Advanced policy options to regulate sugar-sweetened beverages to support public health

Need for specific sugar-sweetened beverage lessons for fourth- and fifth-graders

OBJECTIVE

Consumption of sugar-sweetened beverages (SSB) is linked to obesity. The authors hypothesized that school-based nutrition education would decrease SSB consumption.

DESIGN

Self-selected interventional cohort with random selection for pre and post measurements.

SETTING

Arizona Supplemental Nutrition Assistance Program-Education Program-eligible schools.

PARTICIPANTS

Randomly selected (9%) fourth- and fifth-grade classroom students.

INTERVENTION

The University of Arizona Nutrition Network provided general nutrition education training and materials to teachers, to be delivered to their students. The University of Arizona Nutrition Network administered behavioral questionnaires to students in both fall and spring.

MAIN OUTCOME MEASURE(S)

Change in SSB consumption.

ANALYSES

Descriptive statistics were computed for student demographics and beverage consumption on the day before testing. Paired t tests evaluated change in classroom averages. Linear regression assessed potential correlates of SSB consumption.

RESULTS

Fall mean SSB consumption was 1.1 (± 0.2) times; mean milk and water intake were 1.6 (± 0.2) and 5.2 (± 0.7) times, respectively. Beverage consumption increased (3.2%) in springtime, with increased SSBs (14.4%) accounting for the majority (P = .006). Change in SSB consumption was negatively associated with baseline SSB and water consumption but positively associated with baseline milk fat (P ≤ .05).

CONCLUSIONS AND IMPLICATIONS

The results suggest the need for beverage-specific education to encourage children to consume more healthful beverages in warmer weather.

Healthy food subsidies and unhealthy food taxation: A systematic review of the evidence

The Global Burden of Disease Study and related studies report unhealthy diet is the leading risk for death and disability globally. Given the evidence associating diet and non-communicable diseases (NCDs), international and national health bodies including the World Health Organization and United Nations have called for population health interventions to improve diet as a means to target NCDs. One of the proposed interventions is to ensure healthy foods/beverages are more accessible to purchasers and unhealthy ones less accessible via fiscal policy, namely taxation and subsidies. The objective of this systematic review was to evaluate the evidence base to assess the effect of healthy food/beverage subsidies and unhealthy food/beverage taxation. A comprehensive review was conducted by searching PubMed, Medline, and Google Scholar for peer-reviewed publications and seventy-eight studies were identified for inclusion in this review. This review was performed in keeping with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidance. Although moderate in quality, there was consistent evidence that taxation and subsidy intervention influenced dietary behaviors. The quality, level and strength of evidence along with identified gaps in research support the need for further policies and ongoing evaluation of population-wide food/beverage subsidies and taxation. To maximize success and effect, this review suggests that food taxes and subsidies should be a minimum of 10 to 15% and preferably used in tandem. Implementation of population-wide polices for taxation and subsides with ongoing evaluation of intended and unintended effects are supported by this review.

Soda and cell aging: associations between sugar-sweetened beverage consumption and leukocyte telomere length in healthy adults from the National Health and Nutrition Examination Surveys

OBJECTIVES

We tested whether leukocyte telomere length maintenance, which underlies healthy cellular aging, provides a link between sugar-sweetened beverage (SSB) consumption and the risk of cardiometabolic disease.

METHODS

We examined cross-sectional associations between the consumption of SSBs, diet soda, and fruit juice and telomere length in a nationally representative sample of healthy adults. The study population included 5309 US adults, aged 20 to 65 years, with no history of diabetes or cardiovascular disease, from the 1999 to 2002 National Health and Nutrition Examination Surveys. Leukocyte telomere length was assayed from DNA specimens. Diet was assessed using 24-hour dietary recalls. Associations were examined using multivariate linear regression for the outcome of log-transformed telomere length.

RESULTS

After adjustment for sociodemographic and health-related characteristics, sugar-sweetened soda consumption was associated with shorter telomeres (b = -0.010; 95% confidence interval [CI] = -0.020, -0.001; P = .04). Consumption of 100% fruit juice was marginally associated with longer telomeres (b = 0.016; 95% CI = -0.000, 0.033; P = .05). No significant associations were observed between consumption of diet sodas or noncarbonated SSBs and telomere length.

CONCLUSIONS

Regular consumption of sugar-sweetened sodas might influence metabolic disease development through accelerated cell aging.

