Expected changes in obesity after reformulation to reduce added sugars in beverages: A modeling study

Health and economic burden of sugar-sweetened beverages consumption in Brazil

Sugar-sweetened beverages (SSBs) are a major source of added sugar and are associated with noncommunicable diseases (NCDs) such as obesity and diabetes. This study assessed the impact of SSBs consumption on disease burden in Brazil, including deaths, disability-adjusted life years (DALYs), and healthcare costs. A 3-stage methodology was used to assess the direct effects of SSBs on diabetes, cardiovascular diseases, and body mass index (BMI), along with the influence of BMI on disease incidence. These assessments were then used to estimate the economic and health burden using population-attributable factors. Results showed that 2.7% and 11% of adult and children overweight/obesity cases were attributable to SSBs, respectively. SSBs consumption in Brazil led to 1,814,486 cases, 12,942 deaths, 362,088 DALYs, and USD 2,915.91 million in medical costs related to diabetes, cardiovascular diseases, oncological diseases, and other NCDs. Urgent implementation of public policies is crucial to address the consumption of SSBs, recognized as a key risk factor for NCDs.

Associated substitution and complementation patterns of processed discretionary foods and drinks on total energy and added sugar intake

BACKGROUND

Processed discretionary foods and drinks (industrialised sugary drinks, sweet and savoury snacks, and grain-based sweets) are often target of policies aimed at regulating the food environment. We aimed to understand if a lower intake of processed foods or drinks is associated with substitution or complementation patterns and overall intake.

METHODS

We analysed a subsample with two 24-h dietary recalls of the Mexican National Health and Nutrition Survey 2012 (358 children, 253 adolescents and 278 adults). We compared within-person, energy and added sugar intakes between days with and without consumption of each food group with fixed-effects regressions. We estimated the relative change (change in intake when not consumed/average intake when consumed × 100).

RESULTS

Processed discretionary foods were not fully substituted, as total energy was 200-400 kcal/day lower when these foods were not consumed. The change in total intake was larger than the intake when consumed (i.e., complemented) for industrialised sugary drinks in adolescents (-136%) and adults (-215%), and sweet, savoury snacks for children (-141%). The change was lower (i.e., partially substituted) for grain-based sweets among children (-78%) and adolescents (-73%). For added sugars, most processed discretionary groups were complemented.

CONCLUSIONS

Days without intake of processed discretionary foods were associated with lower total energy and lower added sugar intake compared to days when those foods were consumed. This suggests that regulatory policies to reduce the intake of processed foods could have a meaningful impact on improving the overall diet.

The burden of disease and economic impact of sugar-sweetened beverages' consumption in Argentina: A modeling study

BACKGROUND

Approximately two-thirds of Argentine adults are overweight or obese, and 11% have diabetes. Over the last two decades, all population groups have increased their consumption of ultra-processed foods and sugar-sweetened beverages (SSB). We aimed to estimate the disease burden-deaths, events, and costs to the health system-attributed to SSB consumption in Argentina.

METHODS

We used a comparative risk assessment framework to estimate the health and economic impacts that would be avoided in a scenario without sugar-sweetened beverage (SSB) consumption. We calculated the direct effects on diabetes, cardiovascular disease, and BMI, and then estimated the effects of BMI on disease incidence. Finally, we applied the population attributable factor to calculate the health and economic burden avoided in Argentina in 2020.

RESULTS

Our model estimated that about 4,425 deaths, 110,000 healthy life years lost to premature death and disability, more than 520,000 cases of overweight and obesity in adults, and 774,000 in children and adolescents would be attributed to SSB Consumption in Argentina. This disease burden corresponds to 23% of type-2 diabetes cases and other significant proportions of cardiovascular disease and cancer. The overweight and obesity costs attributable to SSB totaled approximately $47 million in adults and $15 million in children and adolescents.

CONCLUSION

A significant number of disease cases, deaths, and health care costs could be attributed to SSB consumption in Argentina. Implementing measures to reduce the sugar content in beverages is a pending debt for the country and could lead to measurable improvements in population health, especially among children and adolescents.

Health and economic burden of disease of sugar-sweetened beverage consumption in four Latin American and Caribbean countries: a modelling study

OBJECTIVE

Overweight and obesity are important contributors to the non-communicable disease burden. The consumption of sugar-sweetened beverages (SSBs) has been associated with an increased risk of type 2 diabetes mellitus (T2DM), cardiovascular disease, cancer and other conditions. The objective of this study was to estimate the burden of disease attributable to the consumption of SSBs and the costs to the healthcare systems in Argentina, Brazil, El Salvador, and Trinidad and Tobago.

DESIGN

Following a systematic review of models, a comparative risk assessment framework was developed to estimate the health and economic impact associated with the consumption of SSBs.

