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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Association Between a State-Level Fat Tax and Fast Food Purchases

Importance

India faces an increasing obesity problem, including in the Indian state of Kerala in which the fat tax was implemented but was nullified 11 months later. A fat tax, defined as a tax on unhealthy foods, may be associated with changes in food purchases and outcomes for multiple diet-related diseases.

Objective

To investigate the association between the state-level fat tax and fast food purchases in Kerala, India.

Design, Setting, and Participants

This cohort study analyzed a large-scale credit and debit card transaction data set and aggregated this sample at the account-year-month level of fast food purchases in Kerala state and 9 major cities in other Indian states (Ahmedabad, Bangalore, Bhubaneswar, Chennai, Delhi, Gurgaon, Kolkata, Mumbai, and Surat). Purchase records were obtained for January 1, 2016, to December 31, 2017. The association between the fat tax and fast food purchases was examined using the difference-in-differences method. This analysis was initiated on December 1, 2022.

Exposures

The exposure was the fat tax. Kerala was the exposed group, and 9 major Indian cities were the control group.

Main Outcomes and Measures

The main outcome was the fast food purchase ratio, defined as the proportion of fast food purchases of the total food purchases. Changes in the fast food purchase ratio were estimated in Kerala across the sample period and then compared with 9 major cities.

Results

The sample for analysis included 238 015 credit and debit card accounts, of which 36.7% were in Kerala and 63.3% were in 9 major cities. The cardholders included 191 603 males (80.5%) with a mean (SD) age of 36.6 (12.8) years. During the fat tax implementation (August 2016-June 2017), Kerala's fast food purchase ratio decreased by 3.9 percentage points (β [SE], -0.039 [0.002]; 95% CI, -0.042 to -0.036), compared with 9 major cities. After the fat tax was nullified, the fast food purchase ratio reduced by 5.6 percentage points (γ [SE], -0.056 [0.002]; 95% CI, -0.059 to -0.052) compared with 9 major cities and using the pretax period as the benchmark.

Conclusions and Relevance

Results of this cohort study suggest that the Kerala fat tax was associated with fewer fast food purchases. Food tax policies need to have an elaborate design, and related issues, such as social inequality, nutritional deficiency, and political concerns, need to be evaluated in future studies.

Considerations for modelling a broad food tax in the Philippines and other low-income and middle-income countries

Fiscal policies to improve diet are a promising strategy to address the increasing burden of non-communicable disease, the leading cause of death globally. Sugar-sweetened beverage taxes are the most implemented type of fiscal policy to improve diet. Yet taxes on food, if appropriately structured and applied across the food supply, may support a larger population-level shift towards a healthier diet. Designing these policies and guiding them through the legislative process requires evidence. Equity-oriented cost-effectiveness analyses that estimate the distribution of potential health and economic gains can provide this critical evidence. Taxes on less healthy foods are rarely modelled in low-income and middle-income countries.We describe considerations for modelling the effect of a food tax, which can provide guidance for food tax policy design. This includes describing issues related to the availability, reliability and level of detail of national data on dietary habits, the nutrient content of foods and food prices; the structure of the nutrient profile model; type of tax; tax rate; pass-through rate and price elasticity. Using the Philippines as an example, we discuss considerations for using existing data to model the potential effect of a tax, while also taking into account the political and food policy context. In this way, we provide a modelling framework that can help guide policy-makers and advocates in designing a food policy to improve the health and well-being of future generations in the Philippines and elsewhere.

