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

National taxation on sugar-sweetened beverages and its association with overweight, obesity, and diabetes

BACKGROUND

Consumption of sugar-sweetened beverages (SSBs) has been linked to several adverse health outcomes, thus many countries introduced taxation to reduce it.

OBJECTIVES

To summarize national SSB taxation laws and to assess their association with obesity, overweight and diabetes.

METHODS

We conducted a systematic scoping review up to January 2022 on PubMed, Web of Science, Embase, and Google Search to identify taxes on SSBs. An interrupted time series analysis (ITSA) was conducted on 17 countries with taxation implemented in 2013 or before to evaluate the level and slope modifications in the rate of change of standardized prevalence rates of overweight, obesity, and diabetes. Random-effects meta-regression was used to assess whether year of entry into force of the law, national income, and tax design affected observed results.

RESULTS

We included 76 tax laws issued between 1940 and 2020 by 43 countries, which were heterogeneous in terms of tax design, amount, and taxed products. Among children and adolescents, ITSA showed level or slope reduction for prevalence of overweight and obesity in 5 (Brazil, Samoa, Palau, Panama, Tonga) and 6 (El Salvador, Uruguay, Nauru, Norway, Palau, Tonga) countries out of 17, respectively. No clear pattern of modification of results according to investigated factors emerged from the meta-regression analysis.

CONCLUSIONS

Taxation is highly heterogeneous across countries in terms of products and design, which might influence its effectiveness. Our findings provide some evidence regarding a deceleration of the increasing prevalence rates of overweight and obesity among children occurring in some countries following introduction of taxation. PROSPERO registration number: CRD42021233309.

Examining the Role and Strategies of Advocacy Coalitions in California's Statewide Sugar-Sweetened Beverage Tax Debate (2001-2018)

PURPOSE

California's failed attempts to enact a statewide sugary beverage tax presents an opportunity to advance understanding of advocacy coalition behavior. We investigate the participation of advocacy coalitions in California's statewide sugar-sweetened beverage (SSB) tax policy debate.

DESIGN

Document analysis of legislative bills and newspaper articles collected in 2019.

SETTING

California.

METHOD

A total of 11 SSB tax-related bills were introduced in California's legislature between 2001-2018 according to the state's legislative website. Data sources include legislative bill documents (n = 94) and newspaper articles (n = 138). Guided by the Advocacy Coalition Framework (ACF), we identify advocacy coalitions involved in California's SSB tax debate and explore strategies and arguments used to advance each coalitions' position.

RESULTS

Two coalitions (public health, food/beverage industry) were involved in California's statewide SSB tax policy debate. The public health coalition had higher member participation and referred to scientific research evidence while the industry coalition used preemption and financial resources as primary advocacy strategies. The public health coalition frequently presented messaging on the health consequences and financial benefits of SSB taxes. The industry coalition responded by focusing on the potential negative economic impact of a tax.

CONCLUSION

Multiple attempts to enact a statewide SSB tax in California have failed. Our findings add insight into the challenges of enacting an SSB tax considering industry interference. Results can inform future efforts to pass evidence-based nutrition policies.

Online Health Communities' Portrayal of Obesity on Social Media Platforms in South Africa

The rapidly increasing prevalence of obesity in South Africa, intertwined with extensive changes in diet, life expectancy, and nutritional status has led to a complex framing of obesity on social media. This has prompted the prioritization of media-based social and behavior change communication interventions leveraging social media for obesity prevention. This study was conducted to understand how obesity is constructed and represented on social media in South Africa. A media review of Facebook and Twitter platforms in South Africa was conducted over a six-month period using Meltwater software for data collection. The search yielded 13 500 posts and tweets. Data were cleaned and coded in Microsoft Excel. Content and framing analysis were performed to add insight into the nature of obesity discourse on social media. Portrayals of obesity on social media were dominated by stigmatizing imagery blaming individuals for unhealthy lifestyles, poor diets, and lack of physical activity. Future media-based social and behavior change communication interventions for obesity prevention can leverage social media to reach the broader public and insights into media portrayals of obesity have the potential to influence the shape and development of these behavioral interventions.

Adherence to '5-2-1-0' guidelines and multiple risky behaviours among adolescents in nine sub-Saharan African countries: evidence from Global School-based Student Health Survey 2012-2017

OBJECTIVE

Overweight and obesity constitute a new challenge in low-income and middle-countries. The obesity prevention programme, called '5-2-1-0', promotes healthy eating habits, physical activity and limited screen time among young people.This study aimed to assess adherence to the '5-2-1-0' recommendations and to study multiple risky behaviours among adolescents in nine countries in sub-Saharan Africa.

