Search

BackgroundThe 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 findingsWe 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.ConclusionsWe 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.

BackgroundTaxes 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 findingsIn 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.ConclusionsIn 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.

[This corrects the article DOI: 10.1371/journal.pmed.1003269.].

BackgroundExcess consumption of salt is linked to an increased risk of hypertension and cardiovascular disease. The United Kingdom has had a comprehensive salt reduction programme since 2003, setting a series of progressively lower, product-specific reformulation targets for the food industry, combined with advice to consumers to reduce salt. The aim of this study was to assess the changes in the sales-weighted mean salt content of grocery foods sold through retail between 2015 and 2020 by category and company.Methods and findingsInformation for products, including salt content (g/100 g), was collected online from retailer websites for 6 consecutive years (2015 to 2020) and was matched with brand-level retail sales data from Euromonitor for 395 brands. The sales-weighted mean salt content and total volume of salt sold were calculated by category and company. The mean salt content of included foods fell by 0.05 g/100 g, from 1.04 g/100 g in 2015 to 0.90 g/100 g in 2020, equivalent to -4.2% (p = 0.13). The categories with the highest salt content in 2020 were savoury snacks (1.6 g/100 g) and cheese (1.6 g/100 g), and the categories that saw the greatest reductions in mean salt content over time were breakfast cereals (-16.0%, p = 0.65); processed beans, potatoes, and vegetables (-10.6%, p = 0.11); and meat, seafood, and alternatives (-9.2%, p = 0.56). The total volume of salt sold fell from 2.41 g per person per day to 2.25 g per person per day, a reduction of 0.16 g or 6.7% (p = 0.54). The majority (63%) of this decrease was attributable to changes in mean salt content, with the remaining 37% accounted for by reductions in sales. Across the top 5 companies in each of 9 categories, the volume of salt sold decreased in 26 and increased in 19 cases. This study is limited by its exclusion of foods purchased out of the home, including at restaurants, cafes, and takeaways. It also does not include salt added at the table, or that naturally occurring in foods, meaning the findings underrepresent the population's total salt intake. The assumption was also made that the products matched with the sales data were entirely representative of the brand, which may not be the case if products are sold exclusively in convenience stores or markets, which are not included in this database.ConclusionsThere has been a small decline in the salt content of foods and total volume of salt sold between 2015 and 2020, but observed changes were not statistically significant so could be due to random variations over time. We suggest that mandatory reporting of salt sales by large food companies would increase the transparency of how individual businesses are progressing towards the salt reduction targets.

BackgroundReducing meat consumption could bring health and environmental benefits, but there is little research to date on effective interventions to achieve this. A non-randomised controlled intervention study was used to evaluate whether prominent positioning of meat-free products in the meat aisle was associated with a change in weekly mean sales of meat and meat-free products.Methods and findingsWeekly sales data were obtained from 108 stores: 20 intervention stores that moved a selection of 26 meat-free products into a newly created meat-free bay within the meat aisle and 88 matched control stores. The primary outcome analysis used a hierarchical negative binomial model to compare changes in weekly sales (units) of meat products sold in intervention versus control stores during the main intervention period (Phase I: February 2019 to April 2019). Interrupted time series analysis was also used to evaluate the effects of the Phase I intervention. Moreover, 8 of the 20 stores enhanced the intervention from August 2019 onwards (Phase II intervention) by adding a second bay of meat-free products into the meat aisle, which was evaluated following the same analytical methods. During the Phase I intervention, sales of meat products (units/store/week) decreased in intervention (approximately -6%) and control stores (-5%) without significant differences (incidence rate ratio [IRR] 1.01 [95% CI 0.95-1.07]. Sales of meat-free products increased significantly more in the intervention (+31%) compared to the control stores (+6%; IRR 1.43 [95% CI 1.30-1.57]), mostly due to increased sales of meat-free burgers, mince, and sausages. Consistent results were observed in interrupted time series analyses where the effect of the Phase II intervention was significant in intervention versus control stores.ConclusionsProminent positioning of meat-free products into the meat aisle in a supermarket was not effective in reducing sales of meat products, but successfully increased sales of meat-free alternatives in the longer term. A preregistered protocol (https://osf.io/qmz3a/) was completed and fully available before data analysis.

