Global Coverage and Design of Sugar-Sweetened Beverage Taxes.

Importance: Sugar-sweetened beverage (SSB) taxes are gaining in popularity. The lack of a comprehensive repository of standardized data on SSB taxes and their designs, however, has stymied understanding of current practice in SSB taxes. Objective: To assess the coverage and design of SSB taxes worldwide using the new Global SSB Tax Database. Evidence Review: Sugar-sweetened beverage taxes were collated from existing data sources, hand-searching of peer-reviewed and gray literature, and an internet search. Relevant legislation was identified to verify each tax and extract data on designs. Findings: A total of 118 taxes were verified, including 105 national and 13 subnational taxes. National SSB taxes are in effect in 103 countries and territories, covering 51% of the world's population. A total of 67% of people living in low-income and 73% in lower-middle-income economies are covered by national SSB taxes, compared with 29% in upper-middle-income and high-income economies. National SSB taxes cover 98% of the population in South Asia compared with only 10% in East Asia and the Pacific. Most SSB taxes are excise taxes (104 of 118 [88%]). Excise taxes in high-income economies are mostly specific (27 of 36 [75%]), whereas ad valorem and mixed taxes are more common in low- and middle-income economies (36 of 66 [55%]). Most specific excise taxes are based on volume only (54 of 59 [92%]), with just 3 jurisdictions applying purely sugar-specific excise taxes. More than half of excise taxes worldwide (55 of 104 [53%]) apply tiered rates, with tiers more commonly defined by beverage type (41 of 55 [75%]) than by sugar content (18 of 55 [33%]). Tiers defined by sugar content are mainly used in high-income countries (13 of 18 [72%]) and Europe and Central Asia (10 of 18 [56%]). Almost one-third of excise taxes worldwide (30 of 104 [29%]) and almost half of excise taxes in low- and middle-income economies (28 of 66 [42%]) apply to unsweetened bottled water. Conclusions and Relevance: This study provides a comprehensive review of global coverage and design of SSB taxes. Sugar-sweetened beverage tax coverage is higher than previously reported, with clear differences in designs between regions and income groups. These findings can inform a more empirically grounded approach to SSB tax guidance.

Nutritional marketing of plant-based meat-analogue products: an exploratory study of front-of-pack and website claims in the USA.

OBJECTIVE: To explore how some of the largest food companies involved in producing alternative proteins (AP) use health and nutrition claims to market their products. DESIGN: We identified the largest food manufacturers, meat processors and AP companies selling plant-based AP products in the USA. Using publicly available data, we analysed the voluntary health and nutrition claims made on front-of-pack labels (FOPL) and company webpages. We also analysed company websites for further nutrition and health-related statements about their products or AP more generally. Claim classification was guided by the INFORMAS (International Network for Food and Obesity/Non-Communicable Diseases Research, Monitoring, and Action Support) taxonomy for health-related food labelling. SETTING: USA. PARTICIPANTS: Not applicable. RESULTS: 1394 health and nutrition-related FOPL claims were identified on 216 products, including 685 nutrition claims and 709 'other health-related' claims. No FOPL health claims were identified. Most nutrient claims were for nutrients associated with meat, with 94 % of products carrying a protein claim and 30 % carrying a cholesterol claim. 74 % of products carried a GMO-free claim, and 63 % carried a plant-based claim. On their websites, some companies expanded on these claims or discussed the health benefits of specific ingredients. CONCLUSIONS: Companies involved in this category appear to be using nutritional marketing primarily to position their products in relation to meat. There is a focus on nutrient and ingredient claims, with discussion of processing largely avoided. The findings highlight the challenges companies face in positioning AP products as healthy against the backdrop of debates about ultra-processed foods.

Addressing inequities in healthy eating.

What, when, where and how much people eat is influenced by a complex mix of factors at societal, community and individual levels. These influences operate both directly through the food system and indirectly through political, economic, social and cultural pathways that cause social stratification and influence the quality of conditions in which people live their lives. These factors are the social determinants of inequities in healthy eating. This paper provides an overview of the current evidence base for addressing these determinants and for the promotion of equity in healthy eating.

