! ! ! Predicting*the*potential*health*and*economic* impact*of*a*sugary*drink*tax*in*Canada:** a*modelling*study* ! ! ! ! ! by! ! Amanda!Clarisse!Jones! ! ! ! ! ! ! ! ! ! ! A!thesis! presented!to!the!University!of!Waterloo! in!fulfilment!of!the! thesis!requirement!for!the!degree!of! Doctor!of!Philosophy!! in! Public!Health!and!Health!Systems! ! ! ! ! ! Waterloo,!Ontario,!Canada,!2018! ©!Amanda!Clarisse!Jones!2018! ! EXAMINING*COMMITTEE*MEMBERSHIP* The!following!served!on!the!Examining!Committee!for!this!thesis.!The!decision!of!the!Examining! Committee!is!by!majority!vote.! ! External!Examiner! ! ! ! DR.!KATERINA!MAXIMOVA! ! ! ! ! ! ! Assistant!Professor! ! Supervisor! ! ! ! ! DR.!DAVID!HAMMOND! ! ! ! ! ! ! Professor! ! Internal!Member! ! ! ! DR.!SUSAN!HORTON! ! ! ! ! ! ! Professor! ! Internal!Member! ! ! ! DR.!SHARON!KIRKPATRICK! ! ! ! ! ! ! Assistant!Professor! ! InternalTexternal!Member! ! ! DR.!GORETTY!DIAS! ! ! ! ! ! ! Assistant!Professor! ! * ii! ! AUTHOR’S*DECLARATION* I!hereby!declare!that!I!am!the!sole!author!of!this!thesis.!This!is!a!true!copy!of!the!thesis,!including! any!required!final!revisions,!as!accepted!by!my!examiners.! ! I!understand!that!my!thesis!may!be!made!electronically!available!to!the!public.! * iii! ! ABSTRACT* * BACKGROUND* Consistent!with!global!trends,!high!body!mass!index!(BMI)!and!high!blood!glucose!have!risen!at! rapid!rates!among!Canadians.!The!consumption!of!sugarTsweetened!beverages!(SSBs)!is!a!wellT established!and!important!dietary!risk!factor!for!these!conditions.!A!growing!body!of!research! suggests!that!SSB!taxes!can!achieve!meaningful!health!impacts!by!shifting!dietary!preferences.! However,!there!are!several!key!literature!gaps,!including!no!estimations!of!the!potential!benefit! of!taxing!‘sugary!drinks’,!a!beverage!category!that!includes!both!SSBs!and!100%!juice,!which!is! high!in!sugar.!In!addition,!no!published!studies!have!simulated!a!tax!on!SSBs!or!sugary!drinks!for! the!Canadian!population.! ! PURPOSE* The!proposed!study’s!objectives!were:!1)!to!investigate!Canadians’!consumption!of!sugary!drink! types,!and!differences!by!socioTeconomic!characteristics;!and!2)!to!estimate!the!potential!impact! among!the!Canadian!population!of!a!simulated!national!tax!on!SSBs!and!a!simulated!tax!on! sugary!drinks.! ! METHODS* The!study!was!conducted!in!two!components.!First,!sugary!drink!intake!(volume!and!energy)!was! estimated!using!24Thour!dietary!recall!data!from!the!2015!Canadian!Community!Health!Survey!–! Nutrition!(respondents!ages!>1!year;!final!sample!N=20,176).!For!100%!juice!and!‘total!SSBs’! (which!included!15!beverage!types),!intake!was!reported!overall!and!by!socioTeconomic! measures:!sex,!age,!ethnicity,!income,!province,!and!BMI!category.!Student’s!tTtest!and!Wald!FT test!tested!for!differences!among!population!subTgroups.!SSB!and!sugary!drink!intakes!were!also! estimated!for!inclusion!in!the!study’s!second!component:!a!simulation!of!a!sugary!drink!tax.!The! impact!of!the!tax!intervention!was!estimated!using!a!proportional!multiTstate!life!tableTbased! Markov!model!adapted!to!simulate!the!2015!Canadian!adult!population.!The!model!applied!10%,! 