The distributional impact of taxing sugar-sweetened beverages: findings from an extended cost-effectiveness analysis in South Africa

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.

Extended cost-effectiveness analysis of interventions to improve uptake of diabetes services in South Africa

The rising prevalence of diabetes in South Africa (SA), coupled with significant levels of unmet need for diagnosis and treatment, results in high rates of diabetes-associated complications. Income status is a determinant of utilization of diagnosis and treatment services, with transport costs and loss of wages being key barriers to care. A conditional cash transfer (CCT) programme, targeted to compensate for such costs, may improve service utilization. We applied extended cost-effectiveness analysis (ECEA) methods and used a Markov model to compare the costs, health benefits and financial risk protection (FRP) attributes of a CCT programme. A population was simulated, drawing from SA-specific data, which transitioned yearly through various health states, based on specific probabilities obtained from local data, over a 45-year time horizon. Costs and disability-adjusted life years (DALYs) were applied to each health state. Three CCT programme strategies were simulated and compared to a 'no programme' scenario: (1) covering diagnosis services only; (2) covering treatment services only; (3) covering both diagnosis and treatment services. Cost-effectiveness was reported as incremental net monetary benefit (INMB) using a cost-effectiveness threshold of USD3015 per DALY for SA, while FRP outcomes were reported as catastrophic health expenditure (CHE) cases averted. Distributions of the outcomes were reported by income quintile and sex. Covering both diagnosis and treatment services for the bottom two quintiles resulted in the greatest INMB (USD22 per person) and the greatest CHE cases averted. There were greater FRP benefits for women compared to men. A CCT programme covering diabetes diagnosis and treatment services was found to be cost-effective, when provided to the poorest 40% of the SA population. ECEA provides a useful platform for including equity considerations to inform priority setting and implementation policies in SA.

Area-level deprivation and individual-level socioeconomic correlates of the diabetes care cascade among black south africans in uMgungundlovu, KwaZulu-Natal, South Africa

South Africa is experiencing a rapidly growing diabetes epidemic that threatens its healthcare system. Research on the determinants of diabetes in South Africa receives considerable attention due to the lifestyle changes accompanying South Africa's rapid urbanization since the fall of Apartheid. However, few studies have investigated how segments of the Black South African population, who continue to endure Apartheid's institutional discriminatory legacy, experience this transition. This paper explores the association between individual and area-level socioeconomic status and diabetes prevalence, awareness, treatment, and control within a sample of Black South Africans aged 45 years or older in three municipalities in KwaZulu-Natal. Cross-sectional data were collected on 3,685 participants from February 2017 to February 2018. Individual-level socioeconomic status was assessed with employment status and educational attainment. Area-level deprivation was measured using the most recent South African Multidimensional Poverty Index scores. Covariates included age, sex, BMI, and hypertension diagnosis. The prevalence of diabetes was 23% (n = 830). Of those, 769 were aware of their diagnosis, 629 were receiving treatment, and 404 had their diabetes controlled. Compared to those with no formal education, Black South Africans with some high school education had increased diabetes prevalence, and those who had completed high school had lower prevalence of treatment receipt. Employment status was negatively associated with diabetes prevalence. Black South Africans living in more deprived wards had lower diabetes prevalence, and those residing in wards that became more deprived from 2001 to 2011 had a higher prevalence diabetes, as well as diabetic control. Results from this study can assist policymakers and practitioners in identifying modifiable risk factors for diabetes among Black South Africans to intervene on. Potential community-based interventions include those focused on patient empowerment and linkages to care. Such interventions should act in concert with policy changes, such as expanding the existing sugar-sweetened beverage tax.

Determinants of dietary diversity and drivers of food choice among low-income consumers in urban Kenya, Malawi and Zimbabwe

INTRODUCTION

Rapid urbanisation affects lifestyle and eating habits, predominantly causing a dietary shift that adds challenges to meet dietary recommendations within a complex food system. This research investigated dietary diversity and food choice drivers among low-income consumers in three urban settlements (Nairobi, Kenya; Bulawayo, Zimbabwe and Lilongwe, Malawi, representing rapid, moderate and slow urban growth patterns, respectively) as a first step towards improving diets across cultures and geographies.

