Associations between trajectories of obesity prevalence in English primary school children and the UK soft drinks industry levy: An interrupted time series analysis of surveillance data

Estimated changes in free sugar consumption one year after the UK soft drinks industry levy came into force: controlled interrupted time series analysis of the National Diet and Nutrition Survey (2011-2019)

BACKGROUND

The UK soft drinks industry levy (SDIL) was announced in March 2016 and implemented in April 2018, encouraging manufacturers to reduce the sugar content of soft drinks. This is the first study to investigate changes in individual-level consumption of free sugars in relation to the SDIL.

METHODS

We used controlled interrupted time series (2011-2019) to explore changes in the consumption of free sugars in the whole diet and from soft drinks alone 11 months after SDIL implementation in a nationally representative sample of adults (>18 years; n=7999) and children (1.5-19 years; n=7656) drawn from the UK National Diet and Nutrition Survey. Estimates were based on differences between observed data and a counterfactual scenario of no SDIL announcement/implementation. Models included protein consumption (control) and accounted for autocorrelation.

RESULTS

Accounting for trends prior to the SDIL announcement, there were absolute reductions in the daily consumption of free sugars from the whole diet in children and adults of 4.8 g (95% CI 0.6 to 9.1) and 10.9 g (95% CI 7.8 to 13.9), respectively. Comparable reductions in free sugar consumption from drinks alone were 3.0 g (95% CI 0.1 to 5.8) and 5.2 g (95% CI 4.2 to 6.1). The percentage of total dietary energy from free sugars declined over the study period but was not significantly different from the counterfactual.

CONCLUSION

The SDIL led to significant reductions in dietary free sugar consumption in children and adults. Energy from free sugar as a percentage of total energy did not change relative to the counterfactual, which could be due to simultaneous reductions in total energy intake associated with reductions in dietary free sugar.

Optimization and performance analytics of global aircraft-based wastewater surveillance networks

Aircraft wastewater surveillance has been proposed as a novel approach to monitor the global spread of pathogens. Here we develop a computational framework to provide actionable information for designing and estimating the effectiveness of global aircraft-based wastewater surveillance networks (WWSNs). We study respiratory diseases of varying transmission potentials and find that networks of 10 to 20 strategically placed wastewater sentinel sites can provide timely situational awareness and function effectively as an early warning system. The model identifies potential blind spots and suggests optimization strategies to increase WWSNs effectiveness while minimizing resource use. Our findings highlight that increasing the number of sentinel sites beyond a critical threshold does not proportionately improve WWSNs capabilities, stressing the importance of resource optimization. We show through retrospective analyses that WWSNs can significantly shorten the detection time for emerging pathogens. The presented approach offers a realistic analytic framework for the analysis of WWSNs at airports.

Evaluating the impact of sugar-sweetened beverages tax on overweight, obesity, and type 2 diabetes in an affluent Asian setting: A willingness-to-pay survey and simulation analysis

BACKGROUND

The potential health effects of taxing sugar-sweetened beverages (SSBs) has been insufficiently examined in Asian contexts. This study aimed to assess the impact of SSB taxation on the prevalence of obesity/overweight and type 2 diabetes mellitus (T2DM) in Hong Kong using a willingness-to-pay (WTP) survey and simulation analysis.

METHODS

A random telephone survey was conducted with 1000 adults from May to June 2020. We used a contingent valuation approach to assess individuals' WTP for SSBs under four tax payment scenarios (5%, 10%, 40%, and 50% of the current market price). Based on the WTP, a simulation analysis was conducted to project changes in SSB purchase and associated reductions in the prevalence of obesity/overweight and T2DM over a 10-year simulation period.

FINDINGS

When 5% and 10% taxation rates were introduced, approximately one-third of the population were unwilling to maintain their SSB purchase. Our simulation demonstrated a gradual decline in the prevalence of obesity/overweight and diabetes with a more pronounced decrease when higher taxation rates were introduced. 10% taxation resulted in a mean reduction of 1532.7 cases of overweight/obesity per 100 thousand population at the sixth year, while T2DM prevalence decreased by 267.1 (0.3%).

CONCLUSIONS

This study underscores the effects of an SSB tax on purchase behaviors and health outcomes in an affluent Asia setting, with a more pronounced influence on adult population. These findings are expected to inform policymakers in making decisions regarding an effective and equitable tax rate on SSBs.

The contract between NHS dentistry and communities and how this varies by neighbourhood types

Introduction There is a growing concern that the NHS's ability to deliver dental care is not keeping pace with population growth. Also, existing capacity may not be evenly distributed, potentially creating dental deserts in some neighbourhoods.Aims This study aims to explore recent trends in NHS general practice dental capacity in England and analyse if these trends vary depending on neighbourhood context.Design This research employs a descriptive analysis of time trends.Materials and methods The study uses data on NHS-contracted capacity in England, measured in units of dental activity (UDAs). These UDAs are geo-located to neighbourhood types using practice postcodes. Changes in the populations of these neighbourhoods provide context for the capacity trends.Results Some trends remain stable over time, albeit at insufficient levels. Rural areas continue to have the lowest capacity for NHS dental treatments. Additionally, areas with previously generous provision are experiencing significant percentage decreases in capacity.Discussion To prevent the formation of dental deserts, two critical issues require attention: firstly, the accessibility of NHS treatment and how it varies across urban/suburban and rural neighbourhoods; secondly, balancing supply and demand by matching the supply of dental care with the demand, conditioned by socio-economic and socio-demographic factors within different neighbourhoods.