20%,!and!30%!ad!valorem!taxes!on!SSBs!and!sugary!drinks,!and!compared!two!populations:!one! with!a!tax!intervention!and!one!without!a!tax!intervention.!The!model!simulated!the!effect!of! iv! ! energy!intake!from!beverages!on!19!diseases!mediated!by!body!mass,!and!the!direct!effects!of! intake!on!type!2!diabetes,!accounting!for!beverage!substitution.!Sensitivity!analyses!examined! key!assumptions!and!Monte!Carlo!simulation!assessed!uncertainty.! ! RESULTS* A!large!proportion!of!respondents!reported!consuming!100%!juice!(children,!39.3%;!adults! 22.8%)!or!some!type!of!SSB!(children,!53.0%;!adults,!40.8%)!during!the!previous!24Thour!period.! In!2015,!each!Canadian!consumed!an!average!of!74.3!ml!(33.7!kcal)!of!100%!juice!and!203.6!ml! (98.7!kcal)!of!SSBs!per!day.!100%!juice!was!consumed!more!than!any!other!sugary!drink,! followed!closely!by!regular!carbonated!soft!drinks.!Compared!to!females,!males’!consumption! was!significantly!higher!for!100%!juice!(37%!greater!volume)!and!total!SSBs!(54%!greater).! Children!consumed!more!sugary!drinks!on!average!each!day!than!adults:!nearly!double!the! volume!of!100%!juice!(86%!more)!and!14%!more!SSBs.!Beverage!intake!differed!by!ethnicity,! province,!and!BMI!category,!but!not!by!income!quintile.!For!the!simulated!taxes,!there!were! sizeable!differences!in!the!impacts!of!a!SSB!tax!versus!sugary!drinks!tax:!prevalence!of! overweight/obesity!changed!from!63.3%!to!61.7%!vs!61.0%;!type!2!diabetes!incidence!rate! decreased!by!T5.9%!vs!T7.4%.!Over!a!25Tyear!period,!compared!to!a!SSB!tax,!a!sugary!drinks!tax! produced!47%!more!averted!disabilityTadjusted!life!years!(DAlYs;!314,326!versus!460,812),!45%! greater!health!care!costs!savings!($7.5!billion!vs!$10.9!billion!Canadian!dollars),!and!37%!more! annual!tax!revenue!($1.0!billion!CAD!vs!$1.4!billion!CAD).! ! CONCLUSIONS* Consumption!of!sugary!drinks!remains!an!important!disease!risk!factor!among!the!Canadian! population.!Average!intake!of!sugary!drinks!in!2015!is!lower!than!2004!estimates,!but!remains! high,!especially!among!children!and!youth.!The!current!study!suggests!that!a!beverage!tax!in! Canada!has!the!potential!to!substantially!reduce!the!health!burden!while!generating!health!care! savings!and!tax!revenue,!especially!if!100%!juice!is!among!taxed!beverages.!Given!Canadians’! high!100%!juice!consumption,!the!mounting!evidence!on!adverse!effects!associated!with!free! sugar!consumption,!and!the!role!of!100%!juice!as!a!substitute!beverage!to!SSBs,!there!is!a!strong! rationale!for!its!inclusion!as!a!taxed!beverage.!Future!studies!could!examine!the!potential!impact! v! ! of!a!‘tiered’!tax!based!on!beverage!sugar!content,!as!well!as!the!effects!of!a!tax!relative!to!other! nutrition!interventions.! ! * vi! ! ACKNOWLEDGEMENTS* Funding!for!this!study!was!provided!by!a!Canadian!Institutes!of!Health!Research!