Transcript 20131114DMriskACTNOW&SweetedDrinkTax

Journal Club
Briggs AD, Mytton OT, Kehlbacher A, Tiffin R, Rayner M, Scarborough P.
Overall and income specific effect on prevalence of overweight and obesity of 20%
sugar sweetened drink tax in UK: econometric and comparative risk assessment
modelling study.
BMJ. 2013 Oct 31;347:f6189.
Defronzo RA, Tripathy D, Schwenke DC, Banerji M, Bray GA, Buchanan TA,
Clement SC, Henry RR, Kitabchi AE, Mudaliar S, Ratner RE, Stentz FB, Musi N,
Reaven PD, Gastaldelli A; ACT NOW Study.
Prediction of diabetes based on baseline metabolic characteristics in individuals at
high risk.
Diabetes Care. 2013 Nov;36(11):3607-12.
2013年11月14日 8:30-8:55
８階 医局
埼玉医科大学 総合医療センター 内分泌・糖尿病内科
Department of Endocrinology and Diabetes,
Saitama Medical Center, Saitama Medical University
松田 昌文
Matsuda, Masafumi
HR 3322, the Eliminating Disparities in Diabetes Prevention,
Access and Care Act (EDDPAC)
May 30, 2012
米ニューヨーク市のマイケル ブルームバーグ市長は、肥満
対策に取り組むために、レストラン、映画館、食料品店での
高カロリーの清涼飲料の販売を規制するプランを発表した。
September 13, 2012
The New York City Board of Health approved a measure that
says sugary beverages with more than 25 calories per eight
ounces can only be sold in portions of 16 ounces or less. The ban
on larger quantities applies to the following food service
establishments: restaurants, mobile food carts, delis and
concessions at movie theaters, stadiums and arenas. The new
regulation, which goes into effect on March 12, 2013, will give
establishments six months to comply.
Objective To model the overall and
income specific effect of a 20% tax on
sugar sweetened drinks on the
prevalence of overweight and obesity in
the UK.
Design Econometric and comparative risk assessment
modelling study.
Setting United Kingdom.
Population Adults aged 16 and over.
Intervention A 20% tax on sugar sweetened drinks.
Main outcome measures The primary outcomes were
the overall and income specific changes in the number
and percentage of overweight (body mass index ≥25)
and obese (≥30) adults in the UK following the
implementation of the tax. Secondary outcomes were
the effect by age group (16-29, 30-49, and ≥50 years)
and by UK constituent country. The revenue generated
from the tax and the income specific changes in
weekly expenditure on drinks were also estimated.
A tax on sugar sweetened drinks may be an effective measure to improve
health for several reasons.
Firstly, good evidence shows that regular consumption of sugar sweetened
drinks is associated with ill health—principally, adverse weight gain, type 2
diabetes, cardiovascular disease, and dental caries. Although much of the
evidence comes from prospective cohort studies, the associations with weight
gain are also supported by clinical trial data. Moreover, this evidence is
complemented by laboratory studies that elucidate the mechanisms by which
sugar sweetened drinks are likely to damage cardio-metabolic health.
Secondly, as sugar sweetened drinks are weak appetite suppressants, a
reduction in their consumption is likely to lead to a reduction in calorie intake,
with people being unlikely to seek alternative sources of calories.
Thirdly, sugar sweetened drinks are non-necessities and contain no beneficial
nutrients, so direct harm from reducing consumption will not occur. Fourthly,
whereas taxes on unhealthy foods may be problematic because of concern
about unintended substitution effects (for example, a tax on foods high in
saturated fat may lead to a shift towards salty foods),13 the potential substitutes
for sugar sweetened drinks (diet drinks, fruit juice, milk, water) are probably less
harmful for health.
Finally, from a legislative perspective, sugar sweetened drinks can be clearly
defined.
The markedly different levels of consumption of sugar
sweetened drinks in the United States and the UK (735
kJ/person/day in the US compared with 209 kJ in the
UK) suggest that a tax may have a lesser effect in the
UK.