The UK Soft Drinks Industry Levy and childhood hospital admissions for asthma in England

Sugar sweetened beverage consumption has been suggested as a risk factor for childhood asthma symptoms. We examined whether the UK Soft Drinks Industry Levy (SDIL), announced in March 2016 and implemented in April 2018, was associated with changes in National Health Service hospital admission rates for asthma in children, 22 months post-implementation of SDIL. We conducted interrupted time series analyses (2012-2020) to measure changes in monthly incidence rates of hospital admissions. Sub-analysis was by age-group (5-9,10-14,15-18 years) and neighbourhood deprivation quintiles. Changes were relative to counterfactual scenarios where the SDIL wasn't announced, or implemented. Overall, incidence rates reduced by 20.9% (95%CI: 29.6-12.2). Reductions were similar across age-groups and deprivation quintiles. These findings give support to the idea that implementation of a UK tax intended to reduce childhood obesity may have contributed to a significant unexpected and additional public health benefit in the form of reduced hospital admissions for childhood asthma.

The impact of the UK soft drink industry levy on the soft drink marketplace, 2017-2020: An interrupted time series analysis with comparator series

BACKGROUND

In April 2018, the UK government implemented a levy on soft drinks importers and manufacturers, tiered according to the amount of sugar in drinks. The stated aim was to encourage manufacturers to reduce sugar and portion sizes. Previous evidence suggests that the policy has been successful in reducing sugar in drinks in the short-term since implementation, but their sustained effects have not been explored. This study aimed to assess the impact of the soft drink industry levy (SDIL) on sugar levels, price, portion size and use of non-sugar sweeteners in the medium-term.

METHODS AND FINDINGS

Product data from 30 November 2017 to 14 March 2020 from one major UK retail supermarket were analysed (112,452 observations, 126 weekly time points). We used interrupted time series analysis, to assess the impact of the soft-drink industry levy (SDIL) on levy-eligible soft drinks, with exempt drinks (i.e. 100% fruit juices, milks, flavoured milks) acting as a comparator series. At the point of implementation of the SDIL (April 2018) there was a step change in the proportion of eligible drinks with sugar content below the SDIL levy threshold (5g per 100ml) (+0.08, 95%CI: +0.04, +0.12), with a similar sized decrease in the proportion in the highest levy category (> = 8g sugar per 100ml) (-0.06, 95%CI: -0.10, -0.03). Between April 2018 and March 2020, the proportion of eligible drinks below the SDIL levy threshold continued to gradually increase (p = 0.003), while those in the highest levy category decreased (p = 0.007). There was a step change in price of eligible drinks in the higher levy category at the point of implementation of +£0.049 (95%CI: +£0.034, +£0.065) per 100mL (for comparison, the levy is set at £0.024 per 100mL for this group). Trends in price for the high levy category were not altered by the SDIL. In the no levy category, there was a step change in price at the implementation (+£0.012 per 100mL, 95%CI: +£0.008, +£0.023), followed by a second step change in October 2018 (-£0.018p per 100mL, 95%CI: -£0.033, -£0.001p). The volume of products in the higher levy group decreased at the time of the implementation (-305mL on average including multipacks, 95%CI: -511, -99). The change in trend for the product volume of drinks in the higher levy group between April 2018 and March 2020 was in the increasing direction (+704mL per year, 95%CI: -95, 1504), but it did not meet our threshold for statistical significance (p = 0.084). There were no changes observed in the volume of lower levy drinks or no levy drinks. There was a step change in the proportion of drinks with non-sugar sweeteners at the implementation of the SDIL (+0.04, 95%CI: +0.02, +0.06).

CONCLUSION

These results suggest that the SDIL was successful in [1] producing reductions in sugar levels that were maintained over the medium term up to March 2020 and [2] a reduction in product volume for higher tier drinks that may be diminishing over time. Our results also show that the SDIL was associated with a maintained price differential between high and low sugar drinks.

[Nutrition counseling in medical practices-a cross-sectional study]

INTRODUCTION

The purpose of this study was to assess the status of nutrition care and counseling in German medical practices, including physicians' nutrition interest and knowledge, existing obstacles, and possible ways of improving nutrition care.

METHODS

After development and a two-stage pretest, questionnaires with 32 items were distributed to all resident doctors of general medicine, internal medicine, gynecology and obstetrics, orthopedics, and occupational medicine in Aachen (n = 360) in early spring 2022.

RESULTS

The response rate was 29.2% and n = 105 participants were included in the analysis. During their consultation hours, 85.7% of the doctors conducted nutrition counseling (NC). While doctors estimated that 39.5% of their patients need NC, they counseled only 28.1%. General practitioners spent an average of 13 min on NC; all other specialties spent 9.5 min. Most participants felt well informed about healthy nutrition (95.2%). Nutrition was of high personal interest to 57.7% of the participants, and 47.6% considered it important for their work as a doctor. Barriers preventing better NC included the lack of nutrition education during medical studies (89.5%) and specialist training (79.6%), and the lack of time (75.2%). Most participants were willing to conduct more NC if they were paid better and had more time for NC during their working hours.

DISCUSSION

Doctors consider NC a relevant part of their work, despite many barriers. To make better use of NC as a measure for treating and preventing common diseases, improvements like better nutrition education for doctors, better funding, and more time for NC are required.

