The Impact of a Tax on Sugar-Sweetened Beverages on Health and Health Care Costs: A Modelling Study

The productivity gains associated with a junk food tax and their impact on cost-effectiveness

Objective

To estimate the productivity impacts of a policy intervention on the prevention of premature mortality due to obesity.

Methods

A simulation model of the Australian population over the period from 2003 to 2030 was developed to estimate productivity gains associated with premature deaths averted due to an obesity prevention intervention that applied a 10% tax on unhealthy foods. Outcome measures were the total working years gained, and the present value of lifetime income (PVLI) gained. Impacts were modelled over the period from 2003 to 2030. Costs are reported in 2018 Australian dollars and a 3% discount rate was applied to all future benefits.

Results

Premature deaths averted due to a junk food tax accounted for over 8,000 additional working years and a $307 million increase in PVLI. Deaths averted in men between the ages of 40 to 59, and deaths averted from ischaemic heart disease, were responsible for the largest gains.

Conclusions

The productivity gains associated with a junk food tax are substantial, accounting for almost twice the value of the estimated savings to the health care system. The results we have presented provide evidence that the adoption of a societal perspective, when compared to a health sector perspective, provides a more comprehensive estimate of the cost-effectiveness of a junk food tax.

The indirect costs of ischemic heart disease through lost productive life years for Australia from 2015 to 2030: results from a microsimulation model

Background

Most studies measure the impact of ischemic heart disease (IHD) on individuals using quality of life metrics such as disability-adjusted life-years (DALYs); however, IHD also has an enormous impact on productive life years (PLYs). The objective of this study was to project the indirect costs of IHD resulting from lost PLYs to older Australian workers (45–64 years), government, and society 2015–2030.

Methods

Nationally representative data from the Surveys of Disability, Ageing and Carers (2003, 2009) were used to develop the base population in the microsimulation model (Health&WealthMOD2030), which integrated data from established microsimulation models (STINMOD, APPSIM), Treasury’s population and workforce projections, and chronic conditions trends.

Results

We projected that 6700 people aged 45–64 were out of the labour force due to IHD in 2015, increasing to 8100 in 2030 (21 increase). National costs consisted of a loss of AU$273 (US$263) million in income for people with IHD in 2015, increasing to AU$443 ($US426) million (62% increase). For the government, extra welfare payments increased from AU$106 (US$102) million in 2015 to AU$143 (US$138) million in 2030 (35% increase); and lost income tax revenue increased from AU$74 (US$71) million in 2015 to AU$117 (US$113) million in 2030 (58% increase). A loss of AU$785 (US$755) million in GDP was projected for 2015, increasing to AU$1125 (US$1082) million in 2030.

Conclusions

Significant costs of IHD through lost productivity are incurred by individuals, the government, and society. The benefits of IHD interventions include not only improved health but also potentially economic benefits as workforce capacity.

Drink Choice is Important: Beverages Make a Substantial Contribution to Energy, Sugar, Calcium and Vitamin C Intake among Australians

It is important to understand the role of beverages in population dietary intake in order to give relevant advice. Population estimates were derived from one-day food recall dietary data from 12,153 participants in the 2011–2012 Australian National Nutrition and Physical Activity Survey. Almost all Australians (99.9%) consumed at least one beverage on the day of the survey, accounting for 16.6% of the total energy intake for adults (aged 19 years and over) and 13.0% for children (aged 2–18 years). Similarly, beverages contributed 26–29% to calcium intake, 22–28% to vitamin C intake, and 35–36% to sugar intake. Water was consumed on the day of the survey by 84.1% of Australian adults and 90.5% of children. For adults, the greatest beverage contributors to total energy intake were alcoholic drinks (5.6%), coffee (3.1%), and soft drinks (1.9%), and for children, plain milk (3.1%), flavoured milk (2.8%), and fruit juice (2.6%). Coffee (10.6%) made the greatest contribution to calcium intake for adults; and plain milk (9.9%) and flavoured milk (7.6%) for children. The greatest contributors to vitamin C intake were fruit juice (13.4%) and alcoholic drinks (6.1%) for adults; and fruit juice (23.4%) for children. For total sugar intake, soft drinks (8.0%), coffee (8.4%), and fruit juice (5.9%) made the highest contribution for adults; and fruit juice (9.8%) and soft drinks (8.7%) for children. The type and amount of beverage consumption has considerable relevance to dietary quality for Australians.

Australia's sugar tale

OBJECTIVE

To establish high intake of free sugars and its related disease burden as a significant public health challenge in Australia.

DESIGN

We discuss five key actions to reduce intake of free sugars tailored to the Australian context. These strategies are informed by reviewing the global scientific evidence on the effectiveness of a range of policy responses to reduce intake of free sugars at the population level.

SETTING

Australia.

PARTICIPANTS

Australian population.

RESULTS

The five key actions to reduce population levels for intake of free sugars tailored to the Australian context include prioritising health in trade agreements and policy; introducing a fiscal policy supporting health and promoting food reformulation; regulating advertising and improving labelling; strengthening the current dietary guidelines; and encouraging healthy choices.

CONCLUSIONS

The adoption and implementation of the strategies discussed in the current commentary would aid in tackling the rising health burden from the intake of free sugars in Australia.

Society of Behavioral Medicine (SBM) position statement: Enact taxes on sugar sweetened beverages to prevent chronic disease

The Society of Behavioral Medicine (SBM) encourages stakeholders to implement a sugar sweetened beverage excise tax. Sugar sweetened beverages are the largest source of added sugars in the USA and have detrimental effects on population health by increasing risks for chronic diseases. Based on existing research evidence, SBM supports an excise tax equivalent to at least 20% to meaningfully affect consumption patterns. As evidenced by research studies in Mexico and the USA, sugar sweetened beverage taxes can have positive impacts on population health and can raise significant tax revenue. To avoid potential unintended consequences that may arise from taxes to improve diet-related behaviors, it is important to monitor industry and consumer behavior in response to the tax.

