Putting a price on healthy eating: public perceptions of the need for further food pricing policies in the UK.

BACKGROUND: Understand factors that influence food choice and explore public perceptions of the need for government policies to improve diets in the UK, particularly food pricing interventions. METHODS: A qualitative study design was used with semi-structured interviews. The study was carried out in Greater Manchester, England. In all, 15 participants from a diverse range of backgrounds were recruited. RESULTS: Food price, lack of time, availability, and food knowledge and culture were key factors that led some study participants towards unhealthy food choices. The UK's individual, willpower-focused approach to tackling obesity was deemed ineffective and many participants supported further government intervention. Product reformulation was supported as a less intrusive and less regressive way of improving diets than taxation. There was also support for increasing cooking classes within schools. CONCLUSIONS: Whilst the government ambition to half childhood obesity by 2030 is welcome, population level interventions that enable healthier food choices are needed to achieve this goal. Rising global food prices may make reformulation a more practical policy option than further pricing interventions. Mandatory reformulation of convenience meal and snack products and strengthening education in schools may represent a publicly acceptable and effective package of interventions within a comprehensive strategy to tackle obesity.

Universal or targeted cardiovascular screening? Modelling study using a sector-specific distributional cost effectiveness analysis.

Distributional cost effectiveness analysis is a new method that can help to redesign prevention programmes by explicitly modelling the distribution of health opportunity costs as well as the distribution of health benefits. Previously we modelled cardiovascular disease (CVD) screening audit data from Liverpool, UK to see if the city could redesign its cardiovascular screening programme to enhance its cost effectiveness and equity. Building on this previous analysis, we explicitly examined the distribution of health opportunity costs and we looked at new redesign options co-designed with stakeholders. We simulated four plausible scenarios: a) no CVD screening, b) 'current' basic universal CVD screening as currently implemented, c) enhanced universal CVD screening with 'increased' population-wide delivery, and d) 'universal plus targeted' with top-up delivery to the most deprived fifth. We also compared assumptions around whether displaced health spend would come from programmes that might benefit the poor more and how much health these programmes would generate. The main outcomes were net health benefit and change in the slope index of inequality (SII) in QALYs per 100,000 person years. 'Universal plus targeted' dominated 'increased' and 'current' and also reduced health inequality by -0.65 QALYs per 100,000 person years. Results are highly sensitive to assumptions about opportunity costs and, in particular, whether funding comes from health care or local government budgets. By analysing who loses as well as who gains from expenditure decisions, distributional cost effectiveness analysis can help decision makers to redesign prevention programmes in ways that improve health and reduce health inequality.

Future cost-effectiveness and equity of the NHS Health Check cardiovascular disease prevention programme: Microsimulation modelling using data from Liverpool, UK.

BACKGROUND: Aiming to contribute to prevention of cardiovascular disease (CVD), the National Health Service (NHS) Health Check programme has been implemented across England since 2009. The programme involves cardiovascular risk stratification-at 5-year intervals-of all adults between the ages of 40 and 74 years, excluding any with preexisting vascular conditions (including CVD, diabetes mellitus, and hypertension, among others), and offers treatment to those at high risk. However, the cost-effectiveness and equity of population CVD screening is contested. This study aimed to determine whether the NHS Health Check programme is cost-effective and equitable in a city with high levels of deprivation and CVD. METHODS AND FINDINGS: IMPACTNCD is a dynamic stochastic microsimulation policy model, calibrated to Liverpool demographics, risk factor exposure, and CVD epidemiology. Using local and national data, as well as drawing on health and social care disease costs and health-state utilities, we modelled 5 scenarios from 2017 to 2040: Scenario (A): continuing current implementation of NHS Health Check;Scenario (B): implementation 'targeted' toward areas in the most deprived quintile with increased coverage and uptake;Scenario (C): 'optimal' implementation assuming optimal coverage, uptake, treatment, and lifestyle change;Scenario (D): scenario A combined with structural population-wide interventions targeting unhealthy diet and smoking;Scenario (E): scenario B combined with the structural interventions as above. We compared all scenarios with a counterfactual of no-NHS Health Check. Compared with no-NHS Health Check, the model estimated cumulative incremental cost-effectiveness ratio (ICER) (discounted £/quality-adjusted life year [QALY]) to be 11,000 (95% uncertainty interval [UI] -270,000 to 320,000) for scenario A, 1,500 (-91,000 to 100,000) for scenario B, -2,400 (-6,500 to 5,700) for scenario C, -5,100 (-7,400 to -3,200) for scenario D, and -5,000 (-7,400 to -3,100) for scenario E. Overall, scenario A is unlikely to become cost-effective or equitable, and scenario B is likely to become cost-effective by 2040 and equitable by 2039. Scenario C is likely to become cost-effective by 2030 and cost-saving by 2040. Scenarios D and E are likely to be cost-saving by 2021 and 2023, respectively, and equitable by 2025. The main limitation of the analysis is that we explicitly modelled CVD and diabetes mellitus only. CONCLUSIONS: According to our analysis of the situation in Liverpool, current NHS Health Check implementation appears neither equitable nor cost-effective. Optimal implementation is likely to be cost-saving but not equitable, while targeted implementation is likely to be both. Adding structural policies targeting cardiovascular risk factors could substantially improve equity and generate cost savings.

