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

Long-term impact of unhealthy food tax on consumption and the drivers behind: A longitudinal study in Hungary

Several countries have introduced public health product taxes with the objective of reducing the absolute amount of consumption of unhealthy food and tackling obesity. This study aims to estimate the long-term impact of the Hungarian public health product tax introduced in 2011. To achieve this, a unique consumer purchase dataset was analysed to examine daily fast-moving consumer goods purchases from a representative sample of 2,000 households from 2010 to 2018. The results indicate that the tax has been fully reflected in consumer prices. A decline in consumption was observed initially, consistent with previous experiences in Hungary and other countries. However, over time, the data suggests a recovery and even an increase in line with the growth of disposable income. The proportion of taxed products in total fast-moving consumer goods purchases increased from 5.9 % (95 % CI: 5.7 % to 6.0 %) in 2010 to 7.4 % (95 % CI: 7.3 % to 7.6 %) in 2018. Furthermore, the tax has contributed to increased inequality as low-income households spend a higher proportion of their total expenditure on it. Although taxes on unhealthy foods have proven effective in the short-term, they may not be adequate for reducing overall consumption in the long-term, particularly as disposable income increases. In conclusion, implementing complex interventions is necessary to achieve sustainable positive changes in dietary habits.

Do Negative Self-Evaluative Emotions Enhance Healthier Food Choices? Exploring the Moderating Role of Self-Affirmation

Negative self-evaluative emotions arise when an individual engages in behavior that is perceived as inadequate or inconsistent with personal or societal norms and values, leading to feelings of inadequacy, shame, and dissatisfaction with oneself. These emotions are a central motivating force for changing unhealthy behaviors. However, negative evaluative emotions may also direct individuals towards defensive reactions such as reactance and avoidance. This can cause negative self-evaluative emotions to be less effective in reducing unhealthy behavior. More importantly, empirical evidence is needed to explore strategies for enhancing the effectiveness of interventions. In this study, we used an online experiment with 100 student participants to examine if increasing self-affirmation can increase the effectiveness of negative self-evaluative emotions in reducing unhealthy food consumption. We found that negative self-evaluative emotions can significantly increase healthy food consumption. However, our analysis did not reveal a significant moderating impact of self-affirmation on the effectiveness of negative self-evaluative emotions in reducing unhealthy consumption. This is the first study to explore the moderating impact of self-affirmation on the effectiveness of negative self-evaluative emotions on health behavioral change, which opens new avenues for studying how to apply the combination of stimulating negative self-evaluative emotions and increasing self-affirmation to induce behavioral change regarding healthy diets and even a broader range of fields.

Food price trends during the COVID-19 pandemic in Brazil

The present study aims to analyze the trends in food price in Brazil with emphasis on the period of the Covid-19 pandemic (from March 2020 to March 2022). Data from the Brazilian Household Budget Survey and the National System of Consumer Price Indexes were used as input to create a novel data set containing monthly prices (R$/Kg) for the foods and beverages most consumed in the country between January 2018 and March 2022. All food items were divided according to the Nova food classification system. We estimated the mean price of each food group for each year of study and the entire period. The monthly price of each group was plotted to analyze changes from January 2018 to March 2022. Fractional polynomial models were used to synthesize price changes up to 2025. Results of the present study showed that in Brazil unprocessed or minimally processed foods and processed culinary ingredients were more affordable than processed and ultra-processed foods. However, trend analyses suggested the reversal of the pricing pattern. The anticipated changes in the prices of minimally processed food relative to ultra-processed food, initially forecasted for Brazil, seem to reflect the impact of the Covid-19 pandemic on the global economy. These results are concerning as the increase in the price of healthy foods aggravates food and nutrition insecurity in Brazil. Additionally, this trend encourages the replacement of traditional meals for the consumption of unhealthy foods, increasing a health risk to the population.

The relationship between the price and demand of alcohol, tobacco, unhealthy food, sugar-sweetened beverages, and gambling: an umbrella review of systematic reviews

BACKGROUND

The WHO highlight alcohol, tobacco, unhealthy food, and sugar-sweetened beverage (SSB) taxes as one of the most effective policies for preventing and reducing the burden of non-communicable diseases. This umbrella review aimed to identify and summarise evidence from systematic reviews that report the relationship between price and demand or price and disease/death for alcohol, tobacco, unhealthy food, and SSBs. Given the recent recognition as gambling as a public health problem, we also included gambling.

METHODS

The protocol for this umbrella review was pre-registered (PROSPERO CRD42023447429). Seven electronic databases were searched between 2000-2023. Eligible systematic reviews were those published in any country, including adults or children, and which quantitatively examined the relationship between alcohol, tobacco, gambling, unhealthy food, or SSB price/tax and demand (sales/consumption) or disease/death. Two researchers undertook screening, eligibility, data extraction, and risk of bias assessment using the ROBIS tool.

RESULTS

We identified 50 reviews from 5,185 records, of which 31 reported on unhealthy food or SSBs, nine reported on tobacco, nine on alcohol, and one on multiple outcomes (alcohol, tobacco, unhealthy food, and SSBs). We did not identify any reviews on gambling. Higher prices were consistently associated with lower demand, notwithstanding variation in the size of effect across commodities or populations. Reductions in demand were large enough to be considered meaningful for policy.

CONCLUSIONS

Increases in the price of alcohol, tobacco, unhealthy food, and SSBs are consistently associated with decreases in demand. Moreover, increasing taxes can be expected to increase tax revenue. There may be potential in joining up approaches to taxation across the harm-causing commodities.

The equitable impact of sugary drink taxation structures on sugary drink consumption among Canadians: a modelling study using the 2015 Canadian Community Health Survey-Nutrition

OBJECTIVE

Estimate the impact of 20 % flat-rate and tiered sugary drink tax structures on the consumption of sugary drinks, sugar-sweetened beverages and 100 % juice by age, sex and socio-economic position.

DESIGN

We modelled the impact of price changes - for each tax structure - on the demand for sugary drinks by applying own- and cross-price elasticities to self-report sugary drink consumption measured using single-day 24-h dietary recalls from the cross-sectional, nationally representative 2015 Canadian Community Health Survey-Nutrition. For both 20 % flat-rate and tiered sugary drink tax scenarios, we used linear regression to estimate differences in mean energy intake and proportion of energy intake from sugary drinks by age, sex, education, food security and income.

SETTING

Canada.

PARTICIPANTS

19 742 respondents aged 2 and over.

RESULTS

In the 20 % flat-rate scenario, we estimated mean energy intake and proportion of daily energy intake from sugary drinks on a given day would be reduced by 29 kcal/d (95 % UI: 18, 41) and 1·3 % (95 % UI: 0·8, 1·8), respectively. Similarly, in the tiered tax scenario, additional small, but meaningful reductions were estimated in mean energy intake (40 kcal/d, 95 % UI: 24, 55) and proportion of daily energy intake (1·8 %, 95 % UI: 1·1, 2·5). Both tax structures reduced, but did not eliminate, inequities in mean energy intake from sugary drinks despite larger consumption reductions in children/adolescents, males and individuals with lower education, food security and income.

CONCLUSIONS

Sugary drink taxation, including the additional benefit of taxing 100 % juice, could reduce overall and inequities in mean energy intake from sugary drinks in Canada.

How an agreement with restriction of unhealthy food marketing and sodium taxation influenced high fat, salt or sugar (HFSS) food consumption

BACKGROUND

Food taxation and food marketing policy are very cost-effectiveness to improve healthy diets among children. The objective of this study was to investigate the socio-demographic characteristics of Thais and attitude towards on policy unhealthy food marketing restriction and sodium taxation which influence high fat, sodium, and sugar (FHSS) food eating.

METHODS

The data were obtained from the 2021 Health Behavior of Population Survey, four-stage sampling method of the Thai people, aged 15 years and above, using a offline survey application-assisted face-to-face interview. Logistic Regression were used to analyze the explanatory variables on agreement and HFSS food intake.

RESULTS

Almost half (48.4%) of samples disagreed with sodium taxation, and 42.7% of the samples disagreed with food marketing restriction. Most (99.6%) of Thai respondents consumed HFSS food, including sugar sweetened beverages (SSB). Gender, age, education, income, BMI, and health status were associated with agreement with food marketing restriction policy and sodium taxation policy. There is no association between agreement with policy on sodium taxation and food marketing and HFSS food consumption.