Sugar-sweetened beverage price elasticities in a hypothetical convenience store

An increase in sugar-sweetened beverage (SSB) prices has been suggested to reduce SSB intake to improve population health. Using a discrete choice experiment, we tested the effect of price changes on beverage choices in an online hypothetical convenience store setting amongst 1,008 Australian adults in May to June 2016. From this we calculated pre-packaged beverage price elasticities overall and for health policy-target consumer subgroups; and identified consumer subgroups likely to be most reactive to beverage price changes. Using mixed logit analysis, we found similar price elasticities for age, gender and income groups. More frequent SSB consumers tended to be less sensitive to SSB price changes. Latent class analysis revealed five consumer groups, none of which fit the desirable policy-target of highly price sensitive, frequent SSB consumers. An improved understanding of responsiveness to beverage price changes and consumer preferences could improve predictions of whose health is likely to benefit most from pricing interventions.

Estimating the health benefits and cost-savings of a cap on the size of single serve sugar-sweetened beverages

Sugar-sweetened beverage (SSB) intake is associated with tooth decay, obesity and diabetes. We aimed to model the health and cost impact of reducing the serving size of all single serve SSB to a maximum of 250 ml in New Zealand. A 250 ml serving size cap was modeled for all instances of single serves (<600 ml) of sugar-sweetened carbonated soft drinks, fruit drinks, carbonated energy drinks, and sports drinks in the New Zealand National Nutrition Survey intake data (2008/09). A multi-state life-table model used the change in energy intake and therefore BMI to predict the resulting health gains in quality-adjusted life-years (QALYs) and health system costs over the remaining life course of the New Zealand population alive in 2011 (N = 4.4 million, 3% discounting). The 'base case' model (no compensation for reduced energy intake) resulted in an average reduction in SSB and energy intake of 23 ml and 44 kJ (11 kcal) per day or 0.22 kg of weight modeled over two years. The total health gain and cost-savings were 82,100 QALYs (95% UI: 65100 to 101,000) and NZ$1.65 billion [b] (95% UI: 1.19 b to 2.24 b, (US$1.10 b)) over the lifespan of the cohort. QALY gains increased to 116,000 when the SSB definition was widened to include fruit juices and sweetened milks. A cap on single serve SSB could be an effective part of a suite of obesity prevention and sugar reduction interventions in high income countries.

Modelling the impact of a tax on sweetened beverages in the Philippines: an extended cost-effectiveness analysis

OBJECTIVE

To assess the potential impact of a new tax on sweetened beverages on premature deaths associated with noncommunicable diseases in the Philippines.

METHODS

In January 2018, the Philippines began imposing a tax of 6 Philippine pesos per litre (around 13%) on sweetened beverages to curb the obesity burden. Using national data sources, we conducted an extended cost-effectiveness analysis to estimate the effect of the tax on the numbers of premature deaths averted attributed to type 2 diabetes mellitus, ischaemic heart disease and stroke, across income quintiles over the period 2018-2037. We also estimated the financial benefits of the tax from reductions in out-of-pocket payments, direct medical costs averted and government health-care cost savings.

FINDINGS

The tax could avert an estimated 5913 deaths related to diabetes, 10 339 deaths from ischaemic heart disease and 7950 deaths from stroke over 20 years. The largest number of deaths averted could be among the fourth and fifth (highest) income quintiles. The tax could generate total health-care savings of 31.6 billion Philippine pesos (627 million United States dollars, US$) over 20 years, and raise 41.0 billion Philippine pesos (US$ 813 million) in revenue per annum. The poorest quintile could bear the smallest tax burden increase (14% of the additional tax; 5.6 billion Philippine pesos) and have the lowest savings in out-of-pocket payments due to relatively large health-care subsidies. Finally, we estimated that 13 890 cases of catastrophic expenditure could be averted.

CONCLUSION

The new sweetened beverage tax may help to reduce obesity-related premature deaths and improve financial well-being in the Philippines.

Cost-Effectiveness of a US National Sugar-Sweetened Beverage Tax With a Multistakeholder Approach: Who Pays and Who Benefits

OBJECTIVES

To estimate the health impact and cost-effectiveness of a national penny-per-ounce sugar-sweetened beverage (SSB) tax, overall and with stratified costs and benefits for 9 distinct stakeholder groups.

METHODS

We used a validated microsimulation model (CVD PREDICT) to estimate cardiovascular disease reductions, quality-adjusted life years gained, and cost-effectiveness for US adults aged 35 to 85 years, evaluating full and partial consumer price pass-through.

RESULTS

From health care and societal perspectives, the SSB tax was highly cost-saving. When we evaluated health gains, taxes paid, and out-of-pocket health care savings for 6 distinct consumer categories, incremental cost-effectiveness ratios ranged from $20 247 to $42 662 per quality-adjusted life year for 100% price pass-through (incremental cost-effectiveness ratios similar with 50% pass-through). For the beverage industry, net costs were $0.92 billion with 100% pass-through (largely tax-implementation costs) and $49.75 billion with 50% pass-through (largely because of partial industry coverage of the tax). For government, the SSB tax positively affected both tax revenues and health care cost savings.

CONCLUSIONS

This stratified analysis improves on unitary approaches, illuminating distinct costs and benefits for stakeholders with political influence over SSB tax decisions.