Systematic review of dietary trans-fat reduction interventions.

OBJECTIVE: To systematically review published studies of interventions to reduce people's intake of dietary trans-fatty acids (TFAs). METHODS: We searched online databases (CINAHL, the CRD Wider Public Health database, Cochrane Database of Systematic Reviews, Ovid®, MEDLINE®, Science Citation Index and Scopus) for studies evaluating TFA interventions between 1986 and 2017. Absolute decrease in TFA consumption (g/day) was the main outcome measure. We excluded studies reporting only on the TFA content in food products without a link to intake. We included trials, observational studies, meta-analyses and modelling studies. We conducted a narrative synthesis to interpret the data, grouping studies on a continuum ranging from interventions targeting individuals to population-wide, structural changes. RESULTS: After screening 1084 candidate papers, we included 23 papers: 12 empirical and 11 modelling studies. Multiple interventions in Denmark achieved a reduction in TFA consumption from 4.5 g/day in 1976 to 1.5 g/day in 1995 and then virtual elimination after legislation banning TFAs in manufactured food in 2004. Elsewhere, regulations mandating reformulation of food reduced TFA content by about 2.4 g/day. Worksite interventions achieved reductions averaging 1.2 g/day. Food labelling and individual dietary counselling both showed reductions of around 0.8 g/day. CONCLUSION: Multicomponent interventions including legislation to eliminate TFAs from food products were the most effective strategy. Reformulation of food products and other multicomponent interventions also achieved useful reductions in TFA intake. By contrast, interventions targeted at individuals consistently achieved smaller reductions. Future prevention strategies should consider this effectiveness hierarchy to achieve the largest reductions in TFA consumption.

Systematic review of dietary salt reduction policies: Evidence for an effectiveness hierarchy?

