Taxes to reduce the consumption of sugar-sweetened beverages (SSBs) such as soda drinks have been endorsed by the World Health Organization and are now in place in France, Hungary, and Mexico, and scheduled for Portugal, South Africa, and Great Britain. Such taxes have so far been impossible to enact in the United States at the state or federal level, but since 2014 seven local jurisdictions have put them in place. Three necessary conditions for local political enactment emerge from this recent experience: Democratic Party dominance, external financial support for pro-tax advocates, and a political message appropriate to the process (public health for ballot issues; budget revenue for city council votes). Roughly 40 percent of Americans live within local jurisdictions where the Democratic Party dominates, so room exists for local SSB taxes to continue spreading.
POLICY POINTS: Suboptimal intake of fruit and vegetables is associated with increased risk of diet‐related diseases. A national retail‐based fruit and vegetable subsidy program could broadly benefit the health of the entire population. Existing fruit and vegetable subsidy programs can inform potential implementation mechanisms; Congress's powers to tax, spend, and regulate interstate commerce can be leveraged to create a federal program. Legal and administrative feasibility considerations support a conditional funding program or a federal‐state cooperative program combining regulation, licensing, and state or local options for flexible implementation strategies. Strategies to engage key stakeholders would enable the program to utilize lessons learned from existing programs. CONTEXT: Suboptimal intake of fruit and vegetables (F&Vs) is associated with increased risk of diet‐related diseases. Yet, there are no US government programs to support increased F&V consumption nationally for the whole population, most of whom purchase food at retail establishments. To inform policy discussion and implementation, we identified mechanisms to effectuate a national retail‐based F&V subsidy program. METHODS: We conducted legal and policy research using LexisNexis, the UConn Rudd Center Legislation Database, the Centers for Disease Control and Prevention Chronic Disease State Policy Tracking System, the US Department of Agriculture's website, Congress.gov, gray literature, and government reports. First, we identified existing federal, state, local, and nongovernmental organization (NGO) policies and programs that subsidize F&Vs. Second, we evaluated Congress's power to implement a national retail‐based F&V subsidy program. FINDINGS: We found five federal programs, three federal bills, four state laws, and 17 state (including the District of Columbia [DC]) bills to appropriate money to supplement federal food assistance programs with F&Vs; 74 programs (six multistate, 22 state [including DC], and 46 local) ...
OBJECTIVES: Excess caloric intake is linked to weight gain, obesity and related diseases including type 2 diabetes and cardiovascular disease (CVD). Obesity incidence has been on the rise, with almost 2 of 3 people being overweight or obese in the US. In 2018, the US federal government passed a law mandating the labeling of calories on all menu items across chain restaurants, as a strategy to support informed consumer choice and reduce caloric intake. Yet, potential health and economic impacts of this policy remain unclear. METHODS: We used a validated microsimulation model (CVD-PREDICT) to estimate reductions in CVD events, diabetes cases, gains in quality-adjusted life-years (QALYs), costs, and cost-effectiveness of two policy scenarios: (1) implementation of the federal menu calorie labelling (menu calorie label), and (2) further accounting for corresponding industry reformulation (menu calorie label + reformulation). The model utilized nationally representative demographic and dietary data from NHANES 2009–2016; policy effects on consumer intake and BMI-disease effects from published meta-analyses; and policy effects on industry reformulation, policy costs (policy administration, industry compliance and reformulation) and health-related costs (formal and informal healthcare costs, productivity costs) from established sources. We conservatively modeled change in calories to change in weight using an established dynamic weight-change model. Findings were evaluated over 10 years and lifetime from a healthcare and societal perspective. Costs were inflated to constant 2018 USD, and costs and QALYs were discounted at 3% annually. We performed probabilistic analyses and a range of one-way sensitivity and subgroup analyses to assess the robustness of our findings. RESULTS: Sample statistics were shown (Table). American adults (35+) consume ∼21% calorie from restaurants (Figure) that would be reduced by 2% due to this law at the population level. Government administration costs were estimated at 11.6$M, industry ...
