Association of a Workplace Sales Ban on Sugar-Sweetened Beverages With Employee Consumption of Sugar-Sweetened Beverages and Health.

Importance: Reductions in sugar-sweetened beverage (SSB) intake can improve health, but are difficult for individuals to achieve on their own. Objectives: To evaluate whether a workplace SSB sales ban was associated with SSB intake and cardiometabolic health among employees and whether a brief motivational intervention provides added benefits to the sales ban. Design, Setting, and Participants: This before-after study and additional randomized trial conducted from July 28, 2015, to October 16, 2016, at a Northern California university and hospital assessed SSB intake, anthropometrics, and cardiometabolic biomarkers among 214 full-time English-speaking employees who were frequent SSB consumers (≥360 mL [≥12 fl oz] per day) before and 10 months after implementation of an SSB sales ban in a large workplace, with half the employees randomized to receive a brief motivational intervention targeting SSB reduction. Interventions: The employer stopped selling SSBs in all workplace venues, and half the sample was randomized to receive a brief motivational intervention and the other half was a control group that did not receive the intervention. This intervention was modeled on standard brief motivational interventions for alcohol used in the workplace that promote health knowledge and goal setting. Main Outcomes and Measures: Outcomes included changes in SSB intake, Homeostatic Model Assessment of Insulin Resistance (HOMA-IR), and measures of abdominal adiposity. The primary associations tested were the correlation between changes in SSB intake and changes in HOMA-IR. Results: Among the 214 study participants, 124 (57.9%) were women, with a mean (SD) age of 41.2 (11.0) years and a baseline mean (SD) body mass index of 29.4 (6.5). They reported a mean daily intake of 1050 mL (35 fl oz) of SSBs at baseline and 540 mL (18 fl oz) at follow-up-a 510-mL (17-fl oz) (48.6%) decrease (P < .001). Reductions in SSB intake correlated with improvements in HOMA-IR (r = 0.16; P = .03). Those not randomized to receive the brief intervention reduced their SSB intake by a mean (SD) of 246.0 (84.0) mL (8.2 [2.8] fl oz), while those also receiving the brief intervention reduced SSB intake by 762.0 (84.0) mL (25.4 [2.8] fl oz). From baseline to follow-up, there were significant reductions in mean (SE) waist circumference (2.1 [2.8] cm; P < .001). Conclusions and Relevance: This study's findings suggest that the workplace sales ban was associated with a reduction in SSB intake and a significant reduction in waist circumference among employees within 10 months. The randomized clinical trial portion of this study found that targeting those at high risk with a brief motivational intervention led to additional improvements. Workplace sales bans may offer a promising new private-sector strategy for reducing the health harms of SSB intake. Trial Registration: ClinicalTrials.gov identifier: NCT02585336.

Changes in prices, sales, consumer spending, and beverage consumption one year after a tax on sugar-sweetened beverages in Berkeley, California, US: A before-and-after study.