BACKGROUND: Non-communicable disease (NCD) prevention strategies now prioritise four major risk factors: food, tobacco, alcohol and physical activity. Dietary salt intake remains much higher than recommended, increasing blood pressure, cardiovascular disease and stomach cancer. Substantial reductions in salt intake are therefore urgently needed. However, the debate continues about the most effective approaches. To inform future prevention programmes, we systematically reviewed the evidence on the effectiveness of possible salt reduction interventions. We further compared "downstream, agentic" approaches targeting individuals with "upstream, structural" policy-based population strategies. METHODS: We searched six electronic databases (CDSR, CRD, MEDLINE, SCI, SCOPUS and the Campbell Library) using a pre-piloted search strategy focussing on the effectiveness of population interventions to reduce salt intake. Retrieved papers were independently screened, appraised and graded for quality by two researchers. To facilitate comparisons between the interventions, the extracted data were categorised using nine stages along the agentic/structural continuum, from "downstream": dietary counselling (for individuals, worksites or communities), through media campaigns, nutrition labelling, voluntary and mandatory reformulation, to the most "upstream" regulatory and fiscal interventions, and comprehensive strategies involving multiple components. RESULTS: After screening 2,526 candidate papers, 70 were included in this systematic review (49 empirical studies and 21 modelling studies). Some papers described several interventions. Quality was variable. Multi-component strategies involving both upstream and downstream interventions, generally achieved the biggest reductions in salt consumption across an entire population, most notably 4g/day in Finland and Japan, 3g/day in Turkey and 1.3g/day recently in the UK. Mandatory reformulation alone could achieve a reduction of approximately 1.45g/day (three separate studies), followed by voluntary reformulation (-0.8g/day), school interventions (-0.7g/day), short term dietary advice (-0.6g/day) and nutrition labelling (-0.4g/day), but each with a wide range. Tax and community based counselling could, each typically reduce salt intake by 0.3g/day, whilst even smaller population benefits were derived from health education media campaigns (-0.1g/day). Worksite interventions achieved an increase in intake (+0.5g/day), however, with a very wide range. Long term dietary advice could achieve a -2g/day reduction under optimal research trial conditions; however, smaller reductions might be anticipated in unselected individuals. CONCLUSIONS: Comprehensive strategies involving multiple components (reformulation, food labelling and media campaigns) and "upstream" population-wide policies such as mandatory reformulation generally appear to achieve larger reductions in population-wide salt consumption than "downstream", individually focussed interventions. This 'effectiveness hierarchy' might deserve greater emphasis in future NCD prevention strategies.

Food for thought? Potential conflicts of interest in academic experts advising government and charities on dietary policies.

BACKGROUND: A conflict of interest (CoI) can occur between public duty and private interest, in which a public official's private-capacity interest could improperly influence the performance of their official duties and responsibilities. The most tangible and commonly considered CoI are financial. However, CoI can also arise due to other types of influence including interpersonal relationships, career progression, or ideology. CoI thus exist in academia, business, government and non-governmental organisations. However, public knowledge of CoI is currently limited due to a lack of information. The mechanisms of managing potential conflicts of interest also remain unclear due to a lack of guidelines. We therefore examined the independence of academic experts and how well potential CoI are identified and addressed in four government and non-governmental organisations in the UK responsible for the development of food policy. METHODS: Policy analysis. We developed an analytical framework to explore CoI in high-level UK food policy advice, using four case studies. Two government policy-making bodies: Department of Health 'Obesity Review Group' (ORG), 'Scientific Advisory Committee on Nutrition' (SACN) and two charities: 'Action on Sugar' (AoS), & 'Heart of Mersey' (HoM). Information was obtained from publicly available sources and declarations. We developed a five point ordinal scale based upon the ideology of the Nolan Principles of Public Life. Group members were individually categorised on the ordinal ConScale from "0", (complete independence from the food and drink industry) to "4", (employed by the food and drink industry or a representative organisation). RESULTS: CoI involving various industries have long been evident in policy making, academia and clinical practice. Suggested approaches for managing CoI could be categorised as "deny", "describe", or "diminish". Declared CoI were common in the ORG and SACN. 4 out of 28 ORG members were direct industry employees. In SACN 11 out of 17 members declared industry advisory roles or industry research funding. The two charities appeared to have equally strong academic expertise but fewer conflicts. No HoM members declared CoI. 5 out of 21 AoS members declared links with industry, mainly pharmaceutical companies. We were unable to obtain information on conflicts for some individuals. CONCLUSIONS: Conflicts of interest are unavoidable but potentially manageable. Government organisations responsible for policy development and implementation must institutionalize an approach to identify (disclose) and manage (mitigate or eliminate) perceived and actual CoI to improve public confidence in government decision-making relevant to food policy.

Sugar-sweetened beverages coverage in the British media: an analysis of public health advocacy versus pro-industry messaging.