CONCLUSION

Nearly half of Thais indicated that they disagreed with policy on food marketing restriction and sodium taxation. Therefore, understanding and awareness of the two policies among Thais should be further investigated in order to develop better policy communication for increased public understanding and engagement.

Game changers: do new medications make lifestyle-based treatment of obesity obsolete?

Historically, obesity was viewed as a lifestyle disease, with an associated lifestyle solution, and approaches that embody the "eat less, move more" idea have dominated obesity treatment recommendations for over half a century. Meanwhile, the prevalence and severity of obesity continue to increase globally. Enter the so-called "game changers": glucagon-like peptide-1 receptor agonists. In the media frenzy around these and other new antiobesity medications in the pipeline, lifestyle-based treatment researchers and practitioners may find themselves wondering whether behavioral approaches to obesity will become obsolete in this new therapeutic era. In this Perspective, the authors contend that medical approaches impact physiologic pathways to support the success of behavioral approaches. Similarly, behavioral approaches can improve weight loss-adjacent outcomes that are not addressed by medication. Thus, the two approaches are complementary and must coexist if we are to make a significant, population-level impact on the obesity epidemic.

Health-environment efficiency of diets shows nonlinear trends over 1990-2011

Understanding the impacts of diets on health and the environment, as well as their association with socio-economic development, is key to operationalize and monitor food systems shifts. Here we propose a health-environment efficiency indicator defined as a ratio of health benefits and four key food-related environmental impacts (greenhouse gas emissions, scarcity-weighted water withdrawal, acidifying and eutrophying emissions) to assess how diets have performed in supporting healthy lives in relation to environmental pollution and resource consumption across 195 countries from 1990 to 2011. We find that the health-environment efficiency of each environmental input follows a nonlinear path along the Socio-Demographic Index gradient representing different development levels. Health-environment efficiency first increases thanks to the elimination of child and maternal malnutrition through greater food supply, then decreases driven by additional environmental impacts from a shift to animal products, and finally shows a slow growth in some developed countries again as they shift towards healthier diets.

Public preferences for policies promoting a healthy diet: a discrete choice experiment

BACKGROUND

Worldwide obesity rates have nearly tripled over the past five decades. So far, policies to promote a healthier diet have been less intrusive than those to reduce tobacco and alcohol consumption. Not much is known about public support for policies that aim to promote a healthy diet. In this study, a discrete choice experiment (DCE) was used to elicit stated preferences for policies varying in intrusiveness among a representative sample of the public of The Netherlands.

METHODS

The choice tasks presented respondents a hypothetical scenario of two policy packages, each comprising a mix of seven potential policies that differed in level of intrusiveness. We estimated mixed logit models (MXL) to estimate respondents' preferences for these policies and performed latent class analyses to identify heterogeneity in preferences.

RESULTS

The MXL model showed that positive financial incentives like subsidies for vegetables and fruit yielded most utility. A tax of 50% on sugary drinks was associated with disutility while a tax of 20% was associated with positive utility compared to no tax at all. We identified three subgroups with distinct preferences for the seven policies to promote a healthy diet, which were characterized as being "against", "mixed" and "pro" policies to promote a healthy diet.

CONCLUSION

Preferences for policies promoting a healthy diet vary considerably in the Dutch population, particularly in relation to more intrusive policies. This makes selection and implementation of a policy package that has wide public support challenging.

Digital Marketing and Fast-Food Intake in the UAE: The Role of Firm-Generated Content among Adult Consumers

In the contemporary digital marketing context, this study aimed to investigate the influence of firm-generated content and social media advertising on fast-food consumption patterns among the adult population. Utilizing a questionnaire distributed to customers of a restaurant in Fujairah, United Arab Emirates, convenience sampling was employed. The findings underscored a significant positive relationship between firm-generated content and social media engagement, as well as between the latter and online shopping behavior. However, it was determined that word of mouth did not significantly moderate the relationship between attitudes towards social media advertisements and fast-food consumption patterns. From a theoretical perspective, these results enrich the understanding of how digital dynamics shape consumer behavior in specific contexts. Practically speaking, they prompt a critical reflection on the ethics of marketing in promoting products potentially detrimental to health, urging both companies and policymakers to reconsider their strategies and regulations, respectively.

The Activities of the Slovenian Strategic Council for Nutrition 2023/24 to Improve the Health of the Slovenian Population and the Sustainability of Food: A Narrative Review

The health status of individuals in Slovenia across age groups is a matter of concern, as current unsustainable lifestyle choices are already leading to various chronic noncommunicable diseases (NCDs). Outdated national dietary guidelines, their inconsistent implementation, and a lack of structural changes represent obstacles to promoting healthy and sustainable nutrition. Limited access to and rising prices of healthy, sustainable foods, in addition to the high availability of low-priced, highly processed foods, increase the risk of NCDs. The lack of systematic health monitoring and early disease detection poses a challenge. Global and local environmental issues, resistance, and/or the inability to adopt healthier diets hinder individuals from changing their nutritional behaviours. In this narrative review, we provide an overview of the current situation in Slovenia as well as planned activities initiated by the Slovenian government and the Prime Minister's Strategic Council for Nutrition, aiming to make progress in supporting healthy and sustainable nutrition, limiting food waste, and increasing the availability of healthier foods for all. Improving the sustainability of the Slovenian food system can contribute to several Sustainable Development Goals (SDGs), ensuring Slovenia's commitment to internationally agreed-upon targets. This could lead Slovenia to take a role as a pilot country in testing and implementing the necessary systemic changes, which could be further applied in other countries.

An umbrella review of the acceptability of fiscal and pricing policies to reduce diet-related noncommunicable disease

CONTEXT

Poor diet has been implicated in a range of noncommunicable diseases. Fiscal and pricing policies (FPs) may offer a means by which consumption of food and non-alcoholic beverages with links to such diseases can be influenced to improve public health.

OBJECTIVE

To examine the acceptability of FPs to reduce diet-related noncommunicable disease, based on systematic review evidence.

DATA SOURCES

MEDLINE, EMBASE, PsychInfo, SCI, SSCI, Web of Science, Scopus, EconLit, the Cochrane Library, Epistemonikos, and the Campbell Collaboration Library were searched for relevant studies published between January 1, 1990 and June 2021.

DATA EXTRACTION

The studies included systematic reviews of diet-related FPs and: used real-world evidence; examined real or perceived barriers/facilitators; targeted the price of food or non-alcoholic beverages; and applied to entire populations within a jurisdiction. A total of 9996 unique relevant records were identified, which were augmented by a search of bibliographies and recommendations from an external expert advisory panel. Following screening, 4 systematic reviews remained.

DATA ANALYSIS

Quality appraisal was conducted using the AMSTAR 2 tool. A narrative synthesis was undertaken, with outcomes grouped according to the WHO-INTEGRATE criteria. The findings indicated a paucity of high-quality systematic review evidence and limited public support for the use of FPs to change dietary habits. This lack of support was related to a number of factors that included: their perceived potential to be regressive; a lack of transparency, ie, there was mistrust around the use of revenues raised; a paucity of evidence around health benefits; the deliberate choice of rates that were lower than those considered necessary to affect diet; and concerns about the potential of such FPs to harm economic outcomes such as employment.

CONCLUSION

The findings underscore the need for high-quality systematic review evidence on this topic, and the importance of responding to public concerns and putting in place mechanisms to address these when implementing FPs. This study was funded by Safefood [02A-2020].

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration no. CRD42021274454.

Evaluating the relative impact of multiple healthy food choice interventions on choice process variables and choices

Fiscal tools-taxes and/or subsidies-are increasingly used to address diet-related health problems. However, some studies have found that these tools are markedly more effective if attention is drawn to the tax or subsidy, suggesting that the price change alone may go unnoticed in the complex food environments that consumers face. Interventions that prompt individuals to consider health during choice show promise for promoting healthy food choices in both simple laboratory settings and complex, real-world markets. In this pre-registered study, I examine the impact of dietary fiber health prompts and/or dietary fiber subsidies on the per-serving fiber content of foods chosen, the documented set of products considered, and (self-reported) nutrition information use by participants in an online supermarket setting. Participants were randomized to one of four conditions: 1) control, 2) subsidy, 3) fiber prompt, and 4) fiber prompt + subsidy. Results show that both the prompt and prompt + subsidy conditions significantly increase fiber content of foods chosen (with the latter having a larger effect). While all three interventions influence the probability of using nutrition information during food choice and affect the set of products that respondents consider relative to the control condition, the effects were larger for the prompt and prompt + subsidy conditions. A multiple mediation analysis illustrates that both direct and indirect (through the set of products considered and the use of fiber information during choice) pathways lead to the significant overall increase in fiber content of selected foods.

