changes in adequacy based on international recommendations and a global dataset of nutrient content and supply. In the health analysis, we estimated changes in mortality using a comparative risk assessment with nine diet and weight-related risk factors. In the environmental analysis, we combined country-specific and food group-specific footprints for greenhouse gas emissions, cropland use, freshwater use, nitrogen application, and phosphorus application to analyse the relationship between the health and environmental impacts of dietary change. FINDINGS Following environmental objectives by replacing animal-source foods with plant-based ones was particularly effective in high-income countries for improving nutrient levels, lowering premature mortality (reduction of up to 12% [95% CI 10-13] with complete replacement), and reducing some environmental impacts, in particular greenhouse gas emissions (reductions of up to 84%). However, it also increased freshwater use (increases of up to 16%) and had little effectiveness in countries with low or moderate consumption of animal-source foods. Following food-security objectives by reducing underweight and overweight led to similar reductions in premature mortality (reduction of up to 10% [95% CI 9-11]), and moderately improved nutrient levels. However, it led to only small reductions in environmental impacts at the global level (all impacts changed by <15%), with reduced impacts in high-income and middle-income countries, and increased resource use in low-income countries. Following public health objectives by adopting energy-balanced, low-meat dietary patterns that are in line with available evidence on healthy eating led to an adequate nutrient supply for most nutrients, and large reductions in premature mortality (reduction of 19% [95% CI 18-20] for the flexitarian diet to 22% [18-24] for the vegan diet). It also markedly reduced environmental impacts globally (reducing greenhouse gas emissions by 54-87%, nitrogen application by 23-25%, phosphorus application by 18-21%, cropland use by 8-11%, and freshwater use by 2-11%) and in most regions, except for some environmental domains (cropland use, freshwater use, and phosphorus application) in low-income countries. INTERPRETATION Approaches for sustainable diets are context specific and can result in concurrent reductions in environmental and health impacts globally and in most regions, particularly in high-income and middle-income countries, but they can also increase resource use in low-income countries when diets diversify. A public health strategy focused on improving energy balance and dietary changes towards predominantly plant-based diets that are in line with evidence on healthy eating is a suitable approach for sustainable diets. Updating national dietary guidelines to reflect the latest evidence on healthy eating can by itself be important for improving health and reducing environmental impacts and can complement broader and more explicit criteria of sustainability. FUNDING Wellcome Trust, EAT, CGIAR, and British Heart Foundation.
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Affiliation(s)
- Marco Springmann
- Oxford Martin Programme on the Future of Food and Centre on Population Approaches for Non-Communicable Disease Prevention, Nuffield Department of Population Health, University of Oxford, Oxford, UK.
| | - Keith Wiebe
- Environment and Production Technology Division, International Food Policy Research Institute, Washington, DC, USA
| | - Daniel Mason-D'Croz
- Environment and Production Technology Division, International Food Policy Research Institute, Washington, DC, USA; Global Food and Nutrition Security Group, Commonwealth Scientific and Industrial Research Organisation, St Lucia, QLD, Australia
| | - Timothy B Sulser
- Environment and Production Technology Division, International Food Policy Research Institute, Washington, DC, USA
| | - Mike Rayner
- Oxford Martin Programme on the Future of Food and Centre on Population Approaches for Non-Communicable Disease Prevention, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Peter Scarborough
- Oxford Martin Programme on the Future of Food and Centre on Population Approaches for Non-Communicable Disease Prevention, Nuffield Department of Population Health, University of Oxford, Oxford, UK
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Godfray HCJ, Aveyard P, Garnett T, Hall JW, Key TJ, Lorimer J, Pierrehumbert RT, Scarborough P, Springmann M, Jebb SA. Meat consumption, health, and the environment. Science 2018; 361:361/6399/eaam5324. [PMID: 30026199 DOI: 10.1126/science.aam5324] [Citation(s) in RCA: 587] [Impact Index Per Article: 97.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2018] [Accepted: 06/05/2018] [Indexed: 12/14/2022]
Abstract
Both the global average per capita consumption of meat and the total amount of meat consumed are rising, driven by increasing average individual incomes and by population growth. The consumption of different types of meat and meat products has substantial effects on people's health, and livestock production can have major negative effects on the environment. Here, we explore the evidence base for these assertions and the options policy-makers have should they wish to intervene to affect population meat consumption. We highlight where more research is required and the great importance of integrating insights from the natural and social sciences.
