Family Meliaceae, Subfamily Melioideae, Tribe Guareeae.
Habit and leaf form. Trees. 'Normal' plants. Leaves cauline. To 7–30 m high. Mesophytic. Leaves medium-sized, or large, or very large; alternate; spiral; petiolate; not gland-dotted; with 'normal' orientation; compound; pinnate (rarely with limited apical growth); paripinnate, or imparipinnate. Leaflets 6–22; 3–21.5 cm long. Lateral leaflets alternate, or opposite. Leaflets elliptic, or oblong, or ovate; cuneate at the base, or oblique at the base, or rounded at the base ('obtuse'); flat. Leaflet margins flat. Leaf blades dorsiventral; pinnately veined. Mature leaf blades adaxially glabrous, or pubescent; abaxially glabrous, or pubescent. Leaf blade margins entire; flat. Leaf anatomy. Hairs present. Unicellular hairs present.
Reproductive type, pollination. Fertile flowers hermaphrodite, or functionally male, or functionally female. Unisexual flowers present. Plants hermaphrodite, or dioecious. Plants not viviparous; homostylous. Floral nectaries present. Nectar secretion from the disk.
Inflorescence and flower features. Flowers aggregated in 'inflorescences'. Inflorescence many-flowered. Flowers in racemes, or in spikes, or in panicles. Inflorescences simple, or compound. The terminal inflorescence unit racemose. Inflorescences axillary. Flowers pedicellate; small; regular; 3–6 merous; cyclic. Perianth with distinct calyx and corolla; 6–12; 2 -whorled; isomerous, or anisomerous (rarely). Calyx present; 3–5(–6); 1 -whorled; gamosepalous, or polysepalous (rarely); lobed, or entire (rarely). Calyx lobes markedly shorter than the tube, or about the same length as the tube, or markedly longer than the tube. Calyx glabrous, or hairy; imbricate, or open in bud; exceeded by the corolla; unequal but not bilabiate. Corolla present; 3–6; 1 -whorled; polypetalous (sometimes fused to the lower or upper half of the staminal tube); imbricate, or valvate; regular; glabrous abaxially, or hairy abaxially; glabrous adaxially, or hairy adaxially; white, or cream, or pink. Corolla members entire. Androecial members definite in number. Androecium 8–10. Androecial members free of the perianth, or adnate (partially, to the corolla in the lower or upper half of the staminal tube); all equal; coherent (filaments fused into a tube); 1 - adelphous; 1 -whorled. Stamens 8–10; all more or less similar in shape; diplostemonous (or nearly so). Anthers all alike. Gynoecium 2–5 carpelled. The pistil 2–5 celled. Carpels reduced in number relative to the perianth, or isomerous with the perianth. Gynoecium syncarpous; eu-syncarpous; superior. Ovary plurilocular; 2–5 locular. Gynoecium stylate. Styles 1; apical. Stigmas 1; 1 - lobed; discoid or less frequently small and capitate. Placentation axile. Ovules 1–2 per locule.
Fruit and seed features. Fruit 8–32 mm long; dehiscent; a capsule. Capsules loculicidal. Dispersal unit the seed. Cotyledons 2. Seedling. Germination cryptocotylar (Pennington & Styles (1975)).
Geography, cytology, number of species. World distribution: found in Indomalesia, Australia, New Guinea, Polynesia and New Zealand. Native of Australia, or adventive. Endemic to Australia, or not endemic to Australia. Australian states and territories: Western Australia, or Northern Territory, or Queensland, or New South Wales. Northern Botanical Province. N=10,20,42; 2n=80,84. A genus of 60 species; 1 species in Western Australia; D. latifolium.


text:
PERFORMANCES PAST
Suitcase Sam
o Friday, April 28, 2023 - The Cameron House (Toronto,ON) *full band
o Saturday, March 11, 2023 - The Dakota w/ John Borra and Sam Ferrara (Toronto,ON) *full band
o Thursday, February 23, 2023 - The Third Set (Toronto, ON) *solo
o Thursday, January 26, 2023 - The Third Set (Toronto,ON) *solo

redpajama_set_name: RedPajamaCommonCrawl


text:
Евріпонт (Евріпон) () — напівлегендарний цар Спарти близько 890—860 роках до н. е.