The effects of a sugar-sweetened beverage tax: moving beyond dental health outcomes and service utilisation

Despite considerable academic and policy interest in the taxation of sugar-sweetened beverages (SSBs), its extra-health implications remain largely unexplored. We investigated the impact of an SSB tax on school absenteeism due to improved dental health, in a framework that accounted for the distribution of the benefit. We designed a quantitative, decision-analytic model that synthesised existing evidence in the areas of dental epidemiology, public health and economics, and simulated causal mechanisms that lead to changes in school attendance in Australian children and adolescents aged 6-17, in a tax vs no tax scenarios. Introducing a 20% sales tax on SSBs would result in a 0.73% (95% confidence interval: 0.38; 1.10), or 4684 (2412; 7071) days per year nationwide, reduction in school absences attributable to dental health reasons. While positive impacts would be seen across the board, the distribution of benefit was favourable towards boys, older teens and those from lower socio-economic status. Our study highlights the need for, and the viability of, quantifying distributions of direct and indirect consequences of public health policy. Despite modest effect size, the equity profile of SSB tax, the long-lasting benefits of educational gains, and potential synergies with other interventions, make it an attractive option for policymakers to consider.

Ethical and economic implications of the adoption of novel plant-based beef substitutes in the USA: a general equilibrium modelling study

BACKGROUND

Slowing climate change is crucial to the future wellbeing of human societies and the greater environment. Current beef production systems in the USA are a major source of negative environmental impacts and raise various animal welfare concerns. Nevertheless, beef production provides a food source high in protein and many nutrients as well as providing employment and income to millions of people. Cattle farming also contributes to individual and community identities and regional food cultures. Novel plant-based meat alternatives have been promoted as technologies that could transform the food system by reducing negative environmental, animal welfare, and health effects of meat production and consumption. Recent studies have conducted static analyses of shifts in diets globally and in the USA, but have not considered how the whole food system would respond to these changes, nor the ethical implications of these responses. We aimed to better explore these dynamics within the US food system and contribute a multiple perspective ethical assessment of plant-based alternatives to beef.

METHODS

In this national modelling analysis, we explored multiple ethical perspectives and the implications of the adoption of plant-based alternatives to beef in the USA. We developed USAGE-Food, a modified version of USAGE (a detailed computable general equilibrium model of the US economy), by improving the representation of sector interactions and dependencies, and consumer behaviour to better reflect resource use across the food system and the substitutability of foods within households. We further extended USAGE, by linking estimates of the environmental footprint of US agriculture, to estimate how changes across the agriculture sector could alter the environmental impact of primary food production across the whole sector, not only the beef sector. Using USAGE-Food, we simulated four beef replacement scenarios against a baseline of current beef demand in the USA: BEEF10, in which beef expenditure is replaced by other foods and three scenarios wherein 10%, 30%, or 60% of beef expenditure is replaced by plant-based alternatives.

FINDINGS

The adoption of plant-based beef alternatives is likely to reduce the carbon footprint of US food production by 2·5-13·5%, by reducing the number of animals needed for beef production by 2-12 million. Impacts on other dimensions are more ambiguous, as the agricultural workforce and natural resources, such as water and cropland, are reallocated across the food system. The shifting allocation of resources should lead to a more efficient food system, but could facilitate the expansion of other animal value chains (eg, pork and poultry) and increased exports of agricultural products. In aggregate, these changes across the food system would have a small, potentially positive, impact on national gross domestic product. However, they would lead to substantial disruptions within the agricultural economy, with the cattle and beef processing sectors decreasing by 7-45%, challenging the livelihoods of the more than 1·5 million people currently employed in beef value chains (primary production and animal processing) in the USA.

INTERPRETATION

Economic modelling suggests that the adoption of plant-based beef alternatives can contribute to reducing greenhouse gas emissions from the food system. Relocation of resources across the food system, simulated by our dynamic modelling approach, might mitigate gains across other environmental dimensions (ie, water or chemical use) and might facilitate the growth of other animal value chains. Although economic consequences at the country level are small, there would be concentrated losses within the beef value chain. Reduced carbon footprint and increased resource use efficiency of the food system are reasons for policy makers to encourage the continued development of these technologies. Despite this positive outcome, policy makers should recognise the ethical assessment of these transitions will be complex, and should remain vigilant to negative outcomes and be prepared to target policies to minimise the worst effects.

FUNDING

The Stavros Niarchos Foundation, the Bill & Melinda Gates Foundation, Johns Hopkins University, the Commonwealth Scientific and Industrial Research Organisation, Cornell University, and Victoria University.