METHODS

Mixed methods data collection was employed for this study. Qualitative methods such as rapid foodscape appraisal workshops and food stories in selected low-income settlements in Nairobi, Bulawayo and Lilongwe were utilised to collect information on the food environments (food balances, infrastructure, safety, policies and institutions). Quantitative data such as socio-demographic characteristics and dietary diversity were collected via structured questionnaires using Cognitive Edge's SenseMaker® (n = 890, 450 and 440 for Nairobi, Bulawayo and Lilongwe, respectively). The dietary intake of respondents was assessed using a 24-h recall, which was then converted to the food group diversity score (FGDS).

RESULTS

Different levels of compounded stress affected dietary diversity and quality, including high food prices, concerns about sanitation and hygiene and the role of food standards regulation bodies. The mean FGDS across all locations was lower than the recommended cut-off of 5 (4.5, 2.8 and 2.6 across Nairobi, Zimbabwe and Lilongwe, respectively). Additionally, in Nairobi, there were gender differences in diet diversity, with men having a higher dietary diversity score than women (4.6% vs. 4.3%; p = 0.004). The majority of respondents in Lilongwe (65%) reported price as the most important driver of food choice, compared to 38% in Nairobi and 42% in Bulawayo.

DISCUSSION/CONCLUSIONS

Our observation of poor-quality diets provides further evidence of the need for food policies that are cognisant of the nutrition and health of the growing population of the urban poor. Such policies would focus on lowering the costs of nutritious foods as well as ensuring food safety within the complex food system observed in the urban low-income environment.

The health and economic impact and cost effectiveness of interventions for the prevention and control of overweight and obesity in Kenya: a stakeholder engaged modelling study

BACKGROUND

The global increase in mean body mass index has resulted in a substantial increase of non-communicable diseases (NCDs), including in many low- and middle-income countries such as Kenya. This paper assesses four interventions for the prevention and control of overweight and obesity in Kenya to determine their potential health and economic impact and cost effectiveness.

METHODS

We reviewed the literature to identify evidence of effect, determine the intervention costs, disease costs and total healthcare costs. We used a proportional multistate life table model to quantify the potential impacts on health conditions and healthcare costs, modelling the 2019 Kenya population over their remaining lifetime. Considering a health system perspective, two interventions were assessed for cost-effectiveness. In addition, we used the Human Capital Approach to estimate productivity gains.

RESULTS

Over the lifetime of the 2019 population, impacts were estimated at 203,266 health-adjusted life years (HALYs) (95% uncertainty interval [UI] 163,752 - 249,621) for a 20% tax on sugar-sweetened beverages, 151,718 HALYs (95% UI 55,257 - 250,412) for mandatory kilojoule menu labelling, 3.7 million HALYs (95% UI 2,661,365-4,789,915) for a change in consumption levels related to supermarket food purchase patterns and 13.1 million HALYs (95% UI 11,404,317 - 15,152,341) for a change in national consumption back to the 1975 average levels of energy intake. This translates to 4, 3, 73 and 261 HALYs per 1,000 persons. Lifetime healthcare cost savings were approximately United States Dollar (USD) 0.14 billion (USD 3 per capita), USD 0.08 billion (USD 2 per capita), USD 1.9 billion (USD 38 per capita) and USD 6.2 billion (USD 124 per capita), respectively. Lifetime productivity gains were approximately USD 1.8 billion, USD 1.2 billion, USD 28 billion and USD 92 billion. Both the 20% tax on sugar sweetened beverages and the mandatory kilojoule menu labelling were assessed for cost effectiveness and found dominant (health promoting and cost-saving).

CONCLUSION

All interventions evaluated yielded substantive health gains and economic benefits and should be considered for implementation in Kenya.