Життєпис
Син царя Сооса. Напевне сприяв розбудові управління в Спарті, уславивши предки. На честь його отримала назву уся династія — Евріпонтидів. Плутарх розповідає про те, що він послабив царську владу, потураючи демагогам. Проте напевне вплив звичайних спартіатів був сильним, й царю довелося потупитися частиною влади на користь народних зборів.

Поліен розповідає про війну спартанського війська під орудоб Евріпонта з аркадянським містом Мантінея через вимогу видати вбивць свого співцаря Агіса I. Викликав розгардяж серед грмоадян Мантінеї, після чого зумів захопити місто.

Йому спадкував син Пританід.

Джерела
 Paul Poralla: Prosopographie der Lakedaimonier bis auf die Zeit Alexanders des Großen. Dissertation Breslau 1913, S. 59

спартанські царі

redpajama_set_name: RedPajamaWikipedia


Helmut Kreutz Mahlwerke GmbH is active in the fields of raw materials preparation and the manufacture of oxide ceramics.
Since 1965, the company has been a leader in Germany in the non-ferrous custom milling sector and in the preparation of mineral raw materials for the refractory, chemical and ceramics industries.
In addition to our own products, such as the zirconium silicate Kreutzonit® and the aluminium oxide ceramic material Kreutzalox® that is produced in-house, Kreutz also offers non-ferrous custom milling.


Pakistani Marriage Bureau in USA, Dubai, Australia, Canada, Saudi Arab, Oman, Kuwait, Qatar for Pakistani Brides, Pakistani Grooms, Pakistani Rishta of Educated Pakistani families and Pakistani Individuals. We are also offering Online Professional matchmaker services in Karachi, Lahore, Islamabad, Multan, Faislalabad, Sialkot, Gujranwala. We also deals with widow, divorce and in second marriage of man as long as he can afford second wife.
Assistance Request for: Pakistani Marriage Bureau in USA, Dubai, Australia, Canada, Saudi Arab, Oman, Kuwait, Qatar for Pakistani Brides, Pakistani Grooms, Pakistani Rishta of Educated Pakistani families and Pakistani Individuals. We are also offering Online Professional matchmaker services in Karachi, Lahore, Islamabad, Multan, Faislalabad, Sialkot, Gujranwala. We also deals with widow, divorce and in second marriage of man as long as he can afford second wife.