How state taxes and policies targeting soda consumption modify the association between school vending machines and student dietary behaviors: a cross-sectional analysis

Background

Sodas are widely sold in vending machines and other school venues in the United States, particularly in high school. Research suggests that policy changes have reduced soda access, but the impact of reduced access on consumption is unclear. This study was designed to identify student, environmental, or policy characteristics that modify the associations between school vending machines and student dietary behaviors.

Methods

Data on school vending machine access and student diet were obtained as part of the National Youth Physical Activity and Nutrition Study (NYPANS) and linked to state-level data on soda taxes, restaurant taxes, and state laws governing the sale of soda in schools. Regression models were used to: 1) estimate associations between vending machine access and soda consumption, fast food consumption, and lunch source, and 2) determine if associations were modified by state soda taxes, restaurant taxes, laws banning in-school soda sales, or student characteristics (race/ethnicity, sex, home food access, weight loss behaviors.)

Results

Contrary to the hypothesis, students tended to consume 0.53 fewer servings of soda/week (95% CI: -1.17, 0.11) and consume fast food on 0.24 fewer days/week (95% CI: -0.44, -0.05) if they had in-school access to vending machines. They were also less likely to consume soda daily (23.9% vs. 27.9%, average difference = -4.02, 95% CI: -7.28, -0.76). However, these inverse associations were observed primarily among states with lower soda and restaurant tax rates (relative to general food tax rates) and states that did not ban in-school soda sales. Associations did not vary by any student characteristics except for weight loss behaviors.

Conclusion

Isolated changes to the school food environment may have unintended consequences unless policymakers incorporate other initiatives designed to discourage overall soda consumption.

Americans' opinions about policies to reduce consumption of sugar-sweetened beverages

OBJECTIVE

Strategies to reduce consumption of sugar-sweetened beverages are a key component of public health promotion and obesity prevention, yet the introduction of many of these policies has been met with political controversy. The objective of this study is to assess the levels of and determinants of U.S. public support for policies to reduce consumption of sugar-sweetened beverages.

METHODS

An Internet-based survey (N=1319) was fielded with a nationally-representative sample of U.S. adults aged 18-64 during fall 2012.

RESULTS

Respondents have the highest support for calorie labeling (65%) and removing drinks from schools (62%), and the lowest support for taxes (22%) or portion size restrictions (26%). Examining several determinants of support simultaneously, Democrats and those with negative views of soda companies are more likely to support these policies.

CONCLUSIONS

The results provide policymakers and advocates with insights about the political feasibility of policy approaches to address the prevalent consumption of sugar-sweetened beverages, as well as the role of attitudes toward soda companies as an independent predictor of the public's opinions.

Sugary beverage tax policy: lessons learned from tobacco

Excise taxes on sugary beverages have been proposed as a method to replicate the public health success of tobacco control and to generate revenue. As policymakers increase efforts to pass sugary beverage taxes, they can anticipate that manufacturers will emulate the strategies employed by tobacco companies in their attempts to counteract the impact of such taxes. Policymakers should therefore consider 2 complementary laws-minimum price laws and prohibitions on coupons and discounting-to accomplish the intended price increase.

Greenhouse gas emissions and the Australian diet--comparing dietary recommendations with average intakes

Nutrition guidelines now consider the environmental impact of food choices as well as maintaining health. In Australia there is insufficient data quantifying the environmental impact of diets, limiting our ability to make evidence-based recommendations. This paper used an environmentally extended input-output model of the economy to estimate greenhouse gas emissions (GHGe) for different food sectors. These data were augmented with food intake estimates from the 1995 Australian National Nutrition Survey. The GHGe of the average Australian diet was 14.5 kg carbon dioxide equivalents (CO2e) per person per day. The recommended dietary patterns in the Australian Dietary Guidelines are nutrient rich and have the lowest GHGe (~25% lower than the average diet). Food groups that made the greatest contribution to diet-related GHGe were red meat (8.0 kg CO2e per person per day) and energy-dense, nutrient poor "non-core" foods (3.9 kg CO2e). Non-core foods accounted for 27% of the diet-related emissions. A reduction in non-core foods and consuming the recommended serves of core foods are strategies which may achieve benefits for population health and the environment. These data will enable comparisons between changes in dietary intake and GHGe over time, and provide a reference point for diets which meet population nutrient requirements and have the lowest GHGe.

