In contrast to deaths which are clearly attributable to a given causality (such as motor vehicle collisions, suicides, falls, fires, drowning etc..), deaths due to pollution and to personal behaviours, such as smoking, sedentariness and nutritional habits are harder to identify. Despite this difficulty, obesity and overweight have been implicated as risk factors for many causes of death [
17,
49,
50].
The estimate of 6402 deaths annually attributable to overweight and obesity (around 15% of all deaths) is over 17 times the magnitude of suicides, 18 times that of road accident fatalities and around 50 times that of homicides in Israel [
23]. The direct cost of treating morbidity from overweight and obesity, is around 2.18 billion NIS, equivalent to 0.19% (95% CI: 0.08–0.23%) of Israel’s GDP [
23,
24] or 2.5% (95% CI: 1.0–3.9%) of all health expenditures. This represents an average annual cost of 391 NIS and 802 NIS respectively, for each obese or overweight Israeli aged 20 and over.
The total costs to society of treating morbidity from obesity and overweight, is around 3.8 billion NIS, equivalent to 0.32% (95% CI: 0.27–0.43%) of GDP. [
17,
18], an average annual expenditure of 674 NIS and 1381 NIS respectively for each obese or overweight Israeli aged 20 and over. Due to the high burden of disease, introduction of programs to reduce sugar consumption are desirable.
Impact of reducing sugar consumption
An as yet undefined, national program of reducing energy from sugar consumption from its current level of 12.45 to 10% will reduce damage from sugar related obesity (and overweight) by 3.7% over a five year time horizon [
7] and reduce caries by 16.1%. This will annually, on average, prevent 237 (95% CI: 112–325) deaths, 9917 days hospitalization and around 180,000 fillings (Table
5). This will result in annual savings of direct treatment costs of around 121 million NIS (including 40 million NIS from caries reduction) and total societal costs of 180 million (95% CI: 118–294 million) NIS or 0.02% (95% CI: 0.01–0.03%) of GDP (Table
5).
Table 5
Average annual mortality, morbidity decreases and cost savings (NIS) by sugar consumption goals
10% of energy from sugar in 5 years |
Averted:- |
Deaths | 237 | 122 | 325 |
General hospital days | 9917 | 4993 | 13,068 |
Caries | 179,625 | 153,843 | 205,050 |
Savings (NIS):- |
Fewer fillings | 40,276,302 | 34,495,259 | 45,977,166 |
Overweight & obesity treatment | 80,854,527 | 47,172,679 | 143,248,124 |
Total direct costs (NIS): | 121,130,829 | 81,667,937 | 189,225,290 |
Indirect costs | 58,375,715 | 36,166,004 | 105,129,999 |
Total societal costs (NIS) | 179,506,544 | 117,833,941 | 294,355,290 |
% of per capita GDP | 0.02% | 0.01% | 0.03% |
5% of energy from sugar in 15 years |
Averted:- |
Deaths | 494 | 254 | 677 |
General hospital days | 20,699 | 10,423 | 27,277 |
Caries | 336,484 | 288,187 | 384,111 |
Savings (NIS):- |
Fewer fillings | 75,447,779 | 64,618,411 | 86,126,949 |
Overweight & obesity treatment | 168,767,366 | 98,463,364 | 299,001,300 |
Total direct costs (NIS): | 244,215,145 | 163,081,775 | 385,128,250 |
Indirect costs | 121,847,423 | 75,489,171 | 219,437,473 |
Total Societal Costs (NIS) | 366,062,568 | 238,570,946 | 604,565,723 |
% of per capita GDP | 0.03% | 0.02% | 0.05% |
If a more ambitious target of reducing consumption to 5% is achieved over a 15 year period, sugar related obesity (and overweight) will decrease by 7.7% [
7] and caries by 49.1%. This means that annually an average of 494 (95% CI: 254–677) deaths, 20,699 days hospitalization and 336,000 fillings will be prevented, resulting in savings of around 244 million NIS in direct costs (including 75 million NIS in caries reduction) and societal costs of 366 million (95% CI: 239–605 million) or 0.03% (95% CI: 0.02–0.05%) of GDP.
Cost utility analysis of reducing sugar consumption
Assuming the imposition of an intervention program will succeed in reducing energy consumption from sugar to 10% over 5 years, there will be a saving of 1184 lives and 14,703 PYLL, giving a total of 8425 averted discounted DALYS. Since 99.7% of these DALYS are due to mortality gains, varying the disability weight of hospitalization between 0.2 and 0.4 will have an insignificant effect on the results.
