Estimating the impact of mandatory menu calorie labelling policy and sugar-sweetened beverage taxes on adult obesity prevalence and cardiovascular mortality in two European countries: a simulation modelling study

BackgroundImplementing population-based policies such as mandatory menu calorie labelling in out-of-home food businesses and sugar-sweetened beverage (SSB) taxes are promising approaches to improve population health. We aimed to estimate and compare the likely impacts of menu calorie labelling and SSB taxes on reducing obesity prevalence, cardiovascular disease (CVD) mortality, and socioeconomic-related equitable impacts, in two European countries (Belgium and Germany). MethodsWe used microsimulation models over a 20-year simulation horizon (2022-2041). For both policies, we modelled the impacts through assumed changes in energy intake due to consumer responses and food industry reformulation. Scenarios of partial (in "large" out-of-home businesses; [≥] 250 employees) and full (in all out-of-home businesses) implementation for menu calorie labelling and different tax rates for SSBs (10%, 20%, 30%) were simulated. FindingsCompared to the counterfactual scenario (e.g., without additional policies), assuming policies effects on both consumer and industry behaviour, menu calorie labelling applied to all out-of-home businesses was estimated to reduce obesity prevalence by 3{middle dot}61 (95% uncertainty interval-UI: [2{middle dot}78, 4{middle dot}30]) and 4{middle dot}28 (95% UI: [3{middle dot}64, 5{middle dot}06]) percentage points and prevent 1600 (95% UI: [400, 3800]) and 30000 (95% UI: [10000, 58000]) CVD deaths in Belgium and Germany over 20 years, respectively. The 30% SSB tax was estimated to reduce obesity prevalence by 0{middle dot}27 (95% UI: [0{middle dot}17, 0{middle dot}43]) and 0{middle dot}27 (95% UI: [0{middle dot}17, 0{middle dot}39]) percentage points and postpone 2500 (95% UI: [800, 5200]) and 16000 (95% UI: [7500, 28000]) CVD deaths in Belgium and Germany, respectively. SSB taxation may have socioeconomic-related equitable impacts, while menu calorie labelling may not. InterpretationThe menu calorie labelling and SSB taxation have substantial impacts in reducing obesity prevalence and preventing CVD deaths in Belgium and Germany. Implementing both policies will be important to reduce obesity and related CVD burden. FundingEuropean Research Council, National Institute of Health and Care Research Research in contextO_ST_ABSEvidence before this studyC_ST_ABSWe searched simulation modelling studies on the impacts of food-related policies in MEDLINE from 1st January 2000 to 30th September 2024 using the search terms ("food polic*" OR "health polic*" OR "fiscal polic*" OR "SSB" OR "sugar" OR "menu label*" OR "calorie label*" OR "energy label*") AND (simulation OR microsimulation) based on titles and abstracts, restricted to human subjects. We identified 602 articles. To date, a few simulation modelling studies estimated the population-level impacts of mandatory menu calorie labelling. In England, implementation of mandatory menu calorie labelling in all out-of-home food businesses were estimated to reduce obesity prevalence by 2{middle dot}65 percentage points and prevent 9200 cardiovascular (CVD) deaths over 20 years. Two different studies in the US estimated 27646 CVD deaths and 16700 cancer deaths prevented over lifetime. Given these estimated impacts and England having pioneered the implementation of mandatory menu calorie labelling in Europe, this policy is currently be considered for implementation in many other European countries. However, no studies have examined the potential impacts of implementing this policy in other countries in Europe, nor the extent to which it may offer greater benefits compared to other widely implemented policies, such as sugar-sweetened beverage (SSB) taxes. Many European countries have implemented SSB taxes, including Belgium and the UK. While SSB taxes have been found to be effective in reducing CVD burden based on a scoping review summarising a handful of studies using simulation modelling approaches in different countries, there are gaps in the literature on the impacts of this policy compared to other policies. No studies have estimated and compared the impacts of mandatory menu calorie labelling and SSB taxes on reducing obesity prevalence and CVD mortality in European countries. Added value of this studyThis study is the first to estimate and compare the impacts of mandatory menu calorie labelling and SSB taxes in two European countries, Belgium and Germany. Our estimates indicate consistent evidence across both countries for greater benefits in reducing obesity prevalence and CVD mortality from implementing menu calorie labelling in all out-of-home food businesses compared to its implementation limited to large out-of-home food businesses only. While higher tax rates on SSBs were estimated to have bigger benefits, the impact on reducing obesity prevalence was estimated to be smaller compared to mandatory menu calorie labelling in both countries. However, the impact of SSB taxes on CVD mortality was projected to be greater than the mandatory calorie labelling in Belgium, but smaller in Germany. More importantly, based on the current evidence used to inform our models, these policies are complementary as they are estimated to impact CVD mortality through different pathways: mandatory menu calorie labelling primarily affects body mass index (BMI), while SSB taxes mainly operate through a direct BMI-independent effect. In terms of equitable impacts, menu calorie labelling may prevent more deaths in high than low education groups, whereas SSB taxation may postpone more deaths in low than high education groups. Implemented together, these policies will result in greater benefits in addressing diet-related diseases. Implications of all the available evidenceMandatory menu calorie labelling and SSB taxation were estimated to have substantial impacts on reducing obesity prevalence and preventing CVD mortality. The findings inform the policymakers of both countries and emphasise both the need to implement mandatory menu calorie labelling across out-of-home food businesses and apply higher SSBs tax rates to maximise public health impacts.