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Affiliation(s)
- H Charles J Godfray
- Oxford Martin Programme on the Future of Food, Oxford Martin School, University of Oxford, 34 Broad Street, Oxford OX1 3BD, UK. .,Department of Zoology, University of Oxford, South Parks Road, Oxford OX1 3PS, UK
| | - Paul Aveyard
- Oxford Martin Programme on the Future of Food, Oxford Martin School, University of Oxford, 34 Broad Street, Oxford OX1 3BD, UK.,Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford OX2 6GG, UK.,NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford OX4 2PG, UK
| | - Tara Garnett
- Oxford Martin Programme on the Future of Food, Oxford Martin School, University of Oxford, 34 Broad Street, Oxford OX1 3BD, UK.,Environmental Change Institute, University of Oxford, South Parks Road, Oxford OX1 3QY, UK.,Food Climate Research Network, Environmental Change Institute, University of Oxford, South Parks Road, Oxford OX1 3QY, UK
| | - Jim W Hall
- Oxford Martin Programme on the Future of Food, Oxford Martin School, University of Oxford, 34 Broad Street, Oxford OX1 3BD, UK.,Environmental Change Institute, University of Oxford, South Parks Road, Oxford OX1 3QY, UK
| | - Timothy J Key
- Oxford Martin Programme on the Future of Food, Oxford Martin School, University of Oxford, 34 Broad Street, Oxford OX1 3BD, UK.,Cancer Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Richard Doll Building, Roosevelt Drive, Oxford OX3 7LF, UK
| | - Jamie Lorimer
- Oxford Martin Programme on the Future of Food, Oxford Martin School, University of Oxford, 34 Broad Street, Oxford OX1 3BD, UK.,School of Geography and the Environment, University of Oxford, South Parks Road, Oxford OX1 3QY, UK
| | - Ray T Pierrehumbert
- Oxford Martin Programme on the Future of Food, Oxford Martin School, University of Oxford, 34 Broad Street, Oxford OX1 3BD, UK.,Department of Physics, University of Oxford, Clarendon Laboratory, Parks Road, Oxford OX1 3PU, UK
| | - Peter Scarborough
- Oxford Martin Programme on the Future of Food, Oxford Martin School, University of Oxford, 34 Broad Street, Oxford OX1 3BD, UK.,Nuffield Department of Population Health, University of Oxford, Old Road Campus, Headington, Oxford OX3 7LF, UK
| | - Marco Springmann
- Oxford Martin Programme on the Future of Food, Oxford Martin School, University of Oxford, 34 Broad Street, Oxford OX1 3BD, UK.,Nuffield Department of Population Health, University of Oxford, Old Road Campus, Headington, Oxford OX3 7LF, UK
| | - Susan A Jebb
- Oxford Martin Programme on the Future of Food, Oxford Martin School, University of Oxford, 34 Broad Street, Oxford OX1 3BD, UK.,Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford OX2 6GG, UK
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Briggs ADM, Scarborough P, Wolstenholme J. Estimating comparable English healthcare costs for multiple diseases and unrelated future costs for use in health and public health economic modelling. PLoS One 2018; 13:e0197257. [PMID: 29795586 PMCID: PMC5967835 DOI: 10.1371/journal.pone.0197257] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 04/28/2018] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES Healthcare interventions, and particularly those in public health may affect multiple diseases and significantly prolong life. No consensus currently exists for how to estimate comparable healthcare costs across multiple diseases for use in health and public health cost-effectiveness models. We aim to describe a method for estimating comparable disease specific English healthcare costs as well as future healthcare costs from diseases unrelated to those modelled. METHODS We use routine national datasets including programme budgeting data and cost curves from NHS England to estimate annual per person costs for diseases included in the PRIMEtime model as well as age and sex specific costs due to unrelated diseases. RESULTS The 2013/14 annual cost to NHS England per prevalent case varied between £3,074 for pancreatic cancer and £314 for liver disease. Costs due to unrelated diseases increase with age except for a secondary peak at 30-34 years for women reflecting maternity resource use. CONCLUSIONS The methodology described allows health and public health economic modellers to estimate comparable English healthcare costs for multiple diseases. This facilitates the direct comparison of different health and public health interventions enabling better decision making.