Perceptions of and Preparedness for the Application of Pharmacoeconomics in Practice, among Final Year Bachelor of Pharmacy Students in South Africa: A National Cross-Sectional Study

For the improvement of access to health, many countries including South Africa, have adopted universal healthcare. However, this requires skills to apply health technology assessments for the facilitation of investment decisions. This study aimed to ascertain final year Bachelor of Pharmacy (BPharm) students' perceptions of the relevance of pharmacoeconomics in pharmacy practice, and their level of preparedness to apply pharmacoeconomic principles, using a quantitative, cross-sectional, and descriptive design. Data were collected using a self-administered questionnaire over 12 months, and included student demographics, knowledge about pharmacoeconomics and its applicability in practice, as well as students' satisfaction with the appropriateness of the curriculum content. Five of nine universities offering pharmacy education took part. The overallstudent response rate was 38.1% (189/496), with 26.2% (45/172) of students signifying a good understanding of basic pharmacoeconomic concepts. Pharmacoeconomics application in South Africa was perceived to be relevant by 87.5% (140/160); however, 47.0% (79/168) felt they were not prepared to apply pharmacoeconomic principles in medicine management, and 86.7% (137/158) wanted to acquire additional pharmacoeconomic knowledge. Whilst students' perceptions of the relevance of pharmacoeconomics were positive, results indicated a gap in knowledge, understanding, and application. Addressing this gap may increase students' preparedness to apply pharmacoeconomic principles and better equip them for the practical application of pharmacoeconomics post qualification. Consequently, we have started this process.

Estimating the healthcare cost of overweight and obesity in South Africa

Background

Overweight and obesity are major risk factors for noncommunicable diseases. This presents a major burden to health systems and to society in South Africa. Collectively, these conditions are overwhelming public healthcare. This is happening when the country has embarked on a journey to universal health coverage, hence the need to estimate the cost of overweight and obesity.

Objective

Our objective was to estimate the healthcare cost associated with treatment of weight-related conditions from the perspective of the South African public sector payer.

Methods

Using a bottom-up gross costing approach, this study draws data from multiple sources to estimate the direct healthcare cost of overweight and obesity in South Africa. Population Attributable Fractions (PAF) were calculated and multiplied by each disease’s total treatment cost to apportion costs to overweight and obesity. Annual costs were estimated for 2020.

Results

The total cost of overweight and obesity is estimated to be ZAR33,194 million in 2020. This represents 15.38% of government health expenditure and is equivalent to 0.67% of GDP. Annual per person cost of overweight and obesity is ZAR2,769. The overweight and obesity cost is disaggregated as follows: cancers (ZAR352 million), cardiovascular diseases (ZAR8,874 million), diabetes (ZAR19,861 million), musculoskeletal disorders (ZAR3,353 million), respiratory diseases (ZAR360 million) and digestive diseases (ZAR395 million). Sensitivity analyses show that the total overweight and obesity cost is between ZAR30,369 million and ZAR36,207 million.

Conclusion

This analysis has demonstrated that overweight and obesity impose a huge financial burden on the public health care system in South Africa. It suggests an urgent need for preventive, population-level interventions to reduce overweight and obesity rates. The reduction will lower the incidence, prevalence, and healthcare spending on noncommunicable diseases.

Taxation of sugar-sweetened beverages in South Africa: Perspectives of consumers in Cape Town

BACKGROUND

Globally, fiscal measures are deemed effective in combating the obesity epidemic at population level. A health promotional levy (HPL) on sugar sweetened beverages (SSBs) was implemented in April 2018 in South Africa to reduce sugar consumption.

DESIGN AND METHODS

This cross-sectional, descriptive study investigated consumers' understanding and opinion of the HPL, and impact on consumption of SSBs. Data was collected outside 15 grocery stores, within four health sub-districts of the City of Cape Town. An interviewer-administered questionnaire was completed with literate, adult consumers (N = 696).

RESULTS

Participants (46.0%) were aware of the HPL but regarded it insufficient to change purchasing behaviour (55.4%). The lower income group (56.4%) was most affected by the increased price of SSBs. Those who agreed (46.8%) that the levy would help to reduce the prevalence of obesity was significantly more likely to notice a price increase in SSBs (54.5%) (p < 0.01) and had a higher education level (p < 0.01). Overall, self-reported consumption of SSBs decreased by 7.7% since the HPL was enacted. Participants who were aware of the detrimental effect of consuming large amounts of sugar, were more likely to change their behaviour (p < 0.01).