text:
Charlene Conklin papers
The Charlene Conklin papers date from 1954 to 1981 (bulk 1965-1978) and measure 7 linear feet. They are arranged in three series: Biographical material, Speeches and writings, and Subject files.
The first, Biographical material, contains a press release with biographical data, a published biographical sketch, and a resume, arranged chronologically.
The second series, Speeches and writings, contains Conklin's speeches, speech notes, and her newspaper column, "Under the Gold Dome," arranged chronologically.
The third series, Subject files, comprises by far the bulk of the papers. It includes correspondence, newspaper clippings, printed materials, legislative bills both proposed and adopted (called House Files (H.F.) or Senate Files (S.F.)), campaign literature, a scrapbook, voting records, and other files relating to Conklin's legislative career, especially her efforts to liberalize Iowa's abortion policy, and to her subsequent involvement in acquiring and restoring the Terrace Hill mansion in Des Moines for the State of Iowa. Of special note in the Terrace Hill Society file is a complete set of blueprints for the mansion. This series is arranged alphabetically.
Conklin, Charlene, 1929- (Person)
Charlene Conklin was born on July 10, 1929 on a farm in Pottawattamie County, Iowa, as Willa Charlene DeWitt, daughter of Charles and Viola DeWitt. After graduating from Griswold High School in 1947, she attended Iowa State Teachers College (now the University of Northern Iowa), graduating in 1950 with a Bachelor of Arts degree in English. From 1950 to 1952 Conklin taught English, speech, and mathematics at Massena (Iowa) High School. In 1952 she married Dr. Dwight E. Conklin, an anesthesiologist in practice at St. Francis Hospital in Waterloo, Iowa. The Conklins, who made their residence in Waterloo, raised five children. In 1953 Conklin graduated from the State University of Iowa (now the University of Iowa) with a Master of Arts degree in speech pathology and audiology and worked from 1953 to 1954 as a speech therapist at the University Hospital for Handicapped Children in Iowa City. In 1966, running as the candidate for the Republican Party, Conklin was elected to the Iowa House of Representatives from Black Hawk County to serve in the 62nd General Assembly for the 1967-1968 term. In 1968 she was elected to the Iowa Senate and served in that capacity for two consecutive terms, 1969-1970 (63rd General Assembly) and 1971-1972 (64th General Assembly). She served on the following Senate committees: Appropriations, Constitutional Amendments and Reapportionment, and Social Services, and was the ranking member on the Schools Committee. In 1973 she chose not to run for reelection. Conklin is perhaps best known for being a key figure in the legislative struggle for the liberalization of abortion rights in the early 1970s. In fact, "she became in some sense the legislative point person for Iowa abortion reform"" (see "Iowa's Abortion Battles", by James C. Mohr in The Annals of Iowa, vol. 50, 1989, p. 71). However, efforts to liberalize Iowa's abortion policy in 1970 and 1971 were repeatedly defeated. The issue was raised again in 1973 after Conklin's retirement from the Senate, but the struggle for reform in Iowa and elsewhere was summarily preempted by the decision of the United States Supreme Court in the case of Roe v. Wade in 1973. In 1971 Conklin, with four other senators, co-sponsored a resolution authorizing the State of Iowa to take possession of Terrace Hill mansion, the classic Victorian home of Frederick M. Hubbell in Des Moines for use either as the governor's mansion or a state museum, or both. After leaving office, Conklin helped organize and was elected president of the Terrace Hill Society, a non-profit group designed to provide funding for and give direction to the restoration of the mansion. The mansion was eventually restored and opened to the public in 1978.
Photographs in Box 1 other_unmapped
Member of the Iowa House of Representatives,1967 to 1969, and the Iowa Senate, 1969 to 1973.
The papers (donor no. 5) were donated by Charlene Conklin in 1984.
A Political Dialogue: Iowa's Women Legislators oral histories (IWA): This collection includes the transcript of an interview with Charlene Conklin.
http://sdrc.lib.uiowa.edu/iwa/findingaids/html/ConklinCharlene.htm#content
Black Hawk County (Iowa)
Conklin, Charlene, 1929-
Iowa. General Assembly. House of Representatives
Iowa. General Assembly. Senate
Pro-choice movement
Social reformers
Terrace Hill Society
Waterloo (Iowa)
wa00013/wa00013.2. Iowa Legislators
George Mullally, 1994, and Special Collections staff.
Charlene Conklin papers, Iowa Women's Archives, The University of Iowa Libraries, Iowa City. http://aspace.lib.uiowa.edu/repositories/4/resources/1833 Accessed January 19, 2020.