Will the next generation of preferential trade and investment agreements undermine prevention of noncommunicable diseases? A prospective policy analysis of the Trans Pacific Partnership Agreement.

The Trans Pacific Partnership Agreement (TPPA) is one of a new generation of 'deep' preferential trade and investment agreements that will extend many of the provisions seen in previous agreements. This paper presents a prospective policy analysis of the likely text of the TPPA, with reference to nutrition policy space. Specifically, we analyse how the TPPA may constrain governments' policy space to implement the 'policy options for promoting a healthy diet' in the World Health Organization's Global Action Plan for Prevention and Control of Noncommunicable Diseases (NCDs) 2013-2020. This policy analysis suggests that if certain binding commitments are made under the TPPA, they could constrain the ability of governments to protect nutrition policy from the influence of vested interests, reduce the range of interventions available to actively discourage consumption of less healthy food (and to promote healthy food) and limit governments' capacity to implement these interventions, and reduce resources available for nutrition education initiatives. There is scope to protect policy space by including specific exclusions and/or exceptions during negotiation of trade and investment agreements like the TPPA, and by strengthening global health frameworks for nutrition to enable them to be used as reference during disputes in trade fora.

Trade policy and public health.

Twenty-first-century trade policy is complex and affects society and population health in direct and indirect ways. Without doubt, trade policy influences the distribution of power, money, and resources between and within countries, which in turn affects the natural environment; people's daily living conditions; and the local availability, quality, affordability, and desirability of products (e.g., food, tobacco, alcohol, and health care); it also affects individuals' enjoyment of the highest attainable standard of health. In this article, we provide an overview of the modern global trade environment, illustrate the pathways between trade and health, and explore the emerging twenty-first-century trade policy landscape and its implications for health and health equity. We conclude with a call for more interdisciplinary research that embraces complexity theory and systems science as well as the political economy of health and that includes monitoring and evaluation of the impact of trade agreements on health.

Australian print news media coverage of sweet, non-alcoholic drinks sends mixed health messages.

OBJECTIVE: This study aimed to analyse the contribution of Australian print news coverage to the public profile of sweet, non-alcoholic beverages. News media portrayal of health contributes to individuals' decision-making. The focus on sugar-sweetened beverages reflects their contribution to excessive energy intake. METHODS: One year's coverage of sweet, non-alcoholic beverages by major Australian newspapers was analysed using content and frame analysis. Research questions addressed which sweet drinks are most prominently covered, what makes sweet drinks newsworthy and how are the health aspects of sweet drinks framed? RESULTS: Fruit juice was the most widely covered sweet drink, closely followed by carbonated, sugar-sweetened soft drinks. Overall coverage was positively oriented towards sweet drinks, with fruit juice primarily portrayed as having health benefits. Some coverage mentioned risks of sweet drinks, such as obesity, tooth decay, metabolic syndrome and heart attack. CONCLUSIONS: Sweet drinks often enjoy positive coverage, with their health benefits and harms central to their ability to attract journalists' attention. However, the mix of coverage may be contributing to consumer confusion about whether it is safe and/or healthy to consume sweet non-alcoholic drinks. IMPLICATIONS: Framing of sweet drinks as healthy may undermine efforts to encourage individuals to avoid excess consumption of energy-dense drinks which offer few or minimal health benefits.

Climate change adaptation at the intersection of food and health.

Nutritious, safe, affordable, and enjoyable food is a fundamental prerequisite for health. As a nation, Australia is currently classified as food secure with the domestic production exceeding domestic consumption of most major food groups. The domestic system is almost self-sufficient in terms of nutritious plant foods, although these foods have seen steady higher price increases relative to other foods, with nutrition equity implications. However, the viability of Australia's food security sits counter to the continued presence of a stable and supportive climate. This article reviews the current state of science concerning the interface between climate change, food systems, and human health to reveal the key issues that must be addressed if Australia is to advance human health and sustainable food systems under a changing climate.