BACKGROUND: Taxes on sugar-sweetened beverages (SSBs) meant to improve health and raise revenue are being adopted, yet evaluation is scarce. This study examines the association of the first penny per ounce SSB excise tax in the United States, in Berkeley, California, with beverage prices, sales, store revenue/consumer spending, and usual beverage intake. METHODS AND FINDINGS: Methods included comparison of pre-taxation (before 1 January 2015) and first-year post-taxation (1 March 2015-29 February 2016) measures of (1) beverage prices at 26 Berkeley stores; (2) point-of-sale scanner data on 15.5 million checkouts for beverage prices, sales, and store revenue for two supermarket chains covering three Berkeley and six control non-Berkeley large supermarkets in adjacent cities; and (3) a representative telephone survey (17.4% cooperation rate) of 957 adult Berkeley residents. Key hypotheses were that (1) the tax would be passed through to the prices of taxed beverages among the chain stores in which Berkeley implemented the tax in 2015; (2) sales of taxed beverages would decline, and sales of untaxed beverages would rise, in Berkeley stores more than in comparison non-Berkeley stores; (3) consumer spending per transaction (checkout episode) would not increase in Berkeley stores; and (4) self-reported consumption of taxed beverages would decline. Main outcomes and measures included changes in inflation-adjusted prices (cents/ounce), beverage sales (ounces), consumers' spending measured as store revenue (inflation-adjusted dollars per transaction) in two large chains, and usual beverage intake (grams/day and kilocalories/day). Tax pass-through (changes in the price after imposition of the tax) for SSBs varied in degree and timing by store type and beverage type. Pass-through was complete in large chain supermarkets (+1.07¢/oz, p = 0.001) and small chain supermarkets and chain gas stations (1.31¢/oz, p = 0.004), partial in pharmacies (+0.45¢/oz, p = 0.03), and negative in independent corner stores and independent gas stations (-0.64¢/oz, p = 0.004). Sales-unweighted mean price change from scanner data was +0.67¢/oz (p = 0.00) (sales-weighted, +0.65¢/oz, p = 0.003), with +1.09¢/oz (p < 0.001) for sodas and energy drinks, but a lower change in other categories. Post-tax year 1 scanner data SSB sales (ounces/transaction) in Berkeley stores declined 9.6% (p < 0.001) compared to estimates if the tax were not in place, but rose 6.9% (p < 0.001) for non-Berkeley stores. Sales of untaxed beverages in Berkeley stores rose by 3.5% versus 0.5% (both p < 0.001) for non-Berkeley stores. Overall beverage sales also rose across stores. In Berkeley, sales of water rose by 15.6% (p < 0.001) (exceeding the decline in SSB sales in ounces); untaxed fruit, vegetable, and tea drinks, by 4.37% (p < 0.001); and plain milk, by 0.63% (p = 0.01). Scanner data mean store revenue/consumer spending (dollars per transaction) fell 18¢ less in Berkeley (-$0.36, p < 0.001) than in comparison stores (-$0.54, p < 0.001). Baseline and post-tax Berkeley SSB sales and usual dietary intake were markedly low compared to national levels (at baseline, National Health and Nutrition Examination Survey SSB intake nationally was 131 kcal/d and in Berkeley was 45 kcal/d). Reductions in self-reported mean daily SSB intake in grams (-19.8%, p = 0.49) and in mean per capita SSB caloric intake (-13.3%, p = 0.56) from baseline to post-tax were not statistically significant. Limitations of the study include inability to establish causal links due to observational design, and the absence of health outcomes. Analysis of consumption was limited by the small effect size in relation to high standard error and Berkeley's low baseline consumption. CONCLUSIONS: One year following implementation of the nation's first large SSB tax, prices of SSBs increased in many, but not all, settings, SSB sales declined, and sales of untaxed beverages (especially water) and overall study beverages rose in Berkeley; overall consumer spending per transaction in the stores studied did not rise. Price increases for SSBs in two distinct data sources, their timing, and the patterns of change in taxed and untaxed beverage sales suggest that the observed changes may be attributable to the tax. Post-tax self-reported SSB intake did not change significantly compared to baseline. Significant declines in SSB sales, even in this relatively affluent community, accompanied by revenue used for prevention suggest promise for this policy. Evaluation of taxation in jurisdictions with more typical SSB consumption, with controls, is needed to assess broader dietary and potential health impacts.

Sugar and health in South Africa: Potential challenges to leveraging policy change.

A growing body of evidence indicates that excessive sugar consumption is driving epidemics of obesity and related non-communicable diseases (NCDs) around the world. South Africa (SA), a major consumer of sugar, is also the third most obese country in Africa, and 40% of all deaths in the country result from NCDs. A number of fiscal, regulatory, and legislative levers could reduce sugar consumption in SA. This paper focuses on a sugar-sweetened beverage (SSB) tax. The purpose of the paper is to highlight the challenges that government might anticipate. Policies cannot be enacted in a vacuum and discussion is focused on the industrial, economic, and societal context. The affected industry actors have been part of the SA economy for over a century and remain influential. To deflect attention, the sugar industry can be expected either to advocate for self-regulation or to promote public-private partnerships. This paper cautions against both approaches as evidence suggests that they will be ineffective in curbing the negative health impacts caused by excessive sugar consumption. In summary, policy needs to be introduced with a political strategy sensitive to the various interests at stake. In particular, the sugar industry can be expected to be resistant to the introduction of any type of tax on SSBs.

Impact of the Berkeley Excise Tax on Sugar-Sweetened Beverage Consumption.