Outcomes of sugar reduction policies, United Kingdom of Great Britain and Northern Ireland

Poor diets are the major cause of death and disease globally, driving high levels of obesity and noncommunicable diseases. Cheap, heavily marketed, ultra-processed, energy-dense and nutrient-poor food and drinks that are high in fat, sugar and salt play a major role. The high-sugar content of these products leads to consumption levels much higher than recommended. The World Health Organization recommends that sugar intake should be reduced to just 5% of energy intake by using fiscal policies and food and drink reformulation strategies. Over the previous decade, the government of the United Kingdom of Great Britain and Northern Ireland has implemented several policies aimed at reducing sugar intake. We compare the soft drinks industry levy and the sugar reduction programme, examining how differences in policy design and process may have influenced the outcomes. Success has been mixed: the mandatory levy achieved a reduction in total sugar sales of 34.3%, and the voluntary reduction programme only achieved a 3.5% reduction in sugar levels of key contributors to sugar intake (despite a target of 20%). Both policies can be improved to enhance their impact, for example, by increasing the levy and reducing the sugar content threshold in the soft drinks industry levy, and by setting more stringent subcategory specific targets in the sugar reduction programme. We also recommend that policy-makers should consider applying a similar levy to other discretionary products that are key contributors to sugar intake. Both approaches provide valuable learnings for future policy in the United Kingdom and globally.

Physical activity, low-grade inflammation, and psychological responses to the COVID-19 pandemic among older adults in England

Mental health responses to the COVID-19 pandemic have been widely studied, but less is known about the potentially protective role of physical activity (PA) and the impact of low-grade inflammation. Using a sample of older adults from England, this study tested (1) if pre-pandemic PA and its changes during the pandemic were associated with mental health responses; (2) if older adults with low-grade inflammation experienced greater increases in depression and anxiety, compared to pre-pandemic levels; (3) if PA attenuated the association between inflammation and depression/anxiety. The study used data from the English Longitudinal Study of Ageing, a cohort study following a national sample aged 50+. Information on mental health and PA were collected before the pandemic (2016/17 and 2018/19) and during November and December 2020. Inflammation was ascertained using pre-pandemic C-reactive protein (CRP). Analyses were adjusted for sociodemographic and health-related factors and pre-pandemic mental health. Increasing PA from before to during the pandemic was linked to reduced odds of depression (OR = 0.955, 95%CI [0.937, 0.974]) and anxiety (OR = 0.954, 95%CI [0.927; 0.982]). Higher pre-pandemic PA was associated with reduced odds of depression (OR = 0.964, 95%CI [0.948, 0.981]) and anxiety (OR = 0.976, 95%CI [0.953, 1.000]), whereas elevated CRP was associated with 1.343 times higher odds of depression (95%CI [1.100, 1.641]). PA did not attenuate the inflammation-depression association. The findings suggest that PA may contribute to psychological resilience among older adults, independently of inflammation. Further research is needed to explore the psychobiological pathways underlying this protective mechanism.

Determinants of overweight and obesity among children between 5 to 11 years in Ecuador: A secondary analysis from the National Health Survey 2018

BACKGROUND

During the 1990s, global eating habits changed, affecting poorer and middle-income nations, as well as richer countries. This shift, known as the "obesity transition," led to more people becoming overweight or obese worldwide. In Ecuador, this change is happening, and now, one in three children is affected by overweight or obesity (OW/OB). This study explores the links between social, economic, and demographic factors and childhood obesity in Ecuador, seeking to provide insights for shaping future health policies in response to this intricate shift.

METHODS

A cross-sectional study using 2018 National Health and Nutrition Survey data from Ecuador. Weighted percentages were computed, and odds ratios for OW/OB unadjusted and adjusted for each category of explanatory variables were estimated using multilevel multivariate logistic regression models.

RESULTS

Among 10,807 Ecuadorian school children aged 5 to 11, the prevalence of OW/OB was 36.0%. Males exhibited 1.26 times higher odds than females (95% CI: 1.20 to 1.33), and each additional year of age increased the odds by 1.10 times (95% CI: 1.09 to 1.10). Economic quintiles indicated increased odds (1.17 to 1.39) from the 2nd to 5th quintile (the richest) compared with the first quintile (the poorest). Larger household size slightly reduced odds of OW/OB (adjusted odds ratio [aOR] = 0.93, 95% CI: 0.91 to 0.95), while regular physical activity decreased odds ([aOR] = 0.79, 95% CI: 0.75 to 0.82). The consumption of school-provided meals showed a non-significant reduction (aOR: 0.93, 95% CI: 0.82 to 1.06). Children from families recognizing and using processed food labels had a higher likelihood of being overweight or obese (aOR = 1.14, 95% CI: 1.02 to 1.26).

CONCLUSION

Age, male gender, and higher economic quintile increase OW/OB in Ecuadorian school children. Larger households and physical activity slightly decrease risks. Ecuador needs policies for healthy schools and homes, focusing on health, protection, and good eating habits.

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Impact of the UK soft drinks industry levy on health and health inequalities in children and adolescents in England: An interrupted time series analysis and population health modelling study

BACKGROUND

The soft drinks industry levy (SDIL) in the United Kingdom has led to a significant reduction in household purchasing of sugar in drinks. In this study, we examined the potential medium- and long-term implications for health and health inequalities among children and adolescents in England.

