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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., Author(s): Linda J. Cobiac 1, Nina T. Rogers 2, Jean Adams 2, Steven Cummins 3, Richard Smith 4, Oliver Mytton 5, Martin White 2, Peter Scarborough 6,* Introduction A soft [...]

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 (IMPACT.sub.NCD 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, [euro]9.6 billion (95%-UI [4.7, 15.3]) and [euro]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]; [euro]11.8 billion costs saved, 95%-UI [[euro]6.7, [euro]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., Author(s): Karl M. F. Emmert-Fees 1,2,3,*, Ben Amies-Cull 4,5, Nina Wawro 3, Jakob Linseisen 6, Matthias Staudigel 7, Annette Peters 3, Linda J. Cobiac 8, Martin O'Flaherty 9, Peter Scarborough [...]

Background Restrictions on the advertising of less-healthy foods and beverages is seen as one measure to tackle childhood obesity and is under active consideration by the UK government. Whilst evidence increasingly links this advertising to excess calorie intake, understanding of the potential impact of advertising restrictions on population health is limited. Methods and findings We used a proportional multi-state life table model to estimate the health impact of prohibiting the advertising of food and beverages high in fat, sugar, and salt (HFSS) from 05.30 hours to 21.00 hours (5:30 AM to 9:00 PM) on television in the UK. We used the following data to parameterise the model: children's exposure to HFSS advertising from AC Nielsen and Broadcasters' Audience Research Board (2015); effect of less-healthy food advertising on acute caloric intake in children from a published meta-analysis; population numbers and all-cause mortality rates from the Human Mortality Database for the UK (2015); body mass index distribution from the Health Survey for England (2016); disability weights for estimating disability-adjusted life years (DALYs) from the Global Burden of Disease Study; and healthcare costs from NHS England programme budgeting data. The main outcome measures were change in the percentage of the children (aged 5-17 years) with obesity defined using the International Obesity Task Force cut-points, and change in health status (DALYs). Monte Carlo analyses was used to estimate 95% uncertainty intervals (UIs). We estimate that if all HFSS advertising between 05.30 hours and 21.00 hours was withdrawn, UK children (n = 13,729,000), would see on average 1.5 fewer HFSS adverts per day and decrease caloric intake by 9.1 kcal (95% UI 0.5-17.7 kcal), which would reduce the number of children (aged 5-17 years) with obesity by 4.6% (95% UI 1.4%-9.5%) and with overweight (including obesity) by 3.6% (95% UI 1.1%-7.4%) This is equivalent to 40,000 (95% UI 12,000-81,000) fewer UK children with obesity, and 120,000 (95% UI 34,000-240,000) fewer with overweight. For children alive in 2015 (n = 13,729,000), this would avert 240,000 (95% UI 65,000-530,000) DALYs across their lifetime (i.e., followed from 2015 through to death), and result in a health-related net monetary benefit of £7.4 billion (95% UI £2.0 billion-£16 billion) to society. Under a scenario where all HFSS advertising is displaced to after 21.00 hours, rather than withdrawn, we estimate that the benefits would be reduced by around two-thirds. This is a modelling study and subject to uncertainty; we cannot fully and accurately account for all of the factors that would affect the impact of this policy if implemented. Whilst randomised trials show that children exposed to less-healthy food advertising consume more calories, there is uncertainty about the nature of the dose-response relationship between HFSS advertising and calorie intake. Conclusions Our results show that HFSS television advertising restrictions between 05.30 hours and 21.00 hours in the UK could make a meaningful contribution to reducing childhood obesity. We estimate that the impact on childhood obesity of this policy may be reduced by around two-thirds if adverts are displaced to after 21.00 hours rather than being withdrawn., Author(s): Oliver T. Mytton 1,*, Emma Boyland 2, Jean Adams 1, Brendan Collins 3, Martin O'Connell 4, Simon J. Russell 5, Kate Smith 4, Rebekah Stroud 4, Russell M. Viner [...]