(CIHR)!Operating! Grant.!The!pilot!study!was!funded!by!the!Canadian!Cancer!Society,!Diabetes!Canada,!the! Childhood!Obesity!Foundation,!the!Chronic!Disease!Prevention!Alliance!of!Canada,!and!the!Heart! &!Stroke!Foundation.!Additional!stipend!support!was!provided!through!Ontario!Graduate! Scholarship,!University!of!Waterloo!President’s!Graduate!Scholarship,!Cancer!Care!Ontario,!and! the!CIHR!Training!Grant!in!Population!Intervention!for!Chronic!Disease!Prevention:!A!PanT Canadian!Program![grant!number!53893].! ! “Doing!a!PhD!is!an!exercise!in!resilience,”!a!wise!mentor!remarked!as!I!was!weighing!whether!or! not!to!apply!to!PhD!programs.!How!true!these!words!have!been.!I!feel!grateful!to!be!at!the!finish! line!of!this!marathon,!and!cannot!imagine!making!it!here!without!the!support!of!so!many!people.!! ! To!my!PhD!committee!members,!thank!you!for!your!contribution!to!this!research!and!my! professional!growth.!Dr.!Susan!Horton!and!Dr.!Sharon!Kirkpatrick,!your!expertise!has!improved! this!project,!as!well!as!challenged!and!inspired!me.!! ! I!will!be!forever!thankful!to!Dr.!David!Hammond,!my!PhD!supervisor,!for!sending!me!that!email! on!April!2,!2013!with!an!invitation!to!take!me!on!as!a!PhD!student.!I!had!a!long!wish!list!for!a! future!supervisor.!You!checked!every!box!and!more.!You!are!an!exceptional!role!model!as!a! professional!and!a!person—one!who!is!both!brilliant!and!caring.!It!has!been!an!honour!working! with!you.!! ! To!the!past!and!present!Hammond!lab!students!and!staff,!working!with!a!group!like!you!was!also! on!my!wish!list.!Your!insights,!comradery,!and!friendship!have!added!colour!and!life!to!my!time! here.!You!will!be!missed.! ! This!study!would!have!been!impossible!without!Dr.!lennert!Veerman,!who!so!generously!shared! his!time!and!coached!me!through!the!simulation!modelling!work.!I!look!forward!to!when!we! meet!in!person,!not!just!over!Skype.!Dr.!Pat!NewcombeTWelch!was!instrumental!in!accessing! Canadian!data!sources!from!the!SouthTWestern!Ontario!Research!Data!Centre.!Thank!you!for! your!expertise,!patience,!and!friendship.!Thank!you!to!the!many!employees!of!Statistics!Canada,! Health!Canada,!and!Public!Health!Agency!of!Canada!who!responded!to!the!dozens!of!emails!and! phone!calls!that!I!made!while!tracking!down!data!sources!for!this!project.!! ! Thank!you!to!the!many!friends!and!family!who!offered!love!and!encouragement!throughout!this! journey.!Christine!Richard,!your!Zumba!class!did!more!for!me!than!any!PhD!class!and!kept!me! sane.!Darryl!Gingerich,!you!are!a!friend!for!life.!Vanessa!Mio,!what!a!treasure!you!are.!You!came! into!my!life!when!I!most!needed!a!kindred!spirit.!! ! To!my!parents,!Tony!and!Sylvia!Jones.!I!love!and!honour!you.!God!knew!that!doing!this!PhD! would!bring!us!closer!together.!I!see!more!than!ever!the!love!you!have!for!me,!the!sacrifices! you’ve!made,!and!depth!of!your!character.!I!am!blessed.!Thank!you.! ! vii! ! TABLE*OF*CONTENTS! EXAMINING!COMMITTEE!MEMBERSHIP!............................................................................................!ii! AUTHOR’S!DECLARATION!..................................................................................................................!iii! ABSTRACT!...........................................................................................................................................!iv! ACKNOWLEDGEMENTS!....................................................................................................................!vii! TABlE!OF!CONTENTS!.......................................................................................................................!viii!