Title:Listening to the experts: is there a place for food taxation in the fight against obesity in early childhood?

Transcription

1 Author's response to reviews Title:Listening to the experts: is there a place for food taxation in the fight against obesity in early childhood? Authors: Erin Pitt (e.pitt@griffith.edu.au) Elizabeth Kendall (e.kendall@griffith.edu.au) Andrew P Hills (a.hills@griffith.edu.au) Tracy Comans (t.comans@griffith.edu.au) Version:2Date:7 July 2014 Author's response to reviews: see over

2 Erin Pitt PhD Candidate, School of Medicine Telephone +61 (0) Facsimile +61 (0) e.pitt@griffith.edu.au Logan campus Griffith University University Drive Meadowbrook Qld 4131 Australia 7 th July 2014 Regarding manuscript submission MS: Listening to the experts: is there a place for food taxation in the fight against obesity in early childhood? Response to Reviewer Comments We would like to thank the Reviewers for their very constructive feedback and suggestions. We have responded to the Reviewers comments below. Reviewer #1: Carlos Alvarez-Dardet We thank the Reviewer for acknowledging our paper as having outstanding merit and interest in its field. Reviewer #2: Judy Jou Comments from Reviewer Major Compulsory Revisions Lines : I d like to see more detail on how panel members were recruited, e.g., which keywords were used in the literature searches; how systematic the searches were in key organizations (were keywords also used?); what constitutes significant experience, contribution, and public presence; etc. This is especially as only 15 experts were invited to the panel, when I d expect a much larger number based on those criteria unless the criteria were more stringent than they give the impression of being. (Participation rate is excellent, though!) Changes made to manuscript Comment: The pool of experts in Australia with both obesity and early childhood expertise is limited, as Australia has a relatively small population. The following text has been added to the methods: Lines : A list of potential expert panel members was constructed by Chief Investigators and team members and was achieved using a combination of methods. Prominent publications and literature were reviewed as identified through literature searches relating to childhood obesity, nutrition, taxation and public policy in the Australian context. Snowballing and purposive sampling was also used to ensure inclusion of key organizations (e.g. Food Standards Australian and New Zealand (FSANZ)) as well as government public health departments and universities. Criteria for inclusion as a member of the panel included holding a position in Australia as a researcher, teaching academic or clinician with significant experience, contribution and public presence in a combination of areas of areas including nutrition, public policy and childhood obesity. Experience and contribution was deemed significant based on a track record of international journal publications, speaker invitations or involvement in relevant professional organisations.

3 Lines : Is this high-protein infant formula? Is there literature showing that high-protein formula is being commonly given to infants who were not premature or low-birthweight, or to children aged 12+ months? Was there discussion of how taxation of this type of product would affect families/children who have health-related reasons to consume it? In the U.S., for instance, proposals for taxing sugarsweetened beverages have often deliberately excluded items like infant formula or nutritional supplements for the elderly, so it s surprising that the panel identified formula as a potential object of taxation. (Or, if the comments were more targeted toward low-quality formulas, consider removing high-protein from the description.) Lines : There has been some research in both of these areas, though mostly based on the U.S. For public opinion on taxing sugar-sweetened beverages, for instance, see Barry et al. (2013) in AJPM or some of the resources from the Rudd Center. For price elasticity, see Andreyeva et al. s (2010) article in AJPH. Again, these are U.S.-based studies, but they could provide the basis for future research specific to the Australian environment. Minor Essential Revisions Lines 67-68: Why is this contentious (cite source)? Comment: The panel was specifically talking about high protein infant formulas that are generally cheaper and of lower quality. Paragraph has been amended to address comments made by reviewer, in light of the panel referring to high-protein infant formula. Lines : The panel discussed the role of high protein infant formula in contributing to obesity. They mentioned this particular group of products is usually of lower quality and is an unnecessary product for young children in the general population above the age of 12 months, who can gain all nutritional requirements from a regular adult diet. Thus the panel felt this distinct group of products would be amenable to taxation to reduce consumption. Panel members mentioned the potentially regressive nature of tax on this particular product however this was not discussed in detail, nor were comment made on the influence of taxation for lower income groups. This section has been amended to acknowledge international work regarding consumer acceptability of taxation and examination of price elasticities. The paragraph also focuses on the limited availability of such work in the Australian context and thus the need for future research to specifically focus on this environment. Lines This sentence has been revised. Lines 66-69: Although some recent literature suggests childhood obesity may be starting to plateau in parts of Australia, the condition continues to be a global public health priority and there is consensus regarding an urgent need for government to take rapid action. Lines : Was the panel open to the public? Where was it held? This sentence has been revised to incorporate additional information. Lines : The expert panel was a closed event held at a hotel near to Brisbane airport to accommodate travel arrangements of inter-state panel members. Lines : I m not quite sure what disenfranchised through food taxation means did the panel member suggest that potentially regressive taxation is acceptable if it s effective in improving health outcomes of those who are obese? The paper does contain some minor grammatical errors and can benefit from close proofreading. Sentence has been removed. Grammatical corrections have been made.