SETTING

Argentina, Brazil, El Salvador, and Trinidad and Tobago.

PARTICIPANTS

Overall population.

PRIMARY AND SECONDARY OUTCOME MEASURES

The model estimated the effects of SSB consumption on health through two causal pathways: one mediated by body mass index (BMI) and health conditions associated with BMI and another that reflected the independent effects of SSB consumption on T2DM and cardiovascular diseases.

RESULTS

The model results indicated that for all four countries, in 1 year, SSB consumption was associated with 18 000 deaths (3.2% of the total disease-related deaths), seven million disease events (3.3% of the total disease-related events), a half-million DALYs and US$2 billion in direct medical costs. This included 1.5 million cases of overweight and obesity in children/adolescents (12% of the excess weight cases) and 2.8 million cases in adults (2.8%); 2.2 million cases of type 2 diabetes (19%); 200 000 cases of heart disease (3.8%); 124 000 strokes (3.9%); 116 000 cases of musculoskeletal disease (0.2%); 102 000 cases of kidney disease (0.9%); and 45 000 episodes of asthma (0.4%). The Trinidad and Tobago population were the most affected by disease events.

CONCLUSIONS

The study results indicate that the consumption of SSBs is associated with a significant burden of disease and death in Latin America and the Caribbean.

[Burden of disease and economic burden attributable to the consumption of sugar-sweetened beverages in El SalvadorCarga de morbidade e econômica atribuível ao consumo de bebidas açucaradas em El Salvador]

Objective

To estimate the burden of disease and economic burden attributable to the consumption of sugar-sweetened beverages in El Salvador.

Methods

A comparative risk model was used to estimate the effects on deaths, health events, disability-adjusted life years (DALYs), and direct medical costs attributable to the consumption of sugar-sweetened beverages.

Results

A total of 520 deaths (8 per 100 000 individuals), 214 082 health events (3 220 per 100 000 individuals) and 16 643 DALYs could be attributable to the consumption of sugar-sweetened beverages in El Salvador, representing US$69.35 million in direct medical costs for the year 2020. In particular, type 2 diabetes (T2DM) events attributable to the consumption of sugar-sweetened beverages could represent more than 20% of total T2DM cases in the country.

Conclusion

A high number of deaths, events, and costs could be attributed to the consumption of sugar-sweetened beverages in El Salvador.

Simulation models of sugary drink policies: A scoping review

INTRODUCTION

Simulation modeling methods are an increasingly common tool for projecting the potential health effects of policies to decrease sugar-sweetened beverage (SSB) intake. However, it remains unknown which SSB policies are understudied and how simulation modeling methods could be improved. To inform next steps, we conducted a scoping review to characterize the (1) policies considered and (2) major characteristics of SSB simulation models.

METHODS

We systematically searched 7 electronic databases in 2020, updated in 2021. Two investigators independently screened articles to identify peer-reviewed research using simulation modeling to project the impact of SSB policies on health outcomes. One investigator extracted information about policies considered and key characteristics of models from the full text of included articles. Data were analyzed in 2021-22.

RESULTS

Sixty-one articles were included. Of these, 50 simulated at least one tax policy, most often an ad valorem tax (e.g., 20% tax, n = 25) or volumetric tax (e.g., 1 cent-per-fluid-ounce tax, n = 23). Non-tax policies examined included bans on SSB purchases (n = 5), mandatory reformulation (n = 3), warning labels (n = 2), and portion size policies (n = 2). Policies were typically modeled in populations accounting for age and gender or sex attributes. Most studies focused on weight-related outcomes (n = 54), used cohort, lifetable, or microsimulation modeling methods (n = 34), conducted sensitivity or uncertainty analyses (n = 56), and included supplementary materials (n = 54). Few studies included stakeholders at any point in their process (n = 9) or provided replication code/data (n = 8).

DISCUSSION

Most simulation modeling of SSB policies has focused on tax policies and has been limited in its exploration of heterogenous impacts across population groups. Future research would benefit from refined policy and implementation scenario specifications, thorough assessments of the equity impacts of policies using established methods, and standardized reporting to improve transparency and consistency.

Invited Commentary: Mechanistic and Biologically Based Models in Epidemiology-A Powerful Underutilized Tool

Mechanistic and biologically based mathematical models of chronic and behavioral disease processes aim to capture the main mechanistic or biological features of the disease development and to connect these with epidemiologic outcomes. These approaches have a long history in epidemiologic research and are complementary to traditional epidemiologic or statistical approaches to investigate the role of risk factor exposures on disease risk. Simonetto et al. (Am J Epidemiol. 2022;191(10):1766-1775) present a mechanistic, process-oriented model to investigate the role of smoking, hypertension, and dyslipidemia in the development of atherosclerotic lesions and their progression to myocardial infarction. Their approach builds on and brings to cardiovascular disease the ideas and perspectives of earlier mechanistic and biologically based models for the epidemiology of cancer and other chronic diseases, providing important insights into the mechanisms and epidemiology of smoking related myocardial infarction. We argue that although mechanistic modeling approaches have demonstrated their value and place in epidemiology, they are highly underutilized. We call for efforts to grow mechanistic and biologically based modeling research, expertise, and awareness in epidemiology, including the development of training and collaboration opportunities to attract more students and researchers from science, technology, engineering, and medical field into the epidemiology field.

