Why is this review important?
As outlined by the World Health Organization, 'globesity' (the rise in overweight and obesity globally) is a major world challenge. A sugar-rich diet, especially when combined with physical inactivity, may cause overweight and obesity, and other harmful health outcomes. There are direct costs to healthcare services of people being overweight or obese, such as preventing and treating health problems that this causes. There are also costs to society as a whole when people who are ill through being overweight or obese are unable to work.
Who will be interested in this review?
This review may be of interest to government public health agencies, policy decision-makers, food retailers, and food industries. This review and subsequent updates of this review may change policy and affect a government's motivation to create a tax on unprocessed sugar and foods with added sugar. It also may motivate food industries to reformulate their products to contain lower levels of added sugar.
What question does this review aim to answer?
We wanted to know if taxation of unprocessed sugar and foods with added sugar (other than sugar-sweetened beverages (SSBs)) reduced their consumption, changed people's energy intake, and reduced overweight and obesity. We also wanted to know if taxation changed people's diet and spending, and had an effect on other diet-related health problems.
Which studies were included in the review?
We searched for ongoing or published studies up to October 2019. Of a total of 24,454 records retrieved, we identified one 'interrupted time series' (ITS) study meeting our eligibility criteria to assess the impact of a tax on sugar-added foods (but not unprocessed sugar). The study used data from the Hungarian Household Budget and Living Conditions Survey, with observations from 40,210 households. Evidence from the study included a 'baseline' (the situation before taxation), ranging from January 2008 to August 2011. The Hungarian public health product tax was implemented on September 2011. The duration of the follow-up period (measuring the effects of taxation) was 16 months. The study was funded by the Scottish Institute for Research in Economics (SIRE) Early Career Engagement Grant.
What does the evidence from the review reveal?
The included study provided very limited evidence that taxing foods with added sugar reduced their consumption by 4%. We are very uncertain about this evidence because the study did not use the strongest methods, looked at other kinds of taxation as well as taxing foods with added sugar, and may not have correctly classified food types. We are uncertain whether taxing foods with added sugar has an effect on reducing their consumption. The included study did not investigate the effects of taxing unprocessed sugar.
What should happen next?
Further research is needed to assess the effectiveness of taxing unprocessed sugar or foods with added sugar for reducing their consumption and preventing obesity or other adverse health outcomes. Studies should take place in countries that have implemented these taxes and should look at cost-effectiveness as well as the health benefits of taxing unprocessed sugar or foods with added sugar as a public health policy for preventing overweight, obesity or other adverse health outcomes. Countries that have implemented these taxes are Bermuda, Dominica, Hungary, India, Norway, the Navajo Nation (USA), and St. Vincent and Grenadines.
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.
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.
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.
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.
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.
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.
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.