Let's consider Psalm 20 meaning. Psalm 20 is a very positive, upbeat kind of psalm – even though it shares some characteristics with lament psalms. And typically – as you know – lament psalms aren't really upbeat. But this one is.
In fact, I can recall a time when I was living on a sheep farm and was having all sorts of struggles. The owners of the farm were expecting more work out of me than I was able to give them – so they weren't very happy with me. My fiance at the time – who's now my wife – was experiencing some pretty perplexing health issues – which required more guidance than I really could give at the time. Those health issues brought about dynamics that quite honestly threatened the continuation of our engagement. I felt alone. I felt directionless. I was very discouraged.
The LORD hear thee in the day of trouble!
The name of the God of Jacob defend thee!
Send thee help from the sanctuary, and strengthen thee out of Zion!
Remember all thy offerings, and accept thy burnt sacrifice!
Grant thee according to thine own heart, and fulfil all thy counsel!
We will rejoice in thy salvation, and in the name of our God we will set up our banners!
The LORD fulfil all thy petitions!
Now, obviously, this chorus of voices wasn't addressing me directly. I mean, this psalm wasn't written for me – Paul Donald Weir living in the early 21st century. But it did encourage me. And my experience with this psalm helps me to know how the original recipient of this psalm might have felt when he heard these words.
You see, this psalm was something of a prayer to God on behalf of the Davidic king of Israel. The people of Israel apparently would sing this song as a prayer to God to deliver their king – maybe right before a battle. Their fate was wrapped up with their king's. If he won, they won. If he lost, they lost. It was in their best interest for the king to win. So, they pray to God for him.
And so, here's one way you could summarize the prayer of the people in this psalm. They're praying for their king to be Protected in the Battle.
In Psalm 20:1-4 we see a prayer to God for the protection of the king.
and accept thy burnt sacrifice; Selah.
and fulfill all thy counsel.
So, here in Psalm 20:1-4 we see the people's prayer to God. They're praying for their king to be delivered or saved or – as I prefer, protected. Now, you wouldn't know necessarily that it's the king that this unidentified group of people is praying for.
But you do get the sense that they are praying, first of all. They say — The Lord hear. The Name defend. Send. Strengthen. Remember. Accept. Grant. And Fulfill. All these verbs – and the way they're stated – alert us to the fact that they're being spoken as a prayer. They're requests. And they're being directed to – Psalm 20:1 – the Lord and the name of the God of Jacob. Those two descriptors point to the same exact being – the only living and true God. So, these people are uttering a request – well, many requests actually. And those requests are being directed to God. So, yes, it's prayer.
Now, on whose behalf are these people praying and making these requests? Look at the pronouns being used. Thee – 4 times in Psalm 20:1-2. Thy – twice in Psalm 20:3. And thee, thine, and thy in Psalm 20:4. The requests are being made on behalf of someone. Not multiple someones. Just one someone. I've already let the cat out of the bag and told you that the prayers are being offered for the king of Israel. But this becomes very clear in the next few verses that we'll turn to shortly.
And, so – though there are multiple requests being made here – there's really only one underlying burden of these people. It's that their king be protected.
In Psalm 20:1, the people ask God to hear or answer their king in the day of trouble. This phrase "day of trouble" or "day of distress" appears over a dozen times in the Old Testament. And in several of those instances, it's speaking of the invasion of a foreign army. And I think that's the point here. The king is going into some military skirmish – weather to aggressively attack the enemy and gain ground or to defend his nation from an invading enemy. And the people are asking God to answer him as he leads the army in battle.
Well, what do you suppose a godly king who's going into a battle would request from the Lord at that moment? Certainly whatever he would request would include the concept found in the next line of Psalm 20:1.
So what will the king likely be asking for in the battle? The second line or statement of Psalm 20:1 asks the Lord to defend the king. In the battle to come, that king will certainly himself be asking the Lord for defense. And the word there for "defense" has the idea of setting something in a high place. The idea is security. So, the picture is that he'd be out of the way of danger.
Now, this is metaphorical and poetic. The people and the king himself wouldn't ask for him to be able to find a high mountain so that he could avoid danger during the battle. Sometimes those kings would be in the battle themselves. No, this is figurative and asking that the king would be protected from danger – as if he were set securely on high – away from all threat of harm.
And it's interesting that the description "the name of the God of Jacob" is in parallel to "the Lord". When the people use this word, "name" – it might be a little confusing to us, because we wouldn't say something like this. This is definitely idiomatic. The word "name" in Hebrew expressed a concept that's just lost on us when it comes over into English as "name". In English, a "name" is something someone is known by. It identifies a person. "Oh, that person over there? Oh, her name is Sue." And I can't really think of any other way we use that word "name".