Fruit and Vegetable Preparation Changes During and After Cost-Offset Community-Supported Agriculture Plus Nutrition Education

OBJECTIVE

Inadequate consumption of fruits and vegetables (FV) can negatively impact health. Cost-offset, or subsidized, community-supported agriculture (CO-CSA) may change FV preparation behaviors among caregivers in low-income households. We assessed changes in FV preparation frequency and methods during and after participation in a CO-CSA plus tailored nutrition education intervention.

DESIGN

Longitudinal comparison of outcomes at baseline, end of CO-CSA season, and 1 year later.

PARTICIPANTS

Caregivers of children aged 2-12 years from households with low income in rural areas of 4 US states (n = 148).

INTERVENTION

Summer season, half-price CO-CSA share plus tailored nutrition education classes. Comparison to a control group not included in this analysis.

VARIABLES MEASURED

Monthly frequency of preparing 9 FV for children's snacks and 5 vegetables for dinner; use of healthy preparation methods for dinner.

ANALYSIS

Repeated measures ANCOVA including state with Bonferroni correction and 95% confidence.

RESULTS

At baseline, caregivers prepared fruit for children's snacks and vegetables for dinner almost daily and vegetables for children's snacks every other day. The frequency of total FV preparation and most vegetable varieties increased during the intervention. Increases in total vegetables for snacks, dinner, and leafy greens were maintained 1 year later (n = 107).

CONCLUSIONS AND IMPLICATIONS

Community-supported agriculture plus education is a promising approach to sustained increases in vegetable preparation for children's snacks and dinner meals.

Attitudes and perceived knowledge of health professionals on the food labelling reform in Israel

OBJECTIVES

To assess the attitudes and perceived knowledge of health professionals regarding the food product judgemental-labelling reform that began in January 2020 in Israel.

DESIGN

Cross-sectional survey.

SETTINGS

An online survey among health professionals working in the Israeli health system.

PARTICIPANTS

456 participants (118 physicians, 207 nurses, 131 nutritionists).

RESULTS

Most respondents (89·9 %) were women, 36 % had over 20 years of professional experience. All nutritionists, 96·6 % of physicians and 94·7 % of nurses reported hearing about the reform, and most (88·9 % of nurses, 76·3 % of physicians and 75·6 % of nutritionists) claimed supporting the reform to a great or very great extent. Most respondents believe they should discuss issues related to healthy eating with their patients (91·8 % of nurses, 94·9 % of physicians and all nutritionists), but only about half (47·5 % of physicians and 57·0 % of nurses) reported that they have sufficient knowledge in this field, particularly about food labelling. Almost two-thirds of nutritionists (60·3 %) reported instructing patients to change their food intake according to labelling v. 40·1 % and 34·7 % of nurses and physicians, respectively. Only some respondents felt that they could influence their patients' nutrition habits. Most participants believe that additional regulatory measures should also be used to promote healthy nutrition.

CONCLUSIONS

There is a gap between the desire of physicians and nurses to provide nutritional guidance to the public and their actual knowledge about the labels' meaning as well as their competencies in providing nutrition counselling. When formulating a reform, policymakers should provide clear guidelines about the expectations of implementing it in therapeutic practice.

A Proposed Strategy against Obesity: How Government Policy Can Counter the Obesogenic Environment

An epidemic of obesity emerged in the USA in 1976-1980. The epidemic then spread to many other Westernized nations. Many interventions have been carried out with the goal of lowering the prevalence of obesity. These have mostly taken the form of various types of health promotion (i.e., providing people with education, advice, and encouragement). These actions have achieved, at most, only limited success. A strategy with a better chance of success starts with the recognition that the fundamental cause of obesity is that we live in an obesogenic environment. It is therefore necessary to change the environment so that it fosters a generally healthy lifestyle, thereby leading to enhanced health for the population, including improved weight control. A major goal is to increase the intake of healthy foods (especially fruit, vegetables, and whole grains), while decreasing intake of unhealthy foods (especially ultra-processed foods such as sugar). This will require major changes of many government policies. Some of the required policies are as follows. Schools should implement policies that create a healthy environment for children. For example, they should adopt a policy that only foods of high nutritional quality are sold in vending machines or given to students within school meals. Policies need to go well beyond the school setting; a broad strategy is needed that creates a healthy environment for children. Another important policy is the manipulation of food prices in order to shift the diet toward healthy foods. This requires using subsidies to lower the price of healthy foods, while adding a tax to less healthy foods to increase the price. This policy has been implemented in many cities and countries in the form of a tax on sugar-sweetened beverages (SSBs). The advertising of unhealthy foods (including fast-food restaurants) should be banned, especially where children and adolescents are the major target. Such a ban could be extended to a complete ban on all advertising for unhealthy foods, including that directed at adults. The proposed policy measures are likely to be strongly opposed by food corporations.

Evolution of global food trade network and its effects on population nutritional status

Changes in food systems during the last decades fostered the establishment of global food networks based on exchanges between countries with different income levels. Recent studies explored configuration and factors associated with trade networks of specific food items during limited periods; however, there is lack of evidence on evolution of trade networks of foods for human consumption and its potential effects on population nutritional status. We present the evolution of the global trade network of foods for human consumption from 1986 to 2020, according to country income level, and we explore potential effects of country network centrality and globalization processes on the prevalence of overweight and obesity. Results show intensification of international food trade and globalization processes in the period of analysis with implications for population nutritional status worldwide.

Effect of sugar-sweetened beverage taxation on sugars intake and dental caries: an umbrella review of a global perspective

BACKGROUND

As part of the Global Strategy on Oral health, the World Health Organization (WHO) is exploring cost-effective interventions for oral health, including taxation on sugar-sweetened beverages (SSBs). To inform this process, this umbrella review aimed to identify the best available estimates pertaining to the impact of SSB taxation on the reduction of sugars intake, and the sugars-caries dose-response, such that estimates of the impact of SSB taxation on averting dental caries in both high (HIC) and low and middle (LMIC) countries be available.

METHODS

The questions addressed were: (1) what are the effects of SSB taxation on consumption of SSBs and (2) sugars? (3) What is the effect on caries of decreasing sugars? and (4) what is the likely impact of a 20% volumetric SSB tax on the number of active caries prevented over 10 years? Data sources included PubMed, Embase, Web of Science, Scopus, CINAHL, Dentistry and Oral Sciences Source, Cochrane Library, Joanna Briggs Institute (JBI) Systematic Review Register, and PROSPERO. The review was conducted with reference to JBI guidelines. The quality of included systematic reviews was assessed using AMSTAR to identify best evidence.

RESULTS

From 419 systematic reviews identified for questions 1 & 2, and 103 for question 3, 48 (Questions 1 & 2) and 21 (Question 3) underwent full text screening, yielding 14 and five included reviews respectively. Best available data indicated a 10% tax would reduce SSB intake by 10.0% (95% CI: -5.0, 14.7%) in HIC and by 9% (range -6.0 to 12.0%) in LMIC, and that a 20% tax would reduce free sugars intake on average by 4.0 g/d in LMIC and 4.4 g/d in HIC. Based on best available dose response data, this could reduce the number of teeth with caries per adults (HIC and LMIC) by 0.03 and caries occurrence in children by 2.7% (LMIC) and 2.9% (HIC), over a 10-year period.

CONCLUSION

Best available data suggest a 20% volumetric SSB tax would have a modest impact on prevalence and severity of dental caries in both HIC and LMIC.