What are the potential preventive population-health effects of a tax on processed meat? A quantitative health impact assessment for Germany

The International Agency for Research on Cancer considers processed meat to be carcinogenic. Further, processed meat is associated with diabetes, ischemic heart disease (IHD) and all-cause mortality. We aimed to assess health gains of four processed meat taxation scenarios in comparison to the reference and a minimum-risk-exposure-scenario. To estimate the shift in processed meat intake following respective taxes, we calculated price elasticities for processed meat. DYNAMO-HIA was used to dynamically project policy-attributable differences in the prevalence of diseases and deaths. In projection year 10, an extra 9300 males and 4500 females would be alive under the lowest tax scenario (4% tax), compared to the reference scenario. Prevalent IHD, diabetes and colorectal cancer cases in males would be 8400, 9500 and 500 lower, respectively, and there would be 4600, 7800 and 300 less cases in females. Of the respective death and disease reduction that would be achieved under the minimum-risk-exposure-scenario, the lowest tax reaches 2.84% (colorectal cancer in males) to 6.02% (diabetes in females). Under the highest tax scenario (33.3% tax), an extra 76,700 males and 37,100 females would be alive, compared to the reference scenario. Prevalent IHD, diabetes and colorectal cancer cases would be 70,800, 77,900 and 4900 lower in males and 29,900, 48,900 and 2300 lower in females, which represents 27.84% (colorectal cancer in males) to 37.76% (diabetes in females) of the maximal preventable death and disease burden. Further research needs to examine to what extent these health benefits are outweighed by a simultaneous tax-induced decrease in fish intake.

How much free sugar do Australians consume? Findings from a national survey

OBJECTIVE

To identify the characteristics of Australian adults exceeding the World Health Organization's free sugar (FS) intake recommendations of <10% and compare the sources of FS among those exceeding (high FS consumers) and complying (low FS consumers) with the recommendations.

METHOD

Nationally weighted data from the Australian National Nutrition and Physical Activity Survey 2011-12 was used to describe the proportions of FS consumption and sources of FS among adults aged ≥18 years (n=9,435) across demographic, socioeconomic and health behavioural subgroups. Six categories of food groups likely to contain FS were generated and analysed.

RESULTS

Almost half of all adults (47%) were high FS consumers. More than one-third of adults in each demographic, socioeconomic and health behaviour subgroup were high FS consumers. Of the food groups containing FS, beverages contributed the most FS (37%), particularly for young adults (48%). High FS consumers obtained twice as much FS from beverages (42%) than low FS consumers (21%). A reverse age gradient was observed for the FS sourced from beverages.

CONCLUSIONS

Almost half the Australians surveyed exceeded the FS intake recommendations. Sugary beverages were the largest source of FS, with young adults being the highest consumers. Implications for public health: Whole population strategies targeting beverages could possibly reduce Australia's high sugar intake.

Australia's Progress in Improving Diets and Preventing Obesity: Clear Opportunities for Action

PURPOSE OF REVIEW

Australia, like other developed countries, has a high prevalence of overweight and obesity, in both adults and children. This review examines progress in food policy in Australia, particularly at a national level, around key policy domains as well as in relation to public education.

RECENT FINDINGS

Australia lacks a national nutrition strategy or an obesity prevention strategy, incorporating best practice recommendations to improve diets. Examination of current progress shows patchy implementation of key food policy initiatives and significant gaps, particularly at the federal level. In the absence of a long-term strategic approach, the response of the federal government has been ad hoc around the adoption of key policies and funding for programs to improve what Australians eat. Consensus around a platform for obesity prevention for national action, including food policy, is building from public health, academic and consumer groups.

A cluster randomised controlled trial of a sugar-sweetened beverage intervention in secondary schools: Pilot study protocol

BACKGROUND

Due to the rising prevalence of overweight and obesity in children and adolescents, reducing childhood overweight and obesity rates is a public-health priority. A significant source of excess sugar and energy in children's diets comes from sugar-sweetened beverages (SSB), with adolescents having the highest intake of all age groups. However, existing interventions targeting SSB intake in adolescents have multiple limitations. Schools have proven to be an appropriate setting for improving student health.

AIM

To assess the effectiveness of a school-based SSB intervention in reducing daily SSB consumption and daily percentage energy from SSBs of secondary-school students.

METHODS

A pilot study ( switchURsip) was designed based on the Health Promoting Schools framework components. A convenience sample of schools in New South Wales, Australia will be used to recruit six schools (three intervention; three control). The study incorporates strategies that focus on factors associated with SSB intake in adolescents. These strategies include: lesson plans on SSB; communication with students and parents; school challenge to build peer support; and school nutrition environment modifications. Support strategies to facilitate implementation are executive leadership and school committees, auditing and feedback, providing resources, staff professional learning and communication and marketing.

CONCLUSION

The high intake of SSB in adolescents has been consistently linked to having overweight and obesity, hence, interventions in this area should be prioritised. This pilot study intends to address identified evidence gaps by piloting the first intervention in Australia of its kind to reduce SSB intake in adolescents.

The Burden of Acute Pesticide Poisoning and Pesticide Regulation in Korea

BACKGROUND

This study aimed to estimate the burden of acute pesticide poisoning and to determine its trend with recently implemented pesticide regulations.

METHODS

Disability-adjusted life-years (DALYs) were calculated as the sum of years of life lost (YLLs) and years lived with disability (YLDs) due to acute pesticide poisoning using the methods of the Global Burden of Disease Study 2013. The values of YLLs, YLDs, and DALYs were stratified by sex, age groups, intentionality of poisoning, and causative agents.

RESULTS

From 2006 to 2014, DALYs decreased by 69% (from 69,550 to 21,742). The decreasing tendency of DALYs was especially marked from 2011. The total burden of acute pesticide poisoning was mainly caused by YLLs and intentional pesticide poisoning. The highest DALYs due to acute pesticide poisoning occurred in those in their 40s and 50s; however, the decreased rates of DALYs were higher in those aged 10-49 years than in those aged more than 50 years. Herbicides including paraquat contributed to the largest proportion of total DALYs.