But in Hebrew, "name" could also communicate the character of someone. So, whatever it was in the Lord that would make these people think that he would defend the king – that's what they were calling on to defend their king. And, now, what was in the character of the Lord that would cause him to defend his Davidic king? How about the fact that God had promised to keep a Davidic king on the throne forever. How about the fact that God keeps his promises. I think those kinds of thoughts are what the people had in mind as they made the requests of Psalm 20:1 to the Lord. Protect our king by answering and defending him in the battle to come. That's the idea.
Next, in Psalm 20:2 the people are still asking God to protect their king. But this time they're focusing on the location from which God will protect the king. They ask that God send help to the king from his sanctuary. Literally, from his "holy". Like a holy place. And that's why "sanctuary" makes sense here.
And this sanctuary is – next statement of Psalm 20:2 – in Zion. In Jerusalem. And so, it's obvious that the people are picturing God as helping the king from his base in the Temple in Jerusalem. It's as if the Temple is God's command center, from which he will send help and strengthen his king. And so in a real sense, the king is leading the army – but the Lord himself is the one sending reinforcements and seeing to it that the battle is won by the good guys.
Next, in Psalm 20:3 – the people ask that the king's religious devotion to the Lord would be accepted. That the Lord would remember and accept all the times when the king had offered an offering according to God's rules.
Now, I admit that sometimes the thought of God answering someone because of what that person does can be uncomfortable. I mean, we're rightly taught that salvation is by grace through faith. It's not because of what we do. It doesn't happen through our works.
But we're not talking about salvation here – spiritual salvation, that is. We're talking about the Lord physically protecting the king of Israel in a battle and giving him victory.
And we need to keep in mind that the Lord actually has answered the prayers of people – apparently based on their deeds. I'm just going to reference one. You have Hezekiah in 2 Kings 20. Remember – he was sick and Isaiah the prophet came to him and told him that he would die. Do you how Hezekiah responded? He turned to the wall and prayed to the Lord. And he said this "I beseech thee, O LORD, remember now how I have walked before thee in truth and with a perfect heart, and have done that which is good in thy sight." And the Lord heard him and healed him. Hezekiah pointed the Lord to his good deeds and his following the Lord in order to appeal to him to answer his prayers. So, I just point this out to say that – while you can't point to your works in order to appeal to the Lord to save you – the people in this psalm have some precedent to beseech the Lord to protect their king – in part because of his acts of genuine devotion to the Lord.
And lastly, in Psalm 20:4, the people are praying that God would give the king anything he desired and that God would bring all his plans to pass. Now, in context I'd have to imagine that they're asking specifically for the king's battle plans to succeed.
And so, that's the people's prayer to God for the protection of their king.
In Psalm 20:5-6 we have the realization of the people's prayers for their king. They picture their king being protected by God. And that causes them to rejoice.
Notice the words "salvation" or "saveth" or "saving". One of those words is used 3 separate times in these two verses. This is where we get the idea that the people are asking for the salvation or deliverance or protection of their king. In the first four verses of the psalm, we saw individual requests. And they all – taken together – amounted to this repeated concept here of "salvation" or protection.
In Psalm 20:5, the people state their plan to rejoice when the Lord protects their king. They'll shout for joy when it happens.
They go on to state in Psalm 20:5 that they planned to set up banners – just like an army does. An army has banners. These people – then – are likely even involved in the military effort for which they're praying. Really, maybe the army itself is the group that would sing this song before a battle. But whatever the case, these people will set up these banners in the name of their God. That name which they prayed in Psalm 20:1 would defend their king, who's leading them into battle.
And then it's as if these people are just overflowing with good desires for their king and his leading them into victory – and they end Psalm 20:5 with just one more request to the Lord for their king. They want the Lord to fulfill all the king's desires.
You just can't help but notice this sense that the people are 100% behind their leader. They want the absolute best for him. There's no hint of the ever-present rebellion that's just been kind of codified into our collective national conscience. It's like – as an American – there's something wrong with you if you're not constantly agitating against authority. Sometimes that's the sense you get from reading the news and seeing society at-large – anarchy is great, that's the message! But that's not how the people reciting this psalm felt. They were totally behind their leader. They knew that their success was wrapped up in his. And so they prayed accordingly.
And I don't want to go too far afield, but I'll just remind us all that it's a Christian practice to pray for those in authority – whether you voted for them or not. Whether you think their main goal in life is to destroy this country or not. In fact, this is a practice – according to 1 Timothy – that the men in the church ought to be doing as we come together for worship. We should be praying for our authorities. And that without wrath or dissension. We should be agreed on this, in other words.
Now, when we enter into Psalm 20:6 it's as if we've turned a new page. The people have been praying for their king to be protected. And now in Psalm 20:6 it's as if the deliverance has been granted. The king has been protected and all is well. And the crowd of praying people has now been reduced to one. The speaker says "now I". It's just him now. And this single individual has come to learn something. Now he knows that God saves his anointed. His Messiah. In the Greek translation of the Old Testament – it's his Christ.
