The implications of policy modeling assumptions for the projected impact of sugar-sweetened beverage taxation on body weight and type 2 diabetes in Germany.

BACKGROUND: Evaluating sugar-sweetened beverage (SSB) taxation often relies on simulation models. We assess how assumptions about the response to SSB taxation affect the projected body weight change and subsequent health and economic impacts related to type 2 diabetes mellitus (T2DM) using Germany as an example. METHODS: In the main analysis, we estimated changes in energy intake by age and sex under a 20% value-added tax on SSBs in Germany using marginal price elasticities (PE) and applied an energy equilibrium model to predict body weight changes. We then quantified the impact of several assumption modifications: SSB own-PE adjusted for consumption (M1)/based on alternative meta-analysis (M2); SSB consumption adjusted for underreporting (M3); substitution via marginal (M4a) or adjusted (M4b) cross-PE/as % of calorie change (M4c). We also assessed scenarios with alternative tax rates of 10% (S1) or 30% (S2) and including fruit juice (S3). We calculated overweight and obesity rates per modification and scenario. We simulated the impact on T2DM, associated healthcare costs, and disability-adjusted life years (DALYs) over the lifetime of the 2011 German adult population with a Markov model. Data included official demographics, national surveys, and meta-analyses. RESULTS: A 20% value-added tax in Germany could reduce the number of men and women with obesity by 210,800 [138,800; 294,100] and 80,800 [45,100; 123,300], respectively. Over the population's lifetime, this would lead to modest T2DM-related health and economic impacts (76,700 DALYs [42,500; 120,600] averted; €2.37 billion [1.33; 3.71] costs saved). Policy impacts varied highly across modifications (all in DALYs averted): (M1) 94,800 [51,500; 150,700]; (M2) 164,200 [99,500; 243,500]; (M3) 52,600 [22,500; 91,100]; (M4a) -18,100 [-111,500; 68,300]; (M4b) 25,800 [-31,400; 81,500]; (M4c) 46,700 [25,300; 77,200]. The variability in policy impact related to modifications was similar to the variability between alternative policy scenarios (all in DALYs averted): (S1) 26,400 [9,300; 47,600]; (S2) 126,200 [73,600; 194,500]; (S3) 342,200 [234,200; 430,400]. CONCLUSIONS: Predicted body weight reductions under SSB taxation are sensitive to assumptions by researchers often needed due to data limitations. Because this variability propagates to estimates of health and economic impacts, the resulting structural uncertainty should be considered when using results in decision-making.

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.

Association of eating motives with anthropometry, body composition, and dietary intake in healthy German adults.

Effective policies to address poor food choices and dietary patterns need to consider the complex set of motives affecting eating behavior. This study examined how different eating motives are associated with anthropometry, body composition, and dietary intake. Our analysis is based on a cross-sectional sample with 429 healthy adults in three different age groups collected in Germany from 2016 to 2018. Dietary intake, Body Mass Index (BMI), waist circumference (WC), and fat-free mass (FFM) were measured by standardized methods. Eating motives were measured using The Eating Motivation Scale (TEMS). Regressing dietary intakes and anthropometric indicators on TEMS motives, we identify the main sources of variation in diet and nutritional status separately for men and women. Results indicated the Health motive to be positively associated with FFM (B±SE=1.72±0.44) and negatively with WC (B±SE=-3.23±0.81) for men. For women, the Need & Hunger motive was positively associated with FFM (B±SE=1.63±0.44) and negatively with WC (B±SE=-2.46±0.81). While Liking and Habits were the most frequently stated eating motives, we did not find them to be significantly related to the nutritional status. Other motives were associated with dietary intake but not anthropometry or body composition. The Price motive was positively and the Convenience motive was negatively associated with energy (B±SE=63.77±19.98;B±SE=-46.96±17.12) and carbohydrate intake (B±SE=7.15±2.65;B±SE=-5.98±2.27) for men. The results highlight the need for more differentiated analyses of eating motives, beyond comparing the relative importance of motives based on mean values, towards the association of motives with dietary intake and nutritional status.

A soft pillow for hard times? Economic insecurity, food intake and body weight in Russia.

This study investigates causal effects of economic insecurity on subjective anxiety, food intake, and weight outcomes. A review of psychological and nutrition studies highlights the complexity of processes at work on each stage of this causal chain. Econometric analyses trace the effects along the hypothesized pathway using detailed household panel data from the Russia Longitudinal Monitoring Survey from 1994 to 2005. Economic insecurity measures serve as key explanatory variables in regressions and are instrumented by exogenous regional indicators. Results support a causal chain from economic insecurity to weight outcomes for some population subgroups. In contrast to the leading hypothesis that economic insecurity increases body weight, I find strong evidence of a decreasing effect among women. Results suggest further that consumption of foods rich in sugar responds strongly to higher levels of economic insecurity. Heterogeneous impacts of economic insecurity on body weight call for individual-level interventions rather than large-scale action.

How (much) do food prices contribute to obesity in Russia?

High BMI and obesity contribute to the Russian health crisis. Previous studies have shown that weight status varies along socioeconomic lines but remains largely unaffected by economic shocks over time. This study is the first that explicitly analyses the impact of food prices on adult BMI and obesity in the Russian Federation. Using panel data from the Russia Longitudinal Monitoring Survey from 1994 to 2005, that included 10,551 urban respondents over 18 years, a reduced form weight demand function is estimated. Controlling for individual heterogeneity by a fixed-effects model, price-weight elasticities are derived. The main result is that food prices are not the essential determinants of BMI and obesity in Russia. Elasticities of BMI with respect to single food prices are low and show absolute values smaller than 0.01. However, some products like chicken meat, milk, onions and butter show significant price effects on body mass. A 20% increase in the price of chicken meat would cause a reduction in body weight of 112 g on average. In contrast to the United States, it is mainly high-income households that show significant weight reactions to food prices in Russia. Separate regressions by gender showed significant effects of milk and butter prices on male BMI and of onion prices on female BMI. The risk of being obese is even less affected by price.