Like parent, like child: a cross-sectional study of intra-household consumption patterns of non-alcoholic beverages among British households with children

OBJECTIVE

Most research investigating sugar-sweetened beverages (SSB) and health, conducted at the individual or household level, ignores potentially important intra-household dynamics. We analysed self-reported consumption relationships between children and adults, and between children of different ages, as well as the associations between intra-household consumption, BMI and sociodemographic characteristics.

DESIGN

A cross-sectional analysis of survey data from Kantar Fast Moving Consumer Goods panellists in September 2017.

SETTING

Great Britain.

PARTICIPANTS

Random sample of 603 households with children under 18 years who regularly purchase non-alcoholic beverages.

RESULTS

Low- or no-sugar/diet beverages dominate consumption across all age categories, particularly children under 12 years. SSB consumption increased as children became older. Children's reported consumption of SSB and low- or no-sugar/diet beverages was positively associated with consumption by adults; a child in adolescence had over nine times the odds of consuming SSB (adjusted OR 9·55, (95 % CI 5·38, 17·00), P < 0·001), and eight times the odds of consuming low- or no-sugar/diet drinks (adjusted OR 8·12, (95 % CI 4·71, 13·97), P < 0·001), if adults did so. In households with multiple children, consumption patterns of older siblings were associated with those of the younger; notably a perfect correlation between children aged 0 and 6 years consuming SSB if siblings 13-18 years did so, and children aged 7-12 years had 22 times the odds of consuming SSB if siblings aged 13-18 years did so (OR 22·33, (95 % CI 8·60, 58·01), P < 0·001).

CONCLUSIONS

Multiple policies, targeting children as well as adults, such as fiscal levers and advertisement restrictions, are needed to reduce and prevent the consumption of SSB.

The political economy of sugar-sweetened beverage taxation in Latin America: lessons from Mexico, Chile and Colombia

BACKGROUND

In Latin America, total sales of sugar-sweetened beverages (SSBs) continue to rise at an alarming rate. Consumption of added sugar is a leading cause of diet-related non-communicable diseases (NCDs). Coalitions of stakeholders have formed in several countries in the region to address this public health challenge including participation of civil society organizations and transnational corporations. Little is currently known about these coalitions - what interests they represent, what goals they pursue and how they operate. Ensuring the primacy of public health goals is a particular governance challenge. This paper comparatively analyses governance challenges involved in the adoption of taxation of sugar-sweetened beverages in Mexico, Chile and Colombia. The three countries have similar political and economic systems, institutional arrangements and regulatory instruments but differing policy outcomes.

METHODS

We analysed the political economy of SSB taxation based on a qualitative synthesis of existing empirical evidence. We identify the key stakeholders involved in the policy process, identified their interests, and assess how they influenced adoption and implementation of the tax.

RESULTS

Coalitions for and against the SSB taxation formed the basis of policy debates in all three countries. Intergovernmental support was critical to framing the SSB tax aims, benefits and implementation; and for countries to adopt it. A major constraint to implementation was the strong influence of transnational corporations (TNCs) in the policy process. A lack of transparency during agenda setting was notably enhanced by the powerful presence of TNCs.

CONCLUSION

NCDs prevention policies need to be supported across government, alongside grassroots organizations, policy champions and civil society groups to enhance their success. However, governance arrangements involving coalitions between public and private sector actors need to recognize power asymmetries among different actors and mitigate their potentially negative consequences. Such arrangements should include clear mechanisms to ensure transparency and accountability of all partners, and prevent undue influence by industry interests associated with unhealthy products.

Falsehoods and facts about dietary sugars: a call for evidence-based policy

Sugar, tobacco, and alcohol have been demonized since the seventeenth century. Yet unlike tobacco and alcohol, there is indisputable scientific evidence that dietary sugars were essential for human evolution and are essential for human health and development. Therefore, the purpose of this analytic review and commentary is to demonstrate that anti-sugar rhetoric is divorced from established scientific facts and has led to politically expedient but ill-informed policies reminiscent of those enacted about alcohol a century ago in the United States. Herein, we present a large body of interdisciplinary research to illuminate several misconceptions, falsehoods, and facts about dietary sugars. We argue that anti-sugar policies and recommendations are not merely unscientific but are regressive and unjust because they harm the most vulnerable members of our society while providing no personal or public health benefits.