CONCLUSION

As this is the first study to quantify the burden of acute pesticide poisoning using DALYs, our results provide comprehensive evidence of the importance of using strict regulations to prevent public health hazards due to acute pesticide poisoning.

Controlled cohort evaluation of the LiveLighter mass media campaign's impact on adults' reported consumption of sugar-sweetened beverages

OBJECTIVE

To evaluate the LiveLighter 'Sugary Drinks' campaign impact on awareness, knowledge and sugar-sweetened beverage (SSB) consumption.

DESIGN

Cohort study with population surveys undertaken in intervention and comparison states at baseline (n=900 each), with 78% retention at follow-up (intervention: n=673; comparison: n=730). Analyses tested interactions by state (intervention, comparison) and time (baseline, follow-up).

SETTING AND PARTICIPANTS

Adults aged 25-49 years residing in the Australian states of Victoria and South Australia.

INTERVENTION

The 6-week mass media campaign ran in Victoria in October/November 2015. It focused on the contribution of SSBs to the development of visceral 'toxic fat', graphically depicted around vital organs, and ultimately serious disease. Paid television advertising was complemented by radio, cinema, online and social media advertising, and stakeholder and community engagement.

PRIMARY OUTCOME MEASURE

Self-reported consumption of SSBs, artificially sweetened drinks and water.

SECONDARY OUTCOME MEASURES

Campaign recall and recognition; knowledge of the health effects of overweight and SSB consumption; perceived impact of SSB consumption on body weight and of reduced consumption on health.

RESULTS

A significant reduction in frequent SSB consumption was observed in the intervention state (intervention: 31% compared with 22%, comparison: 30% compared with 29%; interaction p<0.01). This was accompanied by evidence of increased water consumption (intervention: 66% compared with 73%; comparison: 68% compared with 67%; interaction p=0.09) among overweight/obese SSB consumers. This group also showed increased knowledge of the health effects of SSB consumption (intervention: 60% compared with 71%, comparison: 63% compared with 59%; interaction p<0.05) and some evidence of increased prevalence of self-referent thoughts about SSB's relationship to weight gain (intervention: 39% compared with 45%, comparison: 43% compared with 38%; interaction p=0.06).

CONCLUSIONS

The findings provide evidence of reduced SSB consumption among adults in the target age range following the LiveLighter campaign. This is notable in a context where public health campaigns occur against a backdrop of heavy commercial product advertising promoting increased SSB consumption.

The State of US Health, 1990-2016: Burden of Diseases, Injuries, and Risk Factors Among US States

Introduction

Several studies have measured health outcomes in the United States, but none have provided a comprehensive assessment of patterns of health by state.

Objective

To use the results of the Global Burden of Disease Study (GBD) to report trends in the burden of diseases, injuries, and risk factors at the state level from 1990 to 2016.

Design and Setting

A systematic analysis of published studies and available data sources estimates the burden of disease by age, sex, geography, and year.

Main Outcomes and Measures

Prevalence, incidence, mortality, life expectancy, healthy life expectancy (HALE), years of life lost (YLLs) due to premature mortality, years lived with disability (YLDs), and disability-adjusted life-years (DALYs) for 333 causes and 84 risk factors with 95% uncertainty intervals (UIs) were computed.

Results

Between 1990 and 2016, overall death rates in the United States declined from 745.2 (95% UI, 740.6 to 749.8) per 100 000 persons to 578.0 (95% UI, 569.4 to 587.1) per 100 000 persons. The probability of death among adults aged 20 to 55 years declined in 31 states and Washington, DC from 1990 to 2016. In 2016, Hawaii had the highest life expectancy at birth (81.3 years) and Mississippi had the lowest (74.7 years), a 6.6-year difference. Minnesota had the highest HALE at birth (70.3 years), and West Virginia had the lowest (63.8 years), a 6.5-year difference. The leading causes of DALYs in the United States for 1990 and 2016 were ischemic heart disease and lung cancer, while the third leading cause in 1990 was low back pain, and the third leading cause in 2016 was chronic obstructive pulmonary disease. Opioid use disorders moved from the 11th leading cause of DALYs in 1990 to the 7th leading cause in 2016, representing a 74.5% (95% UI, 42.8% to 93.9%) change. In 2016, each of the following 6 risks individually accounted for more than 5% of risk-attributable DALYs: tobacco consumption, high body mass index (BMI), poor diet, alcohol and drug use, high fasting plasma glucose, and high blood pressure. Across all US states, the top risk factors in terms of attributable DALYs were due to 1 of the 3 following causes: tobacco consumption (32 states), high BMI (10 states), or alcohol and drug use (8 states).

Conclusions and Relevance

There are wide differences in the burden of disease at the state level. Specific diseases and risk factors, such as drug use disorders, high BMI, poor diet, high fasting plasma glucose level, and alcohol use disorders are increasing and warrant increased attention. These data can be used to inform national health priorities for research, clinical care, and policy.

Sweetened beverages, snacks and overweight: findings from the Young Lives cohort study in Peru

Objective

To determine the association between consumption of snacks and sweetened beverages and risk of overweight among children.

Design

Secondary analysis of the Young Lives cohort study in Peru.

Setting

Twenty sentinel sites from a total of 1818 districts available in Peru.

Subjects

Children in the younger cohort of the Young Lives study in Peru, specifically those included in the third (2009) and the fourth (2013) rounds.