CONCLUSIONS

Participants were receptive for legislative measures to combat the prevalence of obesity but lacked clarity of the goal and implementation of the HPL. A multipronged approach is crucial to lower sugar intake sustainably and an environment which offers healthy alternatives to SSBs. A higher HPL combined with transparency of how revenue is utilised could enhance the impact of the sugar tax strategy.

The effect of beverage taxes on youth consumption and body mass index: Evidence from Mauritius

Taxes on sugar-sweetened beverages (SSBs) are relatively new and there is limited evidence about their impact on SSB consumption or body mass index (BMI) (as opposed to prices, purchases, or sales), their impact on youth (as opposed to adults), or their impact in non-Western nations. This paper adds to the evidence across all these dimensions by estimating the effect of an SSB tax on SSB consumption and the BMI of youth in Mauritius, an island nation in the Indian Ocean, which we compare to Maldives, another island nation which did not implement an SSB tax during the time of our data. Results of difference-in-differences models indicate that the tax in Mauritius had no detectable impact on the consumption of SSBs or the BMI of the pooled sample of boys and girls. However, models estimated separately by sex indicate that the probability that boys consumed SSBs fell by 9.4 percentage points (11%). These are among the first estimates of the effect of SSB taxes on youth consumption and contribute to the limited evidence on the impact of SSB taxes on weight, and in non-Western countries.

A Comparative Policy Analysis of the Adoption and Implementation of Sugar-Sweetened Beverage Taxes (2016-2019) in 16 Countries

Taxes on sugar-sweetened beverages (SSBs) are recommended as part of comprehensive policy action to prevent diet-related non-communicable diseases (NCDs), but have been adopted by only one quarter of World Health Organization (WHO) Member States. This paper presents a comparative policy analysis of recent SSB taxes (2016–19) in 16 countries. This study aimed to analyse the characteristics and patterns of factors influencing adoption and implementation of SSB taxes and policy learning between countries, to draw lessons for future SSB taxes. The data collection and analysis were informed by an analytical framework that drew on ‘diffusion of innovation’ and theories of policy learning. Qualitative data were collected from policy documents and media, in addition to national statistics. Qualitative data were thematically analysed and a narrative synthesis approach was used for integrated case study analysis. We found adaptation and heterogeneity in the approaches used for SSB taxation with a majority of countries adopting excise taxes, and consistent health framing in media and policy documents. Common public frames supporting the taxes included reducing obesity/NCDs and raising revenue (government actors) and subsequent health system savings (non-government actors). Opposing frames focused on regressivity and incoherence with other economic policy (government actors) and posited that taxes have limited health benefits and negative economic impacts on the food industry (industry). Evident ‘diffusion networks’ included the WHO, predominantly in middle-income countries, and some regional economic bodies. We found indications of policy learning in the form of reference to other countries’ taxes, particularly countries with membership in the same economic bodies and with shared borders. The study suggests that adoption of SSB taxation could be enhanced through strategic engagement by health actors with the policy-making process, consideration of the economic context, use of consistent health frames by cross-sector coalitions, and robust evaluation and reporting of SSB taxation.

Equity impact of minimum unit pricing of alcohol on household health and finances among rich and poor drinkers in South Africa

Introduction

South Africa experiences significant levels of alcohol-related harm. Recent research suggests minimum unit pricing (MUP) for alcohol would be an effective policy, but high levels of income inequality raise concerns about equity impacts. This paper quantifies the equity impact of MUP on household health and finances in rich and poor drinkers in South Africa.

Methods

We draw from extended cost-effectiveness analysis (ECEA) methods and an epidemiological policy appraisal model of MUP for South Africa to simulate the equity impact of a ZAR 10 MUP over a 20-year time horizon. We estimate the impact across wealth quintiles on: (i) alcohol consumption and expenditures; (ii) mortality; (iii) government healthcare cost savings; (iv) reductions in cases of catastrophic health expenditures (CHE) and household savings linked to reduced health-related workplace absence.

Results

We estimate MUP would reduce consumption more among the poorest than the richest drinkers. Expenditure would increase by ZAR 353 000 million (1 US$=13.2 ZAR), the poorest contributing 13% and the richest 28% of the increase, although this remains regressive compared with mean income. Of the 22 600 deaths averted, 56% accrue to the bottom two quintiles; government healthcare cost savings would be substantial (ZAR 3.9 billion). Cases of CHE averted would be 564 700, 46% among the poorest two quintiles. Indirect cost savings amount to ZAR 51.1 billion.