Modelling step 1—effect of tax rises on drink purchases
Modelling step 2—effect of changes in drink purchases on
energy intake
Modelling step 3—effect of changes in energy intake on body
mass index
The PRIME model has previously been
used to model the effects of dietary
changes on mortality due to chronic
disease in the UK setting.
1日1.8L飲む？
1kJ=約0.2389 kcal（カロリー）
The drink category that shows a relatively large substitution effect (cross price value >0.10; that is,
a 2% or greater increase in consumption for a 20% price rise) for price rises of concentrated sugar
sweetened drinks is concentrated diet soft drinks. For non-concentrated sugar sweetened drinks,
relatively large substitution effects (cross price value >0.10) occur for non-concentrated diet soft
drinks, concentrated sugar sweetened drinks, milk, fruit juice, and tea and coffee.
1英ポンド = 158円
The 20% tax is estimated to generate £276m (£272m to £279m) annually.
£276m million: 43,608,000,000 yen 436億円
日本の人口： 127,817,277
英国の人口： 62,641,000
Results A 20% tax on sugar sweetened drinks was
estimated to reduce the number of obese adults in the
UK by 1.3% (95% credible interval 0.8% to 1.7%) or
180 000 (110 000 to 247 000) people and the number
who are overweight by 0.9% (0.6% to 1.1%) or 285
000 (201 000 to 364 000) people. The predicted
reductions in prevalence of obesity for income thirds 1
(lowest income), 2, and 3 (highest income) were 1.3%
(0.3% to 2.0%), 0.9% (0.1% to 1.6%), and 2.1% (1.3%
to 2.9%). The effect on obesity declined with age.
Predicted annual revenue was £276m (£272m to
£279m), with estimated increases in total expenditure
on drinks for income thirds 1, 2, and 3 of 2.1% (1.4%
to 3.0%), 1.7% (1.2% to 2.2%), and 0.8% (0.4% to
1.2%).
Effects of a 10% tax Our model predicts that a
10% tax on sugar sweetened drinks will have
approximately half the effect of a 20% tax, with 89
400 (55 300 to 124 500) fewer obese people in
the UK, a 0.6% (0.4% to 0.9%) reduction. The
pattern of effect by both age and third of income
is the same as that seen with a 20% tax, and the
estimated revenue generated is £139m (£137m
to £140m).
Conclusions A 20% tax on sugar
sweetened drinks would lead to a reduction
in the prevalence of obesity in the UK of
1.3% (around 180 000 people). The
greatest effects may occur in young people,
with no significant differences between
income groups. Both effects warrant further
exploration. Taxation of sugar sweetened
drinks is a promising population measure to
target population obesity, particularly among
younger adults.
Message
英国での砂糖入り飲料への20％課税による肥満
および過体重の有病率への影響を計量経済学的
およびリスク評価モデル研究で推定。課税導入
により16歳以上の肥満者数は1.3％（約18万人）
低下すると推算され、収入分類別の低下率は低
収入群1.3％、中収入群0.9％、高収入群2.1％
だった。肥満有病率への影響は年齢とともに低
下した。
若い人に有効のようだが、砂糖入り飲料の売り
上げ15%減って(他の飲料は売上増えるかも)、税
金が増えて、あと何に税金を使うのか？と
か．．． 疑問は尽きない ⇒薬で予防もあるよ！
Prevention of Diabetes Mellitus
Trial
publication
follow-up,
year
No. of new
No.(total)
on-set of DM
drug
event
per 1000
person-years
control
37
21
16
391
397
393
105.1
58.8
45.2
37
122
121.3
No. of new
No.(total)
on-set of DM
event
per 1000
person-years
Thiazolidine
*DPP
2005
0.9
Troglitazone
10
387
28.7
Placebo
Metformin
ILS
TRIPOD
2002
2.5
Troglitazone
17
114
59.6
Placebo
PIPOD
2006
3.0
Pioglitazone
11
86
42.6
-
*DREAM
2006
3.0
Rosiglitazone
306
2365
43.1
Placebo
686
2634
86.8
*ACTNOW
2008
4.0
Pioglitazone
10
303
8.3
Placebo
45
299
37.6
*CANOE
2010
3.9
Met+Rosi
14
103
34.9
Placebo
41
104
101.1
Other (α-GI, statin, fibrate, glinide)
WOSCOP
2001
5
Pravastation
57
2999
3.8
Placebo
82
3975
5.5
*STOP- NIDDM
2002
3.3
Acarbose
221
682
98.2
Placebo
285
686
125.9
BIP
2004
6.2
Bezafibrate
66
156
68.2
Placebo
80
147
87.8
*VICTORY
2009
4
Voglibose
50
897
13.9
Placebo
106
881
30.0
*NAVIGATOR
2010
6.5
Nateglinide
1674
3726
69.1
Placebo
1580
3747
64.9
Matsuda M.;GEKKAN TOUNYOUBYOU;2,16-22,2010 2:16-22, 2010.