An umbrella review of the effectiveness of fiscal and pricing policies on food and non-alcoholic beverages to improve health

Poor quality diets represent major risk factors for the global burden of disease. Modeling studies indicate a potential for diet-related fiscal and pricing policies (FPs) to improve health. There is real-world evidence (RWE) that such policies can change behavior; however, the evidence regarding health is less clear. We conducted an umbrella review of the effectiveness of FPs on food and non-alcoholic beverages in influencing health or intermediate outcomes like consumption. We considered FPs applied to an entire population within a jurisdiction and included four systematic reviews in our final sample. Quality appraisal, an examination of excluded reviews, and a literature review of recent primary studies assessed the robustness of our results. Taxes and, to some extent, subsidies are effective in changing consumption of taxed/subsidized items; however, substitution is likely to occur. There is a lack of RWE supporting the effectiveness of FPs in improving health but this does not mean that they are ineffective. FPs may be important for improving health but their design is critical. Poorly designed FPs may fail to improve health and could reduce support for such policies or be used to support their repeal. More high-quality RWE on the impact of FPs on health is needed.

Problems and Solutions of Taxation to Control Unhealthy Goods: A Qualitative Study

Background: Taxes on unhealthy goods, in addition to reducing the consumption of these goods, preventing related diseases, and promoting public health, can provide significant financial resources for the health sector. Objectives: The purpose of this study was to investigate the problems and solutions of taxation to control the consumption of unhealthy goods to improve public health. Methods: This qualitative study was conducted in 2021. Semi-structured interviews with open-ended questions were held to collect information. Sampling was performed by purposive and snowball methods with 31 managers and key experts. The data were analyzed using the content analysis method. MAXQDA software (version 12) was used for classification and coding. Results: This study labeled 2 main themes and 10 subthemes. The main themes included problems of controlling unhealthy goods and solutions to controlling unhealthy goods. Poor decision-making, planning, and execution, production-related problems, smuggling and poor supervision, increased consumption of harmful goods, conflicts of interest, and advertisements of unhealthy goods are the most important of these problems. Imposing taxes, duties, and price hikes, providing alternatives, paying attention to all determinants of supply and demand, and taxation on advertising are also solutions to control unhealthy products. Conclusions: The health level of individuals should be improved by imposing taxes on unhealthy goods, determining accurate tax rates, and simultaneously using measures, such as providing alternatives to unhealthy goods and controlling advertisements. Paying serious attention to the list of harmful goods, coordination and cooperation of related organizations in formulating and implementing tax policies, and providing suitable alternatives to harmful products are the practical suggestions of this study.

Why has the taxing policy on sugar sweetened beverages not reduced their purchase in Iranian households?

Objective

This study aimed at analyzing the effectiveness of the policy of taxing Sugar-Sweetened Beverages (SSBs) on their purchases during the last decade in Iranian households.

Methods

The present mixed method study was done in 2017 in four phases: (1) A meta-review of the fiscal policies during the last decade, (2) Collecting existing data on soft drinks' production, price, and household expenditure during the last decade, (3) Conducting 19 semi-structured interviews with key informants, and (4) Facilitating a national meeting to achieve a consensus on the recommendations and future implications.

Results

Document reviews showed that based on the Permanent Provisions of National Development Plans of Iran, the Ministry of Health and Medical Education (MOHME) should announce the list of health threatening products to increase taxation for them. The government is allowed to impose taxes on domestically produced and imported SSBs. The average household expenditure on SSBs increased in the rural and urban households of Iran during 2006-2016 in spite of taxation. In the different key informants' opinion, only value-added tax (VAT) was implemented among different fiscal policies, and the other parts, including tax and tolls were debated.

Conclusion

The present research findings further proposed some suggestions for increasing the effectiveness of financial policies in reducing the prevalence of NCDs in Iran.

Nutrient density and cost of commonly consumed foods: a South African perspective

Food-based dietary guidelines promote consumption of a variety of nutritious foods for optimal health and prevention of chronic disease. However, adherence to these guidelines is challenging because of high food costs. The present study aimed to determine the nutrient density of foods relative to cost in South Africa, with the aim to identify foods within food groups with the best nutritional value per cost. A checklist of 116 food items was developed to record the type, unit, brand and cost of foods. Food prices were obtained from the websites of three national supermarkets and the average cost per 100 g edible portion was used to calculate cost per 100 kcal (418 kJ) for each food item. Nutrient content of the food items was obtained from the South African Food Composition Tables. Nutrient density was calculated using the Nutrient Rich Food (NRF9.3) Index. Nutrient density relative to cost was calculated as NRF9.3/price per 100 kcal. Vegetables and fruits had the highest NRF9.3 score and cost per 100 kcal. Overall, pulses had the highest nutritional value per cost. Fortified maizemeal porridge and bread had the best nutritional value per cost within the starchy food group. Foods with the least nutritional value per cost were fats, oils, foods high in fat and sugar, and foods and drinks high in sugar. Analysis of nutrient density and cost of foods can be used to develop tools to guide low-income consumers to make healthier food choices by identifying foods with the best nutritional value per cost.

The role of taxation measures in the management of harmful products, services, and practices in Iran: a qualitative study

BACKGROUND AND AIM

Levying a tax on harmful products, services, and practices can affect consumer choices, effectively preventing diseases and reducing health care costs. The goal of this study was to investigate the role of taxation as a powerful financial tool in the management of harmful products, services, and practices to maintain and improve public health and preserve the financial sustainability of the health care system.

MATERIALS AND METHODS

This qualitative study was conducted in 2020-2021. In order to collect information for this study, semi-structured interviews were conducted. Using purposive and snowball sampling methods, 38 managers, policymakers, economists, and key experts were interviewed. Data were analyzed using the content analysis method. The transcribed interviews were further imported into MAXQDA for classification, and relevant codes were extracted.

FINDINGS

In this study, 6 main themes and 19 subthemes were labeled. The main themes included 1) objectives, effects, and requirements of the taxation of harmful products, services, and practices, 2) definition, instances, elasticity, and grading of harmful products, services, and practices, 3) Problems in controlling harmful products, services, and practices, 4) controlling harmful products, services, and practices, 5) traffic violations and accidents, and social harms, and 6) tax revenue use and the share of health care. The effects of taxing harmful products include reduced access to these products, reduced demand for harmful products, and the promotion of public health.

CONCLUSION

Harmful products, services, and practices have major health and financial implications for individuals, families, and society. To improve public health, the demand for these products and services can be controlled through taxation measures to push consumers toward less harmful alternatives.

The impact of sugar-sweetened beverages tax on oral health-related outcomes: a systematic review of the current evidence

Objective To provide a systematic overview of the impact of taxing sugar-sweetened beverages (SSBs) on oral health-related outcomes.Data sources For this PRISMA-compliant review, we searched PubMed, Scopus, Embase, Web of Science and Cochrane Central for relevant studies published from database inception to 27 August 2020.Data selection and extraction Two reviewers assessed the abstracts and then the full text of the studies. Primary studies that evaluated the impact of any kind of SSB tax on oral health-related outcomes (that is, decayed, missing and filled teeth, caries increment and dental treatment costs) were included.Data synthesis Of 503 search results, five studies met the inclusion criteria. All five were modelling studies, from which four studies predicted an SSB tax to have a positive impact on oral health-related outcomes, whereas one study in a developing country did not find an SSB tax to be solely successful. According to three studies, the younger population and men are likely to benefit the most from such a tax. One study demonstrated the benefits of an SSB tax to be potentially more significant among low-income individuals.Conclusion While no empirical studies are available to support the benefits of an SSB tax, the studies covered in this review altogether anticipate a positive impact. Furthermore, this review discusses some of the obstacles and limitations of implementing such a tax predicted by the included studies.

Electoral campaign contributions: an obstacle to sugary drink industry regulation in Brazil?

OBJECTIVE

To assess corporate electoral campaign contributions from industries related to sugary drinks production and the characteristics of the elected officials financed by the sector.

DESIGN

Cross-sectional analysis of electoral campaign contributions from corporations related to sugary drinks production (sugary drink industries and sugary drink input industries) to candidates to the Chamber of Deputies, Brazil.

SETTING

Elections to the 55^th Congress (2015-2019), held in October 2014.

PARTICIPANTS

Candidates to the Chamber of Deputies, Brazil.

