Changes in household food and drink purchases following restrictions on the advertisement of high fat, salt, and sugar products across the Transport for London network: A controlled interrupted time series analysis.

BACKGROUND: Restricting the advertisement of products with high fat, salt, and sugar (HFSS) content has been recommended as a policy tool to improve diet and tackle obesity, but the impact on HFSS purchasing is unknown. This study aimed to evaluate the impact of HFSS advertising restrictions, implemented across the London (UK) transport network in February 2019, on HFSS purchases. METHODS AND FINDINGS: Over 5 million take-home food and drink purchases were recorded by 1,970 households (London [intervention], n = 977; North of England [control], n = 993) randomly selected from the Kantar Fast Moving Consumer Goods panel. The intervention and control samples were similar in household characteristics but had small differences in main food shopper sex, socioeconomic position, and body mass index. Using a controlled interrupted time series design, we estimated average weekly household purchases of energy and nutrients from HFSS products in the post-intervention period (44 weeks) compared to a counterfactual constructed from the control and pre-intervention (36 weeks) series. Energy purchased from HFSS products was 6.7% (1,001.0 kcal, 95% CI 456.0 to 1,546.0) lower among intervention households compared to the counterfactual. Relative reductions in purchases of fat (57.9 g, 95% CI 22.1 to 93.7), saturated fat (26.4 g, 95% CI 12.4 to 40.4), and sugar (80.7 g, 95% CI 41.4 to 120.1) from HFSS products were also observed. Energy from chocolate and confectionery purchases was 19.4% (317.9 kcal, 95% CI 200.0 to 435.8) lower among intervention households than for the counterfactual, with corresponding relative reductions in fat (13.1 g, 95% CI 7.5 to 18.8), saturated fat (8.7 g, 95% CI 5.7 to 11.7), sugar (41.4 g, 95% CI 27.4 to 55.4), and salt (0.2 g, 95% CI 0.1 to 0.2) purchased from chocolate and confectionery. Relative reductions are in the context of secular increases in HFSS purchases in both the intervention and control areas, so the policy was associated with attenuated growth of HFSS purchases rather than absolute reduction in HFSS purchases. Study limitations include the lack of out-of-home purchases in our analyses and not being able to assess the sustainability of observed changes beyond 44 weeks. CONCLUSIONS: This study finds an association between the implementation of restrictions on outdoor HFSS advertising and relative reductions in energy, sugar, and fat purchased from HFSS products. These findings provide support for policies that restrict HFSS advertising as a tool to reduce purchases of HFSS products.

Evaluation of Changes in Grams of Sugar Sold After the Implementation of the Seattle Sweetened Beverage Tax.

Importance: Adults and children routinely exceed recommended intake amounts of added sugars established by dietary guidelines. Taxes are used as a policy tool to reduce demand for sugar-sweetened beverages (SSBs) given consumption-related adverse health outcomes but may induce substitution to other sources of added sugars. Objective: To examine the extent to which changes in grams of sugar sold from taxed beverages may be offset by changes in grams of sugar sold from untaxed beverages, sweets, and stand-alone sugar after the implementation of the Seattle, Washington, Sweetened Beverage Tax (SBT) on January 1, 2018. Design, Setting, and Participants: This study used difference-in-differences analyses to examine changes in grams of sugar sold from taxed and untaxed products in Seattle compared with Portland, Oregon, at year 1 and year 2 post tax. This study used Nielsen scanner data from supermarkets and mass merchandise as well as grocery, drug, convenience, and dollar stores on unit sales and measurements for beverage and food product universal product codes (UPCs) for each site for the pretax period (January 8-December 30, 2017) and the corresponding weeks in year 1 post tax (2018) and in year 2 post tax (2019). Nutritional analyses assessed grams of sugar for each UPC. The analytical balanced sample included 1326 taxed beverage UPCs, 239 untaxed beverage UPCs, 2054 sweets UPCs, and 81 stand-alone sugar UPCs. Statistical analysis was performed from January to August 2021. Exposures: Implementation of the Seattle SBT. Main Outcomes and Measures: Changes in grams of sugar sold from taxed beverages, untaxed beverages, sweets, and stand-alone sugar. Results: At both year 1 and year 2 post tax in Seattle compared with Portland, grams of sugar sold from taxed beverages decreased 23% (year 2 posttax ratio of incidence rate ratios [RIRR] = 0.77; 95% CI, 0.73-0.80). Sugar sold from untaxed beverages increased at year 1 post tax by 4% (RIRR = 1.04; 95% CI, 1.00-1.07) with no change at year 2 post tax. Sugar sold from sweets increased by 4% at both year 1 and year 2 post tax (year 2 posttax RIRR = 1.04; 95% CI, 1.03-1.06). There were no changes in stand-alone sugar sold. Conclusions and Relevance: This study using difference-in-differences analysis found a net 19% reduction in grams of sugar sold from taxed SSBs at year 2 post tax after accounting for changes in sugar sold from untaxed beverages, sweets, and stand-alone sugar. These results suggest that SSB taxes may effectively yield permanent reductions in added sugars sold from SSBs in food stores.