BACKGROUND: Excess caloric intake is linked to weight gain, obesity, and related diseases including type 2 diabetes and cardiovascular disease (CVD). Obesity incidence is rising, with nearly 3 in 4 US adults being overweight or obese. In 2018, the US federal government finalized the implementation of mandatory labeling of calorie content on all menu items across major chain restaurants nationally as a strategy to support informed consumer choice, reduce caloric intake, and potentially encourage restaurant reformulations. Yet, the potential health and economic impacts of this policy remain unclear. METHODS: We used a validated microsimulation model (CVD-PREDICT) to estimate reductions in CVD events, diabetes cases, gains in quality-adjusted life-years (QALYs), costs, and cost-effectiveness of the menu calorie labeling intervention, based on consumer responses alone, and further accounting for potential industry reformulation. The model incorporated nationally representative demographic and dietary data from NHANES 2009–2016; policy effects on consumer diets and BMI-disease effects from published meta-analyses; and policy effects on industry reformulation, policy costs (policy administration, industry compliance and reformulation) and health-related costs (formal and informal healthcare costs, productivity costs) from established sources or reasonable assumptions. We modeled change in calories to change in weight using an established dynamic weight-change model, assuming 50% of expected calorie reductions would translate to long-term reductions. Findings were evaluated over 5 years and a lifetime from healthcare and societal perspectives, with uncertainty incorporated in both one-way and probabilistic sensitivity analyses. RESULTS: Between 2018–2023, implementation of the restaurant menu calorie labeling law was estimated, based on consumer response alone, to prevent 14,698 new CVD cases (including 1,575 CVD deaths) and 21,522 new type 2 diabetes cases, gaining 8,749 QALYs. Over a lifetime, corresponding values ...
BACKGROUND-: Sugar-sweetened beverage (SSB) taxes are a rapidly growing policy tool and can be based on absolute volume, sugar content tiers, or absolute sugar content. Yet, their comparative health and economic impacts have not been quantified, in particular tiered or sugar content taxes that provide industry incentives for sugar reduction. METHODS-: We estimated incremental changes in diabetes and cardiovascular disease (CVD), quality-adjusted life-years (QALYs), costs, and cost-effectiveness of three SSB tax designs in the United States, based on (1) volume ($0.01/oz.), (2) tiers (20 g/8 oz.: $0.02/oz.), and (3) absolute sugar content ($0.01/tsp added sugar), each compared to a base case of modest ongoing voluntary industry reformulation. A validated microsimulation model, CVD-PREDICT, incorporated national demographic and dietary data from NHANES; policy effects and SSB-related diseases from meta-analyses; and industry reformulation and health-related costs from established sources. RESULTS-: Over a lifetime, the volume, tiered, and absolute sugar content taxes would generate $80.4 billion, $142 billion, and $41.7 billion in tax revenue, respectively. From a healthcare perspective, the volume tax would prevent 850,000 CVD (95% CIs: 836,000–864,000) and 269,000 diabetes (265,000–274,000) cases, gain 2.44 million QALYs (2.40–2.48), and save $53.2 billion net costs (52.3–54.1). Health gains and savings were approximately doubled for the tiered and absolute sugar content taxes. Results were robust across for societal and government perspectives, at 10 years follow-up, and with lower (50%) tax pass-through. Health gains were largest in young adults, Blacks and Hispanics, and lower income Americans. CONCLUSIONS-: All SSB tax designs would generate substantial health gains and savings; tiered and absolute sugar content taxes should be considered and evaluated for maximal potential gains.
PURPOSE OF REVIEW. Suboptimal diet is a leading cause of cardiometabolic disease and economic burdens. Evidence-based dietary policies within 5 domains – food prices, reformulation, marketing, labeling, and government food assistance programs – appear promising at improving cardiometabolic health. Yet, the extent of new dietary policy adoption in the US and key elements crucial to define in designing such policies are not well established. We created an inventory of recent US dietary policy cases aiming to improve cardiometabolic health and assessed the extent of their proposal and adoption at federal, state, local and tribal levels; and categorized and characterized the key elements in their policy design. RECENT FINDINGS. Recent federal dietary policies adopted to improve cardiometabolic health include reformulation (trans-fat elimination), marketing (mass-media campaigns to increase fruits and vegetables), labeling (Nutrition Facts Panel updates, menu calorie labeling), and food assistance programs (financial incentives for fruits and vegetables in the Supplemental Nutrition Assistance Program (SNAP) and Women, Infant and Children (WIC) program). Federal voluntary guidelines have been proposed for sodium reformulation and food marketing to children. Recent state proposals included sugar-sweetened beverage (SSB) taxes, marketing restrictions, and SNAP restrictions, but few were enacted. Local efforts varied significantly, with certain localities consistently leading in the proposal or adoption of relevant policies. Across all jurisdictions, most commonly selected dietary targets included fruits and vegetables, SSBs, trans-fat, added sugar, sodium and calories; other healthy (e.g., nuts) or unhealthy (e.g., processed meats) factors were largely not addressed. Key policy elements to define in designing these policies included those common across domains (e.g. level of government, target population, dietary target, dietary definition, implementation mechanism), and domain-specific (e.g., media channels for food ...