Conclusions

A MUP policy in South Africa has the potential to reduce harm and health inequality. Fiscal policies for population health require structured policy appraisal, accounting for the totality of effects using mathematical models in association with ECEA methodology.

Incorporating Equity Concerns in Cost-Effectiveness Analyses: A Systematic Literature Review

OBJECTIVE

The aim of this study was to review analytical methods that enable the incorporation of equity concerns within economic evaluation.

METHODS

A systematic search of PubMed, Embase, and EconLit was undertaken from database inception to February 2021. The search was designed to identify methodological approaches currently employed to evaluate health-related equity impacts in economic evaluation studies of healthcare interventions. Studies were eligible if they described or elaborated on a formal quantitative method used to integrate equity concerns within economic evaluation studies. Cost-utility, cost-effectiveness, cost-benefit, cost-minimisation, and cost-consequence analyses, as well as health technology appraisals, budget impact analyses, and any relevant literature reviews were included. For each of the identified methods, we provided summaries of the scope of equity considerations covered, the methods employed and their key attributes, data requirements, outcomes, and strengths and weaknesses. A traffic light assessment of the practical suitability of each method was undertaken, alongside a worked example applying the different methods to evaluate the same decision problem. Finally, the review summarises the typical trade-offs arising in cost-effectiveness analyses and discusses the extent to which the evaluation methods are able to capture these.

RESULTS

In total, 68 studies were included in the review. Methods could broadly be grouped into equity-based weighting (EBW) methods, extended cost-effectiveness analysis (ECEA), distributional cost-effectiveness analysis (DCEA), multi-criteria decision analysis (MCDA), and mathematical programming (MP). EBW and MP methods enable equity consideration through adjustment to incremental cost-effectiveness ratios, whereas equity considerations are represented through financial risk protection (FRP) outcomes in ECEA, social welfare functions (SWFs) in DCEA, and scoring/ranking systems in MCDA. The review identified potential concerns for EBW methods and MCDA with respect to data availability and for EBW methods and MP with respect to explicitly measuring changes in inequality. The only potential concern for ECEA related to the use of FRP metrics, which may not be relevant for all healthcare systems. In contrast, DCEA presented no significant concerns but relies on the use of SWFs, which may be unfamiliar to some audiences and requires societal preference elicitation. Consideration of typical cost-effectiveness and equity-related trade-offs highlighted the flexibility of most methods with respect to their ability to capture such trade-offs. Notable exceptions were trade-offs between quality of life and length of life, for which we found DCEA and ECEA unsuitable, and the assessment of lost opportunity costs, for which we found only DCEA and MP to be suitable. The worked example demonstrated that each method is designed with fundamentally different analytical objectives in mind.

CONCLUSIONS

The review emphasises that some approaches are better suited to particular decision problems than others, that methods are subject to different practical requirements, and that significantly different conclusions can be observed depending on the choice of method and the assumptions made. Further, to fully operationalise these frameworks, there remains a need to develop consensus over the motivation for equity assessment, which should necessarily be informed with stakeholder involvement. Future research of this topic should be a priority, particularly within the context of equity evaluation in healthcare policy decisions.

Population-level interventions targeting risk factors of diabetes and hypertension in South Africa: a document review

BACKGROUND

South Africa bears an increasing burden of non-communicable diseases (NCDs), particularly diabetes, cardiovascular diseases, and cancer. The objective of this study was to identify which population-level interventions, implemented at the level of governmental or political jurisdictions only, targeting risk factors of diabetes and hypertension were included in policies in South Africa. We also looked at whether these have been implemented or not.

METHODS

A review of relevant reports, journal articles, and policy documents was conducted. Documentation from government reports that contains information regarding the planning, implementation and evaluation of population-level interventions targeting diabetes and hypertension were considered, and various databases were searched. The identified population-level interventions were categorized as supportive policies, supportive programs and enabling environments according to the major risk factors of NCDs i.e., tobacco use, harmful consumption of alcohol, unhealthy diet/nutrition and physical inactivity, in accordance with the WHO 'Best buys'. A content document analysis was conducted.