Population Approaches Targeting Metabolic Syndrome Focusing on Japanese Trials

The clinical importance of assessment of metabolic syndrome lies in the selection of individuals with multiple risk factors based on visceral fat accumulation, and helping them to reduce visceral fat. Behavioral modification by population approach is important, which adds support to the personal approach. The complexity of visceral fat accumulation requires multicomponent and multilevel intervention. Preparation of food and physical environments could be useful strategies for city planners. Furthermore, actions on various frameworks, including organizational, community, and policy levels, have been recently reported. There are universal public health screening programs and post-screening health educational systems in Japan, and diseases management programs in Germany. Understanding one’s own health status is important for motivation for lifestyle modification. The U.S. Preventive Services Task Force recommends that primary care practitioners screen all adults for obesity and offer behavioral interventions and intensive counseling. Established evidence-based guidelines for behavioral counseling are needed within the primary care setting.

Fiscal measures to promote healthier choices: an economic perspective on price-based interventions

INTRODUCTION

Non-communicable diseases strongly linked to lifestyle factors create an increasing burden of disease. Fiscal interventions (tax and subsidy) are one approach to improving lifestyles, but their effective design might be improved.

ECONOMIC FRAMEWORK

Conventional economic theory suggests that fiscal interventions are only used to correct prices for externalities (costs or benefits imposed on others). These can be difficult to calculate accurately. Fiscal interventions operate by altering the prices that consumers face. Price increases are predicted to reduce demand, and the size of the effect is measured by the price elasticity. Tax changes may not translate directly into price changes, however.

EVIDENCE FOR THE EFFECT OF TAXES, SUBSIDIES AND PRICES

There is strong evidence for the effectiveness of taxation in relation to reducing tobacco and alcohol consumption and resulting harms. There has been less evaluation of taxation in relation to other unhealthy behaviors or of subsidies to promote healthy behaviors.

DISCUSSION

Fiscal levers have been used as interventions to improve health rather than for market correction. Taking account of behavioral insights may improve the design of fiscal interventions and combining interventions may increase effectiveness.

CONCLUSION

Both types of intervention have a role in improving health, but there may be challenges in promoting uptake of healthy behaviors.

The Failure to Measure Dietary Intake Engendered a Fictional Discourse on Diet-Disease Relations

Controversies regarding the putative health effects of dietary sugar, salt, fat, and cholesterol are not driven by legitimate differences in scientific inference from valid evidence, but by a fictional discourse on diet-disease relations driven by decades of deeply flawed and demonstrably misleading epidemiologic research. Over the past 60 years, epidemiologists published tens of thousands of reports asserting that dietary intake was a major contributing factor to chronic non-communicable diseases despite the fact that epidemiologic methods do not measure dietary intake. In lieu of measuring actual dietary intake, epidemiologists collected millions of unverified verbal and textual reports of memories of perceptions of dietary intake. Given that actual dietary intake and reported memories of perceptions of intake are not in the same ontological category, epidemiologists committed the logical fallacy of "Misplaced Concreteness." This error was exacerbated when the anecdotal (self-reported) data were impermissibly transformed (i.e., pseudo-quantified) into proxy-estimates of nutrient and caloric consumption via the assignment of "reference" values from databases of questionable validity and comprehensiveness. These errors were further compounded when statistical analyses of diet-disease relations were performed using the pseudo-quantified anecdotal data. These fatal measurement, analytic, and inferential flaws were obscured when epidemiologists failed to cite decades of research demonstrating that the proxy-estimates they created were often physiologically implausible (i.e., meaningless) and had no verifiable quantitative relation to the actual nutrient or caloric consumption of participants. In this critical analysis, we present substantial evidence to support our contention that current controversies and public confusion regarding diet-disease relations were generated by tens of thousands of deeply flawed, demonstrably misleading, and pseudoscientific epidemiologic reports. We challenge the field of nutrition to regain lost credibility by acknowledging the empirical and theoretical refutations of their memory-based methods and ensure that rigorous (objective) scientific methods are used to study the role of diet in chronic disease.