EFFECT OF PIOGLITAZONE AND PLACEBO ON
MATSUDA INDEX OF INSULIN SENSITIVITY
Placebo
Pioglitazone
10
Matsuda Index
8
6
Insulin sensitivity as measured with the
Matsuda index increased more with
pioglitazone than with placebo (4.31±0.24
to 7.65±0.34 vs. 4.31±0.30 to
5.23±0.31, P<0.001).
P<0.001
4
2
0
Pre
Post
Pre
Post
72％reduction!
N Engl J Med 2011;364:1104-15.
1Texas
Diabetes Institute, San Antonio, Texas
of Texas Health Science Center, San Antonio, Texas
3Phoenix VA Health Care System, Phoenix, Arizona
4College of Nursing and Health Innovation, Arizona State University, Phoenix, Arizona
5SUNY Health Science Center at Brooklyn, Brooklyn, New York
6Pennington Biomedical Research Center, Louisiana State University, Baton Rouge, Louisiana
7University of Southern California Keck School of Medicine, Los Angeles, California
8Division of Endocrinology and Metabolism, Georgetown University, Washington, D.C.
9VA San Diego Healthcare System, San Diego, California
10University of California at San Diego, San Diego, California
11Division of Endocrinology, Diabetes, and Metabolism, University of Tennessee, Memphis, Tennessee
12Medstar Research Institute, Hyattsville, Maryland
13Cardiometabolic Risk Unit, Institute of Clinical Physiology, Pisa, Italy
2University
Diabetes Care 36:3607–3612, 2013
OBJECTIVE
Individuals with impaired glucose tolerance
(IGT) are at high risk for developing type 2
diabetes mellitus (T2DM).We examined
which characteristics at baseline predicted
the development of T2DMversus
maintenance of IGT or conversion to normal
glucose tolerance.
RESEARCH DESIGN AND METHODS
We studied 228 subjects at high risk with
IGT who received treatment with placebo in
ACTNOW and who underwent baseline
anthropometric measures and oral glucose
tolerance test (OGTT) at baseline and after
a mean follow-up of 2.4 years.
Figure 1 Relationship between
the MI of insulin sensitivity and
insulin secretion (∆I0–120/∆G0–120)
before (A) and after ln
transformation (B).
After adjusting for age, sex, and center,
increased FPG (odds ratio [OR] 1.11; P < 0.0001),
2-h plasma glucose (1.03; P < 0.001),
ΔG0–120 (1.01; P = 0.001), and
HbA1c (8.37; P < 0.0001) at baseline and
a positive family history (first-degree relative) of diabetes (2.46; P
= 0.02) were associated with increased risk of diabetes.
Higher adipocyte insulin resistance (1.48; P = 0.05),
ln fasting plasma insulin (1.56; P = 0.07), and
ln ΔI0–120 (0.61; P = 0.08) were or tended to be associated with
increased risk for diabetes.
higher insulin secretion (ln ΔI0–120/ΔG0–120; OR 0.44; P = 0.003)
higher ln ΔISR0–120/ΔG0–120 (0.25; P = 0.003) were associated with
decreased risk of diabetes.