RESULTS

The source documents reviewed included Acts and laws, regulations, policy documents, strategic plans, case studies, government reports and editorials. South Africa has a plethora of policies and regulations targeting major risk factors for diabetes and hypertension implemented in line with WHO 'Best buys' since 1990. A total of 28 policies, legislations, strategic plans, and regulations were identified - 8 on tobacco use; 7 on harmful consumption of alcohol; 8 on unhealthy diet and 5 on physical inactivity - as well as 12 case studies, government reports and editorials. There is good progress in policy formulation in line with the 'Best buys'. However, there are some gaps in the implementation of these policies and programs.

CONCLUSION

Curbing the rising burden of NCDs requires comprehensive strategies which include population-level interventions targeting risk factors for diabetes and hypertension and effective implementation with robust evaluation to identify successes and ways to overcome challenges.

Food system development pathways for healthy, nature-positive and inclusive food systems

Sustainable food systems require the integration of and alignment between recommendations for food and land use practices, as well as an understanding of the political economy context and identification of entry points for change. We propose a food systems transformation framework that takes these elements into account and links long-term goals with short-term measures and policies, ultimately guiding the decomposition of transformation pathways into concrete steps. Taking the transition to healthier and more sustainable diets as an example, we underscore the centrality of social inclusion to the food systems transformation debate.

How should we evaluate sweetened beverage tax policies? A review of worldwide experience

Over 45 jurisdictions globally have implemented sweetened beverage taxes. Researchers and policymakers need to assess whether and how these taxes change beverage demand and supply, their intended and unanticipated health, economic and equity impacts. Lessons from such evaluations can maximise the policies' success and impact on non-communicable disease prevention globally. We discuss key theoretical, design and methodological considerations to help policymakers, funders and researchers commission and conduct rigorous evaluations of these policies and related disease prevention efforts. We encourage involving the perspectives of various stakeholders on what evaluations are needed given the specific context, what data and methods are appropriate, readily available or can be collected within time and budget constraints. A logic model /conceptual system map of anticipated implications across sectors and scales should help identify optimal study design, analytical techniques and measures. These models should be updated when synthesising findings across diverse methods and integrating findings across subpopulations using similar methods.

Simulation Modeling for the Economic Evaluation of Population-Based Dietary Policies: A Systematic Scoping Review

Simulation modeling can be useful to estimate the long-term health and economic impacts of population-based dietary policies. We conducted a systematic scoping review following the PRISMA-ScR (Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews) guideline to map and critically appraise economic evaluations of population-based dietary policies using simulation models. We searched Medline, Embase, and EconLit for studies published in English after 2005. Modeling studies were mapped based on model type, dietary policy, and nutritional target, and modeled risk factor-outcome pathways were analyzed. We included 56 studies comprising 136 model applications evaluating dietary policies in 21 countries. The policies most often assessed were reformulation (34/136), taxation (27/136), and labeling (20/136); the most common targets were salt/sodium (60/136), sugar-sweetened beverages (31/136), and fruit and vegetables (15/136). Model types included Markov-type (35/56), microsimulation (11/56), and comparative risk assessment (7/56) models. Overall, the key diet-related risk factors and health outcomes were modeled, but only 1 study included overall diet quality as a risk factor. Information about validation was only reported in 19 of 56 studies and few studies (14/56) analyzed the equity impacts of policies. Commonly included cost components were health sector (52/56) and public sector implementation costs (35/56), as opposed to private sector (18/56), lost productivity (11/56), and informal care costs (3/56). Most dietary policies (103/136) were evaluated as cost-saving independent of the applied costing perspective. An analysis of the main limitations reported by authors revealed that model validity, uncertainty of dietary effect estimates, and long-term intervention assumptions necessitate a careful interpretation of results. In conclusion, simulation modeling is widely applied in the economic evaluation of population-based dietary policies but rarely takes dietary complexity and the equity dimensions of policies into account. To increase relevance for policymakers and support diet-related disease prevention, economic effects beyond the health sector should be considered, and transparent conduct and reporting of model validation should be improved.

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.