Health Impact and Cost-Effectiveness of Achieving the National Salt and Sugar Reduction Initiative Voluntary Sugar Reduction Targets in the United States: A Microsimulation Study.

BACKGROUND: High intake of added sugar is linked to weight gain and cardiometabolic risk. In 2018, the US National Salt and Sugar Reduction Initiative proposed government-supported voluntary national sugar reduction targets. This intervention's potential effects and cost-effectiveness are unclear. METHODS: A validated microsimulation model, CVD-PREDICT (Cardiovascular Disease Policy Model for Risk, Events, Detection, Interventions, Costs, and Trends), coded in C++, was used to estimate incremental changes in type 2 diabetes, cardiovascular disease (CVD), quality-adjusted life-years (QALYs), costs, and cost-effectiveness of the US National Salt and Sugar Reduction Initiative policy. The model was run at the individual level, incorporating the annual probability of each person's transition between health statuses on the basis of risk factors. The model incorporated national demographic and dietary data from the National Health and Nutrition Examination Survey across 3 cycles (2011 through 2016), added sugar-related diseases from meta-analyses, and policy costs and health-related costs from established sources. A simulated nationally representative US population was created and followed until age 100 years or death, with 2019 as the year of intervention start. Findings were evaluated over 10 years and a lifetime from health care and societal perspectives. Uncertainty was evaluated in a 1-way analysis by assuming 50% industry compliance and probabilistic sensitivity analyses through a second-order Monte Carlo approach. Model outputs included averted diabetes cases, CVD events and CVD deaths, QALYs gained, and formal health care cost savings, stratified by age, race, income, and education. RESULTS: Achieving the US National Salt and Sugar Reduction Initiative sugar reduction targets could prevent 2.48 million CVD events, 0.49 million CVD deaths, and 0.75 million diabetes cases; gain 6.67 million QALYs; and save $160.88 billion net costs from a societal perspective over a lifetime. The policy became cost-effective (<150 000/QALYs) at 6 years, highly cost-effective (<50 000/QALYs) at 7 years, and cost-saving at 9 years. Results were robust from a health care perspective, with lower (50%) industry compliance, and in probabilistic sensitivity analyses. The policy could also reduce disparities, with greatest estimated health gains per million adults among Black or Hispanic individuals, lower income, and less educated Americans. CONCLUSIONS: Implementing and achieving the US National Salt and Sugar Reduction Initiative sugar reformation targets could generate substantial health gains, equity gains, and cost savings.

When Industrial Policies Conflict With Population Health: Potential Impact of Removing Food Subsidies on Obesity Rates.

OBJECTIVES: To model the potential impact on obesity of removing butter, cheese, and sugar subsidies in the Canary Islands. METHODS: A simulation model was applied based on a local data set of subsidies and retail prices (2007-2016), data on own-price elasticity estimates, and representative nutritional and health surveys. We estimated marginal obesity prevalence and population attributable fraction to assess the potential impact of the butter, cheese, and sugar subsidies intervention. RESULTS: The intervention was predicted to avoid 10 363 obese adults over the study period, because of the reduction of the obesity prevalence by -0.7 percentage points. Overall, the predicted effect was largest in elderly and male groups, although females with a low socioeconomic status experienced the greatest decrease in the prevalence. The population attributable fraction predicted that 4.0% of population with obesity were attributable to the existence of these subsidies. CONCLUSIONS: This analysis provides policy makers with the predicted impact on obesity of the butter, cheese, and sugar subsidies disposal, enabling them to incorporate this health impact into decision making across policy areas in the economic and health field. This study aims to model the potential impact on obesity of removing industrial subsidies for butter, cheese and sugar in the Canary Islands.