Higher β-cell function (insulin secretion/insulin resistance or
disposition index = ln [ΔI0–120/ΔG0–120 × MI]; OR 0.11; P < 0.0001)
at baseline was the variable most closely associated with reduced
risk of diabetes.
At baseline,
reduced insulin sensitivity (MI) (OR 0.92; P = 0.22),
higher BMI (1.02; P = 0.40),
higher percent body fat (1.02; P = 0.40), and
higher waist circumference (0.99; P = 0.37) were not
significantly related to future diabetes risk.
Increased total cholesterol (1.02; P <0.05) and
reduced HDL (1.05; P = 0.01) at baseline were
associated with increased risk for diabetes, whereas
plasma triglycerides (1.01; P = 0.78),
LDL cholesterol (0.99; P = 0.15),
triglyceride/HDL cholesterol ratio (1.13; P = 0.14), and
blood pressure (systolic blood pressure: OR 1.00; P =
0.85; diastolic blood pressure: OR 1.01; P = 0.60) were
not associated with increased risk of T2DM.
multivariable stepwise regression analysis
HbA1c, FPG, and family history of diabetes predicted the
development of T2DM (r = 0.45; P < 0.0001). Of these three
variables (after adjusting for age, sex, and center), HbA1c had the
greatest predictive power for future glucose tolerance status (R2
= 0.124; P < 0.0001).
When OGTT-derived physiologic variables were included with
HbA1c, FPG, and family history of diabetes in a stepwise
multivariable regression analysis, only HbA1c and ln(log) insulin
secretion/insulin resistance predicted the development of diabetes
(r = 0.49; P < 0.0001).
Of the easiest measured metabolic and physiologic parameters,
HbA1c had the greatest predictive value (adjusted R2 = 0.124; P <
0.0001). Addition of the 2-h plasma glucose (adjusted R2 = 0.143;
P < 0.0001) or ΔG0–120 (adjusted R2 = 0.142; P < 0.0001) during
the OGTT increased the prediction of diabetes development only
modestly. Addition of ΔI0–120 (adjusted R2 = 0.157; P < 0.0001) or
ΔI0–120/ΔG0–120 (adjusted R2 = 0.157; P < 0.0001) to HbA1c
modestly increased the prediction of diabetes more than the
addition of ΔG0–120 to HbA1c did.
RESULTS
In a univariate analysis, 45 of 228 (19.7%) IGT
individuals developed diabetes. After adjusting for age,
sex, and center, increased fasting plasma glucose, 2-h
plasma glucose, ∆G0–120 during OGTT, HbA1c, adipocyte
insulin resistance index, ln fasting plasma insulin, and ln
∆I0–120, as well as family history of diabetes and
presence of metabolic syndrome, were associated with
increased risk of diabetes. At baseline, higher insulin
secretion (ln [∆I0–120/∆G0–120]) during the OGTT was
associated with decreased risk of diabetes. Higher β-cell
function (insulin secretion/insulin resistance or
disposition index; ln [∆I0–120/∆G0–120 × Matsuda index of
insulin sensitivity]; odds ratio 0.11; P < 0.0001) was the
variable most closely associated with reduced risk of
diabetes.
CONCLUSIONS
In a stepwise multiple-variable analysis,
only HbA1c and β-cell function (ln[log] insulin
secretion/insulin resistance index) predicted
the development of diabetes (r = 0.49; P <
0.0001).
Message
ACTNOW研究はかなり以前のものだが、糖尿
病になるかを見ているので、予知因子が検
討できることになる。HbA1cとMatsuda
indexで補正したインスリン分泌指標がよい
という結果だ。HbA1cが現実的には有用。
で、やはりMatsuda index(を使ってインスリ
ン分泌を補正すること)が大切だ．．．