Relation of Change or Substitution of Low- and No-Calorie Sweetened Beverages With Cardiometabolic Outcomes: A Systematic Review and Meta-analysis of Prospective Cohort Studies

BACKGROUND

Adverse associations of low- and no-calorie sweetened beverages (LNCSB) with cardiometabolic outcomes in observational studies may be explained by reverse causality and residual confounding.

PURPOSE

To address these limitations we used change analyses of repeated measures of intake and substitution analyses to synthesize the association of LNCSB with cardiometabolic outcomes.

DATA SOURCES

MEDLINE, Embase, and the Cochrane Library were searched up to 10 June 2021 for prospective cohort studies with ≥1 year of follow-up duration in adults.

STUDY SELECTION

Outcomes included changes in clinical measures of adiposity, risk of overweight/obesity, metabolic syndrome, type 2 diabetes (T2D), cardiovascular disease, and total mortality.

DATA EXTRACTION

Two independent reviewers extracted data, assessed study quality, and assessed certainty of evidence using GRADE. Data were pooled with a random-effects model and expressed as mean difference (MD) or risk ratio (RR) and 95% CI.

DATA SYNTHESIS

A total of 14 cohorts (416,830 participants) met the eligibility criteria. Increase in LNCSB intake was associated with lower weight (5 cohorts, 130,020 participants; MD -0.008 kg/year [95% CI -0.014, -0.002]). Substitution of LNCSB for sugar-sweetened beverages (SSB) was associated with lower weight (three cohorts, 165,579 participants; MD, -0.12 [-0.14, -0.10,] kg/y) and lower incidence of obesity (OB) (one cohort, 15,765 participants; RR 0.88 [95% CI 0.88, 0.89]), coronary heart disease (six cohorts, 233,676 participants; 0.89 [0.81, 0.98]), cardiovascular disease mortality (one cohort, 118,363 participants; 0.95 [0.90, 0.99]), and total mortality (one cohort, 118,363 participants; 0.96 [0.94, 0.98]) with no adverse associations across other outcomes. Substitution of water for SSB showed lower weight (three cohorts, 165,579 participants; MD -0.10 kg/year [-0.13, -0.06]), lower waist circumference (one cohort, 173 participants; -2.71 cm/year [-4.27, -1.15]) and percent body fat (one cohort, 173 participants; -1.51% per year [-2.61, -0.42]), and lower incidence of OB (one cohort, 15,765 participants; RR 0.85 [0.75, 0.97]) and T2D (three cohorts, 281,855 participants; 0.96 [0.94, 0.98]). Substitution of LNCSB for water showed no adverse associations.

LIMITATIONS

The evidence was low to very low certainty owing to downgrades for imprecision, indirectness, and/or inconsistency.

CONCLUSIONS

LNCSB were not associated with cardiometabolic harm in analyses that model the exposure as change or substitutions. The available evidence provides some indication that LNCSB in their intended substitution for SSB may be associated with cardiometabolic benefit, comparable with the standard of care, water.

The nutrition transition to a stage of high obesity and noncommunicable disease prevalence dominated by ultra-processed foods is not inevitable

The Nutrition Transition model is presented with the nature and pace of change in key stages varying by location and subpopulations. At present, all high-income and many low- and middle-income countries are in a stage of the transition where nutrition-related noncommunicable diseases including obesity, type 2 diabetes, and hypertension are dominating adult morbidity and mortality and are very high or growing rapidly in prevalence. Some countries still have key subpopulations facing hunger and undernutrition defined by stunting or extreme thinness among adults. We call these double burden of malnutrition countries. All low- and middle-income countries face rapid growth in consumption of ultra-processed food and beverages, but it is not inevitable that these countries will reach the same high levels of consumption seen in high-income countries, with all the negative impacts of this diet on health. With great political and civil society commitment to adoption of policies shown in other countries to have improved dietary choices and social norms around foods, we can arrest and even reverse the rapid shift to diets dominated by a stage of high ultra-processed food intake and increasing prevalence of nutrition-related noncommunicable diseases.