Risk and Benefit of Natural and Commercial Dark Brown Sugars as Evidenced by Phenolic and Maillard Reaction Product Contents.

Products of dark brown sugar (DBS) from different production processes and raw materials may bring different risks and benefits to human health. Therefore, this study was aimed to evaluate the quality of natural and commercial DBS products. Results showed that physicochemical properties, including pH value, turbidity, and browning degree have no significant difference between natural and commercial DBS products. Total flavonoid content of natural DBS was found to be significantly higher than that of commercial DBS (p < 0.05). Notably, the levels of harmful Maillard reaction products in natural DBS were significantly lower than that in commercial DBS as evidenced by analyses of methylglyoxal and fluorescent advanced glycation end products (p < 0.05). However, the amount of acrylamide in natural DBS was significantly higher than that in commercial DBS. In conclusion, this study provides useful information for risk-benefit assessment of DBS products, which is helpful for food safety management.

A discourse network analysis of UK newspaper coverage of the "sugar tax" debate before and after the announcement of the Soft Drinks Industry Levy.

BACKGROUND: On 6th April 2018, the UK Government introduced the Soft Drinks Industry Levy (SDIL) as a mechanism designed to address increasing prevalence of obesity and associated ill health by reducing sugar consumption. Given that the successful introduction of upstream food and nutrition policies is a highly political enterprise involving multiple interested parties, understanding the complex network of stakeholders seeking to influence such policy decisions is imperative. METHODS: Media content analysis was used to build a dataset of relevant newspaper articles, which were analysed to identify stakeholder agreement or disagreement with defined concept statements. We used discourse network analysis to produce visual representations of the network of stakeholders and coalitions evident in the debate as it was presented in UK newspapers, in the lead up to and following the announcement of the Soft Drinks Industry Levy in the UK, from May 2015 to November 2016. RESULTS: Coding identified 3883 statements made by 214 individuals from 176 organisations, relating to 47 concepts. Network visualisations revealed a complex network of stakeholders with clear sceptical and supportive coalitions. Industry stakeholders appeared less united in the network than anticipated, particularly before the SDIL announcement. Some key industry actors appeared in the supportive coalition, possibly due to the use of corporate social responsibility rhetoric. Jamie Oliver appeared as a dominant stakeholder, firmly embedded with public health advocates. CONCLUSION: This study highlights the complexity of the network of stakeholders involved in the public debate on food policies such as sugar tax and the SDIL. Polarisation of stakeholders arose from differences in ideology, focus on a specific policy and statements about the weight of evidence. Vocal celebrity policy entrepreneurs may be instrumental in gaining public and policy makers' support for future upstream regulation to promote population health, to facilitate alignment around a clear ideology.

Development of a sweetened beverage tax, Philippines.

PROBLEM: Both sugar-sweetened beverage consumption and the incidence of obesity have increased in the Philippines in recent years. APPROACH: A proposal to tax sugar-sweetened beverages was introduced in the House of Representatives and merged into a proposed comprehensive Tax Reform for Acceleration and Inclusion (TRAIN) Bill to increase the likelihood of acceptance. The health department and finance department recommended a policy that would maximize benefits to both public health and government revenue. To advance discussions, the health department expanded the health argument to include the country's poor performance in oral health. The approved TRAIN Law adopted the term sweetened beverage to emphasize that the tax covers both sugar and non-sugar sweetened beverages. The tax rate was set to 6.00 Philippine pesos (0.111 United States dollars) per litre of sweetened beverages. The sugar industry successfully lobbied for higher tax rates on beverages containing high-fructose corn syrup, resulting in a differential rate of 12.00 Philippine pesos per litre. LOCAL SETTING: Despite a 12% value-added tax on sugar-sweetened beverages, sales had been sustained by enhanced marketing and product variants being offered in small portions. RELEVANT CHANGES: One month after implementation of the tax in 1 January 2018, prices of taxable sweetened beverages had increased by 16.6 to 20.6% and sales in sari-sari (convenience) stores had declined 8.7%. LESSONS LEARNT: The tax benefited from high-level government commitment and support, keeping policy simple reduced opportunities for tax avoidance and evasion, and taking both health and non-health considerations into account were helpful in arguing for the tax.