Results

A total of 1813 children were evaluated at baseline; 49·2 % girls and mean age 8·0 (sd 0·3) years. At baseline, 3·3 (95 % CI 2·5, 4·2) % reported daily sweetened beverage consumption, while this proportion was 3·9 (95 % CI 3·1, 4·9) % for snacks. Baseline prevalence of overweight was 22·0 (95 % CI 20·1, 23·9) %. Only 1414 children were followed for 4·0 (sd 0·1) years, with an overweight incidence of 3·6 (95 % CI 3·1, 4·1) per 100 person-years. In multivariable analysis, children who consumed sweetened beverages and snacks daily had an average weight increase of 2·29 (95 % CI 0·62, 3·96) and 2·04 (95 % CI 0·48, 3·60) kg more, respectively, than those who never consumed these products, in approximately 4 years of follow-up. Moreover, there was evidence of an association between daily consumption of sweetened beverages and risk of overweight (relative risk=2·12; 95 % CI 1·05, 4·28).

Conclusions

Daily consumption of sweetened beverages and snacks was associated with increased weight gain v. never consuming these products; and in the case of sweetened beverages, with higher risk of developing overweight.

Burden and trend of diet-related non-communicable diseases in Australia and comparison with 34 OECD countries, 1990-2015: findings from the Global Burden of Disease Study 2015

BACKGROUND

Diet is a major determining factor for many non-communicable chronic diseases (NCDs). However, evidence on diet-related NCD burden remains limited. We assessed the trends in diet-related NCDs in Australia from 1990 to 2015 and compared the results with other countries of the Organization for Economic Co-operation and Development (OECD).

METHODS

We used data and methods from the Global Burden of Disease (GBD) 2015 study to estimate the NCD mortality and disability-adjusted life years (DALYs) attributable to 14 dietary risk factors in Australia and 34 OECD nations. Countries were further ranked from the lowest (first) to highest (35th) burden using an age-standardized population attributable fraction (PAF).

RESULTS

In 2015, the estimated number of deaths attributable to dietary risks was 29,414 deaths [95% uncertainty interval (UI) 24,697 - 34,058 or 19.7% of NCD deaths] and 443,385 DALYs (95% UI 377,680-511,388 or 9.5% of NCD DALYs) in Australia. Young (25-49 years) and middle-age (50-69 years) male adults had a higher PAF of diet-related NCD deaths and DALYs than their female counterparts. Diets low in fruits, vegetables, nuts and seeds and whole grains, but high in sodium, were the major contributors to both NCD deaths and DALYs. Overall, 42.3% of cardiovascular deaths were attributable to dietary risk factors. The age-standardized PAF of diet-related NCD mortality and DALYs decreased over the study period by 28.2% (from 27.0% in 1990 to 19.4% in 2015) and 41.0% (from 14.3% in 1990 to 8.4% in 2015), respectively. In 2015, Australia ranked 12th of 35 examined countries in diet-related mortality. A small improvement of rank was recorded compared to the previous 25 years.

CONCLUSIONS

Despite a reduction in diet-related NCD burden over 25 years, dietary risks are still the major contributors to a high burden of NCDs in Australia. Interventions targeting NCDs should focus on dietary behaviours of individuals and population groups.

Consumption of sugar-sweetened and artificially sweetened soft drinks and risk of obesity-related cancers

OBJECTIVE

To test the hypothesis that more frequent consumption of sugar-sweetened soft drinks would be associated with increased risk of obesity-related cancers. Associations for artificially sweetened soft drinks were assessed for comparison.

DESIGN

Prospective cohort study with cancers identified by linkage to cancer registries. At baseline, participants completed a 121-item FFQ including separate questions about the number of times in the past year they had consumed sugar-sweetened or artificially sweetened soft drinks. Anthropometric measurements, including waist circumference, were taken and questions about smoking, leisure-time physical activity and intake of alcoholic beverages were completed.

SETTING

The Melbourne Collaborative Cohort Study (MCCS) is a prospective cohort study which recruited 41 514 men and women aged 40-69 years between 1990 and 1994. A second wave of data collection occurred in 2003-2007.

SUBJECTS

Data for 35 593 participants who developed 3283 incident obesity-related cancers were included in the main analysis.

RESULTS

Increasing frequency of consumption of both sugar-sweetened and artificially sweetened soft drinks was associated with greater waist circumference at baseline. For sugar-sweetened soft drinks, the hazard ratio (HR) for obesity-related cancers increased as frequency of consumption increased (HR for consumption >1/d v. 1/d v. <1/month=1·00; 95 % CI 0·79, 1·27; P-trend=0·61).

CONCLUSIONS

Our results add to the justification to minimise intake of sugar-sweetened soft drinks.

The nutritional content of supermarket beverages: a cross-sectional analysis of New Zealand, Australia, Canada and the UK

OBJECTIVE

To compare the nutritional content, serving size and taxation potential of supermarket beverages from four different Western countries.

DESIGN

Cross-sectional analysis. Multivariate regression analysis and χ 2 comparisons were used to detect differences between countries.

SETTING

Supermarkets in New Zealand (NZ), Australia, Canada and the UK.

SUBJECTS

Supermarket beverages in the following categories: fruit juices, fruit-based drinks, carbonated soda, waters and sports/energy drinks.

RESULTS

A total of 4157 products were analysed, including 749 from NZ, 1738 from Australia, 740 from Canada and 930 from the UK. NZ had the highest percentage of beverages with sugar added to them (52 %), while the UK had the lowest (39 %, P<0.001).

CONCLUSIONS

There is substantial difference between countries in the mean energy, serving size and proportion of products eligible for fiscal sugar taxation. Current self-regulatory approaches used in these countries may not be effective to reduce the availability, marketing and consumption of sugar-sweetened beverages and subsequent intake of free sugars.