4 Discretionary Revisions The results and discussion of the expert panel actually go quite a bit beyond taxation, especially with the emphasis on subsidizing healthy foods alongside taxing unhealthy ones. The authors might consider re-titling or slightly re-framing the paper to acknowledge the breadth of issues that were addressed. An additional sentence has been added to the results section of the abstract mentioning that the complexities of the topic resulted in discussion that went beyond food taxation. Lines 48-50: They also highlighted the importance of subsidizing fresh fruit and vegetables, whole and unprocessed foods and hence topic complexities resulted in panel discussion being extended beyond the central notion of taxation. Reviewer #3: Kathryn Backholer Comments from Reviewer Major Compulsory Revisions Discussion, line : The authors state that ongoing research could investigate consumer acceptability of taxation and examine price elasticities of proposed taxable foods. There is already quite a lot of data on both of these recommendations for future research that the authors do not acknowledge. Furthermore, given the discussion regarding product substitution, the authors might want to extend the discussion on price elasticities to identify the need to examine both own and cross price elasticities. Discussion: It seems that one of the major findings of this article is the consensus that SSBs may be considered as the food/drink group that is most amenable to taxation. However, this is only mentioned once in the final conclusions. Changes made to manuscript Paragraph has been amended to acknowledge international work regarding consumer acceptability of taxation and examination of price elasticities. Paragraph also focuses on the limited availability of such work in the Australian context. Additional discussion has been included regarding both own and cross price elasticities specifically in relation to product substation. Lines Comment: Panel discussion regarding sugarsweetened beverages is incorporated a number of times throughout the results section. Despite this, we agree the significance of the amenability of SSB s as identified by the panel should be highlighted in the discussion. An additional sentence has been added to the discussion section highlighting the panel s consensus to tax SSB s. this is particularly in light of the challenges associated with reaching consensus on other food items, due to associated barriers and issues that were discussed. Lines Minor Essential Revisions Abstract, results: It would be informative to explicitly state which foods/beverages are problematic and which are more amenable to policy. Results paragraph within the abstract has been amended to include additional information. Lines 44-50: The panel reached consensus about the types of foods that were problematic in terms of their consumption and contribution to early childhood obesity which included prepared foods consumed outside the home; high protein infant formula products and sugar-sweetened beverages. However of these food and beverage items, the panel only deemed sugar-sweetened beverages and infant formula to be potentially amenable to taxation. They also highlighted the importance of subsidizing fresh

5 fruit and vegetables, whole and unprocessed foods and hence topic complexities resulted in panel discussion being extended beyond the central notion of taxation. Background, line 64: I assume the authors are referring to the Australian Health Survey (not )? Background, line 78: The authors state that there are three potential policy leavers available to influence food choice: price, availability and marketing. Given there are potentially other policy leavers not mentioned here (eg. information), it may be more appropriate to acknowledge that there are several (or many) policy leavers, some of which include Methods, line 128: It would be useful if the authors explicitly defined the key categories of food that information was provided for. This is important as it may underpin panel members recommendations. Throughout: Please be consistent as to whether you use sweetened beverages (line179 and elsewhere), sugar-sweetened beverages (line177 and elsewhere) or soft drink (line 298 I assume the authors here are referring to SSBs). Results, line 180: there is no mention of infant formula Discretionary Revisions Final consensus, line 243: This information might be more clearly presented in a table This has been corrected to reflect the Australian Health Survey. This sentence has been amended. Lines 77-79: If we agree that the environment, including the food environment, has a major impact on childhood obesity, there are several potential policy levers available to influence food choices: some of which include price, availability and marketing. This sentence has been amended to include additional information. Lines : The material summarised the epidemiology of childhood obesity; trends in expenditure, consumption and commercial sales of key categories of foods; particularly beverages (e.g. sugarsweetened and artificially sweetened) and unhealthy foods (e.g. take-away foods, snacks and confectionary). Amendments have been made to ensure consistency of the term, sugar-sweetened beverages. Sentence has been revised. Lines : Of slightly lower importance were high protein infant formula products and processed meats. Final consensus outcomes are now presented in Table 2. We hope the manuscript changes presented above will be deemed suitable by the Reviewers. On behalf of my colleagues and myself I would also like to take this opportunity to thank the Reviewers for taking the time to provide comment on our manuscript. Yours sincerely Erin Pitt PhD Candidate School of Medicine Griffith University