Now, let me explain that a little bit. When that term is used in the Old Testament, it's not necessarily speaking of Jesus the Messiah. I think that in Psalm 20, this reference to God's anointed is directly speaking of the Davidic king who's going out to battle the enemy. So, that's the Messiah in this case – the Davidic King for whose deliverance the people are praying. And yet, the Jews were encouraged to believe that there would be some day THE Messiah. The Ultimate Davidic King – who would rule from Jerusalem and restore the fortunes of Jacob. And yet, that Messiah isn't the one in view here. Right now in Psalm 20, the Messiah or anointed one is simply the Davidic king leading his army into battle.
Alright, now this individual speaker in Psalm 20:6 confirms in the second statement of the verse that God will hear his king. This "hear" is the same word used in Psalm 20:1. It was the very first prayer uttered for the king. That the Lord would hear and answer him. Now this individual is convinced that the Lord will answer their prayers and hear their king.
Further, this individual is convinced that the Lord will do this hearing and answering from his holy heaven. The word "holy" there appeared in Psalm 20:2. There, it was translated "sanctuary". So, while the people prayed that God would send help to their king from his sanctuary on earth, this individual recognizes that God's deliverance will come from some place even higher and loftier than that. It will come ultimately from his sanctuary in heaven.
but we are risen, and stand upright.
There are two main contrasts in these two verses.
The first contrast is between the things that a person trusts in. That's Psalm 20:7. And once again, the individual has given way to the group of people – see the term "we"? And now the people are stating this, literally, "These in chariots, and these in horses, But WE the name of the Lord our God will invoke".
In other words, there are some who call upon – as it were – their chariots and horses in the battle. And after all, that makes sense on a certain level. I mean, in ancient Israel, you do battle with chariots and with horses. Those are the materials available to you. But even if it might make some sense, it's totally wrong. And the people of the king know it.
They will certainly use chariots and horses to great profit. But they don't call upon those things. They don't invoke them. They don't put their trust in them. The king's people – in contrast to the enemy – will invoke the name of the Lord. The name that we've seen in Psalm 20:1 defending the king. The name by which the people in Psalm 20:5 were setting up their banners. That name – that's the one that the people call upon.
So, that's the first contrast – the one to whom you call when you're in distress – pragmatic, practical things like horses and chariots. Or the Lord. The king's people chose the Lord. Was that choice justified?
Well, that's where we get to the second contrast in these two verses. Psalm 20:8 is the contrasting results of choosing the Lord for protection or choosing any other means.
What happened to the enemy of Israel in the battle? Psalm 20:8 – they were brought down and they fell. Not what you want to have happen in a battle. But in contrast – "but we" – the king's people proclaim – we are risen and stand upright. Praise the Lord.
Psalm 20:9 serves as the concluding prayer for God to protect the king.
hear us when we call.
Now, I'm going to suggest that the way Psalm 20:9 is translated can be improved. The last phrase "hear us when we call" is correct. It's a request from the people for the Lord to again hear them and the prayers they've offered for their king.
Everything before that phrase – though – is what I think we need help with. You can translate that first part like this – "Lord, save the king". And that would be a perfectly good way to translate the Hebrew there. And doesn't that go along with the entirety of the psalm as we've seen it this morning? That's all we've been hearing about for this whole psalm – that God would deliver his king. So, yes, I think this is a better way to take the Hebrew here.
Plus, this helps us avoid the awkwardness of the people all of a sudden — in the very last verse of the psalm — introducing this idea that they want the king to hear them when they call. But, throughout the whole psalm, they've been calling to the Lord – not the king. They've been wanting the Lord to hear – not really the king to hear. And now at the very end of the psalm, the people change their approach and start asking the king to answer them? No, I think the people are still calling to the Lord to save their king – even in this last verse of the psalm.
So, that's Psalm 20. Protected in the Battle. That's what the people are praying for their king. It's what they rejoice in and what they come to see actually happen. It's what they experience — while the enemy gets cut down because they're looking to something else for protection.
And ultimately it's what we need – we need protection in the battle. And most of our battles are not literal and physical. They're spiritual in nature. But they're just as real and just as deadly. We have an enemy who is unseen. He has forces that are more powerful than we are. And he's constantly influencing wicked people to oppose us. But we need to remember that the true battle isn't against those people. It's against the animating force behind them – the Adversary. This is why we pray, "Lord deliver us from evil" and the evil one. And this is why it's so crucial to put on the whole armor of God. We don't stand a chance otherwise against our unseen enemy.
So, may the Lord hear thee. May he defend thee. And we will rejoice in thy salvation when he does.