Controversy and debate: Memory-Based Methods Paper 1: the fatal flaws of food frequency questionnaires and other memory-based dietary assessment methods

There is an escalating debate over the value and validity of self-reported dietary intake as estimated by Food Frequency Questionnaires and other forms of memory-based dietary assessment methods. Proponents argue that despite limitations, memory-based methods provide valid and valuable information about consumed foods and beverages and therefore can be used to assess diet-disease relations. In fact, over the past 60 years, thousands of memory-based dietary research reports were used to inform public policy and establish the Dietary Guidelines for Americans. Yet, despite this impressive history, our position is that memory-based dietary assessment methods are invalid and inadmissible for scientific research and therefore cannot be used in evidence-based policy making. Herein, we present the empirical evidence and theoretic and philosophic perspectives that render data derived from memory-based methods both fatally flawed and pseudoscientific. First, the use of memory-based methods is founded upon two inter-related logical fallacies: a category error and reification. Second, human memory and recall are not valid instruments for scientific data collection. Third, in standard epidemiologic contexts, the measurement errors associated with self-reported data are nonfalsifiable because there is no way to ascertain if the reported foods and beverages match the respondent's actual consumption. Fourth, the assignment of nutrient and energy values to self-reported intake (i.e., the pseudoquantification of anecdotal data) is impermissible and violates the foundational tenets of measurement theory. Fifth, the proxy estimates created via pseudoquantification are often physiologically implausible and have little relation to actual nutrient and energy consumption. Finally, investigators engendered a fictional discourse on the health effects of dietary sugar, salt, fat and cholesterol when they failed to cite contrary evidence or address decades of research demonstrating the fatal measurement, analytic, and inferential flaws of memory-based dietary assessment methods.

Evaluating the 2014 sugar-sweetened beverage tax in Chile: An observational study in urban areas

BACKGROUND

In October 2014, Chile implemented a tax modification on sugar-sweetened beverages (SSBs) called the Impuesto Adicional a las Bebidas Analcohólicas (IABA). The design of the tax was unique, increasing the tax on soft drinks above 6.25 grams of added sugar per 100 mL and decreasing the tax for those below this threshold.

METHODS AND FINDINGS

This study evaluates Chile's SSB tax, which was announced in March 2014 and implemented in October 2014. We used household-level grocery-purchasing data from 2011 to 2015 for 2,836 households living in cities representative of the urban population of Chile. We employed a fixed-effects econometric approach and estimated the before-after change in purchasing of SSBs controlling for seasonality, general time trend, temperature, and economic fluctuations as well as time-invariant household characteristics. Results showed significant changes in purchasing for the statistically preferred model: while there was a barely significant decrease in the volume of all soft drinks, there was a highly significant decrease in the monthly purchased volume of the higher-taxed, sugary soft drinks by 21.6%. The direction of this reduction was robust to different empirical modelling approaches, but the statistical significance and the magnitude of the changes varied considerably. The reduction in soft drink purchasing was most evident amongst higher socioeconomic groups and higher pretax purchasers of sugary soft drinks. There was no systematic, robust pattern in the estimates by household obesity status. After tax implementation, the purchase prices of soft drinks decreased for the items for which the tax rate was reduced, but they remained unchanged for sugary items, for which the tax was increased. However, the purchase prices increased for sugary soft drinks at the time of the policy announcement. The main limitations include a lack of a randomised design, limiting the extent of causal inference possible, and the focus on purchasing data rather than consumption or health outcomes.