METHODS AND FINDINGS

We conducted a controlled interrupted time series analysis to measure the effects of the SDIL on the amount of sugar per household per week from soft drinks purchased, 19 months post implementation and by index of multiple deprivation (IMD) quintile in England. We modelled the effect of observed sugar reduction on body mass index (BMI), dental caries, and quality-adjusted life years (QALYs) in children and adolescents (0 to 17 years) by IMD quintile over the first 10 years following announcement (March 2016) and implementation (April 2018) of the SDIL. Using a lifetable model, we simulated the potential long-term impact of these changes on life expectancy for the current birth cohort and, using regression models with results from the IMD-specific lifetable models, we calculated the impact of the SDIL on the slope index of inequality (SII) in life expectancy. The SDIL was found to have reduced sugar from purchased drinks in England by 15 g/household/week (95% confidence interval: -10.3 to -19.7). The model predicts these reductions in sugar will lead to 3,600 (95% uncertainty interval: 946 to 6,330) fewer dental caries and 64,100 (54,400 to 73,400) fewer children and adolescents classified as overweight or obese, in the first 10 years after implementation. The changes in sugar purchasing and predicted impacts on health are largest for children and adolescents in the most deprived areas (Q1: 11,000 QALYs [8,370 to 14,100] and Q2: 7,760 QALYs [5,730 to 9,970]), while children and adolescents in less deprived areas will likely experience much smaller simulated effects (Q3: -1,830 QALYs [-3,260 to -501], Q4: 652 QALYs [-336 to 1,680], Q5: 1,860 QALYs [929 to 2,890]). If the simulated effects of the SDIL are sustained over the life course, it is predicted there will be a small but significant reduction in slope index of inequality: 0.76% (95% uncertainty interval: -0.9 to -0.62) for females and 0.94% (-1.1 to -0.76) for males.

CONCLUSIONS

We predict that the SDIL will lead to medium-term reductions in dental caries and overweight/obesity, and long-term improvements in life expectancy, with the greatest benefits projected for children and adolescents from more deprived areas. This study provides evidence that the SDIL could narrow health inequalities for children and adolescents in England.

Parliamentary reaction to the announcement and implementation of the UK Soft Drinks Industry Levy: applied thematic analysis of 2016-2020 parliamentary debates

OBJECTIVE

The UK Soft Drinks Industry Levy (SDIL) (announced in March 2016; implemented in April 2018) aims to incentivise reformulation of soft drinks to reduce added sugar levels. The SDIL has been applauded as a policy success, and it has survived calls from parliamentarians for it to be repealed. We aimed to explore parliamentary reaction to the SDIL following its announcement until two years post-implementation in order to understand how health policy can become established and resilient to opposition.

DESIGN

Searches of Hansard for parliamentary debate transcripts that discussed the SDIL retrieved 186 transcripts, with 160 included after screening. Five stages of Applied Thematic Analysis were conducted: familiarisation and creation of initial codebooks; independent second coding; codebook finalisation through team consensus; final coding of the dataset to the complete codebook; and theme finalisation through team consensus.

SETTING

The United Kingdom Parliament.

PARTICIPANTS

N/A.

RESULTS

Between the announcement (16/03/2016) - royal assent (26/04/2017), two themes were identified 1: SDIL welcomed cross-party 2: SDIL a good start but not enough. Between royal assent - implementation (5/04/2018), one theme was identified 3: The SDIL worked - what next? The final theme identified from implementation until 16/03/2020 was 4: Moving on from the SDIL.

CONCLUSIONS

After the announcement, the SDIL had cross-party support and was recognised to have encouraged reformulation prior to implementation. Lessons for governments indicate that the combination of cross-party support and a policy's documented success in achieving its aim can help cement the resilience of it to opposition and threats of repeal.

Do financial constraint and perceived stress modify the effects of food tax schemes on food purchases: moderation analyses in a virtual supermarket experiment

OBJECTIVE

To investigate whether financial constraint and perceived stress modify the effects of food-related taxes on the healthiness of food purchases.

DESIGN

Moderation analyses were conducted with data from a trial where participants were randomly exposed to: a control condition with regular food prices, an sugar-sweetened beverage (SSB) tax condition with a two-tiered levy on the sugar content in SSB (5-8 g/100 ml: €0·21 per l and ≥8 g/100 ml: €0·28 per l) or a nutrient profiling tax condition where products with Nutri-Score D or E were taxed at a 20 percent level. Outcome measures were overall healthiness of food purchases (%), energy content (kcal) and SSB purchases (litres). Effect modification was analysed by adding interaction terms between conditions and self-reported financial constraint or perceived stress in regression models. Outcomes for each combination of condition and level of effect modifier were visualised.

SETTING

Virtual supermarket.

PARTICIPANTS

Dutch adults (n 386).

RESULTS

Financial constraint or perceived stress did not significantly modify the effects of food-related taxes on the outcomes. Descriptive analyses suggest that in the control condition, the overall healthiness of food purchases was lowest, and SSB purchases were highest among those with moderate/high levels of financial constraint. Compared with the control condition, in a nutrient profiling tax condition, the overall healthiness of food purchases was higher and SSB purchases were lower, especially among those with moderate/high levels of financial constraint. Such patterns were not observed for perceived stress.

CONCLUSION

Further studies with larger samples are recommended to assess whether food-related taxes differentially affect food purchases of subgroups.

New Zealand household purchases of sugar-sweetened, artificially sweetened, and unsweetened beverages: 2015-2019

OBJECTIVE

To assess annual household purchases of sugar-sweetened beverages (SSBs), artificially sweetened beverages (AFSBs), and unsweetened beverages (USBs) by household composition and income, and over time.

DESIGN

Observational cohort study using beverage purchasing data linked to a supermarket database. ANOVA was used to compare total household purchase volumes (L) and the contribution of beverages purchased by category, household composition (size), household income (four categories from New Zealand (NZ) < $30 000 to > $90 000), and over time (trend from 2015 to 2019).

SETTING

Aotearoa NZ.

PARTICIPANTS

∼1800 households in the NielsenIQ Homescan® market research panel.

