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Front-of-Package Food Labeling to Reduce Caries: Economic Evaluation

Front-of-package food labeling (FoPFL) is increasingly advocated as an effective intervention to facilitate behavior changes toward healthier food purchasing and consumption, particularly in relation to products with added sugar. The present study assessed the potential caries-related impacts of FoPFL, using Germany as an example. The outcomes of interest were caries lesions prevented, dental treatment costs avoided, productivity loss reductions, and disability-adjusted life years (DALYs) averted. The baseline consumption of added sugar was derived from the German National Nutrition Survey. The reduction in sugar intake due to FoPFL was modeled according to estimates from a recent meta-analysis. Microsimulations were performed for 500,000 individuals and over a time horizon of 10 y. Deterministic and probabilistic sensitivity analyses were performed to check the robustness of results. For the period from 2017 to 2027, FoPFL was identified to prevent 2,370,715 (95% confidence interval [CI], 2,062,730–2,678,700) caries lesions and avert 677.62 (95% CI, 589.59–765.65) DALYs. Treatment cost savings amounted to €175.67 million (95% CI, €152.85–€198.49), and productivity losses reduced by €27.33 million (95% CI, €23.78–€30.88). Sensitivity analyses showed that the magnitude of the effects is highly dependent on consumers’ response to FoPFL. Our findings suggest that FoPFL has the potential to substantially reduce caries increment, caries-related morbidity, and economic burden. In addition, our study allows for the inclusion of oral health estimates in overall health estimates for sugar-related food labeling. Before prioritizing a strategy to tackle sugar consumption, decision makers should carefully consider all relevant context-specific factors and implementation costs.


Further background information
Food labeling is a frequently proposed strategy for reducing the amount of sugar intake (Kanter et al. 2018). It seeks to convert nutritional information into informed consumer choices towards healthy food and beverage consumption. Relevant prerequisites for food labeling to be effective are sufficient health literacy, i.e. the consumer is able to acquire and interpret health-related information, and self-efficacy, i.e. the consumer beliefs in a healthy diet and is self-confident to achieve it (Cha et al. 2014). To date, there are several labeling schemes employed, varying in presentation and types of information displayed.
When making healthier food choices, the most important are those providing the nutrition content. A variety of formats has been used from presenting the amount of nutrients as a proportion of recommended daily intake, to the usage of symbols, words and colors to evaluate overall healthiness of a product. In addition, they can include positive or negative signposting. As such, label formats may also contribute to the differences in individuals' utilization of nutrition information. For example, with the Nutri-Score, the Traffic Light or the Nordic Keyhole it is sufficient to understand the meanings of colors, logos or symbols, while to select healthier foods with the Reference Intakes, numeracy and literacy skills are required (Cha et al. 2014;Jones et al. 2019). On the other hand, the effects of pricing to reduce the amount of sugar intake (e.g. SSB taxation) are based on the acquisitive power of consumers. Increasing prices of particular unhealthy products would reduce their affordability (e.g. SSB taxation), and it is expected to cause higher demand responses among low-income consumers, assuming that the prices of all other goods and acquisitive power remain equal (Allcott et al. 2019).
Currently, available evidence suggests that there is a relationship between socioeconomic gradient and diet quality. Less affluent groups have a diet of poor quality, with high sugar consumption being one of its most dominant contributors, whereas groups with a high socioeconomic status tend to consume less sugar (Darmon and Drewnowski 2008). In addition, several studies reported that people with lower education demonstrated lower health literacy than people with higher education (Lee et al. 2010;Nutbeam 2008;Van Der Heide et al. 2013).
Most common alternatives for added-sugars are sweeteners and fruits. Various artificial sweeteners have been commonly used as an alternative to high calorie sugar. However, even being often low on calories and cheaper alternative, they are not always teeth-friendly. According to Wiggins et al. (2015), less calorie dense foods, fruits among them, also imply higher costs on consumers. Therefore, purchasing power might still be a limiting factor for changes in purchasing behaviors despite the efforts of FoPFL.