Opening up Australian preschoolers' lunchboxes.

OBJECTIVE: Early childhood services have been identified as key settings for promoting healthy eating and obesity prevention. However, little is known about the obesity-related behaviours of preschool-aged children or food-related policies in these settings. The purpose of this study was to describe the contents of preschoolers' lunchboxes to inform future interventions. METHODS: Cross-sectional survey of 259 children attending preschools in the Sydney West and Sydney South West regions of New South Wales in 2008. Lunchbox data were collected using a purpose-designed audit tool. Food and beverages were classified as fruit, vegetables, dairy, breads and cereals, 'extra' (energy-dense) foods, 'extra' drinks or water. RESULTS: Sandwiches and home-cooked meals were the most frequently identified food item, found in 92% of children's lunchboxes, followed by fresh fruit. However, 60% of lunchboxes contained more than one serve of extra food or drink. CONCLUSION: While nutrition guidelines allow one to two serves of extra foods per day for preschool-aged children, the majority of children appear to consume most of this allocation during their school day, potentially contributing to over-consumption of extra foods and excess kilojoule intake. IMPLICATIONS: Preschool food policies may help to guide the content of children's lunchboxes, however this study emphasises the need for better communication and enforcement of these policies, as well as broader public policy changes.

Adolescent-parent interactions and communication preferences regarding body weight and weight management: a qualitative study.

BACKGROUND: This study aimed to canvass the nature of adolescent-parent interactions about weight, particularly overweight, and to explore ideas of how to foster supportive discussions regarding weight, both in the home and with family doctors. METHODS: A market research company was contracted to recruit and conduct a series of separate focus groups with adolescents and unrelated parents of adolescents from low-middle socio-economic areas in Sydney and a regional centre, Australia. Group discussions were audio recorded, transcribed, and then a qualitative content analysis of the data was performed. RESULTS: Nine focus groups were conducted; two were held with girls (n = 13), three with boys (n = 18), and four with parents (20 mothers, 12 fathers). Adolescent and parent descriptions of weight-related interactions could be classified into three distinct approaches: indirect/cautious (i.e. focus on eating or physical activity behaviors without discussing weight specifically); direct/open (i.e. body weight was discussed); and never/rarely discussing the subject. Indirect approaches were described most frequently by both adolescents and parents and were generally preferred over direct approaches. Parents and adolescents were circumspect but generally supportive of the potential role for family doctors to monitor and discuss adolescent weight status. CONCLUSIONS: These findings have implications for developing acceptable messages for adolescent and family overweight prevention and treatment interventions.

Adolescent-parent interactions and attitudes around screen time and sugary drink consumption: a qualitative study.

BACKGROUND: Little is known about how adolescents and their parents interact and talk about some of the key lifestyle behaviors that are associated with overweight and obesity, such as screen time (ST) and sugary drink (SD) consumption. This qualitative study aimed to explore adolescents' and parents' perceptions, attitudes, and interactions in regards to these topics. METHODS: Using an exploratory approach, semi-structured focus groups were conducted separately with adolescents and (unrelated) parents. Participants were recruited from low and middle socio-economic areas in the Sydney metropolitan area and a regional area of New South Wales, Australia. Transcripts were analysed using thematic analysis for each of the four content areas (adolescent-ST, adolescent-SD consumption, parents' views on adolescents' ST and parents' views on adolescents' SD consumption). RESULTS: Nine focus groups, with a total of 63 participants, were conducted. Broad themes spanned all groups: patterns of behavior; attitudes and concerns; adolescent-parent interactions; strategies for behavior change; and awareness of ST guidelines. While parents and adolescents described similar patterns of behaviour in relation to adolescents' SD consumption and ST, there were marked differences in their attitudes to these two behaviours which were also evident in the adolescent-parent interactions in the home that they described. Parents felt able to limit adolescents' access to SDs, but felt unable to control their adolescents' screen time. CONCLUSION: This study offers unique insights regarding topics rarely explored with parents or adolescents, yet which are part of everyday family life, are known to be linked to risk of weight gain, and are potentially amenable to change.