RESULTS

In 2019, the mean (sd) annual household purchase volume and relative contribution to total beverage volume of SSBs were 72·3 (93·0) L and 33 %, respectively. Corresponding values for AFSBs were 32·5 (79·3) L (15 %), and USBs were 112·5 (100·9) L (52 %). Larger households purchased more of all beverage types except AFSBs. Total purchases were similar by income, but households earning < $NZ 30 000 purchased fewer AFSBs and USBs (but not SSBs) than households earning > $NZ 90 000. Total and USB purchases were unchanged over time, but SSBs dropped by 5·9 L (P-trend = 0·04), and AFSBs increased by 5·3 L (P-trend = 0·00).

CONCLUSIONS

USBs contributed the most to household beverage purchases. Total purchases were higher for larger households and similar by income, including for SSBs. The reduction over time was too small for health benefits. Findings support policies and interventions to reduce SSB consumption and highlight the importance of focusing on equitable outcomes.

Estimated impact of the UK soft drinks industry levy on childhood hospital admissions for carious tooth extractions: interrupted time series analysis

Introduction

Tooth extraction due to dental caries is associated with socioeconomic deprivation and is a major reason for elective childhood hospital admissions in England. Consumption of sugar-sweetened beverages is a risk factor for dental caries. We examined whether the soft drinks industry levy (SDIL), announced in March 2016 and implemented in April 2018, was associated with changes in incidence rates of hospital admissions for carious tooth extraction in children, 22 months post-SDIL implementation.

Methods

Changes in incidence rates of monthly National Health Service hospital admissions for extraction of teeth due to a primary diagnosis of dental caries (International Classification of Diseases; ICD-10 code: K02) in England, between January 2012 and February 2020, were estimated using interrupted time series and compared with a counterfactual scenario where SDIL was not announced or implemented. Periodical changes in admissions, autocorrelation and population structure were accounted for. Estimates were calculated overall, by Index of Multiple Deprivation (IMD) fifths and by age group (0-4 years, 5-9 years, 10-14 years, 15-18 years).

Results

Compared with the counterfactual scenario, there was a relative reduction of 12.1% (95% CI 17.0% to 7.2%) in hospital admissions for carious tooth extractions in all children (0-18 years). Children aged 0-4 years and 5-9 years had relative reductions of 28.6% (95% CI 35.6% to 21.5%) and 5.5% (95% CI 10.5% to 0.5%), respectively; no change was observed for older children. Reductions were observed in children living in most IMD areas regardless of deprivation.

Conclusion

The UK SDIL was associated with reductions in incidence rates of childhood hospital admissions for carious tooth extractions, across most areas regardless of deprivation status and especially in younger children.

Trial registration number

ISRCTN18042742.

Estimating the effects of preventive and weight-management interventions on the prevalence of childhood obesity in England: a modelling study

BACKGROUND

The effects of the systematic delivery of treatments for obesity are unknown. We aimed to estimate the potential effects on the prevalence of childhood obesity of systematically offering preventive and treatment interventions to eligible children in England, based on weight or health status.

METHODS

For this modelling study, we developed a cross-sectional simulation model of the child and young adult population in England using data from multiple years of the Health Survey of England conducted between Jan 1, 2010, and Dec 31, 2019. Individuals were assessed for eligibility via age, BMI, and medical complications. Weight status was defined based on clinical criteria used by the UK National Institute of Health and Care Excellence. Published systematic reviews were used to estimate effect sizes for treatments, uptake, and completion for each weight-management tier. We used all available evidence, including evidence from studies that showed an unfavourable effect. We estimated the effects of two systematic approaches: a staged approach, in which children and young people were simultaneously given the most intensive treatment for which they were eligible, and a stepped approach, in which each management tier was applied sequentially, with additive effects. The primary outcomes were estimated prevalence of clinical obesity, defined as a BMI ≥98th centile on the UK90 growth chart, and difference in comparison with the estimated baseline prevalence.

FINDINGS

18 080 children and young people were included in the analytical sample. Baseline prevalence of clinical obesity was estimated to be 11·2% (95% CI 10·5 to 11·8) for children and young people aged 2-18 years. In modelling, we estimated absolute decreases in the prevalence of obesity of 0·9% (95% CI 0·1 to 1·8) for universal, preventive interventions; 0·2% (0·1 to 0·4) for interventions within a primary-care setting; 1·0% (0·1 to 2·1) for community and lifestyle interventions; 0·2% (0·0 to 0·4) for pharmaceutical interventions; and 0·4% (0·1 to 0·7) for surgical interventions. Staged care was estimated to result in an absolute decrease in the prevalence of obesity of 1·3% (-0·3 to 2·4) and stepped care was estimated to lead to an absolute decrease of 2·4% (0·1 to 4·8).

INTERPRETATION

Although individual effect sizes for prevention and treatment interventions were small, when delivered at scale across England, these interventions have the potential to meaningfully contribute to reducing the prevalence of childhood obesity.

FUNDING

UK National Institute for Health and Care Research.

Projected health and economic impacts of sugar-sweetened beverage taxation in Germany: A cross-validation modelling study

BACKGROUND

Taxes on sugar-sweetened beverages (SSBs) have been implemented globally to reduce the burden of cardiometabolic diseases by disincentivizing consumption through increased prices (e.g., 1 peso/litre tax in Mexico) or incentivizing industry reformulation to reduce SSB sugar content (e.g., tiered structure of the United Kingdom [UK] Soft Drinks Industry Levy [SDIL]). In Germany, where no tax on SSBs is enacted, the health and economic impact of SSB taxation using the experience from internationally implemented tax designs has not been evaluated. The objective of this study was to estimate the health and economic impact of national SSBs taxation scenarios in Germany.

