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. 2020 Apr 9;4(4):CD012333.
doi: 10.1002/14651858.CD012333.pub2.

Taxation of unprocessed sugar or sugar-added foods for reducing their consumption and preventing obesity or other adverse health outcomes

Manuela Pfinder  1   2   3 , Thomas L Heise  3   4 , Michele Hilton Boon  5 , Frank Pega  6 , Candida Fenton  7 , Ursula Griebler  8 , Gerald Gartlehner  8 , Isolde Sommer  8 , Srinivasa Vittal Katikireddi  5 , Stefan K Lhachimi  4   9
Affiliations

Taxation of unprocessed sugar or sugar-added foods for reducing their consumption and preventing obesity or other adverse health outcomes

Manuela Pfinder et al. Cochrane Database Syst Rev. .

Abstract
in English, German

Background: Global prevalence of overweight and obesity are alarming. For tackling this public health problem, preventive public health and policy actions are urgently needed. Some countries implemented food taxes in the past and some were subsequently abolished. Some countries, such as Norway, Hungary, Denmark, Bermuda, Dominica, St. Vincent and the Grenadines, and the Navajo Nation (USA), specifically implemented taxes on unprocessed sugar and sugar-added foods. These taxes on unprocessed sugar and sugar-added foods are fiscal policy interventions, implemented to decrease their consumption and in turn reduce adverse health-related, economic and social effects associated with these food products.

Objectives: To assess the effects of taxation of unprocessed sugar or sugar-added foods in the general population on the consumption of unprocessed sugar or sugar-added foods, the prevalence and incidence of overweight and obesity, and the prevalence and incidence of other diet-related health outcomes.

Search methods: We searched CENTRAL, Cochrane Database of Systematic Reviews, MEDLINE, Embase and 15 other databases and trials registers on 12 September 2019. We handsearched the reference list of all records of included studies, searched websites of international organisations and institutions, and contacted review advisory group members to identify planned, ongoing or unpublished studies.

Selection criteria: We included studies with the following populations: children (0 to 17 years) and adults (18 years or older) from any country and setting. Exclusion applied to studies with specific subgroups, such as people with any disease who were overweight or obese as a side-effect of the disease. The review included studies with taxes on or artificial increases of selling prices for unprocessed sugar or food products that contain added sugar (e.g. sweets, ice cream, confectionery, and bakery products), or both, as intervention, regardless of the taxation level or price increase. In line with Cochrane Effective Practice and Organisation of Care (EPOC) criteria, we included randomised controlled trials (RCTs), cluster-randomised controlled trials (cRCTs), non-randomised controlled trials (nRCTs), controlled before-after (CBA) studies, and interrupted time series (ITS) studies. We included controlled studies with more than one intervention or control site and ITS studies with a clearly defined intervention time and at least three data points before and three after the intervention. Our primary outcomes were consumption of unprocessed sugar or sugar-added foods, energy intake, overweight, and obesity. Our secondary outcomes were substitution and diet, expenditure, demand, and other health outcomes.

Data collection and analysis: Two review authors independently screened all eligible records for inclusion, assessed the risk of bias, and performed data extraction.Two review authors independently assessed the certainty of the evidence using the GRADE approach.

