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      Effectiveness of subsidies in promoting healthy food purchases and consumption: a review of field experiments

      Public Health Nutrition
      Cambridge University Press (CUP)

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          Abstract

          Objective

          To systematically review evidence from field interventions on the effectiveness of monetary subsidies in promoting healthier food purchases and consumption.

          Design

          Keyword and reference searches were conducted in five electronic databases: Cochrane Library, EconLit, MEDLINE, PsycINFO and Web of Science. Studies were included based on the following criteria: (i) intervention: field experiments; (ii) population: adolescents 12–17 years old or adults 18 years and older; (iii) design: randomized controlled trials, cohort studies or pre–post studies; (iv) subsidy: price discounts or vouchers for healthier foods; (v) outcome: food purchases or consumption; (vi) period: 1990–2012; and (vii) language: English. Twenty-four articles on twenty distinct experiments were included with study quality assessed using predefined methodological criteria.

          Setting

          Interventions were conducted in seven countries: the USA ( n 14), Canada ( n 1), France ( n 1), Germany ( n 1), Netherlands ( n 1), South Africa ( n 1) and the UK ( n 1). Subsidies applied to different types of foods such as fruits, vegetables and low-fat snacks sold in supermarkets, cafeterias, vending machines, farmers’ markets or restaurants.

          Subjects

          Interventions enrolled various population subgroups such as school/university students, metropolitan transit workers and low-income women.

          Results

          All but one study found subsidies on healthier foods to significantly increase the purchase and consumption of promoted products. Study limitations include small and convenience samples, short intervention and follow-up duration, and lack of cost-effectiveness and overall diet assessment.

          Conclusions

          Subsidizing healthier foods tends to be effective in modifying dietary behaviour. Future studies should examine its long-term effectiveness and cost-effectiveness at the population level and its impact on overall diet intake.

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          Most cited references73

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          Financial incentive-based approaches for weight loss: a randomized trial.

          Identifying effective obesity treatment is both a clinical challenge and a public health priority due to the health consequences of obesity. To determine whether common decision errors identified by behavioral economists such as prospect theory, loss aversion, and regret could be used to design an effective weight loss intervention. Fifty-seven healthy participants aged 30-70 years with a body mass index of 30-40 were randomized to 3 weight loss plans: monthly weigh-ins, a lottery incentive program, or a deposit contract that allowed for participant matching, with a weight loss goal of 1 lb (0.45 kg) a week for 16 weeks. Participants were recruited May-August 2007 at the Philadelphia VA Medical Center in Pennsylvania and were followed up through June 2008. Weight loss after 16 weeks. The incentive groups lost significantly more weight than the control group (mean, 3.9 lb). Compared with the control group, the lottery group lost a mean of 13.1 lb (95% confidence interval [CI] of the difference in means, 1.95-16.40; P = .02) and the deposit contract group lost a mean of 14.0 lb (95% CI of the difference in means, 3.69-16.43; P = .006). About half of those in both incentive groups met the 16-lb target weight loss: 47.4% (95% CI, 24.5%-71.1%) in the deposit contract group and 52.6% (95% CI, 28.9%-75.6%) in the lottery group, whereas 10.5% (95% CI, 1.3%-33.1%; P = .01) in the control group met the 16-lb target. Although the net weight loss between enrollment in the study and at the end of 7 months was larger in the incentive groups (9.2 lb; t = 1.21; 95% CI, -3.20 to 12.66; P = .23, in the lottery group and 6.2 lb; t = 0.52; 95% CI, -5.17 to 8.75; P = .61 in the deposit contract group) than in the control group (4.4 lb), these differences were not statistically significant. However, incentive participants weighed significantly less at 7 months than at the study start (P = .01 for the lottery group; P = .03 for the deposit contract group) whereas controls did not. The use of economic incentives produced significant weight loss during the 16 weeks of intervention that was not fully sustained. The longer-term use of incentives should be evaluated. clinicaltrials.gov Identifier: NCT00520611.
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            The economics of obesity: dietary energy density and energy cost.

            Highest rates of obesity and diabetes in the United States are found among the lower-income groups. The observed links between obesity and socioeconomic position may be related to dietary energy density and energy cost. Refined grains, added sugars, and added fats are among the lowest-cost sources of dietary energy. They are inexpensive, good tasting, and convenient. In contrast, the more nutrient-dense lean meats, fish, fresh vegetables, and fruit generally cost more. An inverse relationship between energy density of foods (kilojoules per gram) and their energy cost (dollars per megajoule) means that the more energy-dense diets are associated with lower daily food consumption costs and may be an effective way to save money. However, economic decisions affecting food choice may have physiologic consequences. Laboratory studies suggest that energy-dense foods and energy-dense diets have a lower satiating power and may result in passive overeating and therefore weight gain. Epidemiologic analyses suggest that the low-cost energy-dense diets also tend to be nutrient poor. If the rise in obesity rates is related to the growing price disparity between healthy and unhealthy foods, then the current strategies for obesity prevention may need to be revised. Encouraging low-income families to consume healthier but more costly foods to prevent future disease can be construed as an elitist approach to public health. Limiting access to inexpensive foods through taxes on frowned upon fats and sweets is a regressive measure. The broader problem may lie with growing disparities in incomes and wealth, declining value of the minimum wage, food imports, tariffs, and trade. Evidence is emerging that obesity in America is a largely economic issue.
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              Financial incentives for extended weight loss: a randomized, controlled trial.

              Previous efforts to use incentives for weight loss have resulted in substantial weight regain after 16 weeks. To evaluate a longer term weight loss intervention using financial incentives. A 32-week, three-arm randomized controlled trial of financial incentives for weight loss consisting of a 24-week weight loss phase during which all participants were given a weight loss goal of 1 pound per week, followed by an 8-week maintenance phase. Veterans who were patients at the Philadelphia Veterans Affairs Medical Center with BMIs of 30-40. Participants were randomly assigned to participate in either a weight-monitoring program involving a consultation with a dietician and monthly weigh-ins (control condition), or the same program with one of two financial incentive plans. Both incentive arms used deposit contracts (DC) in which participants put their own money at risk (matched 1:1), which they lost if they failed to lose weight. In one incentive arm participants were told that the period after 24 weeks was for weight-loss maintenance; in the other, no such distinction was made. Weight loss after 32 weeks. Results were analyzed using intention-to-treat. There was no difference in weight loss between the incentive arms (P = 0.80). Incentive participants lost more weight than control participants [mean DC = 8.70 pounds, mean control = 1.17, P = 0.04, 95% CI of the difference in means (0.56, 14.50)]. Follow-up data 36 weeks after the 32-week intervention had ended indicated weight regain; the net weight loss between the incentive and control groups was no longer significant (mean DC = 1.2 pounds, 95% CI, -2.58-5.00; mean control = 0.27, 95% CI, -3.77-4.30, P = 0.76). Financial incentives produced significant weight loss over an 8-month intervention; however, participants regained weight post-intervention.
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                Author and article information

                Journal
                Public Health Nutrition
                Public Health Nutr.
                Cambridge University Press (CUP)
                1368-9800
                1475-2727
                July 2013
                November 05 2012
                July 2013
                : 16
                : 7
                : 1215-1228
                Article
                10.1017/S1368980012004715
                3898771
                23122423
                4ab87d6d-c292-4754-87ae-c02124a9b590
                © 2013

                https://www.cambridge.org/core/terms

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