The African urban food environment framework for creating healthy nutrition policy and interventions in urban Africa

This study developed, validated, and evaluated a framework of factors influencing dietary behaviours in urban African food environments, to inform research prioritisation and intervention development in Africa. A multi-component methodology, drawing on concept mapping, was employed to construct a framework of factors influencing dietary behaviours in urban Africa. The framework adapted a widely used socio-ecological model (developed in a high-income country context) and was developed using a mixed-methods research approach that comprised: i. Evidence synthesis consisting of a systematic review of 39 papers covering 14 African countries; ii. Qualitative interview data collected for adolescents and adults (n = 144) using photovoice in urban Ghana and Kenya; and iii. Consultation with interdisciplinary African experts (n = 71) from 27 countries, who contributed to at least one step of the framework (creation, validation/evaluation, finalisation). The final framework included 103 factors influencing dietary behaviours. Experts identified the factors influencing dietary behaviours across all the four levels of the food environment i.e. the individual, social, physical and macro levels. Nearly half (n = 48) were individual-level factors and just under a quarter (n = 26) were at the macro environmental level. Fewer factors associated with social (n = 15) and physical (14) environments were identified. At the macro level, the factors ranked as most important were food prices, cultural beliefs and seasonality. Factors ranked as important at the social level were household composition, family food habits and dietary practices. The type of food available in the neighbourhood and convenience were seen as important at the physical level, while individual food habits, food preferences and socioeconomic status were ranked highly at the individual level. About half of the factors (n = 54) overlap with those reported in an existing socio-ecological food environment framework developed in a high-income country context. A further 49 factors were identified that were not reported in the selected high-income country framework, underlining the importance of contextualisation. Our conceptual framework offers a useful tool for research to understand dietary transitions in urban African adolescents and adults, as well as identification of factors to intervene when promoting healthy nutritious diets to prevent multiple forms of malnutrition.

Changes in beverage purchases following the announcement and implementation of South Africa's Health Promotion Levy: an observational study

BACKGROUND

In 2016, South Africa announced an intention to levy a tax on sugar-sweetened beverages (SSBs). In 2018, the country implemented an SSB tax of approximately 10%, known as the Health Promotion Levy (HPL). We aimed to assess changes in the purchases of beverages before and after the HPL announcement and implementation.

METHODS

We used Kantar Europanel data on monthly household purchases between January, 2014, and March, 2019, among a sample of South African households (n=113 653 household-month observations) from all nine provinces to obtain per-capita sugar, calories, and volume from taxable and non-taxable beverages purchased before and after the HPL announcement and implementation. We describe survey-weighted means for each period, and regression-controlled predictions of outcomes and counterfactuals based on pre-HPL announcement trends, with bootstrapped 95% CIs, and stratify results by socioeconomic status.

FINDINGS

Mean sugar from taxable beverage purchases fell from 16·25 g/capita per day (95% CI 15·80-16·70) to 14·26 (13·85-14·67) from the pre-HPL announcement to post-announcement period, and then to 10·63 g/capita per day (10·22-11·04) in the year after implementation. Mean volumes of taxable beverage purchases fell from 518·99 mL/capita per day (506·90-531·08) to 492·16 (481·28-503·04) from pre-announcement to post announcement, and then to 443·39 mL/capita per day (430·10-456·56) after implementation. Across these time periods, there was a small increase in the purchases of non-taxable beverages, from 283·45 mL/capita per day (273·34-293·56) pre-announcement to 312·94 (296·29-329·29) post implementation. When compared with pre-announcement counterfactual trends, reductions in taxable beverage purchase outcomes were significantly larger than the unadjusted survey-weighted observed reductions. Households with lower socioeconomic status purchased larger amounts of taxable beverages in the pre-announcement period than did households with higher socioeconomic status, but demonstrated bigger reductions after the tax was implemented.

INTERPRETATION

The announcement and introduction of South Africa's HPL were followed by reductions in the sugar, calories, and volume of beverage purchases.

FUNDING

Bloomberg Philanthropies, International Development Research Centre, South African Medical Research Council, and the US National Institutes of Health.