Simulating the impact of excise taxation for disease prevention in low-income and middle-income countries: an application to South Africa

Introduction

Excise taxes are policy tools that have been applied internationally with some success to reduce consumption of products adversely impacting population health including tobacco, alcohol and increasingly junk foods and sugary beverages. As in other low-income and middle-income countries, South Africa faces a growing burden of lifestyle diseases; accordingly we simulate the impact of multiple excise tax interventions in this setting.

Methods

We construct a mathematical model to simulate the health and revenue effects of increased excise taxes, which is adaptable to a variety of settings given its limited data requirements. Applying the model to South Africa, we simulate the impact of increased tax rates on tobacco and beer and of the introduction of a tax on sugar-sweetened beverages (SSB). Drawing on surveys of product usage and risk factor prevalence, the model uses a potential impact fraction to simulate the health effects of tax interventions.

Results

Adopting an excise rate of 60% on tobacco would result in a gain of 858 923 life-years (95% uncertainty interval (UI) 480 188 to 1 310 329), while adopting an excise rate of 25% on beer would result in a gain of 568 063 life-years (95% UI 412 110 to 775 560) and the adoption of a 20% tax on SSBs would result in a gain of 688 719 life-years (95% UI 321 788 to 1 079 653).

Conclusion

More aggressive excise tax policies on tobacco, beer and SSBs in South Africa could result in meaningful improvements in population health and raised revenue.

Modelled Cost-Effectiveness of a Package Size Cap and a Kilojoule Reduction Intervention to Reduce Energy Intake from Sugar-Sweetened Beverages in Australia

Interventions targeting portion size and energy density of food and beverage products have been identified as a promising approach for obesity prevention. This study modelled the potential cost-effectiveness of: a package size cap on single-serve sugar sweetened beverages (SSBs) >375 mL (package size cap), and product reformulation to reduce energy content of packaged SSBs (energy reduction). The cost-effectiveness of each intervention was modelled for the 2010 Australia population using a multi-state life table Markov model with a lifetime time horizon. Long-term health outcomes were modelled from calculated changes in body mass index to their impact on Health-Adjusted Life Years (HALYs). Intervention costs were estimated from a limited societal perspective. Cost and health outcomes were discounted at 3%. Total intervention costs estimated in AUD 2010 were AUD 210 million. Both interventions resulted in reduced mean body weight (package size cap: 0.12 kg; energy reduction: 0.23 kg); and HALYs gained (package size cap: 73,883; energy reduction: 144,621). Cost offsets were estimated at AUD 750.8 million (package size cap) and AUD 1.4 billion (energy reduction). Cost-effectiveness analyses showed that both interventions were “dominant”, and likely to result in long term cost savings and health benefits. A package size cap and kJ reduction of SSBs are likely to offer excellent “value for money” as obesity prevention measures in Australia.

'The university should promote health, but not enforce it': opinions and attitudes about the regulation of sugar-sweetened beverages in a university setting

BACKGROUND

The study aimed to determine the opinions and attitudes of a university population regarding the regulation of sugar-sweetened beverages in a university setting, primarily looking at differences in opinion between younger adults (under 30 years of age) and older adults (30 years of age or older).

METHODS

An online survey was conducted at an Australian university in April-May 2016 using a convenience sample of students and staff between the ages of 16 and 84 years. The survey included questions about consumption of sugar-sweetened beverages and level of agreement and support of proposed sugar-sweetened beverage interventions. Quantitative response data and qualitative open-ended response data were analysed.

RESULTS

Nine hundred thirteen responses from students and staff were analysed. In this population, consumption of sugar-sweetened beverages was low and awareness of the health risks of sugar-sweetened beverages was high. Overall, the surveyed population indicated more support for interventions that require higher levels of personal responsibility. The population did support some environment-centred, population-based interventions, such as increasing access to drinking water and reducing the price of healthier beverage alternatives. However there was less support for more restrictive interventions such as removing sugar-sweetened beverages from sale. Young adults tended to be less supportive of most interventions than older adults.

CONCLUSIONS

These findings indicate there is some support for environment-centred, population-based approaches to reduce the availability and appeal of sugar-sweetened beverages in an adult environment such as a university setting. However these results suggest that public health may need to focus less on educating populations about the harms associated with sugar-sweetened beverages. Instead, there should be greater emphasis on explaining to populations and communities why environment-centred approaches relating to the sale and promotion of sugar-sweetened beverages should be prioritised over interventions that simply target personal responsibility and individual behaviours.

Sugar-Sweetened Beverages Consumption Positively Associated with the Risks of Obesity and Hypertriglyceridemia Among Children Aged 7-18 Years in South China

Aims: Excessive consumption of sugar-sweetened beverages (SSBs) may increase the prevalence of obesity and other metabolic risk factors. However, data regarding the relationship between SSB consumption and metabolic risk factors are insufficient in Chinese children. Hence, we aimed to explore the association between SSB consumption and cardio-metabolic risk factors in children aged 7–18 years living in South China.

Methods: A cross-sectional study was conducted in a total of 2,032 children aged 7–18 years were enrolled, including 1,013 boys and 1,019 girls. Based on a multistage cluster sampling, five elementary and four secondary schools in Guangzhou, China were included. Fasting blood glucose levels, lipid profiles, and anthropometric characteristics were evaluated. Information on demography, dietary, and physical activities were self-reported.

Results: Overall, 34.7% participants were non-drinkers and 21.6% consumed more than 120 mL/day SSB. The body mass index (19.43 ± 0.18 kg/m²) and triglyceride concentration (0.96 ± 0.03 mmol/L) were higher and high-density lipoprotein concentration (1.32 ± 0.31 mmol/L) was lower in consumers than in non-consumers (all P < 0.001). Furthermore, in contrast to non-consumers, the adjusted odds ratio of SSB consumption more than 120 mL/day was 2.08 (95% CI: 1.21–3.54) for obesity, 1.83 (95% CI: 1.25–2.69) for abdominal obesity, and 1.70 (95% CI: 1.02–3.06) for hypertriglyceridemia in consumers.