OBJECTIVES: To assess the extent of media-based public health advocacy versus pro-industry messaging regarding sugar-sweetened beverages (SSBs). DESIGN: We conducted a systematic analysis to identify and examine all articles regarding SSBs published in all mainstream British print newspapers and their online news websites from 1 January 2014 to 31 December 2014. We initially conducted a brief literature search to develop appropriate search terms and categorisations for grouping and analysing the articles. Articles were then coded according to the publishing newspaper, article type, topic, prominence and slant (pro-SSB or anti-SSB). A contextual analysis was undertaken to examine key messages in the articles. RESULTS: We identified 374 articles published during 2014. The majority of articles (81%) suggested that SSBs are unhealthy. Messaging from experts, campaign groups and health organisations was fairly consistent about the detrimental effects of SSB on health. However, relatively few articles assessed any approaches or solutions to potentially combat the problems associated with SSBs. Only one-quarter (24%) suggested any policy change. Meanwhile, articles concerning the food industry produced consistent messages emphasising consumer choice and individual responsibility for making choices regarding SSB consumption, and promoting and advertising their products. The food industry thus often managed to avoid association with the negative press that their products were receiving. CONCLUSIONS: SSBs were frequently published in mainstream British print newspapers and their online news websites during 2014. Public health media advocacy was prominent throughout, with a growing consensus that sugary drinks are bad for people's health. However, the challenge for public health will be to mobilise supportive public opinion to help implement effective regulatory policies. Only then will our population's excess consumption of SSBs come under control.

How much sugar is hidden in drinks marketed to children? A survey of fruit juices, juice drinks and smoothies.

OBJECTIVE: To investigate the amount of sugars in fruit juices, juice drinks and smoothies (FJJDS) marketed to children. DESIGN: We surveyed the sugars content (per 100 ml and standardised 200 ml portion) of all FJJDS sold by seven major UK supermarkets (supermarket own and branded products). Only products specifically marketed towards children were included. We excluded sports drinks, iced teas, sugar-sweetened carbonated drinks and cordials as being not specifically marketed towards children. RESULTS: We identified 203 fruit juices (n=21), juice drinks (n=158) and smoothies (n=24) marketed to children. Sugars content ranged from 0 to 16 g/100 ml. The mean sugars content was 7.0 g/100 ml, but among the 100% fruit juice category, it was 10.7 g/100 ml. Smoothies (13.0 g/100 ml) contained the highest amounts of sugars and juice drinks (5.6 g/100 ml) contained the lowest amount. 117 of the 203 FJJDS surveyed would receive a Food Standards Agency 'red' colour-coded label for sugars per standardised 200 ml serving. Only 63 FJJDS would receive a 'green' colour-coded label. 85 products contained at least 19 g of sugars-a child's entire maximum daily amount of sugars. 57 products contained sugar (sucrose), 65 contained non-caloric sweeteners and five contained both. Seven products contained glucose-fructose syrup. CONCLUSIONS: The sugars content in FJJDS marketed to children in the UK is unacceptably high. Manufacturers must stop adding unnecessary sugars and calories to their FJJDS.

The Health Equity and Effectiveness of Policy Options to Reduce Dietary Salt Intake in England: Policy Forecast.

BACKGROUND: Public health action to reduce dietary salt intake has driven substantial reductions in coronary heart disease (CHD) over the past decade, but avoidable socio-economic differentials remain. We therefore forecast how further intervention to reduce dietary salt intake might affect the overall level and inequality of CHD mortality. METHODS: We considered English adults, with socio-economic circumstances (SEC) stratified by quintiles of the Index of Multiple Deprivation. We used IMPACTSEC, a validated CHD policy model, to link policy implementation to salt intake, systolic blood pressure and CHD mortality. We forecast the effects of mandatory and voluntary product reformulation, nutrition labelling and social marketing (e.g., health promotion, education). To inform our forecasts, we elicited experts' predictions on further policy implementation up to 2020. We then modelled the effects on CHD mortality up to 2025 and simultaneously assessed the socio-economic differentials of effect. RESULTS: Mandatory reformulation might prevent or postpone 4,500 (2,900-6,100) CHD deaths in total, with the effect greater by 500 (300-700) deaths or 85% in the most deprived than in the most affluent. Further voluntary reformulation was predicted to be less effective and inequality-reducing, preventing or postponing 1,500 (200-5,000) CHD deaths in total, with the effect greater by 100 (-100-600) deaths or 49% in the most deprived than in the most affluent. Further social marketing and improvements to labelling might each prevent or postpone 400-500 CHD deaths, but minimally affect inequality. CONCLUSIONS: Mandatory engagement with industry to limit salt in processed-foods appears a promising and inequality-reducing option. For other policy options, our expert-driven forecast warns that future policy implementation might reach more deprived individuals less well, limiting inequality reduction. We therefore encourage planners to prioritise equity.