The palatability of sugar-sweetened beverage taxation: A content analysis of newspaper coverage of the UK sugar debate.

BACKGROUND: Excess sugar consumption, including sugar-sweetened beverages (SSBs), contributes to a variety of negative health outcomes, particularly for young people. The mass media play a powerful role in influencing public and policy-makers' perceptions of public health issues and their solutions. We analysed how sugar and SSB policy debates were presented in UK newspapers at a time of heightened awareness and following the announcement of the UK Government's soft drinks industry levy (SDIL), to inform future public health advocacy. METHODS & FINDINGS: We carried out quantitative content analysis of articles discussing the issues of sugar and SSB consumption published in 11 national newspapers from April 2015 to November 2016. 684 newspaper articles were analysed using a structured coding frame. Coverage peaked in line with evidence publication, campaigner activities and policy events. Articles predominantly supportive of SSB taxation (23.5%) outnumbered those that were predominantly oppositional (14.2%). However, oppositional articles outnumbered supportive ones in the month of the announcement of the SDIL. Sugar and SSB consumption were presented as health risks, particularly affecting young people, with the actions of industry often identified as the cause of the public health problem. Responsibility for addressing sugar overconsumption was primarily assigned to government intervention. CONCLUSION: Our results suggest that the policy landscape favouring fiscal solutions to curb sugar and SSB consumption has benefited from media coverage characterising the issue as an industry-driven problem. Media coverage may drive greater public acceptance of the SDIL and any future taxation of products containing sugar. However, future advocacy efforts should note the surge in opposition coinciding with the announcement of the SDIL, which echoes similar patterns of opposition observed in tobacco control debates.

Own-price, cross-price, and expenditure elasticities on sugar-sweetened beverages in Guatemala.

BACKGROUND: The obesity epidemic is spreading rapidly in Guatemala, a low/middle income country still struggling with undernutrition. Sugar sweetened beverages (SSBs) consumption is strongly associated with overweight, obesity, and non-communicable diseases. In Guatemala, SSBs are readily available and consumption is high, particularly among adolescents. SSB taxes have been proposed as a cost-effective way to reduce consumption and generate revenues for public health, as has been demonstrated in several countries around the world. OBJECTIVE: To estimate the price, expenditure, quality, and cross-price elasticity of beverage demand using household survey data. METHOD: We conducted a secondary analysis on the 2014 Guatemala Living Conditions National Survey that includes national representative household data on expenditure. Own price, expenditure, quality, and cross-price elasticities of milk, soft drinks, packaged juices, and bottled water were estimated using Deaton's Almost Ideal Demand System (AIDS), controlling for goods' quality. Household characteristics and beverage expenditure are summarized for urban and rural locations using descriptive statistics. RESULTS: Positive expenditure on soft drinks was highest (50.9% of households). Positive expenditure on bottled water was next for urban households (43.8%) and lowest for rural households (10.8%). Own-price elasticities for all beverages are negative and statistically significant. Own-price elasticity of soft drinks is -1.39, suggesting that with a 10% increase in price, consumption would decrease by 13.9%. Expenditure elasticity for soft drinks (0.99) suggests that a 10% household expenditure increase would result in a 9.9% increase in demand. Milk (0.07) and soft drinks (0.07) have positive quality elasticity implying that, as household total expenditure increases, the quality of these beverages, measured by their unit values, also increases. CONCLUSION: Soft drink demand is highly sensitive to changes in prices, suggesting that SSB taxes could significantly reduce consumption, which, in turn, could contribute to curbing the overweight/obesity epidemic.

A rapid review examining purchasing changes resulting from fiscal measures targeted at high sugar foods and sugar-sweetened drinks.