Conclusion: A positive association between SSB consumption and the risks of obesity and hypertriglyceridemia was observed in children living in South China, which suggests that high SSB consumption enhances the risk of cardio-metabolic risk factors and the consequent cardio-metabolic diseases.

Modelled health benefits of a sugar-sweetened beverage tax across different socioeconomic groups in Australia: A cost-effectiveness and equity analysis

BACKGROUND

A sugar-sweetened beverage (SSB) tax in Mexico has been effective in reducing consumption of SSBs, with larger decreases for low-income households. The health and financial effects across socioeconomic groups are important considerations for policy-makers. From a societal perspective, we assessed the potential cost-effectiveness, health gains, and financial impacts by socioeconomic position (SEP) of a 20% SSB tax for Australia.

METHODS AND FINDINGS

Australia-specific price elasticities were used to predict decreases in SSB consumption for each Socio-Economic Indexes for Areas (SEIFA) quintile. Changes in body mass index (BMI) were based on SSB consumption, BMI from the Australian Health Survey 2011-12, and energy balance equations. Markov cohort models were used to estimate the health impact for the Australian population, taking into account obesity-related diseases. Health-adjusted life years (HALYs) gained, healthcare costs saved, and out-of-pocket costs were estimated for each SEIFA quintile. Loss of economic welfare was calculated as the amount of deadweight loss in excess of taxation revenue. A 20% SSB tax would lead to HALY gains of 175,300 (95% CI: 68,700; 277,800) and healthcare cost savings of AU$1,733 million (m) (95% CI: $650m; $2,744m) over the lifetime of the population, with 49.5% of the total health gains accruing to the 2 lowest quintiles. We estimated the increase in annual expenditure on SSBs to be AU$35.40/capita (0.54% of expenditure on food and non-alcoholic drinks) in the lowest SEIFA quintile, a difference of AU$3.80/capita (0.32%) compared to the highest quintile. Annual tax revenue was estimated at AU$642.9m (95% CI: $348.2m; $1,117.2m). The main limitations of this study, as with all simulation models, is that the results represent only the best estimate of a potential effect in the absence of stronger direct evidence.

CONCLUSIONS

This study demonstrates that from a 20% tax on SSBs, the most HALYs gained and healthcare costs saved would accrue to the most disadvantaged quintiles in Australia. Whilst those in more disadvantaged areas would pay more SSB tax, the difference between areas is small. The equity of the tax could be further improved if the tax revenue were used to fund initiatives benefiting those with greater disadvantage.

Expected population weight and diabetes impact of the 1-peso-per-litre tax to sugar sweetened beverages in Mexico

STUDY QUESTION

What effect on body mass index, obesity and diabetes can we expect from the 1-peso-per-litre tax to sugar sweetened beverages in Mexico?

METHODS

Using recently published estimates of the reductions in beverage purchases due to the tax, we modelled its expected long-term impacts on body mass index (BMI), obesity and diabetes. Microsimulations based on a nationally representative dataset were used to estimate the impact of the tax on BMI and obesity. A Markov population model, built upon an age-period-cohort model of diabetes incidence, was used to estimate the impact on diagnosed diabetes in Mexico. To analyse the potential of tax increases we also modelled a 2-peso-per-litre tax scenario.

STUDY ANSWER AND LIMITATIONS

Ten years after the implementation of the tax, we expect an average reduction of 0.15 kg/m2 per person, which translates into a 2.54% reduction in obesity prevalence. People in the lowest level of socioeconomic status and those between 20 and 35 years of age showed the largest reductions in BMI and overweight and obesity prevalence. Simulations show that by 2030, under the current implementation of 1-peso-per-litre, the tax would prevent 86 to 134 thousand cases of diabetes. Overall, the 2-peso-per-litre scenario is expected to produce twice as much of a reduction. These estimates assume the tax effect on consumption remains stable over time. Sensitivity analyses were conducted to assess the robustness of findings; similar results were obtained with various parameter assumptions and alternative modelling approaches.

WHAT THIS STUDY ADDS

The sugar-sweetened beverages tax in Mexico is expected to produce sizable and sustained reductions in obesity and diabetes. Increasing the tax could produce larger benefits. While encouraging, estimates will need to be updated once data on direct changes in consumption becomes available.

Obesity-related health impacts of fuel excise taxation- an evidence review and cost-effectiveness study

BACKGROUND

Reducing automobile dependence and improving rates of active transport may reduce the impact of obesogenic environments, thereby decreasing population prevalence of obesity and other diseases where physical inactivity is a risk factor. Increasing the relative cost of driving by an increase in fuel taxation may therefore be a promising public health intervention for obesity prevention.

METHODS

A scoping review of the evidence for obesity or physical activity effect of changes in fuel price or taxation was undertaken. Potential health benefits of an increase in fuel excise taxation in Australia were quantified using Markov modelling to simulate obesity, injury and physical activity related health impacts of a fuel excise taxation intervention for the 2010 Australian population. Health adjusted life years (HALYs) gained and healthcare cost savings from diseases averted were estimated. Incremental cost-effectiveness ratios (ICERs) were reported and results were tested through sensitivity analysis.