Evidence that a tax on sugar sweetened beverages reduces the obesity rate: a meta-analysis

BACKGROUND

Excess intake of sugar sweetened beverages (SSBs) has been shown to result in weight gain. To address the growing epidemic of obesity, one option is to combine programmes that target individual behaviour change with a fiscal policy such as excise tax on SSBs. This study evaluates the literature on SSB taxes or price increases, and their potential impact on consumption levels, obesity, overweight and body mass index (BMI). The possibility of switching to alternative drinks is also considered.

METHODS

The following databases were used: Pubmed/Medline, The Cochrane Database of Systematic Reviews, Google Scholar, Econlit, National Bureau of Economics Research (NBER), Research Papers in Economics (RePEc). Articles published between January 2000 and January 2013, which reported changes in diet or BMI, overweight and/or obesity due to a tax on, or price change of, SSBs were included.

RESULTS

Nine articles met the criteria for the meta-analysis. Six were from the USA and one each from Mexico, Brazil and France. All showed negative own-price elasticity, which means that higher prices are associated with a lower demand for SSBs. Pooled own price-elasticity was -1.299 (95% CI: -1.089 - -1.509). Four articles reported cross-price elasticities, three from the USA and one from Mexico; higher prices for SSBs were associated with an increased demand for alternative beverages such as fruit juice (0.388, 95% CI: 0.009 - 0.767) and milk (0.129, 95% CI: -0.085 - 0.342), and a reduced demand for diet drinks (-0.423, 95% CI: -0.628 - -1.219). Six articles from the USA showed that a higher price could also lead to a decrease in BMI, and decrease the prevalence of overweight and obesity.

CONCLUSIONS

Taxing SSBs may reduce obesity. Future research should estimate price elasticities in low- and middle-income countries and identify potential health gains and the wider impact on jobs, monetary savings to the health sector, implementation costs and government revenue. Context-specific cost-effectiveness studies would allow policy makers to weigh these factors.

Overall and income specific effect on prevalence of overweight and obesity of 20% sugar sweetened drink tax in UK: econometric and comparative risk assessment modelling study

OBJECTIVE

To model the overall and income specific effect of a 20% tax on sugar sweetened drinks on the prevalence of overweight and obesity in the UK.

DESIGN

Econometric and comparative risk assessment modelling study.

SETTING

United Kingdom.

POPULATION

Adults aged 16 and over.

INTERVENTION

A 20% tax on sugar sweetened drinks.

MAIN OUTCOME MEASURES

The primary outcomes were the overall and income specific changes in the number and percentage of overweight (body mass index ≥ 25) and obese (≥ 30) adults in the UK following the implementation of the tax. Secondary outcomes were the effect by age group (16-29, 30-49, and ≥ 50 years) and by UK constituent country. The revenue generated from the tax and the income specific changes in weekly expenditure on drinks were also estimated.

RESULTS

A 20% tax on sugar sweetened drinks was estimated to reduce the number of obese adults in the UK by 1.3% (95% credible interval 0.8% to 1.7%) or 180,000 (110,000 to 247,000) people and the number who are overweight by 0.9% (0.6% to 1.1%) or 285,000 (201,000 to 364,000) people. The predicted reductions in prevalence of obesity for income thirds 1 (lowest income), 2, and 3 (highest income) were 1.3% (0.3% to 2.0%), 0.9% (0.1% to 1.6%), and 2.1% (1.3% to 2.9%). The effect on obesity declined with age. Predicted annual revenue was £276m (£272m to £279m), with estimated increases in total expenditure on drinks for income thirds 1, 2, and 3 of 2.1% (1.4% to 3.0%), 1.7% (1.2% to 2.2%), and 0.8% (0.4% to 1.2%).

CONCLUSIONS

A 20% tax on sugar sweetened drinks would lead to a reduction in the prevalence of obesity in the UK of 1.3% (around 180,000 people). The greatest effects may occur in young people, with no significant differences between income groups. Both effects warrant further exploration. Taxation of sugar sweetened drinks is a promising population measure to target population obesity, particularly among younger adults.

Taxing junk food to counter obesity

We examined the advantages and disadvantages of implementing a junk food tax as an intervention to counter increasing obesity in North America. Small excise taxes are likely to yield substantial revenue but are unlikely to affect obesity rates. High excise taxes are likely to have a direct impact on weight in at-risk populations but are less likely to be politically palatable or sustainable. Ultimately, the effectiveness of earmarked health programs and subsidies is likely to be a key determinant of tax success in the fight against obesity.