Poor diet increases cardiometabolic disease risk, yet the impact of food service guidelines on employee health and its cost effectiveness is poorly understood. Federal food service guidelines (FFSG) aim to provide United States (U.S.) government employees with healthier food options. Using microsimulation modeling, we estimated changes in the incidence of cardiometabolic disease, related mortality, and the cost effectiveness of implementing FFSG in nationally representative model populations of government and private company employees across 5 years and lifetime. We based estimates on changes in workplace intake of six FFSG dietary targets and showed lifetime reductions of heart attacks (– 107/million), strokes (– 30/million), diabetes (– 134/million), ischemic heart disease deaths (– 56/million), and stroke deaths (– 8/million). FFSG is cost saving overall, with total savings in discounted healthcare costs from $4,611,026 (5 years) to $539,809,707 (lifetime) $U.S. This study demonstrates that FFSG improves health outcomes and is cost saving.
POLICY POINTS: The World Health Organization has recommended sodium reduction as a "best buy" to prevent cardiovascular disease (CVD). Despite this, Congress has temporarily blocked the US Food and Drug Administration (FDA) from implementing voluntary industry targets for sodium reduction in processed foods, the implementation of which could cost the industry around $16 billion over 10 years. We modeled the health and economic impact of meeting the two‐year and ten‐year FDA targets, from the perspective of people working in the food system itself, over 20 years, from 2017 to 2036. Benefits of implementing the FDA voluntary sodium targets extend to food companies and food system workers, and the value of CVD‐related health gains and cost savings are together greater than the government and industry costs of reformulation. CONTEXT: The US Food and Drug Administration (FDA) set draft voluntary targets to reduce sodium levels in processed foods. We aimed to determine cost effectiveness of meeting these draft sodium targets, from the perspective of US food system workers. METHODS: We employed a microsimulation cost‐effectiveness analysis using the US IMPACT Food Policy model with two scenarios: (1) short term, achieving two‐year FDA reformulation targets only, and (2) long term, achieving 10‐year FDA reformulation targets. We modeled four close‐to‐reality populations: food system "ever" workers; food system "current" workers in 2017; and subsets of processed food "ever" and "current" workers. Outcomes included cardiovascular disease cases prevented and postponed as well as incremental cost‐effectiveness ratio per quality‐adjusted life year (QALY) gained from 2017 to 2036. FINDINGS: Among food system ever workers, achieving long‐term sodium reduction targets could produce 20‐year health gains of approximately 180,000 QALYs (95% uncertainty interval [UI]: 150,000 to 209,000) and health cost savings of approximately $5.2 billion (95% UI: $3.5 billion to $8.3 billion), with an incremental cost‐effectiveness ratio (ICER) ...
OBJECTIVES: Sugar sweetened beverage (SSB) intake is pervasive in the U.S. and a critical risk factor for weight gain and obesity. Obesity is a preventable factor associated with 13 types of cancers. While SSB taxes can lower SSB intake, the potential impact on cancer outcomes, health costs, and cost-effectiveness in the U.S. is lacking. We aimed to evaluate the health outcomes, costs, and cost-effectiveness of a national SSB tax policy for reducing obesity-related cancer in the U.S. METHODS: We used the Diet Cancer Outcome Model (DiCOM), a probabilistic cohort state-transition model, to project the effect of a national $0.01 per oz SSB excise tax on 13 obesity-associated cancers among U.S. adults age 20+ years over their lifetime. Model inputs included national demographic and dietary data from the National Health and Nutrition Examination Survey (NHANES) 2013–2016, policy effects, diet-BMI effects, and BMI-cancer effects from meta-analyses, and policy and cancer costs from established sources. Cost-effectiveness was evaluated as net costs with 3% annual discounting, under both government affordability and societal perspectives. Probabilistic sensitivity analyses jointly incorporated uncertainty in model inputs using 1000 simulations. RESULTS: The SSB tax policy was estimated to prevent 20,545 (95% uncertainty interval [UI]: 12,586 to 32,000) new cancers cases and 10,181 (6362 to 16,000) cancer deaths and add 67,100 (41,100 to 104,505) quality-adjusted life years (QALYs) over lifetime. Largest health benefits were seen for endometrial, kidney, and liver cancer. The SSB tax was estimated to generate $1.17 billion industry compliance costs, $1.20 billion in government implementation costs, and $5.4 billion in lifetime medical savings for the 13 types of cancer. The SSB tax was net cost saving from a societal perspective and government affordability perspective, at $3.2 billion (95% UI: $2.4 to $4.1) and $4.1 billion (95% UI: $3.4 to $4.9), respectively, not including the $6.6 billion generated from tax revenues. ...