RESULTS

Limited evidence on the effect of policies such as fuel taxation on health-related behaviours currently exists. Only three studies were identified reporting associations between fuel price or taxation and obesity, whilst nine studies reported associations specifically with physical activity, walking or cycling. Estimates of the cross price elasticity of demand for public transport with respect to fuel price vary, with limited consensus within the literature on a probable range for the Australian context. Cost-effectiveness modelling of a AUD0.10 per litre increase in fuel excise taxation using a conservative estimate of cross price elasticity for public transport suggests that the intervention would be cost-effective from a limited societal perspective (237 HALYs gained, AUD2.6 M in healthcare cost savings), measured against a comparator of no additional increase in fuel excise. Under "best case" assumptions, the intervention would be more cost-effective (3181 HALYs gained, AUD34.2 M in healthcare cost savings).

CONCLUSIONS

Exploratory analysis suggests that an intervention to increase fuel excise taxation may deliver obesity and physical activity related benefits. Whilst such an intervention has significant potential for cost-effectiveness, potential equity and acceptability impacts would need to be minimised. A better understanding of the effectiveness and cost-effectiveness of a range of transport interventions is required in order to achieve more physically active transport environments.

The impact on productivity of a hypothetical tax on sugar-sweetened beverages

OBJECTIVES

To quantify the potential impact of an additional 20% tax on sugar-sweetened beverages (SSBs) on productivity in Australia.

METHODS

We used a multi-state lifetable Markov model to examine the potential impact of an additional 20% tax on SSBs on total lifetime productivity in the paid and unpaid sectors of the economy. The study population consisted of Australians aged 20 years or older in 2010, whose health and other relevant outcomes were modelled over their remaining lifetime.

RESULTS

The SSBs tax was estimated to reduce the number of people with obesity by 1.96% of the entire population (437,000 fewer persons with obesity), and reduce the number of employees with obesity by 317,000 persons. These effects translated into productivity gains in the paid sector of AU$751 million for the working-age population (95% confidence interval: AU$565 million to AU$954 million), using the human capital approach. In the unpaid sector, the potential productivity gains amounted to AU$1172 million (AU$929 million to AU$1435 million) using the replacement cost method. These productivity benefits are in addition to the health benefits of 35,000 life years gained and a reduction in healthcare costs of AU$425 million.

CONCLUSIONS

An additional 20% tax on SSBs not only improves health outcomes and reduces healthcare costs, but provides productivity gains in both the paid and unpaid sectors of the economy.

Taxes and Subsidies for Improving Diet and Population Health in Australia: A Cost-Effectiveness Modelling Study

BACKGROUND

An increasing number of countries are implementing taxes on unhealthy foods and drinks to address the growing burden of dietary-related disease, but the cost-effectiveness of combining taxes on unhealthy foods and subsidies on healthy foods is not well understood.

METHODS AND FINDINGS

Using a population model of dietary-related diseases and health care costs and food price elasticities, we simulated the effect of taxes on saturated fat, salt, sugar, and sugar-sweetened beverages and a subsidy on fruits and vegetables, over the lifetime of the Australian population. The sizes of the taxes and subsidy were set such that, when combined as a package, there would be a negligible effect on average weekly expenditure on food (<1% change). We evaluated the cost-effectiveness of the interventions individually, then determined the optimal combination based on maximising net monetary benefit at a threshold of AU$50,000 per disability-adjusted life year (DALY). The simulations suggested that the combination of taxes and subsidy might avert as many as 470,000 DALYs (95% uncertainty interval [UI]: 420,000 to 510,000) in the Australian population of 22 million, with a net cost-saving of AU$3.4 billion (95% UI: AU$2.4 billion to AU$4.6 billion; US$2.3 billion) to the health sector. Of the taxes evaluated, the sugar tax produced the biggest estimates of health gain (270,000 [95% UI: 250,000 to 290,000] DALYs averted), followed by the salt tax (130,000 [95% UI: 120,000 to 140,000] DALYs), the saturated fat tax (97,000 [95% UI: 77,000 to 120,000] DALYs), and the sugar-sweetened beverage tax (12,000 [95% UI: 2,100 to 21,000] DALYs). The fruit and vegetable subsidy (-13,000 [95% UI: -44,000 to 18,000] DALYs) was a cost-effective addition to the package of taxes. However, it did not necessarily lead to a net health benefit for the population when modelled as an intervention on its own, because of the possible adverse cross-price elasticity effects on consumption of other foods (e.g., foods high in saturated fat and salt). The study suggests that taxes and subsidies on foods and beverages can potentially be combined to achieve substantial improvements in population health and cost-savings to the health sector. However, the magnitude of health benefits is sensitive to measures of price elasticity, and further work is needed to incorporate potential benefits or harms associated with changes in other foods and nutrients that are not currently modelled, such as red and processed meats and fibre.

CONCLUSIONS

With potentially large health benefits for the Australian population and large benefits in reducing health sector spending on the treatment of non-communicable diseases, the formulation of a tax and subsidy package should be given a more prominent role in Australia's public health nutrition strategy.

Impact of dental National Partnership Agreements on public dental service waiting lists in Queensland

OBJECTIVE

Analyse the Queensland Dental Public Service waiting list from 2013 to 2015 while various funding agreements between the federal and state and territory governments were in place.

METHODS

Queensland Public Dental Service waiting list is open data and is updated monthly. This analysis reports on the changing number of people waiting for care and the percentage of people waiting beyond the reasonable period.

RESULTS

While the number of people waiting decreased when funding was specifically allocated to "blitz the dental public waiting list", these have since increased back to pre-blitz period numbers. The percentage now waiting beyond the reasonable period has decreased from 57% to 28% over the study period.

CONCLUSIONS

While the 'blitz' was successful in reducing waiting list numbers, this was not sustained. The deferred federal funding to states/territories for dental services may have worsened the situation. Implications for Public Health: While an injection of funds to reduce the waiting list is important and has had an impact, to adequately address oral health will require not just continuing funding, but also a shift away from the current curative 'downstream' approach towards a health-promotive 'upstream' approach. This will reduce not only the cost of treatment, but also waiting lists.