Main results: We retrieved a total of 24,454 records. After deduplicating records, 18,767 records remained for title and abstract screening. Of 11 potentially relevant studies, we included one ITS study with 40,210 household-level observations from the Hungarian Household Budget and Living Conditions Survey. The baseline ranged from January 2008 to August 2011, the intervention was implemented on September 2011, and follow-up was until December 2012 (16 months). The intervention was a tax - the so-called 'Hungarian public health product tax' - on sugar-added foods, including selected foods exceeding a specific sugar threshold value. The intervention includes co-interventions: the taxation of sugar-sweetened beverages (SSBs) and of foods high in salt or caffeine. The study provides evidence on the effect of taxing foods exceeding a specific sugar threshold value on the consumption of sugar-added foods. After implementation of the Hungarian public health product tax, the mean consumption of taxed sugar-added foods (measured in units of kg) decreased by 4.0% (standardised mean difference (SMD) -0.040, 95% confidence interval (CI) -0.07 to -0.01; very low-certainty evidence). The study was at low risk of bias in terms of performance bias, detection bias and reporting bias, with the shape of effect pre-specified and the intervention unlikely to have any effect on data collection. The study was at unclear risk of attrition bias and at high risk in terms of other bias and the independence of the intervention. We rated the certainty of the evidence as very low for the primary and secondary outcomes. The Hungarian public health product tax included a tax on sugar-added foods but did not include a tax on unprocessed sugar. We did not find eligible studies reporting on the taxation of unprocessed sugar. No studies reported on the primary outcomes of consumption of unprocessed sugar, energy intake, overweight, and obesity. No studies reported on the secondary outcomes of substitution and diet, demand, and other health outcomes. No studies reported on differential effects across population subgroups. We could not perform meta-analyses or pool study results.

Authors' conclusions: There was very limited evidence and the certainty of the evidence was very low. Despite the reported reduction in consumption of taxed sugar-added foods, we are uncertain whether taxing unprocessed sugar or sugar-added foods has an effect on reducing their consumption and preventing obesity or other adverse health outcomes. Further robustly conducted studies are required to draw concrete conclusions on the effectiveness of taxing unprocessed sugar or sugar-added foods for reducing their consumption and preventing obesity or other adverse health outcomes.

Hintergrund: Die weltweite Prävalenz von Übergewicht und Adipositas ist alarmierend. Um diesem Public Health Problem zu begegnen, sind präventive Public Health‐ sowie politische Maßnahmen dringend erforderlich. In einigen Ländern wurden in der Vergangenheit Lebensmittelsteuern eingeführt, von denen manche jedoch bereits wieder abgeschafft wurden. Einige Länder wie Norwegen, Ungarn, Dänemark, Bermuda, Dominica, St. Vincent und die Grenadinen, sowie das Navajo Nation Reservat (USA) haben spezielle Steuern auf unverarbeiteten Zucker und/oder Lebensmittel mit zugesetztem Zucker eingeführt. Diese Steuern auf unverarbeiteten Zucker und Lebensmittel mit zugesetztem Zucker sind fiskalpolitische Interventionen, die eingeführt wurden, um deren Konsum zu verringern und damit wiederum die negativen gesundheitlichen, wirtschaftlichen und sozialen Folgen zu reduzieren.

Ziele: Ziel dieses Reviews war es, die Wirksamkeit einer Besteuerung von unverarbeitetem Zucker oder von Lebensmitteln mit zugesetztem Zucker in der Allgemeinbevölkerung hinsichtlich folgender Endpunkte zu beurteilen: Konsum von unverarbeitetem Zucker oder mit Zucker versetzten Lebensmitteln, Prävalenz und Inzidenz von Übergewicht und Adipositas sowie Prävalenz und Inzidenz anderer ernährungsbedingter Gesundheitsfolgen.

Literatursuche: Am 12. September 2019 durchsuchten wir CENTRAL, die Cochrane Database of Systematic Reviews, MEDLINE, Embase und 15 weitere Datenbanken und Studienregister. Wir durchsuchten händisch die Referenzlisten aller eingeschlossenen Studien. Wir durchsuchten Websites internationaler Organisationen und Institutionen und nahmen Kontakt mit den Mitgliedern des Beratungsgremiums dieses Reviews auf, um geplante, laufende oder unveröffentlichte Studien zu identifizieren.