Health Impact and Cost-Effectiveness of Achieving the National Salt and Sugar Reduction Initiative Voluntary Sugar Reduction Targets in the United States: A Microsimulation Study

BACKGROUND

High intake of added sugar is linked to weight gain and cardiometabolic risk. In 2018, the US National Salt and Sugar Reduction Initiative proposed government-supported voluntary national sugar reduction targets. This intervention's potential effects and cost-effectiveness are unclear.

METHODS

A validated microsimulation model, CVD-PREDICT (Cardiovascular Disease Policy Model for Risk, Events, Detection, Interventions, Costs, and Trends), coded in C++, was used to estimate incremental changes in type 2 diabetes, cardiovascular disease (CVD), quality-adjusted life-years (QALYs), costs, and cost-effectiveness of the US National Salt and Sugar Reduction Initiative policy. The model was run at the individual level, incorporating the annual probability of each person's transition between health statuses on the basis of risk factors. The model incorporated national demographic and dietary data from the National Health and Nutrition Examination Survey across 3 cycles (2011 through 2016), added sugar-related diseases from meta-analyses, and policy costs and health-related costs from established sources. A simulated nationally representative US population was created and followed until age 100 years or death, with 2019 as the year of intervention start. Findings were evaluated over 10 years and a lifetime from health care and societal perspectives. Uncertainty was evaluated in a 1-way analysis by assuming 50% industry compliance and probabilistic sensitivity analyses through a second-order Monte Carlo approach. Model outputs included averted diabetes cases, CVD events and CVD deaths, QALYs gained, and formal health care cost savings, stratified by age, race, income, and education.

RESULTS

Achieving the US National Salt and Sugar Reduction Initiative sugar reduction targets could prevent 2.48 million CVD events, 0.49 million CVD deaths, and 0.75 million diabetes cases; gain 6.67 million QALYs; and save $160.88 billion net costs from a societal perspective over a lifetime. The policy became cost-effective (<150 000/QALYs) at 6 years, highly cost-effective (<50 000/QALYs) at 7 years, and cost-saving at 9 years. Results were robust from a health care perspective, with lower (50%) industry compliance, and in probabilistic sensitivity analyses. The policy could also reduce disparities, with greatest estimated health gains per million adults among Black or Hispanic individuals, lower income, and less educated Americans.

CONCLUSIONS

Implementing and achieving the US National Salt and Sugar Reduction Initiative sugar reformation targets could generate substantial health gains, equity gains, and cost savings.

Simulating international tax designs on sugar-sweetened beverages in Mexico

In response to the high prevalence of overweight and obesity, Mexico implemented a volumetric tax of one Mexican peso (MP) per liter of sugar-sweetened beverage (SSB) in 2014. In contrast to Mexico's volumetric tax design, the United Kingdom (UK) and South Africa (ZA) implemented SSB taxes based on sugar density. This kind of tax is likely to yield larger health benefits than volumetric taxes by imposing a larger tax burden on high-sugar SSB and/or encouraging reformulation. However, sugar-density taxes might yield lower tax revenues. This study aims to simulate the effect of sugar-density taxes as those in the UK and ZA on SSB purchases (in terms of volume and sugar), SSB prices, and tax revenue in Mexico and compare this effect to its counterpart under the current volumetric SSB tax. Additionally, we simulate the effect of sugar-density taxes under different scenarios of reformulation. We conducted all these simulations based on a structural model of demand and supply using household purchase data for 2012-2015 in urban Mexico. We found that the current volumetric one-MP tax led to an SSB purchase reduction of 19% for both volume and sugar and an SSB price increases by MP $1.24. We simulated similar effects under the UK and ZA sugar-density taxes when these taxes were equivalent to the volumetric one-MP tax, and there was no reformulation. When assuming reformulation, the sugar reduction under the sugar-density taxes was up to twice larger than the volumetric one-MP tax. However, we found that the volumetric one-MP tax yielded the largest tax revenue across all tax designs. From a public health perspective, sugar-density taxes are likely to be more effective in tackling the overweight and obesity prevalence in Mexico; however, tax revenue might be lower under these taxes.

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.

Fructose and the Liver

Chronic diseases represent a major challenge in world health. Metabolic syndrome is a constellation of disturbances affecting several organs, and it has been proposed to be a liver-centered condition. Fructose overconsumption may result in insulin resistance, oxidative stress, inflammation, elevated uric acid levels, increased blood pressure, and increased triglyceride concentrations in both the blood and liver. Non-alcoholic fatty liver disease (NAFLD) is a term widely used to describe excessive fatty infiltration in the liver in the absence of alcohol, autoimmune disorders, or viral hepatitis; it is attributed to obesity, high sugar and fat consumption, and sedentarism. If untreated, NAFLD can progress to nonalcoholic steatohepatitis (NASH), characterized by inflammation and mild fibrosis in addition to fat infiltration and, eventually, advanced scar tissue deposition, cirrhosis, and finally liver cancer, which constitutes the culmination of the disease. Notably, fructose is recognized as a major mediator of NAFLD, as a significant correlation between fructose intake and the degree of inflammation and fibrosis has been found in preclinical and clinical studies. Moreover, fructose is a risk factor for liver cancer development. Interestingly, fructose induces a number of proinflammatory, fibrogenic, and oncogenic signaling pathways that explain its deleterious effects in the body, especially in the liver.