Background/Objectives It is not known if diets lower in greenhouse gas (GHG) emissions are also healthier. We evaluated the population health implications of changing to more sustainable diets in the UK, France, Finland, Italy and Sweden. Subjects/Methods We developed a life table model to simulate mortality and morbidity from diet-related diseases over the lifetime of the current population. Populating the model with locally available data for each country, we simulated the impact of country-specific dietary scenarios that had been optimised to meet dietary recommendations and reduce GHG emissions. Outcome measures included a change in disease-specific deaths, life expectancy and disability-adjusted life years (DALYs). Results Diets that meet nutritional recommendations lead to substantial improvements in population health, ranging from 0.19 (95% uncertainty interval: 0.18-0.21) DALYs per person in Italy up to 0.89 (0.80-0.98) DALYs per person in Finland. Simultaneously reducing GHG emissions does not reduce the size of this impact, and in some cases produces additional health benefits. If sustainable diets can be maintained throughout adulthood, life expectancy would increase by between 2.3 (1.6-3.2) and 6.8 (5.5-8.5) months by country. However, results are sensitive to assumptions about how quickly changes in diet can influence disease, and future trends in disease. Conclusions Modelling the health impact of diets that are both nutritional and low in GHG emissions shows the potential for significant co-benefits in health and sustainability from dietary changes. Future work is needed to find effective interventions to deliver healthy sustainable diets., Author(s): Linda J. Cobiac [sup.1] , Peter Scarborough [sup.1] Author Affiliations: (1) Centre on Population Approaches for Non-Communicable Disease Prevention, Big Data Institute, Nuffield Department of Population Health, University of [...]

Objective To develop a new method for estimating the cost to governments of enacting public health legislation. Methods We adopted a central government perspective in estimating costs. The parliamentary cost of legislative acts and regulations in New Zealand was calculated from the proportion of parliamentary time devoted to law-making (i.e. sitting days in the debating chamber), and the cost of associated policy advice from government agencies was calculated from the proportion of documented policy issues related to law-making. The relative costs of acts and regulations were estimated from the number of pages in the legislation. Findings We estimated that, between 1999 and 2010, 26.7% of parliamentary resources and 16.7% of policy advice from government agencies were devoted to generating new laws in New Zealand. The mean cost of an act was 2.6 million United States dollars (US$; 95% uncertainty interval, UI: 1.5 to 4.4 million) and the mean cost of a regulation was US$ 382 000 (95% UI: 221 000 to 665 000). For comparison, the average cost of a bill enacted by the 50 state governments in the United States of America between 2008 and 2009 was US$ 980 000. Conclusion We were able to estimate the cost of new legislation in New Zealand. Our method for estimating this cost seemed to capture the main government costs involved and appears to be generally applicable to other developed countries. Ideally such costs should be included in economic evaluations of public health interventions that involve new legislation. Objectit Mettre au point une nouvelle methode d'estimation du cout de la promulgation de lois de sante publique pour les gouvernements. Methodes Nous avons adopte la perspective du gouvernement central pour l'estimation des couts. Le cout parlementaire des reglements et actes Iegislatifs en Nouvelle-Zelande a ete calcule au prorata du temps parlementaire consacre a l'elaboration des lois (plus precisement en jours de seance dans la chambre des debats), et le cout des conseils politiques associes fournis par les agences gouvernementales a ete calcule au prorata des publications politiques documentees relatives a l'elaboration des lois. Les couts relatifs des lois et reglements ont ete estimes a partir du nombre de pages contenues dans la Iegislation. Resultats Nous avons estime qu'entre 1999 et 2010, 26,7% des ressources parlementaires et 16,7% des conseils politiques des agences gouvernementales ont ete alloues a la proposition de nouvelles lois en Nouvelle-Zelande. Le cout moyen d'une loi etait de 2,6 millions de dollars americains (intervalle d'incertitude de 95%, II:1,5 a 4,4 millions), et le cout moyen d'un reglement etait de 382 000 $ (II de 95%: 221 000 a 665 000). A titre de comparaison, le cout moyen d'un projet de loi adopte par les 50 gouvernements federaux des Etats-Unis d'Amerique entre 2008 et 2009 etait de 980 000 $. Conclusion Nous avons ete en mesure d'estimer le cout de la nouvelle Iegislation en Nouvelle-Zelande. Notre methode d'estimation de ce cout semblait englober les principaux couts gouvernementaux concernes et parait etre globalement applicable a d'autres pays developpes. Dans l'ideal, de tels couts devraient etre inclus dans les evaluations economiques des interventions de sante publique qui impliquent une nouvelle legislation. Objetivo Desarrollar un metodo nuevo para calcular el coste que supondria a los gobiernos la promulgacion de una legislacion sobre sanidad publica. Metodos Hemos adoptado la perspectiva de un gobierno central para calcular los costes. El coste parlamentario de los actos legislativos y reglamentos en Nueva Zelandia se calculo en funcion de la proporcion de tiempo parlamentario consagrado a la creacion de la ley (es decir, de los dias de sesion en la camara de debate) y el coste del asesoramiento sobre politicas por parte de las agencias gubernamentales se calculo a partir de la proporcion de cuestiones politicas documentadas relacionadas con la creacion de la ley. Los costes relativos de las leyes y los reglamentos se calcularon en funcion del numero de paginas en la legislacion. Resultados Se calculo que, entre los anos 1999 y 2010, se dedico el 26,7% de los recursos parlamentarios y el 16,7% del asesoramiento politico procedente de las agencias gubernamentales a la creacion de nuevas leyes en Nueva Zelandia. El coste medio de una ley fue de US$ 2,6 millones (95% intervalo de incertidumbre, II: entre 1,5 y 4,4 millones) y el coste medio de un reglamento fue de US$ 382 000 (95% II: de 221 000 a 66.5 000). A modo de comparativa, el coste medio de un proyecto de ley promulgado por los 50 estados miembros de los Estados Unidos de America entre 2008 y 2009 fue de US$ 980 000. Conclusion Hemos podido calcular el coste de una nueva legislacion en Nueva Zelandia. Nuestro metodo para calcular este coste abarco los principales gastos gubernamentales implicados y podria aplicarse a otros paises desarrollados. Lo ideal seria que dichos costes se incluyeran en las evaluaciones economicas de aquellas intervenciones de la sanidad publica que implicaran unalegislacion nueva., Introduction There is strong scientific evidence that the law can help improve public health. A recent publication identified 65 systematic reviews of studies on the effectiveness of a total of [...]