CONCLUSIONS

The results of subgroup analyses suggest that the policy may have been partially effective, though not necessarily in ways that are likely to reduce socioeconomic inequalities in diet-related health. It remains unclear whether the policy has had a major, overall population-level impact. Additionally, because the present study examined purchasing of soft drinks for only 1 year, a longer-term evaluation-ideally including an assessment of consumption and health impacts-should be conducted in future research.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02926001.

The impact of a local sugar sweetened beverage health promotion and price increase on sales in public leisure centre facilities

BACKGROUND

We aimed to evaluate the impact of a local sugar sweetened beverages (SSB) health promotion and 20p price increase in leisure centre venues and estimate the impact on consumption.

METHOD

Monthly cold drinks sales data and attendance at leisure centres across the city of Sheffield were analysed over the period January 2015-July 2017. Interrupted time-series methods were employed to estimate changes in consumption per attendance of SSB and non-SSB cold drinks following the introduction of the SSB policy from August 2016 adjusting for seasonal variation and autocorrelation. SSB price elasticities were estimated with fixed effects log-log models by SSB product type (soda can, soda bottle, soda post mix, energy drinks, juice from concentrate).

FINDINGS

We estimated a 31% (95% CI 4%, 59%) reduction in units of SSB sold per attendance in the year since the policy was introduced. We did not observe substitution effects to fruit juice or water but found sales of other artificially sweetened non-SSB products increased by 27% (95% CI 6%, 47%) after the introduction of the tax. Price elasticity analysis identified that a 1% increase in price alongside health promotion leads to a 3.8% (95% CI 3.1% 4.4%) decrease in demand for SSB's. Price elasticity of demand was highest for child friendly and high caffeine energy drinks.

INTERPRETATION

Demand for SSB drinks at leisure centre venues is highly responsive to the policy, particularly for child-friendly and high caffeine energy drinks, compared with other SSB tax policy evaluations. The policy also increased purchases of carbonated non-SSB.

Effect of increasing the price of sugar-sweetened beverages on alcoholic beverage purchases: an economic analysis of sales data

Background

Taxing soft-drinks may reduce their purchase, but assessing the impact on health demands wider consideration on alternative beverage choices. Effects on alcoholic drinks are of particular concern, as many contain similar or greater amounts of sugar than soft-drinks and have additional health harms. Changes in consumption of alcoholic drinks may reinforce or negate the intended effect of price changes for soft-drinks.

Methods

A partial demand model, adapted from the Almost Ideal Demand System, was applied to Kantar Worldpanel data from 31 919 households from January 2012 to December 2013, covering drink purchases for home consumption, providing ~6 million purchases aggregated into 11 groups, including three levels of soft-drink, three of other non-alcoholic drinks and five of alcoholic drinks.

Results

An increase in the price of high-sugar drinks leads to an increase in the purchase of lager, an increase in the price of medium-sugar drinks reduces purchases of alcoholic drinks, while an increase in the price of diet/low-sugar drinks increases purchases of beer, cider and wines. Overall, the effects of price rises are greatest in the low-income group.

Conclusion

Increasing the price of soft-drinks may change purchase patterns for alcohol. Increasing the price of medium-sugar drinks has the potential to have a multiplier-effect beneficial to health through reducing alcohol purchases, with the converse for increases in the price of diet-drinks. Although the reasons for such associations cannot be explained from this analysis, requiring further study, the design of fiscal interventions should now consider these wider potential outcomes.

Obesity

Excessive fat deposition in obesity has a multifactorial aetiology, but is widely considered the result of disequilibrium between energy intake and expenditure. Despite specific public health policies and individual treatment efforts to combat the obesity epidemic, >2 billion people worldwide are overweight or obese. The central nervous system circuitry, fuel turnover and metabolism as well as adipose tissue homeostasis are important to comprehend excessive weight gain and associated comorbidities. Obesity has a profound impact on quality of life, even in seemingly healthy individuals. Diet, physical activity or exercise and lifestyle changes are the cornerstones of obesity treatment, but medical treatment and bariatric surgery are becoming important. Family history, food environment, cultural preferences, adverse reactions to food, perinatal nutrition, previous or current diseases and physical activity patterns are relevant aspects for the health care professional to consider when treating the individual with obesity. Clinicians and other health care professionals are often ill-equipped to address the important environmental and socioeconomic drivers of the current obesity epidemic. Finally, understanding the epigenetic and genetic factors as well as metabolic pathways that take advantage of 'omics' technologies could play a very relevant part in combating obesity within a precision approach.