OBJECTIVES: To evaluate the impact of the excise tax on sugar-sweetened beverage (SSB) consumption in Berkeley, California, which became the first US jurisdiction to implement such a tax ($0.01/oz) in March 2015. METHODS: We used a repeated cross-sectional design to examine changes in pre- to posttax beverage consumption in low-income neighborhoods in Berkeley versus in the comparison cities of Oakland and San Francisco, California. A beverage frequency questionnaire was interviewer administered to 990 participants before the tax and 1689 after the tax (approximately 8 months after the vote and 4 months after implementation) to examine relative changes in consumption. RESULTS: Consumption of SSBs decreased 21% in Berkeley and increased 4% in comparison cities (P = .046). Water consumption increased more in Berkeley (+63%) than in comparison cities (+19%; P < .01). CONCLUSIONS: Berkeley's excise tax reduced SSB consumption in low-income neighborhoods. Evaluating SSB taxes in other cities will improve understanding of their public health benefit and their generalizability.

Efficiency of irrigation water application in sugarcane cultivation in Pakistan.

BACKGROUND: Diminishing irrigation water supplies are threatening the sustainability of irrigated agriculture in Pakistan. Within the context of dwindling water resources and low agricultural water productivity, it is imperative to improve efficiency in agricultural production and to make efficient use of available water resources. This study employs a non-parametric approach to estimate the extent of technical and irrigation water efficiency in sugarcane cultivation in Pakistan. RESULTS: The mean technical efficiency score is 0.96 for tube-well owners whereas it is 0.94 for water buyers. The mean irrigation water efficiency score is 0.86 for tube-well owners whereas it is 0.72 for water buyers. We find that across all farms, 59% of the tube-well owners and 45% of the water buyers are fully technically efficient, whereas only 36% of the tube-well owners and 30% of the water buyer are fully efficient in irrigation water use. CONCLUSIONS: This study finds that sugarcane growers are operating at fairly high technical efficiency levels. But, there is considerable potential to improve irrigation water efficiency. This study proposes expanding the role of agricultural extension services from merely agronomic grounds to guide farmers to undertake cost benefit analysis of the available production technology, would help achieve higher efficiency levels.

Trends in added sugar supply and consumption in Australia: there is an Australian Paradox.

In 2011, Barclay and Brand-Miller reported the observation that trends in refined sugar consumption in Australia were the inverse of trends in overweight and obesity (The Australian Paradox). Rikkers et al. claim that the Australian Paradox is based on incomplete data because the sources utilised did not incorporate estimates for imported processed foods. This assertion is incorrect. Indeed, national nutrition surveys, sugar consumption data from the United Nations Food and Agricultural Organisation, the Australian Bureau of Statistics and Australian beverage industry data all incorporated data on imported products.

Trends in sugar supply and consumption in Australia: is there an Australian Paradox?

BACKGROUND: High consumption of refined carbohydrate, in particular sugar, has been identified as a possible contributory factor in greater risk of excess weight gain. In spite of data limitations, one recent paper suggests that Australian sugar consumption has decreased over the same time period that obesity has increased, a so called 'Australian Paradox'. Given the significant public health focus on nutrition, we aimed to estimate Australian sugar supply and consumption over recent decades, to determine whether these data could be used to make any conclusions about sugar's role in obesity. METHODS: Foods high in sugar were identified. Data relating to sugar supply and consumption from 1988 to 2010 were obtained from multiple sources. Using these data we attempted to generate a time series estimate of sugar in Australia's food supply. RESULTS: Australia produces and exports sugar from sugar cane and the sugar in imported foods has received little attention. We were unable to produce a reliable and robust estimate of total sugars in the Australian diet due to data limitations and a lack of current data sources. However, available Import data showed large increases in the volume and value of imported sweetened products between 1988 and 2010 to over 30 grams of sugar per person per day. Value estimates of local production of sweetened products also show substantial increases in this period. CONCLUSION: The Australian Paradox assertion is based on incomplete data, as it excludes sugar contained in imported processed foods, which have increased markedly. A major Australian public health target is to improve the quality of the food supply, and actions have been set in terms of achieving broader environmental changes. However, evaluation of progress is hampered by lack of high quality data relating to supply and consumption. We recommend the regular collection of comprehensive food supply statistics, which include both local production and imports. This would provide an inexpensive addition to survey data and could assist in monitoring sugar consumption trends in food supply. Such information would also help inform public health policy.

Sack and sugar, and the aetiology of gout in England between 1650 and 1900.

A marked increase in gout was observed in England during the 17th to 20th centuries. Many have ascribed this rapid increase in gout to the introduction of wines that were laced with lead. In this article, we suggest another likely contributor, which is the marked increase in sugar intake that occurred in England during this period. Sugar contains fructose, which raises uric acid and increases the risk for gout. Sugar intake increased markedly during this period due to its introduction in liquors, tea, coffee and desserts. We suggest that the introduction of sugar explains why gout was originally a disease of the wealthy and educated, but gradually became common throughout society.

