A COMPARATIVE STUDY OF THE ETIOLOGY AND INTERVENTION OPTIONS OF CHILDHOOD OBESITY IN CHINA AND THE UNITED STATES USING SYSTEMS SCIENCE APPROACHES

Objectives: The overall goal of this research project is to study the etiology and intervention options of childhood obesity through comparative research between China and the US. Three specific aims are: 1) examine the relationship between Western fast food consumption (FFC) and childhood obesity; 2) examine the effects of social norms on school children’s weight status and food behavior; 3) assess the effects of fiscal policies on children’s beverage and energy intake. Methods: The three aims are presented in three separate papers. In the first paper, using the nationwide China Health Nutrition Survey data, Heckman’s two-stage selection model and quantile regression models were fitted. In the second paper, agent-based models (ABMs) were developed and linked with empirical longitudinal data collected in China and in the US. In the third paper, system dynamics models were built to assess the sugar-sweetened beverage (SSB) tax effects in China and the US. Results: Household income was negatively associated with the likelihood of Western FFC decisions, while positively associated with Western FFC frequency in China. The ABM simulation study suggest that, in China, social norms may lead to a 0.05 (kg/m2) BMI increase for one unit of BMI below the social average, and a 0.045 (kg/m2) decrease for one unit of BMI above the social average. In the US, corresponding social norm effects were 0.025 (kg/m2) and 0.015 (kg/m2) respectively. The third essay indicates, in China, a 20% tax on SSB might cause an initial 11.5 kcal/d reduction in energy intake from beverage consumption; in a 10-year period, the net reduction of average daily energy intake compared to the level before taxing would decrease to 4 kcal/d. Similarly, in the US, there will be a net reduction of 36 kcal/d initially, with the reduction decreasing to 10 kcal/d over a 10-year period. Subsidizing bottled water consumption could be more effective than SSB taxes. Conclusions: China has its own unique patterns of childhood obesity, while sharing some features with the US. Policies that limit FFC, promote healthy social norms and subsidize bottled water consumption are needed in fighting childhood obesity

Impact of soda tax on beverage price, sale, purchase, and consumption in the US: a systematic review and meta-analysis of natural experiments

BackgroundAs a primary source of added sugars in the US diet, sugar-sweetened beverage (SSB) consumption is presumed to contribute to obesity prevalence and poor oral health. We systematically synthesized and quantified evidence from US-based natural experiments concerning the impact of SSB taxes on beverage prices, sales, purchases, and consumption.MethodsA keyword and reference search was performed in PubMed, Web of Science, Cochrane Library, Scopus, and EconLit from the inception of an electronic bibliographic database to Oct 31, 2022. Meta-analysis was conducted to estimate the pooled effect of soda taxes on SSB consumption, prices, passthrough rate, and purchases.ResultsTwenty-six natural experiments, all adopting a difference-in-differences approach, were included. Studies assessed soda taxes in Berkeley, Oakland, and San Francisco in California, Philadelphia in Pennsylvania, Boulder in Colorado, Seattle in Washington, and Cook County in Illinois. Tax rates ranged from 1 to 2 ¢/oz. The imposition of the soda tax was associated with a 1.06 ¢/oz. (95% confidence interval [CI] = 0.90, 1.22) increase in SSB prices and a 27.3% (95% CI = 19.3, 35.4%) decrease in SSB purchases. The soda tax passthrough rate was 79.7% (95% CI = 65.8, 93.6%). A 1 ¢/oz. increase in soda tax rate was associated with increased prices of SSBs by 0.84 ¢/oz (95% CI = 0.33, 1.35).ConclusionSoda taxes could be effective policy leverage to nudge people toward purchasing and consuming fewer SSBs. Future research should examine evidence-based classifications of SSBs, targeted use of revenues generated by taxes to reduce health and income disparities, and the feasibility of redesigning the soda tax to improve efficiency

Predicting the potential health and economic impact of a sugary drink tax in Canada: a modelling study