Parameter estimation and uncertainties
• Added-sugar consumption Baseline intake of free sugars was obtained from the German National Nutrition Survey II (NVS II).
Data were available for the population aged 14 to 79 (Appendix Table 1), stratified for gender and age groups (15-18, 19-24, 25-34, 35-50, 51-64, 65-80 years old) (Heuer 2018 • Relationship between the amount of added-sugar consumed and caries incidence: Bernabe et al. (2016) have found that "Over 11 years Decayed, Missing, Filled Teeth (DMFT) score increases by 0.1 units for every 10 grams of sugar consumed per day". In our study, we assumed linear caries development over the 11-year time horizon. Therefore, the mean annual increase in DMFT amounts to 0.0091 for every 10 grams consumed per day. It was assumed that the DMFT increment solely presents yearly caries incidence (Kassebaum et al. 2015), and this estimate was converted into the reduction of probability for caries development. • Caries incidence A person-level yearly caries incidence with 95% confidence interval, stratified for age and gender was derived from the publicly available online platform of The Institute for Health Metrics and Evaluation (IHME 2019). A yearly probability for caries development was then established based on the following formula: 1 − (− ) , with YCI being person-level yearly caries incidence.
• Caries-related Disability Adjusted Life Years (DALYs) The caries burden due to morbidity was estimated through DALYs based on the Global Burden of Disease (GBD) methodology (Bernabe et al. 2020

Sensitivity analyses
Given that higher treatment costs are not unusual in Germany due to the possibility of patient copayments for publicly insured patients and a higher than the average multiplication factor of 2.3 being applied for privately insured patients (depending on treatment complexity for the individual patient), treatment costs of a patient under statutory health insurance were modelled. As a reference case, we used a patient who is treated at Heidelberg University Hospital where an additional patient co-payment of €45 is issued for a 1-surface filling; hence the total treatment costs amount to €118.11 in our sensitivity analysis. The results from this sensitivity analysis are shown in Appendix Table 2 below.
To arrive at the population level estimates, person-level impacts were multiplied by the population size for each age category (Federal Statistical Office 2019). Annual discount rates of 3% for both benefits and costs were applied according to the applicable recommendations (IQWiG 2019).
Appendix used as input. The results from this sensitivity analysis are shown in Appendix Table 3 below. Finally, for probabilistic sensitivity analysis, due to unavailable standard deviation (sd) for the cost of restoration, we used the confidence interval as +/-20% of the mean reported value (€74.10).
Appendix collection of the necessary information to be presented on the label, label re-design and administration.
The cost of familiarizing with new policy was estimated at €1408 per company (the baseline year 2004).
For our analysis, we assumed the same cost, amounting to €1741 when adjusted for inflation rates to the 2017 price year. According to GTAI (2019), there were 6000 companies within the food industry in Germany in 2017. Therefore, the familiarization with new regulations would incur costs of €5.22 million. We assumed food producers to be already familiar with the content of their products and the necessary information to be displayed on front-of-package (FOP) labels. Due to the lack of settingspecific data on re-labeling costs we were not able to take this into account. However, more than 80% of companies would change their labels over a 3-year period irrespectively of food labeling interventions (Rabinovich et al. 2008). The overall administration-related burden due to general food labeling legislation ranges between 0.01-0.69% of the food industry revenues, where nutrition labeling accounts for 4% of it (The Commission of the European Communities 2008). In 2017, the food industry revenues for added-sugar containing products were as follows: 1) €11.9 billion for confectionery and snacks (chocolate products, sugar products, fine baked goods, snacks, cocoa and chocolate semi-finished products, ice-cream, raw mixtures); 2) €6.7 billion for non-alcoholic beverages (€2.7 billion for water) (GTAI 2019). Administrative costs due to nutrition labeling of added-sugar containing products amounts between €64,800 and € 4,341,600. In total, considering currently available evidence, the implementation of FOPFL of added-sugar was estimated to incur costs between €5.29 and €9.56 million, excluding the cost of relabeling.

Interactive web-based dissemination tool
The interactive tool, displayed in Figure 1, will calculate the individual-level effects in caries lesions and costs per person over 10 years given the values set in the tool. Additionally, the tool will calculate the total caries lesions prevented and treatment costs avoided by simulating all the age categories and multiplying the estimates by the size of the selected population group.