To aim of the review was to examine the most recent (2010 onwards) research evidence on the health and behavioural impacts, in adults and children, of fiscal strategies that target high sugar foods and sugar-sweetened drinks (SSDs). A pragmatic rapid review was undertaken using a systematic search strategy. The review was part of a programme of work to support policy development in relation to high sugar food and SSDs. A total of 11 primary research publications were included, describing evidence from France (n = 1), the Netherlands (n = 3), and the United States of America (n = 7), assessed through a variety of study designs, with the majority in adult populations (n = 10). The evidence reviewed focused on consumer behaviour outcomes and suggested that fiscal strategies can influence purchases of high sugar products. Although the majority of studies (n = 10), including three field studies, demonstrated that an increase in the price of high sugar foods and SSDs resulted in a decrease in purchases, eight studies were conducted in a laboratory or virtual setting which may not reflect real-life situations.Findings from this review support evidence from the broader literature that suggests that fiscal measures can be effective in influencing the purchasing of high sugar foods and SSDs.

Global Trends in the Affordability of Sugar-Sweetened Beverages, 1990-2016.

INTRODUCTION: The objective of this study was to quantify changes in the affordability of sugar-sweetened beverages, a product implicated as a contributor to rising rates of obesity worldwide, as a function of product price and personal income. METHODS: We used international survey data in a retrospective analysis of 40 high-income and 42 low-income and middle-income countries from 1990 to 2016. Prices of sugar-sweetened beverages were from the Economist Intelligence Unit's World Cost of Living Survey. Income and inflation data were from the International Monetary Fund's World Economic Outlook Database. The measure of affordability was the average annual percentage change in the relative-income price of sugar-sweetened beverages, which is the annual rate of change in the proportion of per capita gross domestic product needed to purchase 100 L of Coca-Cola in each country in each year of the study. RESULTS: In 79 of 82 countries, the proportion of income needed to purchase sugar-sweetened beverages declined on average (using annual measures) during the study period. This pattern, described as an increase in the affordability of sugar-sweetened beverages, indicated that sugar-sweetened beverages became more affordable more rapidly in low-income and middle-income countries than in high-income countries, a fact largely attributable to the higher rate of income growth in those countries than to a decline in the real price of sugar-sweetened beverages. CONCLUSION: Without deliberate policy action to raise prices, sugar-sweetened beverages are likely to become more affordable and more widely consumed around the world.

The impact of a tax on sugar-sweetened beverages according to socio-economic position: a systematic review of the evidence.

OBJECTIVE: A tax on sugar-sweetened beverages (SSB) has been proposed to address population weight gain but the effect across socio-economic position (SEP) is unclear. The current study aimed to clarify the differential impact(s) of SSB taxes on beverage purchases and consumption, weight outcomes and the amount paid in SSB taxes according to SEP. DESIGN: Databases (OVID and EMBASE) and grey literature were systematically searched in June 2015 to identify studies that examined effects of an SSB price increase on beverage purchases or consumption, weight outcomes or the amount paid in tax across SEP, within high-income countries. RESULTS: Of the eleven included articles, three study types were identified: (i) those that examined the association between variation in SSB taxes and SSB consumption and/or body weight (n 3); (ii) price elasticity estimation of SSB demand (n 1); and (iii) modelling of hypothetical SSB taxes by combining price elasticity estimates with population SEP-specific beverage consumption, energy intake or body weight (n 7). Few studies statistically tested differences in outcomes between SEP groups. Nevertheless, of the seven studies that reported on changes in weight outcomes for the total population following an increase in SSB price, all reported either similar reductions in weight across SEP groups or greater reductions for lower compared with higher SEP groups. All studies that examined the average household amount paid in tax (n 5) reported that an SSB tax would be regressive, but with small differences between higher- and lower-income households (0·10-1·0 % and 0·03 %-0·60 % of annual household income paid in SSB tax for low- and high-income households, respectively). CONCLUSIONS: Based on the available evidence, a tax on SSB will deliver similar population weight benefits across socio-economic strata or greater benefits for lower SEP groups. An SSB tax is shown to be consistently financially regressive, but to a small degree.