METHODS AND FINDINGS

In this modelling study, we evaluated a 20% ad valorem SSB tax with/without taxation of fruit juice (based on implemented SSB taxes and recommendations) and a tiered tax (based on the UK SDIL) in the German adult population aged 30 to 90 years from 2023 to 2043. We developed a microsimulation model (IMPACTNCD Germany) that captures the demographics, risk factor profile and epidemiology of type 2 diabetes, coronary heart disease (CHD) and stroke in the German population using the best available evidence and national data. For each scenario, we estimated changes in sugar consumption and associated weight change. Resulting cases of cardiometabolic disease prevented/postponed and related quality-adjusted life years (QALYs) and economic impacts from healthcare (medical costs) and societal (medical, patient time, and productivity costs) perspectives were estimated using national cost and health utility data. Additionally, we assessed structural uncertainty regarding direct, body mass index (BMI)-independent cardiometabolic effects of SSBs and cross-validated results with an independently developed cohort model (PRIMEtime). We found that SSB taxation could reduce sugar intake in the German adult population by 1 g/day (95%-uncertainty interval [0.05, 1.65]) for a 20% ad valorem tax on SSBs leading to reduced consumption through increased prices (pass-through of 82%) and 2.34 g/day (95%-UI [2.32, 2.36]) for a tiered tax on SSBs leading to 30% reduction in SSB sugar content via reformulation. Through reductions in obesity, type 2 diabetes, and cardiovascular disease (CVD), 106,000 (95%-UI [57,200, 153,200]) QALYs could be gained with a 20% ad valorem tax and 192,300 (95%-UI [130,100, 254,200]) QALYs with a tiered tax. Respectively, €9.6 billion (95%-UI [4.7, 15.3]) and €16.0 billion (95%-UI [8.1, 25.5]) costs could be saved from a societal perspective over 20 years. Impacts of the 20% ad valorem tax were larger when additionally taxing fruit juice (252,400 QALYs gained, 95%-UI [176,700, 325,800]; €11.8 billion costs saved, 95%-UI [€6.7, €17.9]), but impacts of all scenarios were reduced when excluding direct health effects of SSBs. Cross-validation with PRIMEtime showed similar results. Limitations include remaining uncertainties in the economic and epidemiological evidence and a lack of product-level data.

CONCLUSIONS

In this study, we found that SSB taxation in Germany could help to reduce the national burden of noncommunicable diseases and save a substantial amount of societal costs. A tiered tax designed to incentivize reformulation of SSBs towards less sugar might have a larger population-level health and economic impact than an ad valorem tax that incentivizes consumer behaviour change only through increased prices.

Trends in Uterine Cancer Mortality in the United States: A 50-Year Population-Based Analysis

OBJECTIVE

To analyze mortality trends in uterine cancer in the United States over 50 years with an emphasis on age and race and ethnicity.

METHODS

Data on uterine cancer deaths from 1969 to 2018 were obtained from the National Center for Health Statistics. Trends were examined by age and race and ethnicity after adjustment for the hysterectomy rate and pregnancy.

RESULTS

Uterine cancer mortality decreased between 1969 and 1997 (from 6.03 to 4.00/100,000) but increased between 1997 and 2018 (from 4.00 to 5.02/100,000). From 2001 to 2018, mortality rates increased by 1.25-fold across all age groups. In 2018, the mortality rate from uterine cancer for patients aged 70 years or older and 60-69 years was sixfold and threefold higher, respectively, than in younger patients (aged 50-59 years) (54.87/100,000 vs 27.80/100,000 vs 8.70/100,000). The mortality rate for non-Hispanic Black women was 2.2-fold higher than for non-Hispanic White, Hispanic, and non-Hispanic Asian or Pacific Islander women (17.6/100,000 vs 7.82/100,000, 6.54/100,000, and 4.24/100,000, respectively). On an intersection analysis of age and race, non-Hispanic Black women aged older than 60 years had a threefold higher mortality rate than non-Hispanic White women (72/100,000 vs 24/100,000). A notable finding was that young non-Hispanic Black and Hispanic women (30-39 years) had the highest annual increases in mortality at 3.3% and 3.8% per year compared with 2.2% in non-Hispanic White women.

CONCLUSION

Since 2001, the uterine cancer mortality rate has increased across all four racial and ethnic groups examined, with the highest increase seen among non-Hispanic Black women. The largest increase in mortality was observed among younger non-Hispanic Black and Hispanic women.

How Could Taxes on Sugary Drinks and Foods Help Reduce the Burden Of Type 2 Diabetes?

PURPOSE OF REVIEW

Taxes on sugary drinks and foods have emerged as a key strategy to counteract the alarming levels of diabetes worldwide. Added sugar consumption from industrialized foods and beverages has been strongly linked to type 2 diabetes. This review provides a synthesis of evidence on how taxes on sugary products can influence the onset of type 2 diabetes, describing the importance of the different mechanisms through which the consumption of these products is reduced, leading to changes in weight and potentially a decrease in the incidence of type 2 diabetes.

RECENT FINDINGS

Observational studies have shown significant reductions in purchases, energy intake, and body weight after the implementation of taxes on sugary drinks or foods. Simulation studies based on the association between energy intake and type 2 diabetes estimated the potential long-term health and economic effects, particularly in low- and middle-income countries, suggesting that the implementation of sugary food and beverage taxes may have a meaningful impact on reducing type 2 diabetes and complications. Public health response to diabetes requires multi-faceted approaches from health and non-health actors to drive healthier societies. Population-wide strategies, such as added sugar taxes, highlight the potential benefits of financial incentives to address behaviors and protective factors to significantly change an individual's health trajectory and reduce the onset of type 2 diabetes worldwide, both in terms of economy and public health.