RESULTS

Forty-nine companies or corporate groups that produce sugary drinks and fifty-two corporations that produce inputs for sugary drinks manufacturing contributed to electoral campaigns of candidates in the 2014 Election. Contributions from this industry sector represented 7·3 % of all corporate contributions and helped finance 11·7 % of the candidates and 46·2 % of the elected officials. The transnationals Ambev and Coca-Cola were the first and second biggest donors, respectively. Revenues mediated by political parties, from sugary drink industries and from corporate members of some industry associations (Abir, Unica and CitrusBR), were more prevalent. Among elected officials, a significant association was found between being financed by the sector and representing the south-east region, having higher education level and referring themselves as being professional politicians. In the multivariate model, financed candidates were 27 % more likely to be elected.

CONCLUSIONS

Corporations related to sugary drinks production have contributed to the electoral campaigns of almost half of the Federal Deputies in Brazil in 2014. This possibly facilitates access to decision-makers and could help buy influence on legislative proposals, including health-related food policies.

Public perception of the tax on sweetened beverages in France

OBJECTIVE

To assess in 2021 the acceptance and perception of the French tax on sweetened beverages, following its revision in 2018, and factors associated with a higher level of acceptance.

DESIGN

A cross-sectional survey within the NutriNet-Santé cohort study. Participants were invited to complete a self-reported questionnaire in March 2021. Weighting was applied to the sample to allow inferences on the French population. Individual characteristics associated with support for the tax were investigated using logistic regression modelling.

SETTINGS

NutriNet-Santé prospective cohort study.

PARTICIPANTS

Adults engaged in the NutriNet-Santé cohort, aged 18 years or older (n 28 344), living in mainland France.

RESULTS

Almost two-thirds (63·4 %) of the participants were aware of the existence of a tax on sweetened beverages, although less than a quarter had specific knowledge regarding its design and the 2018 revision. In turn, 64·7 % of participants expressed a favourable opinion towards the taxation scheme. This proportion was higher if tax revenues were used to finance health-related measures (respectively 68·8 % of favourable opinion if used to finance a reduction in prices of healthy products and 76·4 % if used to finance the healthcare system). Multivariable analyses showed that support towards the tax varied among subgroups of the population. Groups who tended to be less financially affected by the measure and those who perceived sugar-sweetened beverages as having detrimental effects were more likely to support the tax.

CONCLUSION

The revised French sugar-sweetened beverage tax appeared to be favourably received and perceived by the public.

The effect of unhealthy dietary habits on the incidence of dental caries and overweight/obesity among Egyptian school children (A cross-sectional study)

Background

Obesity and dental caries are public health problems in Egypt. Factors such as unhealthy diet, poor oral hygiene, and physical inactivity can play a major role in both problems. This study was carried out to illuminate the mutual unhealthy dietary risk factors associated with the incidence of both health conditions.

Methods

Between 1 October 2020 and 1 July 2021, 369 Egyptian children (5-10 years) were examined. Dental status was assessed using decayed, missing/extracted, and filled tooth indices (dmft, deft, and DMFT) for deciduous, mixed, and permanent dentitions, respectively. Moreover, the lifestyle, food habits, and body mass index (BMI) were recorded.

Results

A total of 342 (93.7%) of the included subjects suffered from caries, and only 27(7.3%) were caries-free. Based on BMI percentiles, 247 (66.9%) of the youngsters were overweight/obese, while 122 (33.1%) had normal weight. The mean dmft was 6.9 (±4.6), deft 4.2 (±3.3), and DMFT 0.1 (±1.7). In the primary dentition, a significant positive correlation was detected between dmft and BMI, legumes, sweetened milk and juice, soft drinks, and desserts, while a significant negative correlation was detected between dmft/deft, meat/poultry/fish, fresh fruits, and vegetables. A significant positive correlation was detected between deft and BMI, sweetened milk and juice, ice cream, candies, and crackers. In the permanent dentition, a significant positive correlation was detected between age, soft drinks, sweetened juice, desserts, and DMFT, while a significant negative correlation was detected with fresh fruits and vegetables. BMI was significantly negatively correlated with a healthy lifestyle, meat/poultry/fish consumption, and fresh fruits and vegetables while positively correlated with legumes, ice cream, soft drinks, granulated sugars, desserts, fast food, and caffeinated drinks.

Conclusion

Overweight/obesity was positively correlated with primary dentition dental caries. Desserts (sweetened snacks) and soft drinks could be the common risk factors associated with high caries and overweight/obesity incidence among Egyptian school children; conversely, consumption of fruits and vegetables could hinder both health conditions. Moreover, sweetened juices were associated with primary and permanent dental caries.

The Magnitude of NCD Risk Factors in Ethiopia: Meta-Analysis and Systematic Review of Evidence

Background: Non-communicable Diseases (NCDs) and their risk factors are the leading contributors to morbidity and mortality globally, particularly in low- and middle-income countries including Ethiopia. To date, there has been no synthesis of the literature on the relative prevalence of NCD risk factors in Ethiopia. Methodology: We conducted a systematic review and meta-analysis of primary studies reporting on the prevalence of NCD risk factors in Ethiopia published in English from 2012 to July 2020. Pre-tested NCD search terms were applied to Medline, Embase, Scopus, CINAHL, and Global Health. Three reviewers screened and appraised the quality of the identified papers. Data extraction was conducted using a pilot tested proforma. Meta-analysis was conducted using Stata 16 and pooled prevalence estimated with associated 95% confidence intervals. Clinically heterogeneous studies that did not fulfil the eligibility criteria for meta-analysis were narratively synthesised. I² was used to assess statistical heterogeneity. Results: 47 studies fulfilled the inclusion criteria and contributed 68 NCD risk factor prevalence estimates. Hypertension was the most frequently examined NCD risk factor, with a pooled prevalence of 21% (n = 27 studies). The pooled prevalence percentages for overweight and obesity were 19.2% and 10.3%, respectively (n = 7 studies each), with a combined prevalence of 26.8% (n = 1 study). It was not possible to pool the prevalence of alcohol consumption, smoking, metabolic disorders, or fruit consumption because of heterogeneity across studies. The prevalence of alcohol use, as reported from the included individual studies, ranged from 12.4% to 13.5% (n = 7 studies). More than 90% of participants met the WHO-recommended level of physical activity (n = 5 studies). The prevalence of smoking was highly variable, ranging between 0.8% and 38.6%, as was the prevalence of heavy alcohol drinking (12.4% to 21.1%, n = 6 studies) and metabolic syndrome (4.8% to 9.6%, n = 5 studies). Fruit consumption ranged from 1.5% up to the recommended level, but varied across geographic areas (n = 3 studies). Conclusion and recommendations: The prevalence of NCD risk factors in Ethiopia is relatively high. National NCD risk factor surveillance is required to inform the prioritisation of policies and interventions to reduce the NCD burden in Ethiopia.

Public Support for the Imposition of a Tax on Sugar-Sweetened Beverages and the Determinants of Such Support in Spain

(1) Background: Taxes on sugar-sweetened beverages are an effective public health intervention, but can be difficult to implement in the absence of public support. This is the first study to analyze the Spanish population’s support for a tax on sugar-sweetened beverages. (2) Methods: We conducted a cross-sectional study of a representative sample of the Spanish adult population (n = 1002), using a computer-aided telephone interview with a questionnaire on nutritional policies. The support for the tax was calculated by the percentage of those who agreed plus those who strongly agreed with the measure. The sociodemographic determinants of support for the tax were analyzed using chi-squared test (χ2) and Poisson multiple regression models with robust variance. (3) Results: Of the participants, 66.9% supported a tax on sugar-sweetened beverages. Support for the tax was 9.2% higher (70% vs. 64.1%) when responders were first asked about support for tax relief and subsidies for healthy foods (p = 0.049). Support for the tax was 16% and 35% lower among persons reporting center and right-wing political sympathies (p < 0.01), and 16% lower among regular consumers of sugar-sweetened beverages (p = 0.01). (4) Conclusions: A clear majority of the Spanish population is in favor of imposing a tax on sugar-sweetened beverages. Awareness-raising campaigns and a policy of combining the measure with subsidies or tax cuts on healthy foods could increase the level of support among those currently against the intervention.

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.

Replacing ultra-processed foods with fresh foods to meet the dietary recomendations: a matter of cost?

