[Using Pricing Policies to Promote Public Health: The Sugar Sweetened Beverages Taxation Experience in Portugal].

N/A

The ethics of taxing sugar-sweetened beverages to improve public health

The World Health Organization highlights fiscal policies as priority interventions for the promotion of healthy eating in its Action Plan for the Prevention and Control of Non-communicable Diseases. The taxation of sugar sweetened beverages (SSBs) in particular is noted to be an effective measure, and SSBs taxes have already been implemented in several countries worldwide. However, although the evidence base suggests that this will be effective in helping to combat rising obesity rates, opponents of SSBs taxation argue that it is illiberal and paternalistic, and therefore should be avoided. Bioethical analysis may play an essential role in clarifying whether policymakers should adopt SSBs taxes as part of wider obesity strategy. In this article we argue that no single ethical theory can account for the complexities inherent in obesity prevention strategy, especially the liberal theories relied upon by opponents of SSBs taxation. We contend that a pluralist approach to the ethics of SSBs taxation must be adopted as the only suitable way of accounting for the multiple overlapping, and sometimes, conflicting factors that are relevant to determining the moral acceptability of such an intervention

Salt reduction strategies in Portuguese school meals, from pre-school to secondary education-the Eat Mediterranean program

High sodium (salt) consumption is associated with an increased risk of developing non-communicable diseases. However, in most European countries, Portugal included, sodium intake is still high. This study aimed to assess the sodium content of school meals before and after the Eat Mediterranean (EM) intervention-a community-based program to identify and correct nutritional deviations through the implementation of new school menus and through schools' food handlers training. EM (2015-2017) was developed in 25 schools (pre to secondary education) of two Portuguese Municipalities, reaching students aged 3-21 years old. Samples of the complete meals (soup + main course + bread) from all schools were collected, and nutritional quality and laboratory analysis were performed to determine their nutritional composition, including sodium content. Overall, there was a significant decrease (-23%) in the mean sodium content of the complete school meals, which was mainly achieved by the significant reduction of 34% of sodium content per serving portion of soup. In conclusion, EM had a positive effect on the improvement of the school meals' sodium content, among the participant schools. Furthermore, school setting might be ideal for nutrition literacy interventions among children, for flavors shaping, and for educating towards less salty food acceptance

Dwarf-cashew resistance to whitefly (Aleurodicus cocois) linked tomorphological and histochemical characteristics of leaves.

The cashewwhitefly (CW), Aleurodicus cocois, is an important pest of cashewin Brazil. The use of resistant plants may be an effective strategy for the control of this pest. In a preliminary assay,we found thatdwarf-cashewclones showdifferent levels of resistance to CW.Here,we hypothesized that such resistance is associated with morphological characteristics of cashew leaves and their content of phenolic compounds. We determined (i) the attractiveness and suitability for oviposition of five dwarf-cashew clones towards CW, (ii) the leaf morphology and chemistry of those clones, and (iii) the relationship between leaf characteristics and resistance to CW. In greenhouse multiple-choice assays, PRO143/7 and CCP76 showed, respectively, the lowest and highest counts of both CWadults and eggs. Scanning electron microscopy (SEM) analysis revealed that PRO143/7 and EMBRAPA51 have, respectively, the highest and lowest numbers of leaf glandular trichomes.We found a negative correlation between number of trichomes in the abaxial surface of cashew leaves and CW oviposition. In addition, confocal microscopy analysis and histochemical tests with ferrous sulfate indicated a higher accumulation of phenolic compounds in the resistant clone PRO143/7 relative to the other clones. Dwarf-cashew clones did not significantly differ based on the number of leaf epicuticular striations, and the thickness of both leaf lamina and the epidermal layer. The resistance of dwarf-cashew plants to CW is associated with an elevated number of trichomes and accumulation of high levels of phenolics in leaves. Additionally, the contribution of epicuticular striation density and thickness of leaf lamina/epidermal layer are insignificant

Projected impact of the Portuguese sugar-sweetened beverages tax on obesity incidence across different age groups: a modelling study

