Cost-Effectiveness of Fiscal Policies to Prevent Obesity

Economic Evaluations of Obesity-Targeted Sugar-Sweetened Beverage (SSB) Taxes-A Review to Identify Methodological Issues

INTRODUCTION

Economic evaluations of public health interventions like sugar-sweetened beverage (SSB) taxes face difficulties similar to those previously identified in other public health areas. This stems from challenges in accurately attributing effects, capturing outcomes and costs beyond health, and integrating equity effects. This review examines how these challenges were addressed in economic evaluations of SSB taxes.

METHODS

A systematic review was conducted to identify economic evaluations of SSB taxes focused on addressing obesity in adults, published up to February 2021. The methodological challenges examined include measuring effects, valuing outcomes, assessing costs, and incorporating equity.

RESULTS

Fourteen economic evaluations of SSB taxes were identified. Across these evaluations, estimating SSB tax effects was uncertain due to a reliance on indirect evidence that was less robust than evidence from randomised controlled trials. Health outcomes, like quality-adjusted life years, along with a healthcare system perspective for costs, dominated the evaluations of SSB taxes, with a limited focus on broader non-health consequences. Equity analyses were common but employed significantly different approaches and exhibited varying degrees of quality.

CONCLUSION

Addressing the methodological challenges remains an issue for economic evaluations of public health interventions like SSB taxes, suggesting the need for increased attention on those issues in future studies. Dedicated methodological guidelines, in particular addressing the measurement of effect and incorporation of equity impacts, are warranted.

The Cost Effectiveness of Taxation of Sugary Foods and Beverages: A Systematic Review of Economic Evaluations

BACKGROUND

With increasing concerns about the health consequences and economic burden of excess sugar consumption, a sugar tax is increasingly considered an effective policy to curb sugar consumption. However, little is known about the cost effectiveness of sugar taxes. To inform policy decision makers, we systematically reviewed and analyzed the evidence regarding the cost effectiveness of sugar taxation.

METHODS

We systematically searched six databases (MEDLINE, Web of Science, EMBASE, The Cochrane Library, EconLit, and Google Scholar) to identify relevant journal articles. Two reviewers independently scanned and selected all retrieved studies. Only studies that evaluated sugar taxes and applied economic evaluation methods were included. The quality of included studies was assessed using established standards.

RESULTS

Fifteen good-quality studies that originated from six countries (the US, Australia, South Africa, Canada, the UK, and Mexico) were included. These studies revealed that sugar tax improved health-related quality of life. Savings from avoided health care costs and revenue from the sugar taxes (totalling US$87 to US$167,799 million) exceeded intervention costs (US$5 to US$2177 million). Each of the 15 studies concluded that sugar tax constitutes a cost-effective intervention that led to cost savings.

CONCLUSIONS

Sugar tax is a practical and cost-effective policy option to reduce the health and economic burden resulting from excess sugar consumption. The impact of sugar taxes depends on the target population, time horizons, and other parameters. Economic evaluations of taxation of a broader set of sugary products and economic evaluations that combine sugar taxation with other interventions are important to inform further action to curb sugar consumption.

Assessing sugar-sweetened beverage intakes, added sugar intakes and BMI before and after the implementation of a sugar-sweetened beverage tax in South Africa

OBJECTIVE

To provide insight into the context and public health implications of the South African sugar-sweetened beverage (SSB) tax (Health Promotion Levy; HPL) by describing SSB and added sugar intakes, as well as BMI, 1 year prior to, at the time of and 1 year after implementation of the HPL.

DESIGN

Longitudinal dietary intake was assessed using a quantitative food frequency questionnaire (QFFQ) and BMI was measured via anthropometry.

SETTING

Soweto, Johannesburg, South Africa.

PARTICIPANTS

Adolescents, young adults and middle-aged adults (n 617).

RESULTS

At baseline, median SSB intakes were 36 ml/d, 214 ml/d and 750 ml/d for those in low, medium and high consumption tertiles, respectively. SSB intake decreased by two times/week in medium consumers and seven times/week in high consumers between baseline and 12 months, equivalent to 107 ml/d and 536 ml/d reductions, respectively. These reduced levels were maintained in the following year (i.e. to 24 months). There was an overall decrease in the amount of energy consumed as added sugar in the low (-48 kJ/d), medium (-153 kJ/d) and high (-106 kJ/d) SSB consumption groups between baseline and 24 months; however, the percentage of total energy consumed as added sugar remained relatively consistent (between 10 and 11 %). There were small overall increases in BMI across low (0·6 kg/m2), medium (0·9 kg/m2) and high (1·0 kg/m2) SSB tertiles between baseline and 24 months.