We are buyers of Aluminium Automobile Engine Scrap. Our current requirement is 200 MTS. Quote in USD CIF Mundra. We will inspect the goods and visit the factory before making any payments and our representatives will be present at the time of Final Stuffing.


Professional Left Podcast: Episode 369 -- "Finally, A Resistance Podcast!"
Brought to you this week by MacGuffin's Muffins!
A lot of discussion by our favorite podcasting couple (at least until Ari and I start to do one <3 <3 <3) of the lack of permanent liberal infrastructure, one of my favorite obsessions.
I just want to place a finer point on something DG & BG discussed. Uber-wealthy liberals don't put money into said infrastructure because they focus their money on direct services like feeding poor Africans or AIDS medicine (though that's not entirely true -- a lot of liberalish tycoons put money into places like university endowments at schools that don't need it), and there also isn't the kind of payback for them that conservatives aim for in tax cuts and deregulation.
What's left unsaid, but I think is important, is that even though liberal donors give to some pretty misguided things (hello, charter schools!), their hearts are at least 80% in the right place, while Sheldon Adelson, Foster Friess, the Kochs, the Mercers, et al, aren't even burdened by possessing a heart at all! They can be 100% about self-interest and that's why they're focused enough to spend their money all the way down to the school boards and to fund wingnut welfare.
But Happy New Year, Cornfield Resistance!
UPDATE (12/31/16, 7:50 PM): I forgot the link! Listen here.