BackgroundConsumption of free sugars in the UK greatly exceeds dietary recommendations. Public Health England (PHE) has set voluntary targets for industry to reduce the sales-weighted mean sugar content of key food categories contributing to sugar intake by 5% by 2018 and 20% by 2020. The aim of this study was to assess changes in the sales-weighted mean sugar content and total volume sales of sugar in selected food categories among UK companies between 2015 and 2018.Methods and findingsWe used sales data from Euromonitor, which estimates total annual retail sales of packaged foods, for 5 categories-biscuits and cereal bars, breakfast cereals, chocolate confectionery, sugar confectionery, and yoghurts-for 4 consecutive years (2015-2018). This analysis includes 353 brands (groups of products with the same name) sold by 99 different companies. These data were linked with nutrient composition data collected online from supermarket websites over 2015-2018 by Edge by Ascential. The main outcome measures were sales volume, sales-weighted mean sugar content, and total volume of sugar sold by category and company. Our results show that between 2015 and 2018 the sales-weighted mean sugar content of all included foods fell by 5.2% (95% CI -9.4%, -1.4%), from 28.7 g/100 g (95% CI 27.2, 30.4) to 27.2 g/100 g (95% CI 25.8, 28.4). The greatest change seen was in yoghurts (-17.0% [95% CI -26.8%, -7.1%]) and breakfast cereals (-13.3% [95% CI -19.2%, -7.4%]), with only small reductions in sugar confectionery (-2.4% [95% CI -4.2%, -0.6%]) and chocolate confectionery (-1.0% [95% CI -3.1, 1.2]). Our results show that total volume of sugars sold per capita fell from 21.4 g/d (95% CI 20.3, 22.7) to 19.7 g/d (95% CI 18.8, 20.7), a reduction of 7.5% (95% CI -13.1%, -2.8%). Of the 50 companies representing the top 10 companies in each category, 24 met the 5% reduction target set by PHE for 2018. The key limitations of this study are that it does not encompass the whole food market and is limited by its use of brand-level sales data, rather than individual product sales data.ConclusionsOur findings show there has been a small reduction in total volume sales of sugar in the included categories, primarily due to reductions in the sugar content of yoghurts and breakfast cereals. Additional policy measures may be needed to accelerate progress in categories such as sugar confectionery and chocolate confectionery if the 2020 PHE voluntary sugar reduction targets are to be met.

BackgroundSugar-sweetened beverage (SSB) consumption is positively associated with obesity, type 2 diabetes, and cardiovascular disease. The World Health Organization recommends that member states implement effective taxes on SSBs to reduce consumption. The United Kingdom Soft Drinks Industry Levy (SDIL) is a two-tiered tax, announced in March 2016 and implemented in April 2018. Drinks with ≥8 g of sugar per 100 ml (higher levy tier) are taxed at £0.24 per litre, drinks with ≥5 to 1.2% alcohol by volume are exempt. We aimed to determine if the announcement of the SDIL was associated with anticipatory changes in purchases of soft drinks prior to implementation of the SDIL in April 2018. We explored differences in the volume of and amount of sugar in household purchases of drinks in each levy tier at 2 years post announcement.Methods and findingsWe used controlled interrupted time series to compare observed changes associated with the announcement of the SDIL to the counterfactual scenario of no announcement. We used data from Kantar Worldpanel, a commercial household purchasing panel with approximately 30,000 British members that includes linked nutritional data on purchases. We conducted separate analyses for drinks liable for the SDIL in the higher, lower, and no-levy tiers controlling with household purchase volumes of toiletries. At 2 years post announcement, there was no difference in volume of or sugar from purchases of higher-levy-tier drinks compared to the counterfactual of no announcement. In contrast, a reversal of the existing upward trend in volume (ml) of and amount of sugar (g) in purchases of lower-levy-tier drinks was seen. These changes led to a -96.1 ml (95% confidence interval [CI] -144.2 to -48.0) reduction in volume and -6.4 g (95% CI -9.8 to -3.1) reduction in sugar purchased in these drinks per household per week. There was a reversal of the existing downward trend in the amount of sugar in household purchases of the no-levy drinks but no change in volume purchased. At 2 years post announcement, these changes led to a 6.1 g (95% CI 3.9-8.2) increase in sugar purchased in these drinks per household per week. There was no evidence that volume of or amount of sugar in purchases of all drinks combined was different from the counterfactual. This is an observational study, and changes other than the SDIL may have been responsible for the results reported. Purchases consumed outside of the home were not accounted for.ConclusionsThe announcement of the UK SDIL was associated with reductions in volume and sugar purchased in lower-levy-tier drinks before implementation. These were offset by increases in sugar purchased from no-levy drinks. These findings may reflect reformulation of drinks from the lower levy to no-levy tier with removal of some but not all sugar, alongside changes in consumer attitudes and beliefs.Trial registrationISRCTN Registry ISRCTN18042742.