BACKGROUND Consistent with global trends, high body mass index (BMI) and high blood glucose have risen at rapid rates among Canadians. The consumption of sugar-sweetened beverages (SSBs) is a well-established and important dietary risk factor for these conditions. A growing body of research suggests that SSB taxes can achieve meaningful health impacts by shifting dietary preferences. However, there are several key literature gaps, including no estimations of the potential benefit of taxing ‘sugary drinks’, a beverage category that includes both SSBs and 100% juice, which is high in sugar. In addition, no published studies have simulated a tax on SSBs or sugary drinks for the Canadian population. PURPOSE The proposed study’s objectives were: 1) to investigate Canadians’ consumption of sugary drink types, and differences by socio-economic characteristics; and 2) to estimate the potential impact among the Canadian population of a simulated national tax on SSBs and a simulated tax on sugary drinks. METHODS The study was conducted in two components. First, sugary drink intake (volume and energy) was estimated using 24-hour dietary recall data from the 2015 Canadian Community Health Survey – Nutrition (respondents ages >1 year; final sample N=20,176). For 100% juice and ‘total SSBs’ (which included 15 beverage types), intake was reported overall and by socio-economic measures: sex, age, ethnicity, income, province, and BMI category. Student’s t-test and Wald F-test tested for differences among population sub-groups. SSB and sugary drink intakes were also estimated for inclusion in the study’s second component: a simulation of a sugary drink tax. The impact of the tax intervention was estimated using a proportional multi-state life table-based Markov model adapted to simulate the 2015 Canadian adult population. The model applied 10%, 20%, and 30% ad valorem taxes on SSBs and sugary drinks, and compared two populations: one with a tax intervention and one without a tax intervention. The model simulated the effect of energy intake from beverages on 19 diseases mediated by body mass, and the direct effects of intake on type 2 diabetes, accounting for beverage substitution. Sensitivity analyses examined key assumptions and Monte Carlo simulation assessed uncertainty. RESULTS A large proportion of respondents reported consuming 100% juice (children, 39.3%; adults 22.8%) or some type of SSB (children, 53.0%; adults, 40.8%) during the previous 24-hour period. In 2015, each Canadian consumed an average of 74.3 ml (33.7 kcal) of 100% juice and 203.6 ml (98.7 kcal) of SSBs per day. 100% juice was consumed more than any other sugary drink, followed closely by regular carbonated soft drinks. Compared to females, males’ consumption was significantly higher for 100% juice (37% greater volume) and total SSBs (54% greater). Children consumed more sugary drinks on average each day than adults: nearly double the volume of 100% juice (86% more) and 14% more SSBs. Beverage intake differed by ethnicity, province, and BMI category, but not by income quintile. For the simulated taxes, there were sizeable differences in the impacts of a SSB tax versus sugary drinks tax: prevalence of overweight/obesity changed from 63.3% to 61.7% vs 61.0%; type 2 diabetes incidence rate decreased by -5.9% vs -7.4%. Over a 25-year period, compared to a SSB tax, a sugary drinks tax produced 47% more averted disability-adjusted life years (DALYs; 314,326 versus 460,812), 45% greater health care costs savings ($7.5 billion vs$10.9 billion Canadian dollars), and 37% more annual tax revenue ($1.0 billion CAD vs$1.4 billion CAD). CONCLUSIONS Consumption of sugary drinks remains an important disease risk factor among the Canadian population. Average intake of sugary drinks in 2015 is lower than 2004 estimates, but remains high, especially among children and youth. The current study suggests that a beverage tax in Canada has the potential to substantially reduce the health burden while generating health care savings and tax revenue, especially if 100% juice is among taxed beverages. Given Canadians’ high 100% juice consumption, the mounting evidence on adverse effects associated with free sugar consumption, and the role of 100% juice as a substitute beverage to SSBs, there is a strong rationale for its inclusion as a taxed beverage. Future studies could examine the potential impact of a ‘tiered’ tax based on beverage sugar content, as well as the effects of a tax relative to other nutrition interventions

The influence of sugar taxes and front-of-package nutrition labels on consumer purchasing behaviours: a randomized experimental marketplace