BACKGROUND: Sugar-sweetened beverage (SSB) consumption contributes to obesity, a risk factor for 13 cancers. Although SSB taxes can reduce intake, the health and economic impact on reducing cancer burdens in the United States are unknown, especially among low-income Americans with higher SSB intake and obesity-related cancer burdens. METHODS: We used the Diet and Cancer Outcome Model, a probabilistic cohort state-transition model, to project health gains and economic benefits of a penny-per-ounce national SSB tax on reducing obesity-associated cancers among US adults aged 20 years and older by income. RESULTS: A national SSB tax was estimated to prevent 22 075 (95% uncertainty interval [UI] = 16 040-28 577) new cancer cases and 13 524 (95% UI = 9841-17 681) cancer deaths among US adults over a lifetime. The policy was estimated to cost $1.70 (95% UI = $1.50-$1.95) billion for government implementation and $1.70 (95% UI = $1.48-$1.96) billion for industry compliance, while saving $2.28 (95% UI = $1.67-$2.98) billion cancer-related healthcare costs. The SSB tax was highly cost-effective from both a government affordability perspective (incremental cost-effectiveness ratio [ICER] = $1486, 95% UI = -$3516-$9265 per quality-adjusted life year [QALY]) and a societal perspective (ICER = $13 220, 95% UI = $3453-$28 120 per QALY). Approximately 4800 more cancer cases and 3100 more cancer deaths would be prevented, and $0.34 billion more healthcare cost savings would be generated among low-income (federal poverty-to-income ratio [FPIR] ≤ 1.85) than higher-income individuals (FPIR > 1.85). CONCLUSIONS: A penny-per-ounce national SSB tax is cost-effective for cancer prevention in the United States, with the largest health gains and economic benefits among low-income Americans.
In: Bulletin of the World Health Organization: the international journal of public health = Bulletin de l'Organisation Mondiale de la Santé, Band 94, Heft 12, S. 931-934
Background A key component of achieving universal health coverage is ensuring that all populations have access to quality health care. Examining where gains have occurred or progress has faltered across and within countries is crucial to guiding decisions and strategies for future improvement. We used the Global Burden of Diseases, Injuries, and Risk Factors Study 2016 (GBD 2016) to assess personal health-care access and quality with the Healthcare Access and Quality (HAQ) Index for 195 countries and territories, as well as subnational locations in seven countries, from 1990 to 2016. Methods Drawing from established methods and updated estimates from GBD 2016, we used 32 causes from which death should not occur in the presence of effective care to approximate personal health-care access and quality by location and over time. To better isolate potential effects of personal health-care access and quality from underlying risk factor patterns, we risk-standardised cause-specific deaths due to non-cancers by location-year, replacing the local joint exposure of environmental and behavioural risks with the global level of exposure. Supported by the expansion of cancer registry data in GBD 2016, we used mortality-to-incidence ratios for cancers instead of risk-standardised death rates to provide a stronger signal of the effects of personal health care and access on cancer survival. We transformed each cause to a scale of 0-100, with 0 as the first percentile (worst) observed between 1990 and 2016, and 100 as the 99th percentile (best); we set these thresholds at the country level, and then applied them to subnational locations. We applied a principal components analysis to construct the HAQ Index using all scaled cause values, providing an overall score of 0-100 of personal health-care access and quality by location over time. We then compared HAQ Index levels and trends by quintiles on the Socio-demographic Index (SDI), a summary measure of overall development. As derived from the broader GBD study and other data sources, we examined relationships between national HAQ Index scores and potential correlates of performance, such as total health spending per capita. Findings In 2016, HAQ Index performance spanned from a high of 97.1 (95% UI 95.8-98.1) in Iceland, followed by 96.6 (94.9-97.9) in Norway and 96.1 (94.5-97.3) in the Netherlands, to values as low as 18.6 (13.1-24.4) in the Central African Republic, 19.0 (14.3-23.7) in Somalia, and 23.4 (20.2-26.8) in Guinea-Bissau. The pace of progress achieved between 1990 and 2016 varied, with markedly faster improvements occurring between 2000 and 2016 for many countries in sub-Saharan Africa and southeast Asia, whereas several countries in Latin America and elsewhere saw progress stagnate after