Functional foods and urban agriculture: two responses to climate change-related food insecurity.

Affluent diets have negative effects on the health of the population and the environment. Moreover, the ability of industrialised agricultural ecosystems to continue to supply these diets is threatened by the anticipated consequences of climate change. By challenging the ongoing supply the diets of affluent countries, climate change provides a population and environmental health opportunity. This paper contrasts two strategies for dealing with climate change-related food insecurity. Functional foods are being positioned as one response because they are considered a hyper-efficient mechanism for supplying essential micronutrients. An alternative response is civic and urban agriculture. Rather than emphasising increased economic or nutritional efficiencies, civic agriculture presents a holistic approach to food security that is more directly connected to the economic, environmental and social factors that affect diet and health.

Determinants and patterns of soft drink consumption in young adults: a qualitative analysis.

OBJECTIVE: To explore knowledge, attitudes and behaviours regarding caloric soft drinks in a group of young adults attending university and to identify opportunities for a health promotion intervention aimed at reducing consumption. DESIGN: In-depth, semi-structured focus groups segmented by gender. SETTING: Sydney, Australia. SUBJECTS: Undergraduate University of Sydney students aged 18-30 years (n 35). RESULTS: Social and environmental cues, intrinsic qualities of beverages and personal health beliefs were identified as important influences on consumption. Social cues included settings in which alcohol is usually consumed, socialising with friends, and family influences. Environmental cues included purchasing of fast foods, and ready availability, preferential pricing and promotion of caloric beverages. Reinforcing intrinsic qualities of caloric soft drinks included taste, sugar and caffeine content, and their association with treats and rewards. Major gender differences as well as variations in individual readiness for behaviour change were observed. Raising awareness of the sugar content of various beverages and the potential health impacts associated with their consumption was considered important. CONCLUSIONS: The findings provide new insights with important implications for policy and practice, and suggest that there is considerable scope for promoting awareness in this group. Carefully designed social marketing campaigns highlighting the health issues and addressing social and environmental cues relating to caloric soft drink consumption are required. There is a need for gender-differentiated intervention programmes which are both informational and appealing to young adults. Further research is warranted, particularly to investigate beverage consumption relating to fast-food meal deals and young adults' consumption patterns in more depth.

Persuasive food marketing to children: use of cartoons and competitions in Australian commercial television advertisements.

While there is a recognized link between high levels of exposure to advertising of unhealthy foods and overweight and obesity among children, there is little research on the extent to which these exposures include persuasive marketing techniques. This study aimed to measure children's exposure to the use of persuasive marketing within television food advertisements. Advertisements broadcast on all three commercial Australian television channels were recorded for an equivalent 1 week period in May 2006 and 2007 (714 h). Food advertisements were analysed for their use of persuasive marketing, including premium offers, such as competitions, and the use of promotional characters, including celebrities and cartoon characters. Advertised foods were categorized as core, non-core or miscellaneous foods. Commercial data were purchased to determine children's peak viewing times and popular programs. A total of 20 201 advertisements were recorded, 25.5% of which were for food. Significantly more food advertisements broadcast during children's peak viewing times, compared to non-peak times, contained promotional characters (P < 0.05) and premium offers (P < 0.001). During programs most popular with children, there were 3.3 non-core food advertisements per hour containing premium offers, compared to 0.2 per hour during programs most popular with adults. The majority of advertisements containing persuasive marketing during all viewing periods were for non-core foods. Persuasive marketing techniques are frequently used to advertise non-core foods to children, to promote children's brand recognition and preference for advertised products. Future debate relating to television advertising regulations must consider the need to restrict the use of persuasive marketing techniques to children.