Imposing a tax on sugar products could be part of the multifaceted approach to reducing sugar consumption. Taxing soft drinks could annually generate around 280 million NIS of income (based on adjusted UK estimates). In the UK such revenues are earmarked to improve primary school sports facilities. In Israel, around 24 million NIS of the revenues annually could be earmarked to add 100 full time equivalent dietician posts (including office facilities) to help implement other parts of the multifaceted program to reduce sugar consumption. Over 5 years this hypothetical intervention will for an intervention cost of around 120 million NIS, generate 1400 million in tax revenues, save 606 million NIS in direct treatment costs and a further 292 million in indirect costs, resulting in a net (cost-) saving of 2178 million NIS.
However, the Health Minister is reluctant to impose a sugar tax, on the grounds that such a tax will raise consumer prices in a regressive fashion [
11]. In this scenario, the intervention will still be cost saving to the tune of 778 million NIS. While any future imposition of a sugar tax will impose only a small legislative cost, lessons should be learned from the recent experience in New York of the practical problems of imposing such a tax, especially in that it should be based on a per calorie as opposed to per volume formula [
50].
These estimates, of damage from sugar consumption, should be regarded as preliminary as they can be improved upon if the following data ever becomes available:
i)
Israeli-based cause and age-specific relative risks, thus allowing calculation of PAF due to obesity and overweight in Israel.
ii)
Israeli based disease specific costs and utilization rates of geriatric hospitals, out of hospital pharmaceutical and other care costs (home helps, physiotherapy, ambulatory doctor visits etc.).
iii)
Israeli-based cause specific estimates of work productivity losses and other indirect costs.
iv)
Estimates of disability weights relating to morbidity in an out-of hospital setting. This would correct for the underestimation of DALYS averted (and subsequent overestimation of Costs per DALY averted) since only estimates for morbidity losses during the period of hospitalisation were included in the model.
Gains from reduced caries might also be overestimated to the extent that some people in Israel are already exposed to fluoride via toothpaste and their natural water supplies. On the other hand, estimates of the costs of treating caries and hence potential savings attributable to reductions in sugar consumption can be considered as being very conservative as they do not include any costs incurred by persons aged 18 years and over, who will almost certainly benefit from a reduction in sugar consumption [
51].
Further underestimations of averted DALYS and averted treatment costs arose because the model was based solely on the relative risks of overweight and obese persons and was unable (because of lack of data) to take into account the impact of reductions in sugar consumption in persons of normal weight. For example, many new onset cases of type II diabetes occur in persons of normal anthropometric proportions who would also benefit from reduction in sugar consumption [
52].
All the estimates are subject to the important caveat that any achieved calorific reduction due to decreased sugar consumption is not compensated for by increased calorific intake of other (non-sugar) foods. But even in the event that a compensating rise in calorific consumption occurs (resulting possibly in an isocaloric situation), some health benefits are likely to still be generated as “not all calories are equal” since there is evidence that the quality of fat and carbohydrate can play a more important role than the quantity [
53]. The resultant diet that is lower in sugar (carbohydrates) is likely be healthier than the initial high in sugar diet, especially with respect to type II diabetes risk factors in young people [
54]. If full calorific compensation occurs, then the mortality and morbidity gains estimated in this paper will be around 74% lower [
55], resulting in there being a gain of 2190 DALYs and a net saving of only 113 million NIS in the scenario where no tax is imposed on sugar.
Reducing energy from sugar consumption from its current level of 12.45 to 10%, over a five year time horizon is considered to be a very reasonable and attainable short-term goal. Over these 5 years, this would save 2178 million NIS in costs (778 million NIS if no taxes are imposed) as well as 1184 lives. Achieving a reduction to 5% over a 15 year period would be a far harder goal to achieve, but the rewards in terms of decreased mortality, morbidity and expenditures would be greater.
It is highly likely that any package of interventions, with or without the imposition of taxes on sugar, will be cost-saving (i.e. supplying quality adjusted life years at no additional net cost), since costs savings from morbidity reductions (and possible tax revenues) will exceed the costs of the intervention. This will still be true if we view the results just from just the direct costs of health services perspective. Finally, it should be noted that other many other interventions available to reduce overweight and obesity are available, that have also been shown to be cost-saving or very cost effective [
21,
56].