When Are Caregivers More Likely to Offer Sugary Drinks and Snacks to Infants? A Qualitative Thematic Synthesis

Many children consume more sugar than is recommended, and caregivers often find it difficult to change this habit once established. This thematic synthesis aims to identify the "critical situations" where caregivers may be more likely to offer infants sugary drinks and snacks. This thematic synthesis is reported in accordance with the statement for enhancing transparency in reporting the synthesis of qualitative research (ENTREQ). Our confidence in the findings of our synthesis was assessed using the CERQual (Confidence in the Evidence From Reviews of Qualitative Research Approach). We included 16 studies from the United States, the United Kingdom, Australia, and Denmark. We identified eight "critical situations" when caregivers may be more likely to offer sugary drinks and snacks to infants. Interventions that seek to reduce sugar intake for caries prevention in infants and young children may be more successful if they provide caregivers with practical parenting strategies to replace the nonnutritive functions of sugary foods and drinks, as opposed to taking an information-giving approach.

The brain, obesity and addiction: an EEG neuroimaging study

Obesity is among the greatest challenges facing healthcare systems with 20% of the world’s population afflicted. Great controversy exists whether obesity can be regarded as an addictive disorder or not. Recently the Yale Food Addiction Scale questionnaire has been developed as a tool to identify individuals with traits of addiction towards food. Using clinical and source localized EEG data we dichotomize obesity. Brain activity in food-addicted and non-food-addicted obese people is compared to alcohol-addicted and non-addicted lean controls. We show that food addiction shares common neural brain activity with alcohol addiction. This ‘addiction neural brain activity’ consists of the dorsal and pregenual anterior cingulate cortex, parahippocampal area and precuneus. Furthermore, common neural obesity neural brain activity exists as well. The ‘obesity neural brain activity’ consists of dorsal and pregenual anterior cingulate cortex, posterior cingulate extending into the precuneus/cuneus as well as the parahippocampal and inferior parietal area. However food-addicted differ from non-food-addicted obese people by opposite activity in the anterior cingulate gyrus. This food addiction and non-food-addiction obesity dichotomy demonstrates there is at least 2 different kinds of obesity with overlapping network activity, but different in anterior cingulate cortex activity.

Higher Retail Prices of Sugar-Sweetened Beverages 3 Months After Implementation of an Excise Tax in Berkeley, California

OBJECTIVES

We assessed the short-term ability to increase retail prices of the first US 1-cent-per-ounce excise tax on the distribution of sugar-sweetened beverages (SSBs), which was implemented in March 2015 by Berkeley, California.

METHODS

In 2014 and 2015, we examined pre- to posttax price changes of SSBs and non-SSBs in a variety of retailers in Berkeley and in the comparison cities Oakland and San Francisco, California. We examined price changes by beverage, brand, size, and retailer type.

RESULTS

For smaller beverages (≤ 33.8 oz), price increases (cents/oz) in Berkeley relative to those in comparison cities were 0.69 (95% confidence interval [CI] = 0.36, 1.03) for soda, 0.47 (95% CI = 0.08, 0.87) for fruit-flavored beverages, and 0.47 (95% CI = 0.25, 0.69) for SSBs overall. For 2-liter bottles and multipacks of soda, relative price increases were 0.46 (95% CI = 0.03, 0.89) and 0.49 (95% CI = 0.21, 0.77). We observed no relative price increases for nontaxed beverages overall.

CONCLUSIONS

Approximately 3 months after the tax was implemented, SSB retail prices increased more in Berkeley than in nearby cities, marking a step in the causal pathway between the tax and reduced SSB consumption.