The study aimed to analyze the economic impact of the adoption of optimized and nutritionally balanced diets to Brazilian families, considering the Brazilian dietary guidelines and the economic disparities of the population. Data from the Brazilian Household Budget Survey from 2008-2009 (550 strata; 55,970 households) were used. About 1,700 foods and beverages purchased by the Brazilians were classified into 4 groups according to NOVA system. Linear programming models estimated isoenergetic diets preserving the current diet as baseline and optimizing healthier diets gradually based on the "golden rule" of the Brazilian dietary guidelines, respecting nutritional restrictions for macronutrients and micronutrients (based on international recommendations) and food acceptance limits (10th and 90th percentiles of the per capita calorie distribution from the population). The diet cost was defined based on the sum of the average cost of each food group, both in the current and optimized diets (BRL per 2,000Kcal/person/day). The economic impact of the Brazilian dietary guidelines to Brazilian household budget was analyzed by comparison the cost of the optimized diets to the cost of the current diet, calculated for the total population and by income level. Three healthier diets were optimized. Current diet cost was BRL 3.37, differed among low- and high-income strata (BRL 2.62 and BRL 4.17, respectively). Regardless of income, diet cost decreased when approaching the guidelines. However, low-income strata compromised their household budget more than two times the high-income strata (20.2% and 7.96%, respectively). Thus, the adoption of healthier eating practices can be performed with the same or lower budget.

Strategies and interventions for healthy adolescent growth, nutrition, and development

Adolescence is a pivotal point in the life course, characterised by transformative physical, cognitive, and emotional growth, an openness to change, and a drive to reshape the social environment. It offers unique opportunities to adopt changes in diet and physical activity that can persist into later life. Yet pre-existing nutritional problems, including micronutrient deficiencies, food insecurity, and poor-quality diets, persist at the same time as adolescents face the rapid emergence of an obesity epidemic. Adolescent growth and nutrition has been largely overlooked in intervention and policy research. Most intervention studies have emphasised micronutrient supplementation, with few taking into account the multiple drivers of adolescent diets. This Series paper highlights that effective interventions and policies will need to cut across sectors; be supported by multifaceted and multilevel policy; and extend across education, health, food systems, social protection, and digital media. Better data standardisation and systems will be essential in coordinating and monitoring these responses. In a context of shifts in planetary ecosystems and commercial drivers, resilient food systems will need to both ensure access to healthy and affordable foods and provide the infrastructure and incentives for continuing physical activity. Intergenerational partnerships with young people will be essential in bringing about transformative change and ensuring that food policies reflect their needs and aspirations.

Changes in food habits amongst Norwegian adolescents in 2016 and 2019 according to gender and socioeconomic status

Background

Monitoring dietary habits is important in order to identify risk groups and as a basis for targeted public health initiatives.

Objective

To study trends in consumption of selected foods and beverages from 2016 to 2019 amongst Norwegian adolescents according to gender and parental education.

Design

Repeated cross-sectional study amongst 25,996 adolescents, aged 14–17 years old. Consumption of selected food and beverages was measured by an online food frequency questionnaire and general linear models were applied to estimate changes in dietary habits.

Results

Between 2016 and 2019, we observed a reduced frequency of consumption of vegetables (from 4.7 to 4.4 times/week), fruit and berries (from 4.4 to 4.2 times/week), whole-grain bread (from 5.1 to 4.2 times/week), and fish (from 2.3 to 1.6 times/week). During this time period, we also observed a reduced frequency of consumption of salty snacks (from 2.1 to 1.9 times/week), sweets (from 2.3 to 2.0 times/week), sugar-sweetened beverages (from 2.8 to 2.6 times/week), and artificially sweetened beverages (from 2.2 to 1.5 times/week). In girls, there was a decrease in the reported frequency of consumption of fruit and berries (−4%, vs. no change in boys). The decrease in consumption frequency of whole-grain bread was larger in girls than in boys (−19% vs. −14%). Further, a 17% decrease in consumption of sweets was observed amongst adolescents with no or only one parent having college/university education compared to a 13% decrease in adolescents whose both parents had college/university education.

Conclusion

Our results showed a decrease in frequency of consumption of selected healthy and unhealthy food and beverages amongst adolescents between 2016 and 2019. The gender gap in consumption of fruit and berries and whole-grain bread seemed to decrease during this time period, and the socio-economic gap in consumption of sweets seemed to disappear.

Redefining avoidable and inappropriate admissions

OBJECTIVES

Focusing on policy discourse in the United Kingdom, we examine the chain of causation that is characteristic of the ways in which the concepts of avoidability and inappropriateness are defined and used in these contexts. With a particular focus on diabetes complications, we aim to elucidate the way in which avoidable admission to hospital is conceptualised, measured, and applied to policy development and implementation and build a more inclusive model of identification as a basis for further research in this area.

STUDY DESIGN

Discourse analysis was used in combination with a scoping review.

METHODS

We searched the online databases of the UK Houses of Parliament Hansard, Official reports of the Northern Ireland Assembly and transcripts of the Scottish Parliament in October 2021. We also conducted an electronic search in October 2021 on MEDLINE, PubMed, Google Scholar, EMBASE, CINAHL and The Cochrane Library to review the available literature. In addition, an analysis of policies in place in Scotland, England and Northern Ireland relating to urgent diabetes care was conducted.

RESULTS

'Avoidable' and 'inappropriate' hospital admissions are categories used in health policy and practice internationally as ways of identifying targets for interventions intending to reduce the burden of care. Diabetes mellitus is a chronic condition that is often seen as a costly and avoidable use of health care services and so is a frequent target of such policies. Avoidable admission is interpreted as having a very long chain of causation. The assumption is that people requiring unscheduled hospital admission could have taken steps to prevent the onset of diabetes, or associated complications, arising in the first place. Definitions focus on primary and secondary prevention and largely place responsibility on the individual and their behaviour rather than on structural or social factors. Inadequate or inappropriate care prehospital or in the emergency department is seldom considered as a potential cause of avoidable admissions. Procedural definitions of avoidable admission are proposed whereby health care professionals and people living with diabetes collaborate to identify avoidable admissions in clinical audit rather than using statistical rates of avoidable admission within isolation in policy development and implementation.

CONCLUSIONS

Avoidability and inappropriateness are characteristics of cases in which conduct of the individual or attendant health care professionals was a proximate cause of hospital admission, and but for such conduct, admission could have been avoided. This process of definition seeks to provide a basis for contextualised and considered evaluation of where there are problems in care and where there are reasonable opportunities for prevention.

Using common practices to establish a framework for mobile produce markets in the United States

Access to affordable fruit and vegetables (F&V) remains a challenge within underserved communities across the United States. Mobile produce markets (mobile markets) are a well-accepted and effective strategy for increasing F&V consumption in these communities. Mobile market organizations share similar missions that focus on food, health, and empowerment, participate in incentive programs, offer nutrition education, utilize grassroots-based marketing strategies, prioritize local produce, and sell competitively priced produce through a market style. While mobile markets have become increasingly prevalent, models vary widely. Establishing standardized practices is essential for ensuring the effectiveness and sustainability of this important food access program. This research seeks to identify common practices of established mobile markets and describe the resources they rely on.

Investigating the short and long-term effects of "nutritional-score" pricing on food pantry selections

Approximately one out of ten households in the U.S. experienced food insecurity in 2019 (U. S. Department of Agriculture, 2020). Food pantries have taken on an important role in helping those with both short term and persistent food insecurity. As pantries are increasingly being arranged to allow clients to choose their own food, the question of how to encourage healthy choices is becoming an important topic for discussion. The Des Moines Area Religious Council (DMARC) implemented a "Nutritional-Score" program on September 1, 2017 as an experiment aimed at answering the above question. This program essentially changes the budgets of food pantry clients to make healthier choices cheaper and less healthy choices more expensive. We perform a Bayesian analysis using a zero-inflated Poisson (ZIP) model to help describe the effects of this program on the frequency with which clients choose less healthy items. We find evidence that the Nutritional-score program had a positive effect on the probability of rejecting less healthy items in the short and long term.

Impact of taxes on purchases of close substitute foods: analysis of cross-price elasticities using data from a randomized experiment

OBJECTIVE

To examine the effects of health-related food taxes on substitution and complementary purchases within food groups, including from unhealthier to healthier alternatives and between brands.