Objective: Intensive weight loss programs that incorporate dietary counselling and exercise advice are popular and are supported by evidence of immediate weight loss benefits. We evaluate the cost-effectiveness of two weight loss programs, Lighten Up to a Healthy Lifestyle and Weight Watchers. Methods: Health gains from prevention of chronic disease are modelled over the lifetime of the Australian population. These results are combined with estimates of intervention costs and cost offsets (due to reduced rates of lifestyle-related diseases) to determine the dollars per disability-adjusted life year (DALY) averted by each intervention program, from an Australian health sector perspective. Results: Both weight loss programs produced small improvements in population health compared to current practice. The time and travel associated with attending group-counselling sessions, however, was costly for patients, and overall the cost-effectiveness ratios for Lighten Up ($130,000/DALY) and Weight Watchers ($140,000/DALY) were high. Conclusion: Based on current evidence, these intensive behavioural counselling interventions are not very cost-effective strategies for reducing obesity, and the potential benefits for population health are small. Implications: It will be critical to consider other strategies (e.g. changing the 'obesogenic' environment) or explore alternative methods of intervention delivery (e.g. Internet) to see if they offer a more cost-effective approach by effectively reaching a high number of people at a low cost. Key words: weight loss, cost-effectiveness, diet, exercise. doi: 10.1111/j.1753-6405.2010.00520.x

Background An increasing number of countries are implementing taxes on unhealthy foods and drinks to address the growing burden of dietary-related disease, but the cost-effectiveness of combining taxes on unhealthy foods and subsidies on healthy foods is not well understood. Methods and Findings Using a population model of dietary-related diseases and health care costs and food price elasticities, we simulated the effect of taxes on saturated fat, salt, sugar, and sugar-sweetened beverages and a subsidy on fruits and vegetables, over the lifetime of the Australian population. The sizes of the taxes and subsidy were set such that, when combined as a package, there would be a negligible effect on average weekly expenditure on food ( Conclusions With potentially large health benefits for the Australian population and large benefits in reducing health sector spending on the treatment of non-communicable diseases, the formulation of a tax and subsidy package should be given a more prominent role in Australia's public health nutrition strategy., Author(s): Linda J. Cobiac 1,*, King Tam 2, Lennert Veerman 2, Tony Blakely 3 Introduction The relationship between non-communicable diseases and consumption of unhealthy foods and drinks is well known, [...]