Sugar-sweetened beverage consumption and risk of hyperuricemia: a longitudinal analysis of the Health Workers Cohort Study participants in Mexico

BACKGROUND

The elevated consumption of sugar-sweetened beverages (SSBs) in Mexico is an important public health concern. However, the association between SSB consumption and hyperuricemia has been scarcely studied and not well documented.

OBJECTIVES

To prospectively evaluate the association between SSB consumption and risk of hyperuricemia in Mexican adults.

METHODS

A longitudinal analysis was conducted using data from the Health Workers Cohort Study. Participants were followed from 2004 to 2018, with measurements every 6 y. The analysis sample consisted of 1300 adults, aged 18 to 85 y. SSB consumption during the previous year was evaluated through a semiquantitative FFQ. Hyperuricemia was defined as a concentration of uric acid ≥7.0 mg/dL in men and ≥5.7 mg/dL in women. We evaluated the association of interest using 2 methodologies: fixed-effects logistic regression and generalized estimating equations (GEEs). Potential confounders were included in both approaches.

RESULTS

At baseline, median intake of SSBs was 472.1 mL/wk (IQR: 198.8-1416.4 mL/wk), and 233 participants had hyperuricemia. Uric acid was higher in participants with an SSB intake ≥7 servings/wk, compared with those with an intake <1 serving/wk (P < 0.001). Participants who changed from the lowest to the highest category of servings consumption experienced 2.6 increased odds of hyperuricemia (95% CI: 1.27, 5.26). Results from the GEE model indicated the odds of hyperuricemia increased by 44% (OR=1.44; 95% CI: 1.13, 1.84) in the 2-6 servings/wk group, and by 89% (OR=1.89; 95% CI: 1.39, 2.57) in the ≥7 servings/wk categories, compared with the <1 serving/wk category. Diet soft drinks were not associated with hyperuricemia.

CONCLUSIONS

Our results suggest that the consumption of SSBs is associated with an increased risk of hyperuricemia in Mexican adults, but diet soft drink consumption is not, which supports the need to strengthen existing recommendations to reduce the intake of SSBs.The Health Workers Cohort Study (HWCS) has been approved by the Institutional Review Board of the Mexican Social Security Institute (12CEI 09 006 14), and the National Institute of Public Health of Mexico (13CEI 17 007 36).

Body weight impact of the sugar-sweetened beverages tax in Mexican children: A modeling study

BACKGROUND

In Mexico, a 10% tax to sugar-sweetened beverages was implemented in 2014. Projections of the potential health effect of this tax in children are not available.

OBJECTIVE

To estimate the 1-year effect of the tax on the body weight of children 5 to 17 years old, and estimated alternative scenarios with higher tax rates (20%, 30%, and 40%).

METHODS

We used a dynamical mathematical model, recalibrated to the Mexican population. Input data were obtained from the Mexican National Health and Nutrition Survey 2006 and 2012. We estimated the expected average weight reduction, stratified by category of sugar-sweetened beverages consumption.

RESULTS

With a 10% tax, we estimated an overall weight reduction of 0.26 kg for children and 0.61 kg for adolescents; in high consumers, the reduction could reach 0.50 and 0.87 kg, respectively. Higher tax rates would produce larger weight decreases; in high consumers a 40% tax would result in a reduction of 1.99 kg for children and 3.50 kg for adolescents.

CONCLUSION

The tax represents an effective component of any child or adolescent weight control program, and must be considered as part of any integrated population-level program for children and adolescent obesity prevention.

Predicting obesity reduction after implementing warning labels in Mexico: A modeling study

BACKGROUND

In October 2019, Mexico approved a law to establish that nonalcoholic beverages and packaged foods that exceed a threshold for added calories, sugars, fats, trans fat, or sodium should have an "excess of" warning label. We aimed to estimate the expected reduction in the obesity prevalence and obesity costs in Mexico by introducing warning labels, over 5 years, among adults under 60 years of age.