experiencing considerable advances in the HAQ Index between 1990 and 2000. Striking subnational disparities emerged in personal health-care access and quality, with China and India having particularly large gaps between locations with the highest and lowest scores in 2016. In China, performance ranged from 91.5 (89.1-936) in Beijing to 48.0 (43.4-53.2) in Tibet (a 43.5-point difference), while India saw a 30.8-point disparity, from 64.8 (59.6-68.8) in Goa to 34.0 (30.3-38.1) in Assam. Japan recorded the smallest range in subnational HAQ performance in 2016 (a 4.8-point difference), whereas differences between subnational locations with the highest and lowest HAQ Index values were more than two times as high for the USA and three times as high for England. State-level gaps in the HAQ Index in Mexico somewhat narrowed from 1990 to 2016 (from a 20.9-point to 17.0-point difference), whereas in Brazil, disparities slightly increased across states during this time (a 17.2-point to 20.4-point difference). Performance on the HAQ Index showed strong linkages to overall development, with high and high-middle SDI countries generally having higher scores and faster gains for non-communicable diseases. Nonetheless, countries across the development spectrum saw substantial gains in some key health service areas from 2000 to 2016, most notably vaccine-preventable diseases. Overall, national performance on the HAQ Index was positively associated with higher levels of total health spending per capita, as well as health systems inputs, but these relationships were quite heterogeneous, particularly among low-to-middle SDI countries. Interpretation GBD 2016 provides a more detailed understanding of past success and current challenges in improving personal health-care access and quality worldwide. Despite substantial gains since 2000, many low-SDI and middle-SDI countries face considerable challenges unless heightened policy action and investments focus on advancing access to and quality of health care across key health services, especially non-communicable diseases. Stagnating or minimal improvements experienced by several low-middle to high-middle SDI countries could reflect the complexities of re-orienting both primary and secondary health-care services beyond the more limited foci of the Millennium Development Goals. Alongside initiatives to strengthen public health programmes, the pursuit of universal health coverage upon improving both access and quality worldwide, and thus requires adopting a more comprehensive view and subsequent provision of quality health care for all populations. ; Bill & Melinda Gates Foundation. Barbora de Courten is supported by a National Heart Foundation Future Leader Fellowship (100864). Ai Koyanagi's work is supported by the Miguel Servet contract financed by the CP13/00150 and PI15/00862 projects, integrated into the National R + D + I and funded by the ISCIII —General Branch Evaluation and Promotion of Health Research—and the European Regional Development Fund (ERDF-FEDER). Alberto Ortiz was supported by Spanish Government (Instituto de Salud Carlos III RETIC REDINREN RD16/0019 FEDER funds). Ashish Awasthi acknowledges funding support from Department of Science and Technology, Government of India through INSPIRE Faculty scheme Boris Bikbov has received funding from the European Union's Horizon 2020 research and innovation programme under Marie Sklodowska-Curie grant agreement No. 703226. Boris Bikbov acknowledges that work related to this paper has been done on the behalf of the GBD Genitourinary Disease Expert Group. Panniyammakal Jeemon acknowledges support from the clinical and public health intermediate fellowship from the Wellcome Trust and Department of Biotechnology, India Alliance (2015–20). Job F M van Boven was supported by the Department of Clinical Pharmacy & Pharmacology of the University Medical Center Groningen, University of Groningen, Netherlands. Olanrewaju Oladimeji is an African Research Fellow hosted by Human Sciences Research Council (HSRC), South Africa and he also has honorary affiliations with Walter Sisulu University (WSU), Eastern Cape, South Africa and School of Public Health, University of Namibia (UNAM), Namibia. He is indeed grateful for support from HSRC, WSU and UNAM. EUI is supported in part by the South African National Research Foundation (NRF UID: 86003). Ulrich Mueller acknowledges funding by the German National Cohort Study grant No 01ER1511/D, Gabrielle B Britton is supported by Secretaría Nacional de Ciencia, Tecnología e Innovación and Sistema Nacional de Investigación de Panamá. Giuseppe Remuzzi acknowledges that the work related to this paper has been done on behalf of the GBD Genitourinary Disease