Changes in the number of new takeaway food outlets associated with adoption of management zones around schools: A natural experimental evaluation in England.

By the end of 2017, 35 local authorities (LAs) across England had adopted takeaway management zones (or "exclusion zones") around schools as a means to curb proliferation of new takeaways. In this nationwide, natural experimental study, we evaluated the impact of management zones on takeaway retail, including unintended displacement of takeaways to areas immediately beyond management zones, and impacts on chain fast-food outlets. We used uncontrolled interrupted time series analyses to estimate changes from up to six years pre- and post-adoption of takeaway management zones around schools. We evaluated three outcomes: mean number of new takeaways within management zones (and by three identified sub-types: full management, town centre exempt and time management zones); mean number on the periphery of management zones (i.e. within an additional 100 m of the edge of zones); and presence of new chain fast-food outlets within management zones. For 26 LAs, we observed an overall decrease in the number of new takeaways opening within management zones. Six years post-intervention, we observed 0.83 (95% CI -0.30, -1.03) fewer new outlets opening per LA than would have been expected in absence of the intervention, equivalent to an 81.0% (95% CI -29.1, -100) reduction in the number of new outlets. Cumulatively, 12 (54%) fewer new takeaways opened than would have been expected over the six-year post-intervention period. When stratified by policy type, effects were most prominent for full management zones and town centre exempt zones. Estimates of intervention effects on numbers of new takeaways on the periphery of management zones, and on the presence of new chain fast-food outlets within management zones, did not meet statistical significance. Our findings suggest that management zone policies were able to demonstrably curb the proliferation of new takeaways. Modelling studies are required to measure the possible population health impacts associated with this change.

NHS reference costs: a history and cautionary note.

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.

Projected health and economic impacts of sugar-sweetened beverage taxation in Germany: A cross-validation modelling study.

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.

Estimating the health impacts of sugar-sweetened beverage tax for informing policy decisions about the obesity burden in Vietnam.

BACKGROUND: Taxation on sugar-sweetened beverages (SSBs) has been adopted in more than 40 countries but remained under discussion in Vietnam. This study aimed to estimate the health impacts of different SSBs tax plans currently under discussion to provide an evidence base to inform decision-making about a SSBs tax policy in Vietnam. METHOD & FINDINGS: Five tax scenarios were modelled, representing three levels of price increase: 5%, 11% and 19-20%. Scenarios of the highest price increase were assessed across three different tax designs: ad valorem, volume-based specific tax & sugar-based specific tax. We modelled SSBs consumption in each tax scenario; how this reduction in consumption translates to a reduction in total energy intake and how this relationship in turn translates to an average change in body weight and obesity status among adults by applying the calorie-to weight conversion factor. Changes in type 2 diabetes burden were then calculated based on the change in average BMI of the modelled cohort. A Monte Carlo simulation approach was applied on the conversion factor of weight change and diabetes risk reduction for the sensitivity analysis. We found that the taxation that involved a 5% price increase gave relatively small impacts while increasing SSBs' price up to 20% appeared to impact substantially on overweight and obesity rates (reduction of 12.7% and 12.4% respectively) saving 27 million USD for direct medical cost. The greatest reduction was observed for overweight and obesity class I. The decline in overweight and obesity rates was slightly higher for women than men. CONCLUSION: This study supports the SSB tax policy in pursuit of public health benefits, especially where the tax increase involves around a 20% price increase. The health benefit and revenue gains were evident across all three tax designs with the specific tax based on sugar density achieving greatest effects.

Weight regain after behavioural weight management programmes and its impact on quality of life and cost effectiveness: Evidence synthesis and health economic analyses.

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.

Estimating BMI distributions by age and sex for local authorities in England: a small area estimation study.

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.

Estimating the potential impact of the UK government's sugar reduction programme on child and adult health: modelling study.

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.