High fructose corn syrup and diabetes prevalence: a global perspective.

The overall aim of this study was to evaluate, from a global and ecological perspective, the relationships between availability of high fructose corn syrup (HFCS) and prevalence of type 2 diabetes. Using published resources, country-level estimates (n =43 countries) were obtained for: total sugar, HFCS and total calorie availability, obesity, two separate prevalence estimates for diabetes, prevalence estimate for impaired glucose tolerance and fasting plasma glucose. Pearson's correlations and partial correlations were conducted in order to explore associations between dietary availability and obesity and diabetes prevalence. Diabetes prevalence was 20% higher in countries with higher availability of HFCS compared to countries with low availability, and these differences were retained or strengthened after adjusting for country-level estimates of body mass index (BMI), population and gross domestic product (adjusted diabetes prevalence=8.0 vs. 6.7%, p=0.03; fasting plasma glucose=5.34 vs. 5.22 mmol/L, p=0.03) despite similarities in obesity and total sugar and calorie availability. These results suggest that countries with higher availability of HFCS have a higher prevalence of type 2 diabetes independent of obesity.

Impact of national income and inequality on sugar and caries relationship.

OBJECTIVE: The aim of this study was to examine the impact that national income and income inequality in high and low income countries have on the relationship between dental caries and sugar consumption. METHODS: An ecological study design was used in this study of 73 countries. The mean decayed, missing, or filled permanent teeth (DMFT) for 12-year-old children were obtained from the WHO Oral Health Country/Area Profile Programme. United Nations Food and Agricultural Organization data were used for per capita sugar consumption. Gross national incomes per capita based on purchasing power parity and the Gini coefficient were obtained from World Bank data. Bivariate and multivariate linear regression analysis was performed to estimate the associations between mean DMFT and per capita sugar consumption in different income and income inequality countries. RESULTS: Bivariate and multivariate regression analysis showed that countries with a high national income and low income inequality have a strong negative association between sugar consumption and caries (B = -2.80, R2 = 0.17), whereas countries with a low income and high income inequality have a strong positive relationship between DMFT and per capita sugar consumption (B = -0.89, R2 = 0.20). CONCLUSION: The relationship between per capita consumption of sugar and dental caries is modified by the absolute level of income of the country, but not by the level of income inequality within a country.

Availability of added sugars in Brazil: distribution, food sources and time trends.

OBJECTIVE: To describe the regional and socio-economic distribution of consumption of added sugar in Brazil in 2002/03, particularly products, sources of sugar and trends in the past 15 years. METHODS: The study used data from Household Budget Surveys since the 1980s about the type and quantity of food and beverages bought by Brazilian families. Different indicators were analyzed: % of sugar calories over the total diet energy and caloric % of table sugar fractions and sugar added to processed food/ sugar calories of diet. RESULTS: In 2002/03, of the total energy available for consumption, 16.7% came from added sugar in all regional and socio-economic strata. The table sugar/ sugar added to processed food ratio was inversely proportional to increase in income. Although this proportion fell in the past 15 years, sugar added to processed food doubled, especially in terms of consumption of soft drinks and cookies. CONCLUSIONS: Brazilians consume more sugar than the recommended levels determined by the WHO and the sources of consumption of sugar have changed significantly.

Disponibilidade de "açúcares de adição" no Brasil: distribuição, fontes alimentares e tendência temporal / Availability of added sugars in Brazil: distribution, food sources and time trends

OBJETIVOS: Estimar o consumo de "açúcar de adição" pela população brasileira, nos estratos regionais e socioeconômicos, destacando suas principais fontes alimentares e verificar a tendência do seu consumo nas últimas décadas. MÉTODOS: Contou-se com informações das Pesquisas de Orçamentos Familiares a partir da década de 80 sobre o tipo e a quantidade de alimentos e bebidas adquiridos pelas famílias brasileiras. Os indicadores analisados foram: por cento das calorias de açúcar no total calórico da dieta e por cento calórico das frações de açúcar de mesa e de açúcar adicionado aos alimentos pela indústria/kcal açúcar da dieta. RESULTADOS: Em 2002/03, 16,7 por cento das calorias totais eram provenientes de "açúcar de adição" e sua participação mostrou-se elevada em todos os estratos regionais e de renda. A razão açúcar de mesa/açúcar adicionado pela indústria se inverte com o aumento da renda. A participação do açúcar de mesa nos últimos 15 anos foi reduzida, enquanto a contribuição do açúcar adicionado aos alimentos dobrou, especialmente por meio do consumo de refrigerantes e biscoitos. CONCLUSÕES: O consumo de açúcar no Brasil excede largamente a recomendação da OMS e verificou-se importante alteração nas fontes de consumo.