Estimating the unintended impact of the North American free trade agreement on U.S. public health

The North American Free Trade Agreement (NAFTA) was introduced in 1994 between Canada, Mexico, and the United States to encourage trilateral trade. In 2008, an unrestricted reciprocal sugar trade agreement, was implemented between Mexico and the United States as part of NAFTA, which led to a significant decrease in the United States' sugar price. However, critics argue that free trade agreements that reduce trade barriers on products such as sugar threaten public health. This study uses the synthetic control method to investigate the causal impact of the unrestricted sugar trade agreement on sugar consumption and diabetes prevalence in the United States. First, we show that sugar consumption in the United States increased by an average of 16% annually after the agreement was signed, corresponding to 5240g per capita. Second, we show that the crude prevalence of diabetes increased by an average of 1% annually in the United States after the agreement was signed, with an increase of 1% and 2% for men and women, respectively. This unintended consequence of NAFTA has had an estimated economic cost of $324.37 million annually.

Industry views of the UK Soft Drinks Industry Levy: a thematic analysis of elite interviews with food and drink industry professionals, 2018-2020

OBJECTIVES

The UK Soft Drinks Industry Levy (SDIL), implemented in 2018, has been successful in reducing the sugar content and purchasing of soft drinks, with limited financial impact on industry. Understanding the views of food and drink industry professionals involved in reacting to the SDIL is important for policymaking. However, their perceptions of the challenges of implementation and strategic responses are unknown. The aim of this study, therefore, was to explore how senior food and drink industry professionals viewed the SDIL.

DESIGN

We undertook a qualitative descriptive study using elite interviews. Data were analysed using Braun and Clarke's thematic analysis, taking an inductive exploratory and descriptive approach not informed by prior theory or frameworks.

SETTING AND PARTICIPANTS

Interviews were conducted via telephone with 14 senior professionals working in the food and drink industry.

RESULTS

Five main themes were identified: (1) a level playing field…for some; industry accepted the SDIL as an attempt to create a level playing field but due to the exclusion of milk-based drinks, this was viewed as inadequate, (2) complex to implement, but no lasting negative effects; the SDIL was complex, expensive and time consuming to implement, with industry responses dependent on leadership buy-in, (3) why us?-the SDIL unfairly targets the drinks industry; soft drinks are an unfair target when other categories also contain high sugar, (4) the consumer is king; consumers were a key focus of the industry response to this policy and (5) the future of the SDIL; there appeared to be a wider ripple effect, which primed industry to prepare for future regulation in support of health and environmental sustainability.

CONCLUSIONS

Insights from senior food and drink industry professionals illustrate how sugar-sweetened beverage taxes might be successfully implemented and improve understanding of industry responses to taxes and other food and drink policies.

TRIAL REGISTRATION NUMBER

ISRCTN18042742.

Consumption of Soft Drinks and Overweight and Obesity Among Adolescents in 107 Countries and Regions

Importance

Soft drink consumption is associated with weight gain in children and adolescents, but little is known about the association between soft drink consumption and prevalence of the overweight and obesity in adolescents.

Objective

To investigate the association of soft drink consumption with overweight and obesity in adolescents enrolled in school (hereafter, school-going adolescents) using country-level and individual-level data.

Design, Setting, and Participants

This cross-sectional study used data from 3 cross-sectional studies including 107 countries and regions that participated in the Global School-Based Student Health Survey (2009-2017), the European Health Behavior in School-Aged Children study (2017-2018), and the US Youth Risk Behavior Survey (2019).

Exposure

Daily soft drink consumption (consuming soft drinks 1 or more times per day or not).

Main Outcome and Measure

Overweight and obesity defined by the World Health Organization Growth Reference Data.

Results

Among the 107 countries and regions, 65 were low- and middle-income, and 42 were high-income countries and regions, with a total of 405 528 school-going adolescents (mean [SD] age, 14.2 [1.7] years; 196 147 [48.4%] males). The prevalence of overweight and obesity among adolescent students varied from 3.3% (95% CI, 2.6 to 4.1) in Cambodia to 64.0% (95% CI, 57.0 to 71.6) in Niue, and the prevalence of adolescent students consuming soft drinks 1 or more times per day varied from 3.3% (95% CI, 2.9 to 3.7) in Iceland to 79.6% (95% CI, 74.0 to 85.3) in Niue. There was a positive correlation between the prevalence of daily soft drink consumption and the prevalence of overweight and obesity (R, 0.44; P < .001). The pooled analysis using individual-level data also showed a statistically significant association between daily soft drink consumption and overweight and obesity (daily soft drink consumption vs nondaily soft drink consumption), with an odds ratio of 1.14 (95% CI, 1.08 to 1.21) among school-going adolescents.

Conclusions and Relevance

In this study of 107 countries and regions, the prevalence of daily consumption of soft drinks was associated with the prevalence of overweight and obesity among adolescent students. Our results, in conjunction with other evidence, suggest that reducing soft drink consumption should be a priority in combating adolescent overweight and obesity.

A clinician's guide to obesity prevention in the UK

Across the UK, people's lives are being cut short because of obesity, and the lives of the most deprived members of our communities are being cut the most. The role of the medical professional in managing overweight and obesity is extensive, but, for many patients, maintaining a healthy weight needs to be supported by creating environments that help people to stay healthy in the first place. The building blocks of health are the environmental, commercial, economic and social factors that largely determine our health and wellbeing and impact our capability, opportunity and motivation to maintain healthy-weight behaviours. Although the role of the healthcare professional generally is to focus on the individual patient, clinicians can still influence these building blocks. Clinicians have the skills to create change, they often hold power in organisations with local to international impact and there are actions, big or small, that every clinician can take to improve obesity prevention. Here, we outline an environmental-behavioural framework for the primary prevention of obesity and consider the role of clinicians in catalysing change.