Obesity Prevention Policies in U.S. States and Localities: Lessons from the Field

Obesity is a complex problem requiring large-scale, population-based solutions. Public policy strategies have been identified as critical tools in obesity prevention efforts as they can benefit all who are exposed rather than simply changing individual behaviors one at a time. This paper reviews the peer-reviewed scientific U.S.-based literature published between January 2012 and March 2013 to examine the influence of state laws and local policies on changes to school and other environments, individual activity and nutrition-related behaviors, and obesity and weight outcomes. Virtually all recent studies have focused on policies directed at the school environment and, across-the board, the evidence was mixed. Most studies were cross-sectional, focused on policy implementation in schools and other settings rather than impacts on individual behaviors or obesity. Opportunities exist for impact studies focusing on a broader spectrum of policies as well as for continued policy actions at all levels of government.

Energy drinks: an emerging public health hazard for youth

Energy drinks are emerging as a public health threat and are increasingly consumed by youth internationally. Energy drinks contain high levels of caffeine, sugar, and novel ingredients, and are often marketed through youth-oriented media and venues. We review these practices and the current inconsistent state of labeling. We also examine international support for regulation of these products, including a survey showing that 85 per cent of United States parents agreed that regulations requiring caffeine content disclosure and warning labels on energy drinks are warranted. We then examine the regulatory structure for energy drinks in the United States, analyzing legal and self-regulatory strategies to protect consumers, especially youth, from these potentially dangerous products. Recommended government interventions include revised labeling requirements, addressing problematic ingredients, and enacting retail restrictions. We conclude by identifying areas for future research.

Adolescent caffeine consumption and self-reported violence and conduct disorder

Caffeine is the most widely used psychoactive substance in the world and currently the only one legally available to children and adolescents. The sale and use of caffeinated beverages has increased markedly among adolescents during the last decade. However, research on caffeine use and behaviors among adolescents is scarce. We investigate the relationship between adolescent caffeine use and self-reported violent behaviors and conduct disorders in a population-based cross-sectional sample of 3,747 10th grade students (15-16 years of age, 50.2 % girls) who were enrolled in the Icelandic national education system during February 2012. Through a series of multiple regression models, while controlling for background factors, Attention Deficit Hyperactivity Disorder symptoms and current medication and peer delinquency, and including measures on substance use, our findings show robust additive explanatory power of caffeine for both violent behaviors and conduct disorders. In addition, the association of caffeine to the outcomes is significantly stronger for girls than boys for both violent behaviors and conduct disorders. Future studies are needed to examine to what extent, if at all, these relationships are causal. Indication of causal connections between caffeine consumption and negative outcomes such as those reported here would call into question the acceptability of current policies concerning the availability of caffeine to adolescents and the targeting of adolescence in the marketing of caffeine products.

Cost-Effectiveness of Fiscal Policies to Prevent Obesity

Cost-effective, sustainable strategies are urgently required to curb the global obesity epidemic. To date, fiscal policies such as taxes and subsidies have been driven largely by imperatives to raise revenue or increase supply, rather than to change population behaviours. This paper reviews the economic evaluation literature around the use of fiscal policies to prevent obesity. The cost-effectiveness literature is limited, and more robust economic evaluation studies are required. However, uncertainty and gaps in the effectiveness evidence base need to be addressed first: more studies are needed that collect 'real-world' empirical data, and larger studies with more robust designs and longer follow-up timeframes are required. Reliability of cross-price elasticity data needs to be investigated, and greater consideration given to moderators of intervention effects and the sustainability of outcomes. Economic evaluations should adopt a societal perspective, incorporate a broader spectrum of economic costs and consider other factors likely to affect the implementation of fiscal measures. The paucity of recent cost-effectiveness studies means that definitive conclusions about the value for money of fiscal policies for obesity prevention cannot yet be drawn. However, as in other public health areas such as alcohol and tobacco, early indications are that population-level fiscal policies are likely to be potentially effective and cost-saving.

The bittersweet truth about sugar labeling regulations: they are achievable and overdue

The recent Institute of Medicine recommendation to the Food and Drug Administration to include added sugar in a new front-of-package system provides new justification for reviewing outdated regulations pertinent to sugar and analyzing whether the government's previous resistance to sugar labeling remains valid given new and robust science. I have provided an overview of US sugar consumption, its public health implications, and the science related to added sugar detection. I reviewed US and international sugar intake recommendations and suggested revised regulations to better inform and protect consumers. I concluded by noting new directions in the area of sugar research for future public health policy.