BackgroundDietary sugar, especially in liquid form, increases risk of dental caries, adiposity, and type 2 diabetes. The United Kingdom Soft Drinks Industry Levy (SDIL) was announced in March 2016 and implemented in April 2018 and charges manufacturers and importers at £0.24 per litre for drinks with over 8 g sugar per 100 mL (high levy category), £0.18 per litre for drinks with 5 to 8 g sugar per 100 mL (low levy category), and no charge for drinks with less than 5 g sugar per 100 mL (no levy category). Fruit juices and milk-based drinks are exempt. We measured the impact of the SDIL on price, product size, number of soft drinks on the marketplace, and the proportion of drinks over the lower levy threshold of 5 g sugar per 100 mL.Methods and findingsWe analysed data on a total of 209,637 observations of soft drinks over 85 time points between September 2015 and February 2019, collected from the websites of the leading supermarkets in the UK. The data set was structured as a repeat cross-sectional study. We used controlled interrupted time series to assess the impact of the SDIL on changes in level and slope for the 4 outcome variables. Equivalent models were run for potentially levy-eligible drink categories ('intervention' drinks) and levy-exempt fruit juices and milk-based drinks ('control' drinks). Observed results were compared with counterfactual scenarios based on extrapolation of pre-SDIL trends. We found that in February 2019, the proportion of intervention drinks over the lower levy sugar threshold had fallen by 33.8 percentage points (95% CI: 33.3-34.4, p < 0.001). The price of intervention drinks in the high levy category had risen by £0.075 (£0.037-0.115, p < 0.001) per litre-a 31% pass through rate-whilst prices of intervention drinks in the low levy category and no levy category had fallen and risen by smaller amounts, respectively. Whilst the product size of branded high levy and low levy drinks barely changed after implementation of the SDIL (-7 mL [-23 to 11 mL] and 16 mL [6-27ml], respectively), there were large changes to product size of own-brand drinks with an increase of 172 mL (133-214 mL) for high levy drinks and a decrease of 141 mL (111-170 mL) for low levy drinks. The number of available drinks that were in the high levy category when the SDIL was announced was reduced by 3 (-6 to 12) by the implementation of the SDIL. Equivalent models for control drinks provided little evidence of impact of the SDIL. These results are not sales weighted, so do not give an account of how sugar consumption from drinks may have changed over the time period.ConclusionsThe results suggest that the SDIL incentivised many manufacturers to reduce sugar in soft drinks. Some of the cost of the levy to manufacturers and importers was passed on to consumers as higher prices but not always on targeted drinks. These changes could reduce population exposure to liquid sugars and associated health risks.

BackgroundIn the United Kingdom, the Food Standards Agency-Ofcom nutrient profiling model (FSA-Ofcom model) is used to define less-healthy foods that cannot be advertised to children. However, there has been limited investigation of whether less-healthy foods defined by this model are associated with prospective health outcomes. The objective of this study was to test whether consumption of less-healthy food as defined by the FSA-Ofcom model is associated with cardiovascular disease (CVD).Methods and findingsWe used data from the European Prospective Investigation of Cancer (EPIC)-Norfolk cohort study in adults (n = 25,639) aged 40-79 years who completed a 7-day diet diary between 1993 and 1997. Incident CVD (primary outcome), cardiovascular mortality, and all-cause mortality (secondary outcomes) were identified using record linkage to hospital admissions data and death certificates up to 31 March 2015. Each food and beverage item reported was coded and given a continuous score, using the FSA-Ofcom model, based on the consumption of energy; saturated fat; total sugar; sodium; nonsoluble fibre; protein; and fruits, vegetables, and nuts. Items were classified as less-healthy using Ofcom regulation thresholds. We used Cox proportional hazards regression to test for an association between consumption of less-healthy food and incident CVD. Sensitivity analyses explored whether the results differed based on the definition of the exposure. Analyses were adjusted for age, sex, behavioural risk factors, clinical risk factors, and socioeconomic status. Participants were followed up for a mean of 16.4 years. During follow-up, there were 4,965 incident cases of CVD (1,524 fatal within 30 days). In the unadjusted analyses, we observed an association between consumption of less-healthy food and incident CVD (test for linear trend over quintile groups, p < 0.01). After adjustment for covariates (sociodemographic, behavioural, and indices of cardiovascular risk), we found no association between consumption of less-healthy food and incident CVD (p = 0.84) or cardiovascular mortality (p = 0.90), but there was an association between consumption of less-healthy food and all-cause mortality (test for linear trend, p = 0.006; quintile group 5, highest consumption of less-healthy food, versus quintile group 1, HR = 1.11, 95% CI 1.02-1.20). Sensitivity analyses produced similar results. The study is observational and relies on self-report of dietary consumption. Despite adjustment for known and reported confounders, residual confounding is possible.ConclusionsAfter adjustment for potential confounding factors, no significant association between consumption of less-healthy food (as classified by the FSA-Ofcom model) and CVD was observed in this study. This suggests, in the UK setting, that the FSA-Ofcom model is not consistently discriminating among foods with respect to their association with CVD. More studies are needed to understand better the relationship between consumption of less-healthy food, defined by the FSA-Ofcom model, and indices of health.