Rethinking diabetes in the United States

Despite the availability of effective medical treatments, the diabetes epidemic has accelerated in the United States, efforts to translate treatments into routine clinical practice have stalled, and health inequities have persisted. The National Clinical Care Commission (NCCC) was established by the Congress to make recommendations to better leverage federal policies and programs to more effectively prevent and control diabetes and its complications. The NCCC developed a guiding framework that incorporated elements of the Socioecological and Chronic Care Models. It gathered information from both health-related and non-health-related federal agencies, held 12 public meetings, solicited public comments, met with interested parties and key informants, and performed comprehensive literature reviews. The final report of the NCCC was transmitted to the Congress in January 2022. It called for a rethinking of the problem of diabetes in the United States, including the recognition that the lack of progress is due to a failure to confront diabetes as both a complex societal problem as well as a biomedical problem. To prevent and control diabetes, public policies and programs must be aligned to address both social and environmental determinants of health and health care delivery as they impact diabetes. In this article, we discuss the findings and recommendations of the NCCC as they relate to the social and environmental factors that influence the risk of type 2 diabetes and argue that the prevention and control of type 2 diabetes in the U.S. must begin with concrete population-level interventions to address social and environmental determinants of health.

MaestraNatura Reveals Its Effectiveness in Acquiring Nutritional Knowledge and Skills: Bridging the Gap between Girls and Boys from Primary School

MaestraNatura (MN) is a nutrition education program developed to both enhance awareness about the importance of healthy eating behaviour and skills on food and nutrition in primary school students. The level of knowledge about food and nutritional issues was assessed by a questionnaire administered to 256 students (9–10 years old) attending the last class of primary school and was compared with that of a control group of 98 students frequenting the same schools that received traditional nutrition education based on curricular science lessons and one frontal lesson conducted by an expert nutritionist. The results indicated that students in the MN program showed a higher percentage of correct responses to the questionnaire when compared with the control group (76 ± 15.4 vs. 59 ± 17.7; p < 0.001). Furthermore, the students attending the MN program were requested to organise a weekly menu before (T0) and when finished (T1) the MN program. The results evidenced an overall significant improvement in the score obtained at T1 with respect to those at T0 (p < 0.001), indicating a strong improvement in the ability to translate the theoretical concepts of nutrition guidelines in practice. In addition, the analysis revealed a gender gap between boys and girls, with boys showing a worse score at T0 that was ameliorated after the completion of the program (p < 0.001). Overall, MN program is effective in improving nutrition knowledge amongst 9–10-year-old students. Furthermore, students showed an increased ability to organise a weekly dietary plan after completing the MN program, a result which also bridged gender gaps. Thus, preventive nutrition education strategies specifically addressed to boys and girls, and involving both the school and family, are needed to make children aware of the importance of a healthy lifestyle and to correct inadequate eating habits.

Impact of cuts to local authority spending on cultural, environmental and planning services on inequalities in childhood obesity in England: A longitudinal ecological study

BACKGROUND

Almost 20% of children in England are living with obesity by the end of primary school, with marked and growing inequalities driven by increasing prevalence in more deprived areas. Neighbourhood environments are upstream determinants of childhood weight status. Cultural, Environmental and Planning (CEP) services delivered by local authorities (LAs) in England include various services that contribute to these local environments, e.g. leisure centres, parks, playgrounds, libraries, community safety and environmental protection. Children in deprived areas potentially benefit most from the provision of these universal services. Spending on CEP services has been cut dramatically over the past decade, especially in more deprived areas. Given the potential link between these services and childhood obesity, we examined whether recent cuts in LA spending on CEP services are associated with trends and inequalities in obesity.

METHODS

We compiled annual data (2009-2017) on CEP spending in 324 LAs in England, from Ministry of Housing, Communities and Local Government reports. Obesity prevalence data for Year 6 children were obtained from the National Child Measurement Programme, for LAs and Middle-layer Super Output Areas (MSOAs). Following descriptive and pooled OLS analyses, we used fixed effects panel regression to estimate associations between CEP spending and obesity prevalence, within LAs over time, adjusting for potential confounding by local economic conditions and spending on other public services. Final models included an interaction term between area deprivation (2015 IMD) and year to account for differential background trends in obesity across deprivation levels. We tested for effect modification by deprivation and, using MSOA-level obesity data, explored associations between spending and within-LA obesity inequalities.

RESULTS

In unadjusted pooled OLS analyses, areas with higher CEP spending had higher prevalence of obesity, reflecting the strong social gradient in childhood obesity and the higher levels of central government funding allocated to more deprived areas. Deprivation, other spend, and local economic conditions explained this relationship. In the fixed effects analysis, designed to isolate average within-area change in obesity associated with changing spend, we observed a 0.10 percentage point increase in obesity prevalence for each 10% reduction in spend (95%CI: 0.04,0.15; p < 0.001), but this disappeared after accounting for differential background trends in obesity across deprivation levels (-0.02; 95%CI: 0.07,0.03; p = 0.39). Similar results were observed for obesity inequalities, although sensitivity analyses suggest spending on Environmental Services in particular may affect inequalities in urban local authorities.

CONCLUSIONS

CEP spending levels may influence local childhood obesity risk, but the increasing prevalence and widening inequalities in obesity of the past decade seem to have been driven mainly by factors other than CEP spending cuts, that are also unevenly distributed across deprivation levels. The influence of specific services might be obscured by grouping CEP services for analysis.