Expert Group. Behzad Heibati would like to acknowledge Air pollution Research Center, Iran University of Medical Sciences (IUMS), Tehran, Iran. Syed Aljunid acknowledges the National University of Malaysia for providing the approval to participate in this GBD Project. Azeem Majeed and Imperial College London are grateful for support from the Northwest London National Insititute of Health Research (NIHR) Collaboration for Leadership in Applied Health Research & Care. Tambe Ayuk acknowledges the Institute of Medical Research and Medicinal Plant Studies for office space provided. José das Neves was supported in his contribution to this work by a Fellowship from Fundação para a Ciência e a Tecnologia, Portugal (SFRH/BPD/92934/2013). João Fernandes gratefully acknowledges funding from FCT–Fundação para a Ciência e a Tecnologia (grant number UID/Multi/50016/2013). Jan-Walter De Neve was supported by the Alexander von Humboldt Foundation. Kebede Deribe is funded by a Wellcome Trust Intermediate Fellowship in Public Health and Tropical Medicine (201900). Kazem Rahimi was supported by grants from the Oxford Martin School, the NIHR Oxford BRC and the RCUK Global Challenges Research Fund. Laith J Abu-Raddad acknowledges the support of Qatar National Research Fund (NPRP 9-040-3-008) who provided the main funding for generating the data provided to the GBD-IHME effort. Liesl Zuhlke is funded by the national research foundation of South Africa and the Medical Research Council of South Africa. Monica Cortinovis acknowledges that work related to this paper has been done on the behalf of the GBD Genitourinary Disease Expert Group. Chuanhua Yu acknowleges support from the National Natural Science Foundation of China (grant number 81773552 and grant number 81273179) Norberto Perico acknowledges that work related to this paper has been done on behalf of the GBD Genitourinary Disease Expert Group. Charles Shey Wiysonge's work is supported by the South African Medical Research Council and the National Research Foundation of South Africa (grant numbers 106035 and 108571). John J McGrath is supported by grant APP1056929 from the John Cade Fellowship from the National Health and Medical Research Council and the Danish National Research Foundation (Niels Bohr Professorship). Quique Bassat is an ICREA (Catalan Institution for Research and Advanced Studies) research professor at ISGlobal. Richard G White is funded by the UK MRC and the UK Department for International Development (DFID) under the MRC/DFID Concordat agreement that is also part of the EDCTP2 programme supported by the European Union (MR/P002404/1), the Bill & Melinda Gates Foundation (TB Modelling and Analysis Consortium: OPP1084276/OPP1135288, CORTIS: OPP1137034/OPP1151915, Vaccines: OPP1160830), and UNITAID (4214-LSHTM-Sept15; PO 8477-0-600). Rafael Tabarés-Seisdedos was supported in part by grant number PROMETEOII/2015/021 from Generalitat Valenciana and the national grant PI17/00719 from ISCIII-FEDER. Mihajlo Jakovljevic acknowleges contribution from the Serbian Ministry of Education Science and Technological Development of the Republic of Serbia (grant OI 175 014). Shariful Islam is funded by a Senior Fellowship from Institute for Physical Activity and Nutrition, Deakin University and received career transition grants from High Blood Pressure Research Council of Australia. Sonia Saxena is funded by various grants from the NIHR. Stefanos Tyrovolas was supported by the Foundation for Education and European Culture, the Sara Borrell postdoctoral program (reference number CD15/00019 from the Instituto de Salud Carlos III (ISCIII–Spain) and the Fondos Europeo de Desarrollo Regional. Stefanos was awarded with a 6 months visiting fellowship funding at IHME from M-AES (reference no. MV16/00035 from the Instituto de Salud Carlos III). S Vittal Katikreddi was funded by a NHS Research Scotland Senior Clinical Fellowship (SCAF/15/02), the MRC (MC_UU_12017/13 & MC_ UU_12017/15) and the Scottish Government Chief Scientist Office (SPHSU13 & SPHSU15). Traolach S Brugha has received funding from NHS Digital UK to collect data used in this study. The work of Hamid Badali was financially supported by Mazandaran University of Medical Sciences, Sari, Iran. The work of Stefan Lorkowski is funded by the German Federal Ministry of Education and Research (nutriCARD, Grant agreement number 01EA1411A). Mariam Molokhia's research was supported by the National Institute for Health Research (NIHR) Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust and King's College London. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health. We also thank the countless individuals who have contributed to GBD 2016 in various capacities. ; Peer reviewed