Background: Poor dietary intake remains one of the leading causes of non-communicable disease in Canada and globally. In response, sugar taxes and front-of-package (FOP) nutrition labelling systems are increasingly being implemented around the world with the intention of improving dietary intake and reducing the associated health and economic impacts of diet-related non-communicable disease. However, there is relatively little experimental data on how these strategies influence consumer behaviour and how different policy measures—such as taxes and FOP labels—may interact. In addition, policymakers who implement these measures must decide what type of tax structure or FOP format to use; however, the relative impact of different tax structures or FOP labels on food and beverage purchases remains unclear. Objectives: This dissertation examined the following research questions: (1) do different FOP labels and sugar taxes influence consumer purchases of sugars, sodium, saturated fats, or energy?; (2) do different sociodemographic or individual characteristics moderate the effects of FOP labels and sugar taxes on participants’ purchasing of sugars, sodium, saturated fats, or energy?; (3) how do consumers’ purchases of specific product categories vary across different FOP labelling systems?; and (4) how do consumers’ purchases of specific product categories vary across different sugar taxation formats? Methods: An experimental marketplace study was conducted from March 12 – May 20, 2018. A final sample of 3,584 Canadians 13 years and older participated in the 5 (FOP label condition) × 8 (tax condition) between-within group experiment. Participants received $5 and were presented with images of 20 beverages and 20 snack foods available for purchase. Participants were randomized to one of five FOP label conditions (no label; ‘high in’ nutrient symbol; multiple traffic light (MTL); health star rating (HSR); nutrition grade) and completed eight within-subject purchasing tasks with different taxation conditions (beverages: no tax, 20$5. In Paper 1, analyses compared the sugars, sodium, saturated fats and calorie content of participants’ purchases across tax and labelling conditions. Paper 2 investigated the main and moderating effects of individual-level characteristics on participants’ purchases of sugars, sodium, saturated fats and calories. Paper 3 evaluated participants’ purchases of five specific product categories that received conflicting ratings across FOP label conditions. Paper 4 assessed the impact of the tax conditions on participants’ purchases of two relevant product categories (moderately sugary beverages and 100% fruit juice). Results: Paper 1 – Overall, there were significant differences in the nutrient levels of participants’ purchases across several of the experimental conditions. Compared to those who saw no FOP label, participants who viewed the ‘high in’ symbol purchased less sugar (− 2.5 g), saturated fat (− 0.09 g), and calories (− 12.6 kcal) in the beverage purchasing tasks, and less sodium (− 13.5 mg) and calories (− 8.9 kcal) in the food tasks. All taxes resulted in substantial reductions in mean sugars (− 1.4 to − 4.7 g) and calories (− 5.3 to − 19.8 kcal) purchased, and in some cases, reductions in sodium (− 2.5 to − 6.6 mg) and saturated fat (− 0.03 to − 0.08 g). Taxes that included 100% fruit juice (‘sugary drink’ taxes) produced greater reductions in sugars and calories than those that did not. Paper 2 – There were few moderating effects of individual-level characteristics on the nutrient content of participants’ purchases. Participants who were younger, male, and more frequent consumers of sugary drinks tended to purchase products containing more sugars, sodium, saturated fats and calories. Sex and age moderated the relationship between tax condition and sugars or calories purchased: female participants were more responsive to a tax that included fruit juice compared to males, and younger participants were more responsive to all sugar tax conditions compared to older participants. Reported thirst and education level also moderated the relationship between tax condition and calories purchased. Paper 3 – Participants’ purchases of products that received conflicting ratings varied across some FOP label conditions. Participants who saw the HSR were more likely to purchase 100% fruit juice (compared to MTL) and cheese snacks (compared to no label and ‘high in’). The ‘high in’ label led to fewer purchases of chocolate milk compared to no label. Diet beverage purchases were higher in all FOP conditions relative to no label. Paper 4 – Participants’ responses to the different tax structures were as hypothesized. The odds of purchasing a moderately sugary beverage were higher under tiered versus non-tiered taxes, while purchases of high sugary beverages differed very little under tiered versus non-tiered. The odds of purchasing 100% fruit juice were lower when these products were included in a tax versus when they were not. Conclusions: This study expands the evidence indicating that sugar taxation and FOP labelling strategies can promote healthy food and beverage choices. All sugar taxes were effective at reducing the sugars and energy content of participants’ beverage and snack food purchases; however, some formats, including those that taxed 100% fruit juice, were more effective than others. The results suggest that two key tax formats are likely to function as hypothesized: taxes that include 100% fruit juice products may lead to fewer purchases of fruit juice, and taxes that incorporate multiple tiers may encourage purchases of moderately sugary products to a greater extent than non-tiered formats. The FOP nutrition labels demonstrated smaller—but nevertheless meaningful—effect sizes relative to the taxes, and results were more variable across formats, with the ‘high in’ FOP labels exhibiting the greatest impact. Results also suggest that, despite some similarities, existing FOP systems differ in the extent to which they promote or dissuade common food categories. ‘High in’ and MTL systems may more effectively discourage purchases of products contributing negative nutrients than HSR or nutrition grade systems. Few individual-level characteristics moderated the effects of sugar taxes or FOP labels on nutrients purchased in this study, suggesting that these policies may produce similar effects across key sociodemographic groups. Overall, the results of this experimental study are consistent with evidence from other studies in suggesting that both taxes and FOP nutrition labels have the potential to generate meaningful reductions in the intake of sugars and other nutrients of public health concern. The magnitude of effects observed in this study suggest that sugar taxes and ‘high in’ labels could significantly reduce non-communicable disease at a population level, but would generate even greater improvements when implemented alongside other strategies to improve the food environment