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Affiliation(s)
- Adam D. M. Briggs
- Nuffield Department of Population Health, University of Oxford, Oxford, Oxfordshire, United Kingdom
- The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Lebanon, New Hampshire, United States of America
- * E-mail:
| | - Peter Scarborough
- Nuffield Department of Population Health, University of Oxford, Oxford, Oxfordshire, United Kingdom
| | - Jane Wolstenholme
- Nuffield Department of Population Health, University of Oxford, Oxford, Oxfordshire, United Kingdom
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Teasdale N, Elhussein A, Butcher F, Piernas C, Cowburn G, Hartmann-Boyce J, Saksena R, Scarborough P. Systematic review and meta-analysis of remotely delivered interventions using self-monitoring or tailored feedback to change dietary behavior. Am J Clin Nutr 2018; 107:247-256. [PMID: 29529158 PMCID: PMC5875102 DOI: 10.1093/ajcn/nqx048] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Accepted: 11/30/2017] [Indexed: 12/15/2022] Open
Abstract
Background Self-monitoring (SM) of diet and tailored feedback (TF) have been suggested as tools for changing dietary behavior. New technologies allow users to monitor behavior remotely, potentially improving reach, adherence, and outcomes. Objective We conducted a systematic literature review and meta-analysis to address the following question: are remotely delivered standalone (i.e., no human contact) interventions that use SM or TF effective in changing eating behaviors? Design Five databases were searched in October 2016 (updated in September 2017). Only randomized controlled trials published after 1990 were included. Trials could include any adult population with no history of disordered eating which delivered an SM or TF intervention without direct contact and recorded actual dietary consumption as an outcome. Three assessors independently screened the search results. Two reviewers extracted the study characteristics, intervention details, and outcomes, and assessed risk of bias using the Cochrane tool. Results were converted to standardized mean differences and incorporated into a 3-level (individuals and outcomes nested in studies) random effects meta-analysis. Results Twenty-six studies containing 21,262 participants were identified. The majority of the studies were judged to be unclear or at high risk of bias. The meta-analysis showed dietary improvement in the intervention group compared to the control group with a standardized mean difference of 0.17 (95% CI: 0.10, 0.24; P < 0.0001). The I2 statistic for the meta-analysis was 0.77, indicating substantial heterogeneity in results. A "one study removed" sensitivity analysis showed that no single study excessively influenced the results. Conclusions Standalone interventions containing self-regulatory methods have a small but significant effect on dietary behavior, and integrating these elements could be important in future interventions. However, there was substantial variation in study results that could not be explained by the characteristics we explored, and there were risk-of-bias concerns with the majority of studies.
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Affiliation(s)
| | - Ahmed Elhussein
- Medical Sciences Divisional Office, University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom
| | | | - Carmen Piernas
- Department of Primary Health Care Sciences, University of Oxford, Oxford, United Kingdom
| | - Gill Cowburn
- Centre on Population Approaches for Non-Communicable Disease Prevention, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Jamie Hartmann-Boyce
- Department of Primary Health Care Sciences, University of Oxford, Oxford, United Kingdom
| | - Rhea Saksena
- University College London Medical School, University College London, London, United Kingdom
| | - Peter Scarborough
- Centre on Population Approaches for Non-Communicable Disease Prevention, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
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