METHODS

Meta-analyses with a random effect were used to calculate overall prevalence. Non-random patterns of the co-occurrence of the four risky behaviours were explored using observed/expected prevalence ratios. Data came from the Global School-based Health Survey and 18 314 adolescents were considered.

RESULTS

Among the participants, 12.7% (95% CI 7.5% to 19.0%) had overweight and 3.2% (95% CI 1.1% to 6.1%) had obesity. In almost all countries studied, girls were more affected by overweight and obesity than boys.While only 0.2% (95% CI 0.1% to 0.4%) of the adolescents fully complied with the recommendations, 4.8% (95% CI 3.1% to 6.9%), 28.4% (95% CI 22.4% to 34.8%), 43.8% (95% CI 41.9% to 45.8%) and 17.0% (95% CI 11.8% to 23.0%), respectively, combined 1, 2, 3 and 4 risky behaviours among the four '5-2-1-0' criteria. The most observed combination was found for co-occurrence of three risky behaviours: insufficient fruit/vegetables consumption, physical activity and non-zero consumption of sugar-sweetened beverages.

CONCLUSION

In conclusion, the insufficient adherence to '5-2-1-0' recommendations and the high prevalence of the co-occurrence of risky behaviours underscore the need to strengthen health interventions and programmes to prevent obesity among adolescents in sub-Saharan Africa.

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.

Sixteen-year trends in adolescent consumption of sugar-sweetened soda in six European countries with a soda tax and comparison countries: a repeated cross-sectional survey analysis

OBJECTIVE

To examine changes in the proportions of daily, weekly and occasional consumers of sugar-sweetened soda in six European countries that introduced/updated a tax between 2001-2002 and 2017-2018 and in neighbouring comparison countries (without a tax).

DESIGN

Repeated cross-sectional surveys.

SETTING

Health Behaviour in School-aged Children study, spanning five survey years (school years 2001-2002 to 2017-2018).

PARTICIPANTS

Nationally representative samples of 13-year- and 15-year-old adolescents (n 236 623, 51·0 % girls).

RESULTS

Tax sizes (€0·02/l to €0·22/l) and pre-tax soda consumption were heterogeneous across countries. Prevalence of daily soda consumption reduced in the survey year following tax implementation in Latvia (from 17·9 to 11·9 %, P = 0·01), Finland (4·2 to 2·5 %, P = 0·001), Belgium (35·1 to 27·8 %, P < 0·001) and Portugal (17·4 to 14·9 %, P = 0·02), but not in Hungary (29·8 to 31·3 %, P = 0·47) or France (29·4 to 28·2 %, P = 0·27). However, reductions were similar (Finland) or smaller (Belgium, Portugal) than those in the comparison countries, except in Latvia where the reduction was larger (Pinteraction < 0·001). Prevalence of weekly soda consumption remained stable (Finland, Hungary and France) or increased (Latvia, Belgium); only Portugal experienced a decline (P < 0·001), which was larger than in the comparison country (Pinteraction < 0·001). Prevalence of occasional soda consumption (<1x/week) did not rise after implementation of the tax in Latvia, Finland, Hungary, France or Belgium, or the rise was similar to the comparison country in Portugal (Pinteraction = 0·15).

CONCLUSIONS

Countries with a soda tax did not experience larger beneficial changes in post-tax adolescent consumption frequency of soda than comparison countries. Further studies, with different taxation types, are needed in the adolescent population.

Decomposing consumer and producer effects on sugar from beverage purchases after a sugar-based tax on beverages in South Africa