OBJECTIVE: To describe the regional and socio-economic distribution of consumption of added sugar in Brazil in 2002/03, particularly products, sources of sugar and trends in the past 15 years. METHODS: The study used data from Household Budget Surveys since the 1980s about the type and quantity of food and beverages bought by Brazilian families. Different indicators were analyzed: percent of sugar calories over the total diet energy and caloric percent of table sugar fractions and sugar added to processed food/ sugar calories of diet. RESULTS: In 2002/03, of the total energy available for consumption, 16.7 percent came from added sugar in all regional and socio-economic strata. The table sugar/ sugar added to processed food ratio was inversely proportional to increase in income. Although this proportion fell in the past 15 years, sugar added to processed food doubled, especially in terms of consumption of soft drinks and cookies. CONCLUSIONS: Brazilians consume more sugar than the recommended levels determined by the WHO and the sources of consumption of sugar have changed significantly.

School environment factors were associated with BMI among adolescents in Xi'an City, China.

BACKGROUND: School environment influences students' behaviours. The purpose of this research was to identify school environment factors associated with BMI. METHODS: A cross-sectional study was conducted among 1792 school-aged adolescents from 30 schools in six districts in Xi'an City in 2004. Height and weight were taken from students by trained field staff. School environment characteristics such as physical factors (school facilities, school shops and fast food outlets in school area), school curricula and policies were collected from school doctors using school environment questionnaire. School environment factors were identified in linear mixed effect models with BMI as outcome and adjusted for socio-demographic factors. RESULTS: After adjusted for socio-demographic factors, BMI was associated with the availability of soft drinks at school shops, the availability and the number of western food outlet in the school vicinity. School curricula such as sports-meeting and health education session were also associated with BMI. CONCLUSIONS: Urgent actions are needed to address the obesogenic elements of school environments. Community and school policy makers should make efforts for students to avoid exposure to fast food outlet in school area and soft drinks at school shops, and to improve school curricula to promote healthy behaviours.

Does the EU sugar policy reform increase added sugar consumption? An empirical evidence on the soft drink market.

Whereas National Health authorities recommend a decrease in the consumption of 'added' sugar, a reform on the sugar market will lead to a 36% decrease of the sugar price in the EU. Using French data on soft drinks purchases, this paper investigates the anticipated impact of this reform on the consumption of sugar-sweetened beverages. The reform of the EU sugar policy leads to a decrease in regular soft drink prices by 3% and varies across brands. To assess substitution within this food category, we use a random-coefficients logit model that takes into account a large number of differentiated products and heterogeneity in consumers' behavior. Results suggest that price changes would lead to an increase in market shares of regular products by 7.5% and to substitutions between brands to the benefit of products with the highest sugar content. On the whole, it would raise consumption of regular soft drinks by more than 1 litre per person per year and consumption of added sugar by 124 g per person per year, this increase being larger in households composed of overweight and obese individuals.

Advertising and obesity: a behavioral perspective.

Concern over the levels of obesity observed in Western countries has grown as researchers forecast a rapid growth in the medical care that a progressively more obese population will require. As health workers deal with increased incidences of diabetes and other obesity-related disorders, policymakers have examined the factors contributing to this problem. In particular, advertising that promotes high fat and high sugar products to children has come under increasing scrutiny. Advertisers have rejected claims that advertising contributes to obesity by arguing that it cannot coerce people into purchasing a product, and does not affect primary demand. This reasoning overlooks the role advertising plays in reinforcing and normalising behavior, however, and it assumes that only direct causal links merit regulatory attention. Ehrenberg's "weak" theory suggests advertising will support unhealthy eating behaviors, while the wide range of sales promotions employed will prompt trial and reward continued consumption. This article presents an alternative analysis of how marketing contributes to obesity and uses behavior modification theory to analyse the "fast-food" industry's promotions. We also review the New Zealand government's response to obesity and suggest policy interventions that would foster healthier eating behaviors.