Modelling the Health Impact of an English Sugary Drinks Duty at National and Local Levels.

BACKGROUND: Increasing evidence associates excess refined sugar intakes with obesity, Type 2 diabetes and heart disease. Worryingly, the estimated volume of sugary drinks purchased in the UK has more than doubled between 1975 and 2007, from 510 ml to 1140 ml per person per week. We aimed to estimate the potential impact of a duty on sugar sweetened beverages (SSBs) at a local level in England, hypothesising that a duty could reduce obesity and related diseases. METHODS AND FINDINGS: We modelled the potential impact of a 20% sugary drinks duty on local authorities in England between 2010 and 2030. We synthesised data obtained from the British National Diet and Nutrition Survey (NDNS), drinks manufacturers, Office for National Statistics, and from previous studies. This produced a modelled population of 41 million adults in 326 lower tier local authorities in England. This analysis suggests that a 20% SSB duty could result in approximately 2,400 fewer diabetes cases, 1,700 fewer stroke and coronary heart disease cases, 400 fewer cancer cases, and gain some 41,000 Quality Adjusted Life Years (QALYs) per year across England. The duty might have the biggest impact in urban areas with young populations. CONCLUSIONS: This study adds to the growing body of evidence suggesting health benefits for a duty on sugary drinks. It might also usefully provide results at an area level to inform local price interventions in England.

Are interventions to promote healthy eating equally effective for all? Systematic review of socioeconomic inequalities in impact.

BACKGROUND: Interventions to promote healthy eating make a potentially powerful contribution to the primary prevention of non communicable diseases. It is not known whether healthy eating interventions are equally effective among all sections of the population, nor whether they narrow or widen the health gap between rich and poor. We undertook a systematic review of interventions to promote healthy eating to identify whether impacts differ by socioeconomic position (SEP). METHODS: We searched five bibliographic databases using a pre-piloted search strategy. Retrieved articles were screened independently by two reviewers. Healthier diets were defined as the reduced intake of salt, sugar, trans-fats, saturated fat, total fat, or total calories, or increased consumption of fruit, vegetables and wholegrain. Studies were only included if quantitative results were presented by a measure of SEP. Extracted data were categorised with a modified version of the "4Ps" marketing mix, expanded to 6 "Ps": "Price, Place, Product, Prescriptive, Promotion, and Person". RESULTS: Our search identified 31,887 articles. Following screening, 36 studies were included: 18 "Price" interventions, 6 "Place" interventions, 1 "Product" intervention, zero "Prescriptive" interventions, 4 "Promotion" interventions, and 18 "Person" interventions. "Price" interventions were most effective in groups with lower SEP, and may therefore appear likely to reduce inequalities. All interventions that combined taxes and subsidies consistently decreased inequalities. Conversely, interventions categorised as "Person" had a greater impact with increasing SEP, and may therefore appear likely to reduce inequalities. All four dietary counselling interventions appear likely to widen inequalities. We did not find any "Prescriptive" interventions and only one "Product" intervention that presented differential results and had no impact by SEP. More "Place" interventions were identified and none of these interventions were judged as likely to widen inequalities. CONCLUSIONS: Interventions categorised by a "6 Ps" framework show differential effects on healthy eating outcomes by SEP. "Upstream" interventions categorised as "Price" appeared to decrease inequalities, and "downstream" "Person" interventions, especially dietary counselling seemed to increase inequalities. However the vast majority of studies identified did not explore differential effects by SEP. Interventions aimed at improving population health should be routinely evaluated for differential socioeconomic impact.