Growing global concern about obesity and diet-related non-communicable diseases has raised interest in fiscal policy as a tool to reduce this disease burden and its social costs, especially excise taxes on sugar-sweetened beverages (SSBs). Of particular interest have been nutrient-based taxes to improve diet quality. These can incentivize producers to reformulate existing products and introduce healthier alternatives into their ranges. In 2018, South Africa adopted a sugar-based tax on SSBs, the Health Promotion Levy (HPL). Early findings suggest that purchases of higher-sugar taxable beverages fell and purchases of no- and lower-sugar beverages increased, alongside significant reductions in the sugar content of overall beverage purchases. However, underlying these changes are consumption shifts as well as product reformulation and changes in producers' product portfolios. Drawing on a household scanner dataset, this study employed a descriptive approach to decompose changes in the sugar content of households' non-alcoholic beverage purchases into producer factors (reformulation and product entry and exit) and consumer factors (product switching and volume changes as a result of price changes, changing preferences, or other factors). We look at these factors as the tax was announced and implemented across a sample of over 3000 South African households, and then by Living Standard Measures (LSM) groups (middle vs. high). The sugar content of beverage purchases fell by 4.9 g/capita/day overall, a 32% decrease. Taken in isolation, consumer switching and volume changes together led to a reduction equivalent to 71% of the total change, while reformulation accounted for a decrease equal to 34% of that change. Middle-LSM households experienced larger reductions than high-LSM households due to larger changes on the consumer side. For both LSM groups, reformulation-led reductions mostly occurred after implementation, and most changes came from taxable beverage purchases. As sugary drink tax designs evolve with broader implementation globally, understanding both supply- and demand-side factors will help to better assess the population and equity potential of these policies.

The Healthy Aging Adult South Africa report card: a systematic review of the evidence between 2013 and 2020 for middle-aged South African men and women

Due to the increasing non-communicable disease burden in Africa, several strategies that target the major lifestyle and physiological risk factors have been implemented to combat such diseases. The Healthy Aging Adult South Africa report card systematically reviews national and regional prevalence data of middle-aged South African adults (45-65 years) published between 2013 and 2020 on diet, physical activity, tobacco use and alcohol consumption, obesity, hypertension, dyslipidaemia and diabetes mellitus. Each indicator was assigned two grades, (1) based on the availability of prevalence data, and (2) based on whether policies have been proposed and implemented for the respective indicators. Alcohol consumption, obesity, hypertension and diabetes received an A grade for the availability of prevalence data. Tobacco use and diet received an A grade for policy and implementation. Gaps have been identified that need to be filled by future research focusing on continued surveillance of all indicators in order to inform and implement effective policies.

New developments with the Health Promotion Levy in South Africa

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South Africa's Health Promotion Levy: Excise tax findings and equity potential

In 2016, the South African government proposed a 20% sugar-sweetened beverage (SSB) tax. Protracted consultations with beverage manufacturers and the sugar industry followed. This resulted in a lower sugar-based beverage tax, the Health Promotion Levy (HPL), of approximately 10% coming into effect in April 2018. We provide a synthesis of findings until April 2021. Studies show that despite the lower rate, purchases of unhealthy SSBs and sugar intake consumption from SSBs fell. There were greater reductions in SSB purchases among both lower socioeconomic groups and in subpopulations with higher SSB consumption. These subpopulations bear larger burdens from obesity and related diseases, suggesting that this policy improves health equity. The current COVID-19 pandemic has impacted food and nutritional security. Increased pandemic mortality among people with obesity, diabetes, and hypertension highlight the importance of intersectoral public health disease-prevention policies like the HPL, which should be strengthened.

Towards unified and impactful policies to reduce ultra-processed food consumption and promote healthier eating

The global surges in obesity and nutrition-related non-communicable diseases (NCDs) have created a need for decisive new food policy initiatives. A major concern has been the impact of ultra-processed foods (UPFs) and ultra-processed drinks on weight gain and on the risk of several NCDs. These foods, generally high in calories, added sugar, sodium, and unhealthy fats, and poor in fibre, protein, and micronutrients, have extensive negative effects on human health and on the environment (due to their associated carbon emission and water use). There is a growing tendency worldwide, and especially in South America, for food companies to add micronutrients to UPFs to make health claims regarding these products, to which food-regulating authorities refer to fake foods. Although more than 45 countries and smaller subregional or urban entities have created taxes on ultra-processed drinks, such as sugar-sweetened beverages, only a few have adopted taxes on snacks and other UPFs, and none have added major subsidies for truly healthy, fresh or minimally processed food for people from lower socioeconomic backgrounds. Another major focus has been on developing effective package labelling. A smaller number of countries have selected the most impactful warning labels and linked them with other measures to create a mutually reinforcing set of policies; a few other countries have developed effective school food policies. We herein present in-depth results from key countries involved in all these actions and in comprehensive marketing controls, and conclude with our recommendations for the future. This field is quite new; progress to date is substantial, but much more is left to learn.