Auswahlkriterien: Wir schlossen Studien mit den folgenden Populationen ein: Kinder (0 bis 17 Jahre) und Erwachsene (18 Jahre oder älter) aller Länder und Settings. Ausgeschlossen wurden Studien mit spezifischen Subgruppen, wie z.B. Menschen mit einer Krankheit, die Übergewicht und Adipositas als Nebenwirkungen aufweisen. Der Review schloss Studien ein, die Steuern auf Verkaufspreise oder deren künstlichen Anhebung Verkaufspreise von unverarbeitetem Zucker oder Lebensmittel mit zugesetztem Zucker (z.B. Süßigkeiten, Speiseeis, Süß‐ und Backwaren) oder beide Formen als Intervention beinhalten. Dies geschah unabhängig vom Steuersatz oder der Preiserhöhung. In Übereinstimmung mit den definierten Kriterien der Cochrane Effective Practice and Organisation of Care (EPOC) haben wir randomisierte kontrollierte Studien (RCTs), cluster‐randomisierte kontrollierte Studien (cRCTs), nicht‐randomisierte kontrollierte Studien (nRCTs), kontrollierte Vorher‐Nachher‐Studien (CBA) und Studien mit unterbrochenen Zeitreihen (ITS) eingeschlossen. Wir schlossen kontrollierte Studien mit mehr als einem Interventions‐ oder Kontrollstandort und ITS‐Studien mit einem klar definierten Interventionszeitraum und mindestens drei Datenpunkten vor sowie drei Datenpunkte nach dem Interventionsbeginn ein. Unsere primären Endpunkte waren der Konsum von unverarbeitetem Zucker oder Lebensmitteln mit zugesetztem Zucker, Energiezufuhr, Übergewicht und Adipositas. Unsere sekundären Endpunkte waren Substitution und Ernährung, finanzielle Ausgaben, Nachfrage und andere gesundheitsrelevante Endpunkte. DATENERHEBUNG UND ‐ANALYSE: Zwei Review‐Autoren überprüften unabhängig voneinander alle in Frage kommenden Einträge unterschiedlicher Treffer auf einen möglichen Einschluss, bewerteten das Risiko für Bias und führten die Datenextraktion durch. Zwei Review‐Autoren haben unabhängig voneinander die Vertrauenswürdigkeit der Evidenz, mit Hilfe des GRADE‐Ansatzes bewertet.