The data availability landscape in seven sub-Saharan African countries and its role in strengthening sugar-sweetened beverage taxation

Background: Credible data and indicators are necessary for country-specific evidence to support the design, implementation, monitoring and evaluation of sugar-sweetened beverage (SSB) taxation.Objective: A cross-country analysis was undertaken in seven Sub-Saharan African countries to describe the potential role of available data in strengthening SSB taxation. The objectives were to: document currently available data sources; report on public access; discuss strengths and limitations for use in monitoring SSB taxation; describe policy maker's data needs, and propose improvements in data collection.Methods: The study used a mixed-methods approach involving a secondary data analysis of publicly available documents, and a qualitative exploration of the data needs of policy makers' using primary data. Findings were synthesised and assessed for data strengths and weaknesses, including usability and availability. SSB taxation-related data availability was critically assessed with respect to adequacy in strengthening taxation policy on SSBs.Results: Findings showed a paucity of SSB taxation-related data in all seven countries. National survey data are inadequate regarding the intake of SSBs and household expenditure on SSBs. Fiscal data from SSB tax revenue, value added tax from SSB sales, corporate income tax from SSB companies and SSB custom duty revenues, are lacking. Accurate information on the soft drink industry is not easily accessed.Conclusion: Timely, easily understood, concise, and locally relevant evidence is needed in order to inform policy development on SSBs. The relevant data are drawn from multiple sectors. Cross- sector collaboration is therefore needed. Indicators for SSBs should be developed and included in current data collection tools to ensure monitoring and evaluation for SSB taxation.

How are frames generated? Insights from the industry lobby against the sugar tax in Ireland

There is a causal link between the consumption of ultra-processed foods and a range of non-communicable diseases (NCDs) such as obesity, type 2 diabetes and cancers. Despite this, no country in the world has reduced its obesity levels because the factors that drive obesity continue unchanged (Swinburn et al., 2019). One systemic driver is corporate influence on the public policy process. The world's largest food and beverage manufacturers engage public relations firms to create a narrative which speaks of corporate cooperation with public health policy, while simultaneously influencing policy making in ways that are favorable to industry. We sought to examine framing as a key strategy in the corporate political activity of food industry actors attempting to resist the introduction of a public health policy. Specifically, we analyzed industry submissions for an Irish government consultation for the proposed introduction of a sugar sweetened beverage (SSB) tax in 2018. We describe how a food product like sugar is framed positively by corporate actors who rely on it as their principal ingredient. Sugar is a good focus from a framing perspective because it is currently undergoing recalibration in the public's imagination - from a benign, nourishing treat in its heyday to a dangerous 'substance' that can contribute to premature mortality. Framing is already well established as a corporate political activity (CPA) to influence public policy (Shelton et al., 2017; Nixon et al., 2015; Darmon et al., 2008). Our research expands this understanding by uncovering four underlying mechanisms used to generate frames - dichotomizing, contesting, equating and cropping. Recognizing these mechanisms could help policy makers, public health professionals and business ethicists to deconstruct any given frame that becomes dominant in corporate discourse, such as 'personal responsibility', 'inadequate exercise', 'freedom' and so on. These mechanisms may also apply to other industries such as alcohol, fossil fuels and tobacco, where hazards from interference in public health strategies are a concern.

A narrative review of the effects of sugar-sweetened beverages on human health: A key global health issue

The provision of healthy and safe food is vital for human health, and the addition of unnecessary sugars in foodstuffs is an important global issue, leading to multiple long- and short-term health issues and spiraling costs for individuals and governments alike. The negative effect of excess sugar consumption contributes to adverse health conditions, including obesity, type 2 diabetes, and poor oral health in both high and low resource settings. A key plank of governmental and health promotion bodies' nutritional guidance is to raise public awareness of "hidden" sugars, salt, and fats, such as found in processed foods and sugar-sweetened beverages (SSBs), and guide individuals to reduce their consumption. This rapid narrative review brings together some of the key issues identified in the literature around the consumption of SSBs, including patterns of consumption, the general impact on human health and nutrition, specific effects on oral health and the oral microbiome, and strategies to address over-consumption. The range of long-term adverse effects on health is often misunderstood or unknown by the public. However, some strategies have succeeded in reducing the consumption of SSBs, including public health strategies and interventions and the imposition of taxes or levies, and this article makes recommendations for action.