CONCLUSIONS

These findings suggest reductions in SSB and added sugar consumption contemporaneous to the introduction of the HPL - particularly for those with higher baseline intakes.

New-generation anti-obesity drugs: naltrexone/bupropion and liraglutide. An update for endocrinologists and nutritionists

The prevalence of obesity increases worldwide and has a significant economic impact on health care systems. A comprehensive program of lifestyle modification, including diet, exercise, and behavior therapy is considered the first option for achieving the significant weight loss. However, the intrinsic difficulties associated with maintenance of lifestyle changes contribute to the unsatisfactory long-term outcomes reported and weight regain in the obesity management. In this context, pharmacological approaches are useful to maximize non-pharmacological interventions in the long-term management of obesity. As add-on to lifestyle modification, pharmacological interventions are useful to facilitate clinically weight loss. In the past, anti-obesity drugs were limited. To date, the landscape has changed and naltrexone/bupropion and liraglutide have been recently added as new-generation anti-obesity drugs on obesity treatment and could represent important tools to manage of obesity. Liraglutide is a glucagon-like peptide 1 (GLP-1) receptor agonist that shares 97% homology to native GLP-1 with effects on the limbic system. The treatment with liraglutide 3.0 mg, in combination with a hypocaloric diet and increased physical activity, provides a clinically meaningful weight loss. The combination of naltrexone 32 mg and bupropion 360 mg acts on the mesolimbic reward pathway and the hypothalamic hunger system, two areas of the central nervous system. The combination of naltrexone/bupropion, an adjunct to a hypocaloric diet and increased physical activity, is approved for chronic weight management in adults with obesity or overweight and ≥1 weight-related comorbidity. In the present review, we have focused on the current evidence on two new-generation anti-obesity drugs, naltrexone/bupropion and liraglutide 3.0 mg addressing the main studies that investigated these two new drugs for obesity treatment. Furthermore, evidence on semaglutide, currently in the pipeline for potential future therapeutic use for weight loss, are reported.

Naltrexone-bupropion (Mysimba) in management of obesity: A systematic review and meta-analysis of unpublished clinical study reports

AIMS

To compare the benefits and harms of naltrexone-bupropion using evidence from clinical study reports.

METHODS

We searched Food and Drug Administration and European Medicines Agency websites, PubMed, and Clinicaltrials.gov (May 2016) to identify pivotal trials; we then sent a freedom of information request to the European Medicines Agency (July 2016). We included pivotal, phase III placebo-controlled trials. We assessed the risks of bias using the Cochrane criteria, and the quality of the evidence using GRADE. We used a random-effects model for meta-analyses.

RESULTS

Over a 27-month period (July 2016 to August 2018), we received 31 batches of clinical study report documents containing over 65 000 pages of data from 4 pivotal trials (n = 4536). Significantly more participants who took naltrexone-bupropion achieved ≥5% reduction in body weight: risk ratio (RR) = 2.1 (95% confidence interval 1.35-3.28), P = .001, GRADE = low, number needed to treat (NNT) to benefit = 5 (3-17); this represents a 2.53 kg (1.85-3.21) reduction in baseline body weight compared with placebo. Naltrexone-bupropion had significantly beneficial effects on other cardiovascular risk factors; however, the true effect sizes for these are uncertain because of incomplete outcome data. Naltrexone-bupropion significantly increased the risk of adverse events: RR = 1.11 (1.05-1.18, P = .0004, GRADE = low, NNT to harm = 12 7-27); serious adverse events: RR = 1.70 (1.38-2.1, P < .00001, GRADE = moderate, NNT to harm = 21 13-38); and discontinuation because of adverse events: RR = 1.92 (1.65-2.24, P < .00001, GRADE = moderate, NNT to discontinue treatment = 9 8-13).

CONCLUSIONS

Naltrexone-bupropion significantly reduces body weight by a small amount but significantly increases the risk of adverse events. A rigorous process of postmarketing surveillance is required.

Eat, play, live: a randomized controlled trial within a natural experiment examining the role of nutrition policy and capacity building in improving food environments in recreation and sport facilities

Background

Recreation and sport facilities often have unhealthy food environments that may promote unhealthy dietary patterns among children. In response, some Canadian provinces have released voluntary nutrition guidelines for recreation and sport facilities, however implementation has been limited. Organizational capacity building may overcome barriers to implementing guidelines. Eat, Play, Live was a randomized controlled trial embedded within a natural experiment that tested the impact of an 18 month capacity building intervention (CBI) in enhancing implementation of provincial nutrition guidelines, and whether nutrition guidelines were associated with positive changes. Primary outcomes were facility capacity, policy development and food environment quality.

