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OBJECTIVES: This study tested the hypothesis that disparities in political participation across socioeconomic status affect health. Specifically, the association of voting inequality at the state level with individual self-rated health was examined. METHODS: A multilevel study of 279,066 respondents to the Current Population Survey (CPS) was conducted. State-level inequality in voting turnout by socioeconomic status (family income and educational attainment) was derived from November CPS data for 1990, 1992, 1994, and 1996. RESULTS: Individuals living in the states with the highest voting inequality had an odds ratio of fair/poor self-rated health of 1.43 (95% confidence interval [CI] = 1.22, 1.68) compared with individuals living in the states with the lowest voting inequality. This odds ratio decreased to 1.34 (95% CI = 1.14, 1.56) when state income inequality was added and to 1.27 (95% CI = 1.10, 1.45) when state median income was included. The deleterious effect of low individual household income on self-rated health was most pronounced among states with the greatest voting and income inequality. CONCLUSIONS: Socioeconomic inequality in political participation (as measured by voter turnout) is associated with poor self-rated health, independently of both income inequality and state median household income.

Background: The nutritional composition of foods and beverages consumed away from the home has important implications for population health. Our objective was to determine if the serve size, energy, and sodium contents of fast foods sold at chain restaurants in New Zealand (NZ) changed between 2012 and 2016. Methods: Serve size and nutrient data were collected in annual cross-sectional surveys of all products sold at 10 major fast food chains. Changes over time may occur due to alterations in product availability or individual product reformulation. Linear regression adjusting for food group and chain was used to estimate overall changes in serve size and nutrients. Random effects mixed models were used to estimate reformulation changes on same products available for two or more years. Results: Across all products (n = 5468) increases were observed in mean serve size (+ 9 (3, 15) g, + 5%), energy density (+ 54 (27, 81) kJ/100 g, + 6%), energy per serve (+ 178 (125, 231) kJ, + 14%), and sodium per serve (+ 55 (24, 87) mg, + 12%). Sodium density did not change significantly. Four of 12 food groups (Desserts, Pizza, Sandwiches, and Salads) and four of 10 fast food chains (Domino's, Hell Pizza, Pizza Hut, and Subway) displayed large, undesirable changes for three or more (of five) outcomes (≥10%; p < 0.05). One food group (Asian) and one chain (St Pierre's) displayed large, desirable changes for two or more outcomes. The only significant reformulation change was a drop in sodium density (- 22 (- 36, - 8) mg/100 g, - 7%). Conclusions: The serve size and energy density of NZ fast food products has increased significantly over the past 5 years. Lower sodium concentration in new and reformulated products has been offset by overall increases in serve size. Continued monitoring and development and implementation of Government-led targets for serve size and nutrient content of new and existing fast food products are required.

Background In March, 2016, the UK government proposed a tiered levy on sugar-sweetened beverages (SSBs; high, moderate, and no tax for drinks with >8g, 5g to 8g, and <5g sugar per 100ml). We estimate the effect of possible industry responses to the levy on obesity, diabetes, and dental caries. Methods We modelled three possible industry responses: (1) reformulation to reduce sugar concentration, (2) increasing product price, and (3) changing the market share of high-, mid-, and low-sugar drinks. For each response, we defined a better and worse case health scenario. We developed a comparative risk assessment model to estimate the UK health impact of each scenario. Findings The best modelled scenario for health is SSB reformulation, resulting in 144,000 (95% uncertainty interval: 5,100 to 306,700) fewer adults and children with obesity in the UK, 19,000 (6,900 to 32,700) fewer incident cases of diabetes per year, and 269,000 (82,200 to 470,900) fewer decayed, missing, or filled teeth annually. Increasing the price of SSBs and changes to market share to increase the proportion of low-sugar drinks sold would also result in population health benefits, but to a lesser extent. The greatest benefit for obesity and oral health would be among individuals under 18 years, with people over 65 years experiencing the largest absolute decreases in diabetes incidence. Interpretation The health impact of the soft drink levy is dependent on its implementation by industry. There is uncertainty as to how industry will react and in the estimation of health outcomes. Health gains could be maximised by significant product reformulation with additional benefits possible if the levy is passed onto purchasers through raising the price of high- and mid-sugar drinks, and through activities to increase the market share of low-sugar products.

Background In March, 2016, the UK government proposed a tiered levy on sugar-sweetened beverages (SSBs; high, moderate, and no tax for drinks with >8g, 5g to 8g, and <5g sugar per 100ml). We estimate the effect of possible industry responses to the levy on obesity, diabetes, and dental caries. Methods We modelled three possible industry responses: (1) reformulation to reduce sugar concentration, (2) increasing product price, and (3) changing the market share of high-, mid-, and low-sugar drinks. For each response, we defined a better and worse case health scenario. We developed a comparative risk assessment model to estimate the UK health impact of each scenario. Findings The best modelled scenario for health is SSB reformulation, resulting in 144,000 (95% uncertainty interval: 5,100 to 306,700) fewer adults and children with obesity in the UK, 19,000 (6,900 to 32,700) fewer incident cases of diabetes per year, and 269,000 (82,200 to 470,900) fewer decayed, missing, or filled teeth annually. Increasing the price of SSBs and changes to market share to increase the proportion of low-sugar drinks sold would also result in population health benefits, but to a lesser extent. The greatest benefit for obesity and oral health would be among individuals under 18 years, with people over 65 years experiencing the largest absolute decreases in diabetes incidence. Interpretation The health impact of the soft drink levy is dependent on its implementation by industry. There is uncertainty as to how industry will react and in the estimation of health outcomes. Health gains could be maximised by significant product reformulation with additional benefits possible if the levy is passed onto purchasers through raising the price of high- and mid-sugar drinks, and through activities to increase the market share of low-sugar products. ; RT and AK have previously done work on sugar-sweetened beverage taxes funded by the Union of European Soft Drinks Associations. MR is chair of Sustain and the Children's Food Campaign, which have campaigned for sugar drink taxes in the UK. MR is funded by the British Heart Foundation, grant number 006/PSS/CORE/2016/OXFORD. ADMB and OTM are members of the Faculty of Public Health, which has a position statement supporting sugary drink taxes. ADMB is funded by the Wellcome Trust, grant number 102730/Z/13/Z. OTM is a member of the UK Health Forum, which has also supported a UK sugar drinks tax. OTM is supported by a Wellcome Trust Clinical Doctoral Fellowship. SAJ was the independent Chair of the Department of Health Public Health Responsibility Deal Food Network from 2010 to 2015. SAJ is funded by the National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care Oxford. The views expressed are those of the authors and not necessarily those of the National Health Service, National Institute for Health Research, or the Department of Health. PS is funded by the British Heart Foundation, grant number FS/15/34/31656. TB is funded the Health Research Council of New Zealand (16/443). AE declares no competing interests.