Background Excessive consumption of sugar has a well-established link with obesity. Preliminary results show that a tax levied on sugar-sweetened beverages (SSBs) by the Portuguese government in 2017 led to a drop in sales and reformulation of these products. This study models the impact the market changes triggered by the tax levied on SSBs had on obesity incidence across various age groups in Portugal. Methods and findings We performed a national market analysis and population-wide modelling study using market data for the years 2014–2018 from the Portuguese Association of Non-Alcoholic Drinks (GlobalData and Nielsen Consumer Panel), dietary data from a national survey (IAN-AF 2015–2016), and obesity incidence data from several cohort studies. Dietary energy density from SSBs was calculated by dividing the energy content (kcal/gram) of all SSBs by the total food consumption (in grams). We used the potential impact fraction (PIF) equation to model the projected impact of the tax-triggered change in sugar consumption on obesity incidence, through both volume reduction and reformulation. Results showed a reduction of 6.6 million litres of SSBs sold per year. Product reformulation led to a decrease in the average energy density of SSBs by 3.1 kcal/100 ml. This is estimated to have prevented around 40–78 cases of obesity per year between 2016 and 2018, with the biggest projected impact observed in adolescents 10 to <18 years old. The model shows that the implementation of this tax allowed for a 4 to 8 times larger projected impact against obesity than would be achieved though reformulation alone. The main limitation of this study is that the model we used includes data from various sources, which can result in biases—despite our efforts to mitigate them—related to the methodological differences between these sources. Conclusions The tax triggered both a reduction in demand and product reformulation. These, together, can reduce obesity levels among frequent consumers of SSBs. Such taxation is an effective population-wide intervention. Reformulation alone, without the decrease in sales, would have had a far smaller effect on obesity incidence in the Portuguese population

A new interministerial strategy for the promotion of healthy eating in Portugal: implementation and initial results

ObjectiveTo describe the implementation, main intervention areas and initial results of the Integrated Strategy for the Promotion of Healthy Eating (EIPAS) in Portugal.MethodsEIPAS was published as a Law, in December of 2017, as a result of a collaboration between several ministries, including the Finance, Internal Affairs, Education, Health, Economy, Agriculture, and Sea Ministries, aiming at improving the dietary habits of the Portuguese population. The working group, led by the Ministry of Health, developed this strategy for over a year. The framework produced was based on WHO and European Commission recommendations as well as on relevant data from the last Portuguese dietary intake survey (2015/2016). EIPAS also reflects the results of a public hearing, including the food industry, among others, and the experience gathered, since 2012, through the National Programme for the Promotion of Healthy Eating. It considers the health in all policies' challenge set by WHO and has four different strategic areas, namely (1) creation of healthier food environments, (2) improvement of the quality and accessibility of healthy food choices for consumers, (3) promotion and development of literacy, in order to encourage healthy food choices, and (4) promotion of innovation and entrepreneurship. In order to achieve these goals, a set of 51 actions was established and assigned to the seven ministries involved.ResultsUnder the scope of this strategy, Portugal has already implemented several actions, including (1) definition of standards for food availability at all public healthcare institutions; (2) implementation of a sugar tax on sweetened beverages; (3) implementation of a voluntary agreement with the food industry sector for food reformulation (work in progress); (4) design of a proposal for an interpretative model of front-of-pack food labelling; (5) improvement of the nutritional quality of food aid programmes for low-income groups; and (6) regulation of marketing of unhealthy foods to children.ConclusionsFor the first time, Portugal has a nutrition policy based on the WHO concept of health in all policies' and on the national data on food intake. The implementing process of all 51 actions and the inherent complexities and difficulties found so far have made this process be an authentic political and social laboratory that deserves to be followed

Modelling the health impact of legislation to limit the salt content of bread in Portugal: a macro simulation study

Background: Excessive salt consumption - associated with a range of adverse health outcomes – is very high in Portugal, and bread is the second largest source. Current Portuguese legislation sets a maximum limit of 1.4g salt per 100g bread, but imported and traditional breads are exempted. In 2017 the Ministry of Health proposed reducing the salt threshold to 1.0g/100g by 2022, however the legislation was vetoed by the European Commission on free-trade grounds. Aims: To estimate the health impact of subjecting imported and traditional breads to the current 1.4g threshold, and to model the potential health impact of implementing the proposed 1.0g threshold. Methods: We gathered bread sales, salt consumption, and epidemiological data from robust publicly available data sources. We used the open source WHO PRIME modelling tool to estimate the number of salt-related deaths that would have been averted in 2016 (the latest year for which all data were available) from; 1) Extending the 1.4g threshold to all types of bread, and 2) Applying the 1.0g threshold to all bread sold in Portugal. We used Monte Carlo simulations to generate confidence intervals. Results: Applying the current 1.4g threshold to imported and traditional bread would have averted 107 deaths in 2016 (95%CI: 43 to 172). Lowering the current threshold from 1.4 to 1.0g and applying it to all bread products would reduce daily salt consumption by 3.6 tonnes per day, saving an estimated 286 lives a year (95%CI 123-454). Conclusions: Salt is an important risk factor in Portugal and bread is a major source. Lowering maximum permissible levels and removing exemptions would save lives. The European Commission should revisit its decision on the basis of this new evidence

Health Misinformation: a bioethical approach

The world of "fake news" reaches far beyond its political implications, and the virality of health misinformation content is evidence of the importance of researching it extensively. This paper, awarded the 2020 "João Lobo Antunes" National Bioethics Prize, from the Portuguese Health Ministry, makes that case that addressing health misinformation is not only an acute policy need, but also a bioethical imperative, that should mobilize government, industry and civil society in devising better ways to tackle the problem in a coordinated manner