Methods

Recreation and sport facilities in three guideline provinces were randomized into a guideline + CBI (GL + CBI; n = 17) or a guideline only comparison condition (GL-ONLY; n = 15). Facilities in a province without guidelines constituted a second comparison condition (NO-GL; n = 17). Facility capacity, policy development, and food environment quality (vending and concession) were measured and compared at baseline and follow-up across conditions using repeated measures ANOVA and Chi-square statistics. Healthfulness of vending and concession items was rated as Do Not Sell (least nutritious), Sell Sometimes or Sell Most (most nutritious).

Results

There were significant time by condition effects, with significant increases in facility capacity (mean ± SD: 30.8 ± 15.6% to 62.3 ± 22.0%; p <  0.01), nutrition policy development (17.6% developed new policies; p = 0.049), overall quality of the concession food environment (14.7 ± 8.4 to 17.5 ± 7.2; p <  0.001), and in the proportion of Sell Most (3.7 ± 4.4% to 11.0 ± 9.0%; p = 0.002) and Sell Sometimes vending snacks (22.4 ± 14.4% to 43.8 ± 15.8%; p <  0.001) in GL + CBI facilities, with a significant decline in Do Not Sell vending snacks (74.0 ± 16.6% to 45.2 ± 20.1%; p <  0.001).

Conclusions

Significant improvements in facility capacity, policy development and food environment quality occurred in recreation and sport facilities that were exposed to nutrition guidelines and participated in a CBI. Outcomes did not improve in facilities that were only passively or not at all exposed to guidelines. Ongoing capacity building may enhance implementation of voluntary nutrition guidelines, however food environments remained overwhelmingly unhealthy, suggesting additional scope to enhance implementation.

Trials registration

Clinical trials registration (retrospectively registered): ISRCTN14669997 Jul 3, 2018.

Electronic supplementary material

The online version of this article (10.1186/s12966-019-0811-8) contains supplementary material, which is available to authorized users.

Can policy ameliorate socioeconomic inequities in obesity and obesity-related behaviours? A systematic review of the impact of universal policies on adults and children

This systematic review examined the impact of universal policies on socioeconomic inequities in obesity, dietary and physical activity behaviours among adults and children. PRISMA-Equity guidelines were followed. Database searches spanned from 2004 to August 2015. Eligible studies assessed the impact of universal policies on anthropometric, dietary or physical activity-related outcomes in adults or children according to socioeconomic position. Thirty-six studies were included. Policies were classified as agentic, agento-structural or structural, and their impact on inequities was rated as positive, neutral, negative or mixed according to the dominant associations observed. Most policies had neutral impacts on obesity-related inequities regardless of whether they were agentic (60% neutral), agento-structural (68% neutral) or structural (67% neutral). The proportion of positive impacts was similar across policy types (10% agentic, 18% agento-structural and 11% structural), with some differences for negative impacts (30% agentic, 14% agento-structural and 22% structural). The majority of associations remained neutral when stratified by participant population, implementation level and socioeconomic position measures and by anthropometric and behavioural outcomes. Fiscal measures had consistently neutral or positive impacts on inequities. Findings suggest an important role for policy in addressing obesity in an equitable manner and strengthen the case for implementing a broad complement of policies spanning the agency-structure continuum.

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.

Economics of obesity--learning from the past to contribute to a better future

The discipline of economics plays a varied role in informing the understanding of the problem of obesity and the impact of different interventions aimed at addressing it. This paper discusses the causes of the obesity epidemic from an economics perspective, and outlines various justifications for government intervention in this area. The paper then focuses on the potential contribution of health economics in supporting resource allocation decision making for obesity prevention/treatment. Although economic evaluations of single interventions provide useful information, evaluations undertaken as part of a priority setting exercise provide the greatest scope for influencing decision making. A review of several priority setting examples in obesity prevention/treatment indicates that policy (as compared with program-based) interventions, targeted at prevention (as compared with treatment) and focused “upstream” on the food environment, are likely to be the most cost-effective options for change. However, in order to further support decision makers, several methodological advances are required. These include the incorporation of intervention costs/benefits outside the health sector, the addressing of equity impacts, and the increased engagement of decision makers in the priority setting process.