METHODS AND FINDINGS

Baseline intakes of beverages and snacks were obtained from the 2016 Mexican National Health and Nutrition Survey. The expected impact of labels on caloric intake was obtained from an experimental study, with a 10.5% caloric reduction for beverages and 3.0% caloric reduction for snacks. The caloric reduction was introduced into a dynamic model to estimate weight change. The model output was then used to estimate the expected changes in the prevalence of obesity and overweight. To predict obesity costs, we used the Health Ministry report of the impact of overweight and obesity in Mexico 1999-2023. We estimated a mean caloric reduction of 36.8 kcal/day/person (23.2 kcal/day from beverages and 13.6 kcal/day from snacks). Five years after implementation, this caloric reduction could reduce 1.68 kg and 4.98 percentage points (pp) in obesity (14.7%, with respect to baseline), which translates into a reduction of 1.3 million cases of obesity and a reduction of US$1.8 billion in direct and indirect costs. Our estimate is based on experimental evidence derived from warning labels as proposed in Canada, which include a single label and less restrictive limits to sugar, sodium, and saturated fats. Our estimates depend on various assumptions, such as the transportability of effect estimates from the experimental study to the Mexican population and that other factors that could influence weight and food and beverage consumption remain unchanged. Our results will need to be corroborated by future observational studies through the analysis of changes in sales, consumption, and body weight.

CONCLUSIONS

In this study, we estimated that warning labels may effectively reduce obesity and obesity-related costs. Mexico is following Chile, Peru, and Uruguay in implementing warning labels to processed foods, but other countries could benefit from this intervention.

Role of different nutrient profiling models in identifying targeted foods for front-of-package food labelling in Brazil

Objective:

To compare the degree of strictness and agreement of different nutrient profiling models (NPM) used to identify which foods would be required to show front-of-package (FOP) warning labels.

Design:

Using data of 11 434 packaged foods found in the five largest food retailers in Brazil, we used two published NPM: the Pan American Health Organization (PAHO) model and the NPM used in the Chilean nutritional FOP labelling policy, and compared them with a NPM proposed by the Brazilian National Health Surveillance Agency (Anvisa). The proportion of foods that would be required to show FOP warning labels was calculated overall and by food category. We also tested whether a modified version of the PAHO NPM would behave similarly to the original version.

Setting:

Brazil.

Results:

Two-thirds of the packaged products (62 %) would receive FOP warning labels under the PAHO NPM, as compared with 45 % of products using the proposed Anvisa NPM and 41 % if the Chilean NPM was applied. The PAHO NPM identified more foods high in critical nutrients such as sweetened dairy and non-dairy beverages, canned vegetables and convenience foods. Overall agreement between models was considered good with kappa coefficient ranging from 0·57 to 0·92 but was lower for some food categories.

Conclusions:

We found variations in the degree of strictness and agreement between assessed NPM. The PAHO NPM identified more foods and beverages high in sugar which are among the top contributors to sugar and energy intake in Brazil.

Mortality attributable to sugar sweetened beverages consumption in Mexico: an update

BACKGROUND

In 2010, sugar sweetened beverages (SSBs) were estimated to cause 12% of all diabetes, cardiovascular disease (CVD) and obesity-related cancer deaths in Mexico. Using new risk estimates for SSBs consumption, we aimed to update the fraction of Mexican mortality attributable to SSBs, and provide subnational estimates by region, age, and sex.

METHODS

We used an established comparative risk assessment framework. All-cause mortality estimates were calculated from a recent pooled cohort analysis. Age- and sex-specific relative risks for SSBs-disease relationships were obtained from updated meta-analyses. Demographics and nationally representative estimates of SSBs intake were derived from the National Health and Nutrition Survey 2012; and mortality rates, from the National Institute of Statistics and Geography. Attributable mortality was calculated by estimating the population attributable fraction of each disease, with uncertainty in data inputs propagated through Monte Carlo probabilistic sensitivity analyses.

RESULTS

In Mexican adults 20 years and older, 6.9% (95%UI: 5.4-8.5) of all cause-mortality was attributable to SSBs, representing 40,842 excess deaths/year (95%UI: 31,950-50,138). Furthermore, 19% of diabetes, CVD and obesity-related cancer mortality was attributable to SSBs (95%UI: 11.0-26.5), representing 37,000 excess deaths/year (95%UI 21,240-51,045). Of these, 35.6% were diabetes-related (95%UI 16.4-52.0). Proportional burden was highest in the South (22.8%), followed by the Center (18.0%) and North (17.4%). Men aged 45-64-years in the Center region had highest proportional mortality (37.2%), followed by 20-44-year-old men living in the South (35.7%) and both men and women aged 20-44 living in the Center (34.4%).

CONCLUSIONS

Utilizing current evidence linking SSBs to cardiometabolic disease and obesity-related cancers, earlier estimates of Mexican mortality attributable to SSBs could have been underestimated. Mexico urgently needs stronger policies to reduce SSBs consumption and reduce these burdens.