METHODS

We used data from a virtual supermarket experiment with data from 4,259 shopping events linked to varying price sets. Substitution or complementary effects within six frequently purchased food categories were analyzed. Products' own- and cross-price elasticities were analyzed using Almost Ideal Demand System models.

RESULTS

Overall, 37.5% of cross-price elasticities were significant (p < 0.05) and included values greater than 0.10. Supplementary and complementary effects were particularly found in the dairy, meats and snacks categories. For example, a 1% increase in the price of high saturated fat dairy was associated with a 0.18% (SE 0.06%) increase in purchases of low saturated fat dairy. For name- and home-brand products, significant substitution effects were found in 50% (n = 3) of cases, but only in one case this was above the 0.10 threshold.

CONCLUSIONS/POLICY IMPLICATIONS

Given the relatively low own-price elasticities and the limited substitution and complementary effects, relatively high taxes are needed to substantively increase healthy food purchases at the population level.

TRIAL REGISTRATION

This study included secondary analyses; the original trial was registered in the Australian New Zealand Clinical Trials Registry ACTRN12616000122459 .

Commercial use of evidence in public health policy: a critical assessment of food industry submissions to global-level consultations on non-communicable disease prevention

Background

Ultra-processed food industry (UPFI) actors have consistently opposed statutory regulation in health policy debates, including at the WHO. They do so most commonly with claims that regulatory policies do not work, will have negative consequences or that alternatives such as self-regulation work well or better. Underlying this are often assertions that industry is aligned with principles of evidence-based policymaking. In this study, we interrogate if this holds true by exploring the extent and quality of the evidence UPFI respondents employed to support claims around regulatory policy, and how they did this.

Methods

First, we identified all submissions from organisations who overtly represent UPFI companies to consultations held by the WHO on non-communicable disease policy between 2016 and 2018. Second, we extracted all relevant factual claims made in these submissions and noted if any evidence was referenced in support. Third, we assessed the quality of evidence using independence from UPFI, nature, and publication route as indicators. Lastly, where peer-reviewed research was cited, we examined if the claims made could be justified by the source cited.

Results

Across 26 included consultation responses, factual claims around regulation were made in 18, although only 10 referenced any evidence at all. Of all 114 claims made, 39 pieces of identifiable evidence were cited in support of 56 claims. Of the 39 distinct pieces of evidence, two-thirds were industry-funded or industry-linked, with only 16 externally peer-reviewed. Over half of industry-funded or industry-linked academic articles failed to declare a conflict of interest (COI). Overall, of only six claims which drew on peer-reviewed and independent research, none appropriately represented the source.

Discussion

UPFI respondents made far-reaching claims which were rarely supported by high-quality, independent evidence. This indicates that there may be few, if any, benefits from consulting actors with such a clear COI.

Relative Importance of Determinants of Changes in Eating Behavior during the Transition to Parenthood: Priorities for Future Research and Interventions

Background: Healthy eating behavior throughout pregnancy and postpartum is important. This study aimed to investigate the perceived sex-specific importance of determinants of changes in eating behavior during pregnancy and postpartum. Methods: Fifty-four determinants were rated by first-time parents (n = 179) on their impact. Experts (n = 31) rated the determinants in terms of their modifiability, relationship strength, and population-level effect from which a “priority for research”-score was calculated. Results: During pregnancy, the three highest rated determinants by women were “health concerns”, “physiological changes”, and “fatigue”. Men perceived “health concerns”, “health consciousness”, and “influence of the pregnant partner” as important. Postpartum, the three highest rated determinants by women were “adaptation to rhythm of baby”, “baby becomes priority”, and “practical constraints because of the baby”. Men perceived “adaptation to rhythm of baby”, “fatigue”. and “(lack of) anticipation” as important. According to the experts, “professional influence”, “food knowledge”, and “home food availability” received high priority scores for both sexes and during both periods. Conclusions: Priority for research and interventions should go towards tailored family-based approaches focusing on food education in a broad sense taking into account aspects such as health consciousness, self-efficacy skills, and the social and home food environment while being supported by healthcare professionals.

Socio-economic inequalities in dietary intake in Chile: a systematic review

OBJECTIVE

Understanding the socio-economic inequalities in dietary intake is crucial when addressing the socio-economic gradient in obesity rates and non-communicable diseases. We aimed to systematically assess the association between socio-economic position (SEP) and dietary intake in Chile.

DESIGN

We searched for peer-reviewed and grey literature from inception until 31 December 2019 in PubMed, Scopus, PsycINFO, Web of Sciences and LILACS databases. Observational studies published in English and Spanish, reporting the comparison of at least one dietary factor between at least two groups of different SEP in the general Chilean population, were selected. Two researchers independently conducted data searches, screening and extraction and assessed study quality using an adaptation of the Newcastle Ottawa Quality Assessment Scale.

RESULTS

Twenty-one articles (from eighteen studies) were included. Study quality was considered low, medium and high for 24, 52 and 24 % of articles, respectively. Moderate-to-large associations indicated lower intake of fruit and vegetables, dairy products and fish/seafood and higher pulses consumption among adults of lower SEP. Variable evidence of association was found for energy intake and macronutrients, in both children and adults.

CONCLUSIONS

Our findings highlight some socio-economic inequalities in diets in Chile, evidencing an overall less healthy food consumption among the lower SEP groups. New policies to reduce these inequalities should tackle the unequal distribution of factors affecting healthy eating among the lower SEP groups. These findings also provide important insights for developing strategies to reduce dietary inequalities in Chile and other countries that have undergone similar nutritional transitions.

Ultra-processed food industry regulation for tackling obesity and diet-related non-communicable diseases in the Brazilian legislature: many proposals, no enactments

OBJECTIVE

To assess efforts of the Brazilian legislature to regulate ultra-processed food industry practices related to obesity and diet-related non-communicable diseases during the first 4 years of the United Nations' Decade of Action on Nutrition.

DESIGN

We searched the Chamber of Deputies and Federal Senate internal databases to identify bills under consideration between 2016 and December 2019. Keywords related to the main recommendations of international organisations regarding the regulation of food industry practices were used. Descriptive and content analysis of the bills were carried out.

SETTING

Brazilian legislature (Chamber of Deputies and Federal Senate).

PARTICIPANTS

None.

RESULTS

Eighty-four bills were identified. The most frequently addressed topics were: nutrition labelling (38·1 %), marketing of unhealthy products (30·9 %), availability of unhealthy products (26·2 %) and critical nutrients content (14·3 %). Only 9·5 % of bills have proposed taxation on unhealthy products. No bill was passed during that period; 2·4 % were rejected and 10·7 % archived. Among the bills still under consideration, 52·4 % have not been passed in any Committee.

CONCLUSIONS

Although many bills have been introduced, no regulation of ultra-processed food industry practices has been enacted by the Brazilian legislature by 2020. It is likely that no positive impact on population nutrition in Brazil will be achieved by the end of the United Nation's Decade of Action on Nutrition, in 2025 - especially regarding those goals set by the Brazilian government which were supposed to have been achieved by 2019.

Promoting healthy foods among urban school children in Bangladesh: a qualitative inquiry of the challenges and opportunities

BACKGROUND

In Bangladesh overweight and obesity among urban school children are on the rise. Urban school children tend to consume foods dense in calories and few fruits and vegetables which is associated with overweight and obesity. The current study explored the barriers and opportunities for promoting healthy diets among school children from the perspective of teachers and parents in Dhaka, Bangladesh.

METHODS

We conducted 14 key informant interviews with teachers and principals, six focus group discussions with 31 mothers of school children (5 to 15 year old) and 14 structured observations of the school food environment. Inductive thematic analysis was performed manually.

RESULTS

Schools were important for development of food preferences of children, however, most school cafeterias provided foods based on profit rather than health considerations. A shift in food culture resulted in making eating out acquire many meanings beyond convenience. Mothers, especially those who were employed, struggled to prepare healthy foods due to time pressure. Mothers were generally concerned about chemicals added to raw foods in markets which led to limited fruit and vegetable consumption.