Wesentliche ergebnisse: Unsere Suche ergab 24.454 Treffer. Nach der De‐Duplizierung der Einträge verblieben 18.767 Einträge für das Titel‐ und Abstract‐Screening. Von 11 potentiell relevanten Studien schlossen wir eine ITS‐Studie mit 40.210 Beobachtungen auf Haushaltsebene ein. Die Daten entstammten hierbei einem ungarischen Survey zum Haushaltsbudget und den Lebensbedingungen (Hungarian Household Budget and Living Conditions Survey). Der Studienzeitraum vor Beginn der Intervention war von Januar 2008 bis August 2011. Die Intervention wurde im September 2011 implementiert und bis Dezember 2012 (16 Monate) nachverfolgt. Bei der Intervention handelte es sich um eine Steuer ‐ die so genannte "Hungarian public health product tax" Dabei handelt es sich um eine Steuer auf Lebensmittel mit zugesetztem Zucker, einschließlich ausgewählter Lebensmittel, die einen bestimmten Zuckergrenzwert überschreiten. Die Intervention beinhaltet folgende Kointerventionen: die Besteuerung von zuckergesüßten Getränken (sugar sweetned beverages, SSBs) und Lebensmitteln mit hohem Salz‐ oder Koffeingehalt. Die Studie liefert Evidenz hinsichtlich der Wirkung einer Besteuerung von Lebensmitteln, die einen bestimmten Zuckergrenzwert überschreiten, bezogen auf den Konsum dieser Lebensmittel. Nach Einführung der "Hungarian public health product tax" sank der durchschnittliche Konsum von besteuerten Lebensmitteln mit zugesetztem Zucker (Einheiten gemessen in kg) um 4,0% (standardisierte Mittelwertdifferenz (SMD) ‐0,040, 95% Konfidenzintervall (KI) ‐0,07 bis ‐0,01; sehr niedrige Vertrauenswürdigkeit der Evidenz). Die Studie wies ein geringes Risiko für Performance Bias (keine oder unvollständige Verblindung von Personal und Studienteilnehmer), Detection Bias (keine oder unvollständige Verblindung bei Endpunktbeurteilung) und Reporting Bias (Verzerrung durch selektives Berichten) auf. Gleiches galt für die nachvollziehbare Beschreibung des Interventionszeitpunkts und mögliche Verzerrungen durch Auswirkungen der Intervention auf die Datenerhebung. Die Studie wies ein unklares Risiko für Bias in Bezug auf mögliche Verzerrung durch Unterschiede in Studienteilnahme bzw. ‐abbruch auf (Attrition Bias) sowie ein hohes Risiko in Bezug auf andere Quellen für Bias und die Unabhängigkeit der Intervention auf. Wir bewerteten die Vertrauenswürdigkeit der Evidenz für die primären und sekundären Endpunkte als sehr niedrig. Die "Hungarian public health product tax" beinhaltete eine Steuer auf Lebensmittel mit zugesetztem Zucker, nicht aber eine Steuer auf unverarbeiteten Zucker. Wir fanden keine einschlussfähigen Studien zur Besteuerung von unverarbeitetem Zucker. Keine Studie berichtete Ergebnisse zu den folgenden primären Endpunkten: Konsum von unverarbeitetem Zucker, Energiezufuhr, Übergewicht und Adipositas. Keine Studie berichtete Ergebnisse zu den folgenden sekundären Endpunkten: Substitution und Ernährung, Nachfrage und andere gesundheitsrelevante Endpunkte. Keine Studie untersuchte mögliche subgruppenspezifische Effekte der Intervention innerhalb der Bevölkerung. Wir konnten keine Meta‐Analysen durchführen oder Studienergebnisse anderweitig zusammenfassen.

Schlussfolgerungen der autoren: Die zur Fragestellung des Reviews vorhandene Evidenz kann als sehr begrenzt angesehen werden und die Vertrauenswürdigkeit der Evidenz ist sehr gering. Trotz der berichteten Konsumreduktion von besteuerten Lebensmitteln mit zugesetztem Zucker sind wir unsicher, ob die Besteuerung von unverarbeitetem Zucker oder von Lebensmitteln mit zugesetztem Zucker tatsächlich eine Wirkung auf die Konsumreduktion und die Prävention von Adipositas oder andere unerwünschte Wirkungen auf gesundheitsrelevante Endpunkte hat. Es sind weitere, sorgfältig angelegte Studien erforderlich, um konkrete Schlussfolgerungen über die Wirksamkeit der Besteuerung von unverarbeitetem Zucker oder von Lebensmitteln mit zugesetztem Zucker, hinsichtlich deren Konsumreduktion und im Hinblick auf die Prävention von Adipositas oder andere unerwünschte Wirkungen auf gesundheitsrelevante Endpunkte, zu ziehen.

PubMed Disclaimer

Conflict of interest statement

Manuela Pfinder: none declared

Thomas Heise: none declared

Michele Hilton Boon: none declared

Candida Fenton: none declared

Frank Pega is a Technical Officer at the World Health Organization, but was an Honorary Research Fellow for the University of Otago, at the time of writing.

Gerald Gartlehner: none declared

Ursula Griebler: none declared

Isolde Sommer: none declared

Srinivasa Vittal Katikireddi is a member of the steering group of Obesity Action Scotland, to whom he provides unpaid advice on the evidence base for public health actions to tackle obesity.

Stefan Lhachimi: none declared

Figures

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Typologies of taxes on unprocessed sugar or sugar‐added foods
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Study's initial logic model with causal pathways
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Study flow diagram
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Study's adapted logic model with causal pathways
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Risk of bias summary for ITS study
See this image and copyright information in PMC

Update of

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