Soft drink intake is associated with weight gain, regardless of physical activity levels: the health workers cohort study

Background

While soft drink intake is positively associated with weight gain, no previous study has investigated whether leisure-time physical activity modifies this association. We estimated the association between soft drink intake and body weight, and explored if this association differed by levels of leisure-time physical activity.

Methods

We used data from the health workers cohort study, a prospective study of Mexican adults (20 to 85y old), including 1268 health workers and their families, who were assessed at baseline (2004–2006) and follow-up (2010–2012). We assessed soft drink intake (cola and flavored soda) using a validated food frequency questionnaire. We measured leisure-time physical activity using a self-report questionnaire, and categorized according to the 2010 World Health Organization (WHO) recommendations. Body weight was measured by trained personnel. The association between changes in soft drink intake and weight change, and if such association varied by levels of physical activity was estimated through fixed-effect models.

Results

An increase in one serving per day of soft drink was associated with 0.10 kg (95% CI 0.00, 0.19) increase in weight per year. This association was not modified by leisure-time physical activity, as demonstrated by the magnitude of the coefficient of the interaction between soft drink, leisure-time physical activity, and time (− 0.03 kg, 95% CI − 0.27 to 0.21); people who complied with the WHO physical activity recommendations gained 0.36 kg/year per serving of soft drink, compared to 0.48 kg/year for people without sufficient physical activity.

Conclusions

Soft drink intake was associated with weight gain. Leisure-time physical activity did not modify the association between soft drink intake and weight gain. This finding challenges the idea that leisure-time physical activity is sufficient to counterbalance weight gain associated to soft drink intake.

Beyond the Chair: Public Health and Governmental Measures to Tackle Sugar

Limiting free sugars to <5% of energy intake is a World Health Organization evidence-based recommendation to protect oral health throughout the life course. Achieving this requires a concerted approach with upstream interventions, including legislation underpinning community interventions and health promotion. Global production and trade are the main drivers of sugars consumption, which can be addressed only through prioritization of health impacts in agricultural and trade agreements, including pricing and subsidies. Increasing evidence demonstrates the benefit, including dental benefits, of taxes on sugar-sweetened beverages, a major source of sugars—with taxes based on sugars content being favored due to the dual impact in incentivizing consumers to buy less and encouraging producers to use less through product reformulation. A benefit of product reformulation is that the potential impact on sugars intake occurs independent of consumer behavior change, making the benefits more equitable across social groups. Evidence from meta-analysis indicates that sugars reformulation and portion size reduction could lower energy intake by more than 10% and 16%, respectively. Sophisticated and targeted digital marketing of products high in sugars is another key driver of sugars intake. With the exception of children’s television broadcasting, marketing of products high in sugars is largely unregulated, and increased awareness of modern marketing strategies and more stringent regulation are urgently needed. To ensure a commercial level playing field, mandatory approaches are required. Midstream actions include creating healthier food environments in neighborhoods, community settings (schools, sports centers, hospitals), and workplaces. Only through coalition among authorities responsible for planning and health will “obesogenic and cariogenic” environments be replaced with those that make healthy choices the easiest choice. It is recognized that providing nutrition health education alone is insufficient to achieve necessary sugars reduction; however, education has a key role to play in changing social norms and creating drive for change.

The economic gradient of obesity in Mexico: Independent predictive roles of absolute and relative wealth by gender

Despite the vast literature on the economic gradient of obesity, no study investigates the independent predictive roles of absolute and relative standards of living using a large nationally representative adult sample. This gap limits our ability to discern 'material' and 'psychosocial' pathways to obesity as well as our understanding of the role played by economic inequality in the growing obesity epidemic. Using a large and nationally representative Mexican dataset, we find that absolute wealth and relative deprivation are independently related to obesity, and that such relationships are patterned by sex. Absolute wealth predicts body mass index as well as abdominal obesity according to an inverted-U shape for both sexes, and more markedly so for females. Relative deprivation predicts higher body mass index for females and higher waist circumference for both sexes, with highly relatively deprived females being 24.29% (95% CI [24.26, 24.31]) more likely to be obese and 34.46% (95% CI [34.40,34.53]) more likely to be abdominal obese, and highly relatively deprived males being 14.91% (95% CI [14.88,14.93] more likely to be abdominal obese. Our results offer a new perspective on the economic gradient of obesity and highlight the potential impact of economic inequality, especially for women. Greater awareness of the independent and sex-specific roles of the absolute and relative facets of economic status is needed to better understand and address the obesity epidemic.

Effects of physical activity calorie equivalent food labelling to reduce food selection and consumption: systematic review and meta-analysis of randomised controlled studies

Background

There is limited evidence that nutritional labelling on food/drinks is changing eating behaviours. Physical activity calorie equivalent (PACE) food labelling aims to provide the public with information about the amount of physical activity required to expend the number of kilocalories in food/drinks (eg, calories in this pizza requires 45 min of running to burn), to encourage healthier food choices and reduce disease.