CONCLUSIONS

There were many challenges to promoting healthy foods to school children within and outside the school. It is important to formulate policies and guidance to create a supportive environment for healthy foods in and in the proximity of schools. It is also important to educate consumers about identifying and choosing healthy foods. Laws related to food safety should be adequately implemented to boost the population's confidence in safety of available healthy foods in the food system.

Healthy eating: a privilege for the better-off?

BACKGROUND

Food subsidies for healthier foods and higher taxes for less healthy alternatives have been increasingly used to promote a healthy diet. Yet, some have argued that the fiscal burden on unhealthy products would fall disproportionately on the worse-off, raising equity concerns. This study estimates the association between income and the consumption of key food groups linked to the Mediterranean diet in the adult Portuguese population.

METHODS

We used data from the Portuguese National Food, Nutrition and Physical Activity Survey (IAN-AF 2015-2016), which observed the daily diet of individuals aged above 18 and below 79 years old (n = 3242). Logistic regression models were used to estimate the magnitude of the association between self-reported household income categories and consumption of foods related to the Mediterranean diet (fish, vegetables, fruits and legumes), and not (sweets, sugar-sweetened beverages, cakes & pastries and processed meats). Stratified analyses were performed by education and age categories.

RESULTS

We observed that the intake of fish (35.8 vs 38.8 g p = 0.02), vegetables (146.7 vs 166.2 g p < 0.01), and fruits (119.8 vs 150.1 g p < 0.01) was positively related to income, with a clear gradient for the two latter. Yet, the positive income-consumption link for fish was only observed among low-educated people, and the one for legumes among high educated and youths. Conversely, the consumption of most non-Mediterranean foods was not positively related to income categories, with the exception of sweets (34.8 vs 31.8 g p = 0.01) and cakes (26.4 vs 21.4 g p < 0.01) (more prevalent among the better-off).

CONCLUSIONS

The consumption of healthy food is mostly consistently related to income, contrary to the intake of unhealthy ones. It may well be, therefore, that subsidies to healthy foods could allow access to the worse-off while taxing unhealthy food will not impose a disproportionate burden on them.

A Standardized Guide to Developing an Online Grocery Store for Testing Nutrition-Related Policies and Interventions in an Online Setting

Simulated online grocery store platforms are innovative tools for studying nutrition-related policies and point-of-selection/point-of-purchase interventions in online retail settings, yet there is no clear guidance on how to develop these platforms for experimental research. Thus, we created a standardized guide for the development of an online grocery store, including a detailed description of (1) methods for acquiring and cleaning online grocery store data, and (2) how to design a two-dimensional online grocery store experimental platform. We provide guidance on how to address product categorization, product order/sorting and product details, including how to identify outliers and conflicting nutritional information and methods for standardizing prices. We also provide details regarding our process of “tagging” food items that can be leveraged by future studies examining policies and point-of-selection/point-of-purchase interventions targeting red and processed meat and fruits and vegetables. We experienced several challenges, including obtaining accurate and up-to-date product information and images, and accounting for the presence of store-brand products. Regardless, the methodology described herein will enable researchers to examine the effects of a wide array of nutrition-related policies and interventions on food purchasing behaviors in online retail settings, and can be used as a template for reporting procedures in future research.

Obesity under full fresh fruit and vegetable access conditions

There is no agreement regarding the role of fresh fruit and vegetables' affordability, accessibility and availability, or access in general, on obesity rates. In this article we investigated whether access to fresh fruit and vegetables is related to better biometric indicators such as weight and body mass index. Using mediation and matching methods and assuming that farmers and traditional market sellers have easy access to fruit and vegetables, we found that having better access is not associated to a reduction in weight or body mass index. Potential explanations for this result are that better access was not associated with fresh fruit and vegetables' consumption and fruit and vegetables' consumption was not associated with weight and body mass index. Also, fresh fruit and vegetables' sellers had a higher weight and body mass index compared to the rest of the population but, a similar weight and body mass index compared to people with their same educational level. Therefore, variations on weight and body mass index were more associated with educational level rather than with access. Access may not be the single story to explain fruit and vegetable consumption.

Sodium intake, health implications, and the role of population-level strategies

Evidence to date suggests that high sodium intake affects health adversely, yet the role of a population-level strategy to reduce sodium intake is often contested. This review focuses on current available evidence on regional sodium intake levels, health implications of sodium intake, and population-level strategies implemented worldwide. The limitations in evidence, the difficulties in implementing population-wide strategies to reduce sodium intake, and the need for such strategies are critically reviewed. Evidence clearly shows that sodium has an adverse effect on blood pressure, cardiovascular disease, and mortality. However, whether reduced sodium intake benefits all individuals or only hypertensive individuals is still unclear. Methodological issues and publication bias in current evidence are other matters of concern in sodium-related research. While it is essential to continue working toward the World Health Organization's target of 30% reduction in sodium intake, due consideration should be given to improving the quality of research, reducing bias in publications, and reviewing evidence more critically.

The effect of on-shelf sugar labeling on beverage sales in the supermarket: a comparative interrupted time series analysis of a natural experiment

BACKGROUND

Nutrition labels show potential in increasing healthy food and beverage purchases, but their effectiveness seems to depend on the type of label, the targeted food category and the setting, and evidence on their impact in real-world settings is limited. The aim of this study was to evaluate the effectiveness of an industry-designed on-shelf sugar label on the sales of beverages with no, low, medium and high sugar content implemented within a real-world supermarket.

METHODS

In week 17 of 2019, on-shelf sugar labels were implemented by a Dutch supermarket chain. Non-alcoholic beverages were classified using a traffic-light labeling system and included the beverage categories "green" for sugar free (< 1.25 g/250 ml), "blue" for low sugar (1.25-6.24 g/250 ml), "yellow" for medium sugar (6.25-13.5 g/250 ml) and "amber" for high sugar (> 13.5 g/250 ml). Store-level data on beverage sales and revenue from 41 randomly selected supermarkets for 13 weeks pre-implementation and 21 weeks post-implementation were used for analysis. In total, 30 stores implemented the on-shelf sugar labels by week 17, and the 11 stores that had not were used as comparisons. Outcome measures were differences in the number of beverages sold in the four label categories and the total revenue from beverage sales in implementation stores relative to comparison stores. Analyses were conducted using a multiple-group Interrupted Time Series Approach. Results of individual store data were combined using random effect meta-analyses.

RESULTS

At the end of the intervention period, the changes in sales of beverages with green (B 3.4, 95%CI -0.3; 7.0), blue (B 0.0, 95%CI -0.6; 0.7), yellow (B 1.3, 95%CI -0.9; 3.5), and amber (B 0.9, 95%CI -5.5; 7.3) labels were not significantly different between intervention and comparison stores. The changes in total revenues for beverages at the end of the intervention period were also not significantly different between intervention and comparison stores.

CONCLUSION

The implementation of an on-shelf sugar labeling system did not significantly decrease unhealthy beverage sales or significantly increase healthier beverage sales. Nutrition labeling initiatives combined with complementary strategies, such as pricing strategies or other healthy food nudging approaches, should be considered to promote healthier beverage purchases.

The role of foodbanks in the context of food insecurity: Experiences and eating behaviours amongst users

The study aim was to investigate the role of foodbanks in the context of food insecurity and explore food choices and eating behaviours amongst users. Food insecurity is associated with poor diet quality and obesity; however, the dimensions that influence food choices and eating behaviour remain unclear. Face-to-face interviews were conducted with individuals who had visited a faith-based foodbank in Perth, Western Australia. Participants were thirty-three service users who had collected a food hamper from the foodbank. Interview transcripts were analyzed using thematic analysis. Four main themes emerged: Ties you over until pay day; Food hamper supporting meals and fruit and vegetable consumption; Food choices supplementing hamper; Household gatekeeping and food control. Participants were complimentary about the content of the food hamper received which included a variety of fresh produce. A key new finding was the frequent purchase and consumption of meat and processed meat to supplement the food hamper provision. Future work and interventions to improve eating behaviour and reduce food-related financial pressure for those vulnerable to food insecurity include further exploration of the dimensions influencing food choices (i.e., cultural norms, habits, symbols); exposure to healthy and tasty plant-based meals, (i.e., tasting low-cost and tasty vegetable-based meals); parenting training focused on handling child/partner food choice influences, and, enforcing household rules governing food.