Noncommunicable Diseases

Noncommunicable Diseases: A Compendium introduces readers to noncommunicable diseases (NCDs) – what they are, their burden, their determinants and how they can be prevented and controlled. Focusing on cardiovascular disease, diabetes, cancer and chronic respiratory disease and their five shared main risk factors (tobacco use, harmful use of alcohol, unhealthy diet, physical inactivity and air pollution) as defined by the United Nations, this book provides a synopsis of one of the world’s biggest challenges of the 21st century. NCDs prematurely claim the lives of millions of people across the world every year, with untold suffering to hundreds of millions more, trapping many people in poverty and curtailing economic growth and sustainable development. While resources between and within countries largely differ, the key principles of surveillance, prevention and management apply to all countries, as does the need to focus resources on the most cost-effective and affordable interventions and the need for strong political will, sufficient resources, and sustained and broad partnerships. This compendium consists of 59 short and accessible chapters in six sections: (i) describing and measuring the burden and impact of NCDs; (ii) the burden, epidemiology and priority interventions for individual NCDs; (iii) social determinants and risk factors for NCDs and priority interventions; (iv) global policy; (v) cross-cutting issues; and (vi) stakeholder action. Drawing on the expertise of a large and diverse team of internationally renowned policy and academic experts, the book describes the key epidemiologic features of NCDs and evidence-based interventions in a concise manner that will be useful for policymakers across all parts of society, as well as for public health and clinical practitioners

Reshaping Food Systems to improve Nutrition and Health in the Eastern Mediterranean Region

This detailed and comprehensive study examines nutrition and health in the World Health Organization (WHO) Eastern Mediterranean Region, presenting the six game-changing food systems actions proposed by the WHO and the progress of their implementation in the region. The WHO Eastern Mediterranean Region is a particularly complex place to study: an area of economic contrasts with changing dietary patterns and stark differences between high levels of malnutrition and a prevalence of overweight and obesity. As a result, actions to improve the nutritional situation of the population are urgently sought. The strategies explored in this book offer a unique opportunity to change food systems all over the world, addressing aspects including sustainable food production, the impact of marketing and labelling on behaviour, and the effect of global events such as climate change, war and the COVID-19 pandemic. Reshaping Food Systems is an essential read at a time when malnutrition in all its forms, including undernourishment, micronutrient deficiencies and overweight and obesity, pose a serious threat to global health, and is of particular interest for policymakers working in nutrition and public health

Systems Thinking and Complexity Science Methods and the Policy Process in Non-Communicable Disease Prevention: A Systematic Scoping Review

Background: Given the complex determinants of non-communicable diseases (NCDs), and the dynamic policy landscape, researchers and policymakers are exploring the use of systems thinking and complexity science (STCS) in developing effective policies. The aim of this review is to systematically identify and analyse existing applications of STCS-informed methods in NCD prevention policy. Methods: Systematic scoping review: We searched academic databases (Medline, Scopus, Web of Science, EMBASE) for all publications indexed by 13 October 2020, screening titles, abstracts and full texts and extracting data according to published guidelines. We summarised key data from each study, mapping applications of methods informed by STCS to policy process domains. We conducted a thematic analysis to identify advantages, limitations, barriers and facilitators to using STCS. Results: 4681 papers were screened and 112 papers were included in this review. The most common policy areas were tobacco control, obesity prevention and physical activity promotion. Methods applied included system dynamics modelling, agent-based modelling and concept mapping. Advantages included supporting evidence-informed decision-making; modelling complex systems and addressing multi-sectoral problems. Limitations included the abstraction of reality by STCS methods, despite aims of encompassing greater complexity. Challenges included resource-intensiveness; lack of stakeholder trust in models; and results that were too complex to be comprehensible to stakeholders. Ensuring stakeholder ownership and presenting findings in a user-friendly way facilitated STCS use. Conclusion: This review maps the proliferating applications of STCS methods in NCD prevention policy. STCS methods have the potential to generate tailored and dynamic evidence, adding robustness to evidence-informed policymaking, but must be accessible to policy stakeholders and have strong stakeholder ownership to build consensus and change stakeholder perspectives. Evaluations of whether, and under what circumstances, STCS methods lead to more effective policies compared to conventional methods are lacking, and would enable more targeted and constructive use of these methods.</jats:p