Objective

We aimed to systematically search for randomised controlled trials and experimental studies of the effects of PACE food labelling on the selection, purchase or consumption of food/drinks.

Methods

PACE food labelling was compared with any other type of food labelling or no labelling (comparator). Reports were identified by searching electronic databases, websites and social media platforms. Inverse variance meta-analysis was used to summarise evidence. Weighted mean differences (WMD) and 95% CIs were used to describe between-group differences using a random effects model.

Results

15 studies were eligible for inclusion. When PACE labelling was displayed on food/drinks and menus, significantly fewer calories were selected, relative to comparator labelling (WMD=−64.9 kcal, 95% CI −103.2 to −26.6, p=0.009, n=4606). Presenting participants with PACE food labelling results in the consumption of significantly fewer calories (WMD=−80.4 kcal, 95% CI−136.7 to −24.2, p=0.005, n=486) relative to comparator food labelling.

Conclusion

Based on current evidence PACE food labelling may reduce the number of kilocalories selected from menus and decrease the number of kilocalories/grams of food consumed by the public, compared with other types of food labelling/no labelling.

Trial registration number

CRD42018088567.

The caloric and sugar content of beverages purchased at different store-types changed after the sugary drinks taxation in Mexico

BACKGROUND

Following the 2014 sugary drinks tax implementation in Mexico, promising reduction in the volume of purchases of taxed beverages were observed overall and at different store-types. However, the tax's effects on purchasing patterns of calories and sugar remain unclear.

METHODS

Using longitudinal data from Mexican households (n = 7038), we examined changes in volume, calories and total sugar of packaged beverages purchased from 2012 to 2016 overall and by store-type. We used fixed effects models to estimate means for volume, calories, and sugar of households. To address the potential selectivity from households shopping at different stores, we calculated inverse probability weights to model the purchases changes over time by store-type.

RESULTS

For taxed beverages, the volume of purchases declined by - 49 ml and -30 ml in the first year and second year post tax (2014 and 2015, respectively), while purchases leveled off in the third year of the tax (2016). Calories and sugar from taxed beverage purchases decreased over time, with the majority of the declines occurring in the first two years post-tax implementation. The volume of untaxed beverage purchases increased, whereas changes in calories and total sugar of untaxed beverages were minimal. Store level purchases of taxed beverages significantly decreased in the first two years post taxation (2014 and to 2015) only in supermarkets and traditional stores. The steepest declines in purchases of taxed beverages in 2014 were observed at supermarkets (- 40 ml or - 45%). The volume of purchases of untaxed beverages increased over time in almost all store-types, while calories and sugar minimally decreased over time.

CONCLUSION

Although the Mexican tax on SSBs has lowered the purchases of sugary drinks 3 years after the tax implementation, the tax should be strengthened and store-specific interventions should be implemented to further reduce SSBs purchases in the Mexican population.

The food environment in Latin America: a systematic review with a focus on environments relevant to obesity and related chronic diseases

OBJECTIVE

Food environments may be contributing to the rapid increase in obesity occurring in most Latin American (LA) countries. The present study reviews literature from LA that (i) describes the food environment and policies targeting the food environment (FEP); and (ii) analytic studies that investigate associations between the FEP and dietary behaviours, overweight/obesity and obesity related chronic diseases. We focus on six dimensions of the FEP: food retail, provision, labelling, marketing, price and composition.

DESIGN

Systematic literature review. Three databases (Web of Science, SciELO, LILACS) were searched, from 1 January 1999 up to July 2017. Two authors independently selected the studies. A narrative synthesis was used to summarize, integrate and interpret findings.

SETTING

Studies conducted in LA countries.

PARTICIPANTS

The search yielded 2695 articles of which eighty-four met inclusion criteria.

RESULTS

Most studies were descriptive and came from Brazil (61 %), followed by Mexico (18 %) and Guatemala (6 %). Studies were focused primarily on retail/provision (n 27), marketing (n 16) and labelling (n 15). Consistent associations between availability of fruit and vegetable markets and higher consumption of fruits and vegetables were found in cross-sectional studies. Health claims in food packaging were prevalent and mostly misleading. There was widespread use of marketing strategies for unhealthy foods aimed at children. Food prices were lower for processed relative to fresh foods. Some studies documented high sodium in industrially processed foods.

CONCLUSIONS

Gaps in knowledge remain regarding policy evaluations, longitudinal food retail studies, impacts of food price on diet and effects of digital marketing on diet/health.

Correction: Expected changes in obesity after reformulation to reduce added sugars in beverages: A modeling study

[This corrects the article DOI: 10.1371/journal.pmed.1002664.].