Smorgasbord or symphony? Assessing public health nutrition policies across 30 European countries using a novel framework.

BACKGROUND: Countries across Europe have introduced a wide variety of policies to improve nutrition. However, the sheer diversity of interventions represents a potentially bewildering smorgasbord. We aimed to map existing public health nutrition policies, and examine their perceived effectiveness, in order to inform future evidence-based diet strategies. METHODS: We created a public health nutrition policy database for 30 European countries. National nutrition policies were classified and assigned using the marketing "4 Ps" approach Product (reformulation, elimination, new healthier products); Price (taxes, subsidies); Promotion (advertising, food labelling, health education) and Place (schools, workplaces, etc.). We interviewed 71 senior policy-makers, public health nutrition policy experts and academics from 14 of the 30 countries, eliciting their views on diverse current and possible nutrition strategies. RESULTS: Product Voluntary reformulation of foods is widespread but has variable and often modest impact. Twelve countries regulate maximum salt content in specific foods. Denmark, Austria, Iceland and Switzerland have effective trans fats bans. Price EU School Fruit Scheme subsidies are almost universal, but with variable implementation.Taxes are uncommon. However, Finland, France, Hungary and Latvia have implemented 'sugar taxes' on sugary foods and sugar-sweetened beverages. Finland, Hungary and Portugal also tax salty products. Promotion Dialogue, recommendations, nutrition guidelines, labelling, information and education campaigns are widespread. Restrictions on marketing to children are widespread but mostly voluntary. Place Interventions reducing the availability of unhealthy foods were most commonly found in schools and workplace canteens. Interviewees generally considered mandatory reformulation more effective than voluntary, and regulation and fiscal interventions much more effective than information strategies, but also politically more challenging. CONCLUSIONS: Public health nutrition policies in Europe appear diverse, dynamic, complex and bewildering. The "4 Ps" framework potentially offers a structured and comprehensive categorisation. Encouragingly, the majority of European countries are engaged in activities intended to increase consumption of healthy food and decrease the intake of "junk" food and sugary drinks. Leading countries include Finland, Norway, Iceland, Denmark, Hungary, Portugal and perhaps the UK. However, all countries fall short of optimal activities. More needs to be done across Europe to implement the most potentially powerful fiscal and regulatory nutrition policies.

Perceptions of tuberculosis and health seeking behaviour in rural Inner Mongolia, China.

PURPOSE: This study aimed to explore perceptions of TB, and health care seeking pathways, among poor rural communities in Inner Mongolia. METHODOLOGY: Twenty focus group discussions (FGDs) were held and 105 farmers were included. Six hundred and fourteen randomly selected respondents were surveyed through interview questionnaire, in three poor rural counties with a high TB prevalence. MAIN FINDINGS: A substantial proportion of community members were unclear or misinformed as to how TB was transmitted. Sixty percent of respondents identified prolonged cough as a main symptom of TB, while only 40% perceived TB to be caused by 'close interaction with TB patient'. In addition, 70% could not afford TB treatment and fell into debt as a result of having to seek medical care. Social stigma associated with TB influenced marriage prospects and impeded important social interactions within the community. Respondents' perceptions of TB were associated with their socio-economic status. Women, young people, low-income groups and those with less education tended to be less knowledgeable about TB. All farmers in the study reported only seeking health care after they failed to treat themselves; and most of them then sought care from less qualified village level health care providers. Less educated people, low-income groups and old people were identified as less likely to seek care, or more likely to seek care at village level where it is cheaper. Both financial and structural barriers were found to stop farmers seeking health care. CONCLUSIONS AND POLICY IMPLICATIONS: Perceptions of TB and social stigma associated with the disease, together with socio-economic factors, shape the health seeking behaviour of poor farmers. Accessibility and affordability of TB health care issues should be dealt with through a multi-pronged approach, including health promotion in addition to expansion of the DOTS strategy and rural health insurance schemes.