An article on Metro Manila's top chef-caterers, featuring Rolando Laudico, Sau del Rosario and Pinoy Eats World. Appeared in the December 2012 issues of Forbes in Touch and Dasmariñas Village Gazette. Read the scan here.


text:
Loading metrics
Article metrics are unavailable for recently published articles.
Total Mendeley bookmarks.
Paper's citation count computed by Scopus.
Sum of PLOS and PubMed Central page views and downloads.
Sum of Facebook and Twitter activity.
Projected Impact of Mexico's Sugar-Sweetened Beverage Tax Policy on Diabetes and Cardiovascular Disease: A Modeling Study
Luz Maria Sánchez-Romero,
Affiliations Center for Nutrition and Health Research, National Institute of Public Health, Cuernavaca, Morelos, Mexico, Department of Epidemiology and Public Health, University College London, London, United Kingdom
Joanne Penko,
Affiliations Department of Medicine, University of California, San Francisco, San Francisco, California, United States of America, UCSF Center for Vulnerable Populations at San Francisco General Hospital, San Francisco, California, United States of America
Pamela G. Coxson,
Alicia Fernández,
Antoinette Mason,
Andrew E. Moran,
Affiliation Division of General Internal Medicine, Columbia University Medical Center, New York, New York, United States of America
Leticia Ávila-Burgos,
Affiliation Center for Health Systems Research, National Institute of Public Health, Cuernavaca, Morelos, Mexico
Michelle Odden,
Affiliation Department of Epidemiology, Oregon State University, Corvalis, Oregon, United States of America
Simón Barquera,
Affiliation Center for Nutrition and Health Research, National Institute of Public Health, Cuernavaca, Morelos, Mexico
Kirsten Bibbins-Domingo
* E-mail: kdomingo@medsfgh.ucsf.edu
Affiliations Department of Medicine, University of California, San Francisco, San Francisco, California, United States of America, UCSF Center for Vulnerable Populations at San Francisco General Hospital, San Francisco, California, United States of America, Division of General Internal Medicine, Columbia University Medical Center, New York, New York, United States of America, Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, United States of America
https://doi.org/10.1371/journal.pmed.1002158
Luz Maria Sánchez-Romero Joanne Penko ... Kirsten Bibbins-Domingo
<% if(figureList.length > 1) { %>
All Figures Next Previous
Show in Context
Rates of diabetes in Mexico are among the highest worldwide. In 2014, Mexico instituted a nationwide tax on sugar-sweetened beverages (SSBs) in order to reduce the high level of SSB consumption, a preventable cause of diabetes and cardiovascular disease (CVD). We used an established computer simulation model of CVD and country-specific data on demographics, epidemiology, SSB consumption, and short-term changes in consumption following the SSB tax in order to project potential long-range health and economic impacts of SSB taxation in Mexico.
Methods and Findings
We used the Cardiovascular Disease Policy Model–Mexico, a state transition model of Mexican adults aged 35–94 y, to project the potential future effects of reduced SSB intake on diabetes incidence, CVD events, direct diabetes healthcare costs, and mortality over 10 y. Model inputs included short-term changes in SSB consumption in response to taxation (price elasticity) and data from government and market research surveys and public healthcare institutions. Two main scenarios were modeled: a 10% reduction in SSB consumption (corresponding to the reduction observed after tax implementation) and a 20% reduction in SSB consumption (possible with increases in taxation levels and/or additional measures to curb consumption). Given uncertainty about the degree to which Mexicans will replace calories from SSBs with calories from other sources, we evaluated a range of values for calorie compensation.
We projected that a 10% reduction in SSB consumption with 39% calorie compensation among Mexican adults would result in about 189,300 (95% uncertainty interval [UI] 155,400–218,100) fewer incident type 2 diabetes cases, 20,400 fewer incident strokes and myocardial infarctions, and 18,900 fewer deaths occurring from 2013 to 2022. This scenario predicts that the SSB tax could save Mexico 983 million international dollars (95% UI $769 million–$1,173 million). The largest relative and absolute reductions in diabetes and CVD events occurred in the youngest age group modeled (35–44 y).
This study's strengths include the use of an established mathematical model of CVD and use of contemporary Mexican vital statistics, data from health surveys, healthcare costs, and SSB price elasticity estimates as well as probabilistic and deterministic sensitivity analyses to account for uncertainty. The limitations of the study include reliance on US-based studies for certain inputs where Mexico-specific data were lacking (specifically the associations between risk factors and CVD outcomes [from the Framingham Heart Study] and SSB calorie compensation assumptions), limited data on healthcare costs other than those related to diabetes, and lack of information on long-term SSB price elasticity that is specific to geographic and economic subgroups.
Mexico's high diabetes prevalence represents a public health crisis. While the long-term impact of Mexico's SSB tax is not yet known, these projections, based on observed consumption reductions, suggest that Mexico's SSB tax may substantially decrease morbidity and mortality from diabetes and CVD while reducing healthcare costs.
Author Summary
Why Was This Study Done?
The prevalence of obesity and diabetes in Mexico has risen dramatically in recent years, and the rate of diabetes in Mexico currently ranks among the highest in the world.
Mexicans consume a large volume of sugar-sweetened beverages (SSBs), a preventable risk factor for obesity, diabetes, and cardiovascular diseases.
In order to address the obesity and diabetes epidemic, the Mexican government implemented a 10% excise tax on SSBs in 2014.
Although consumer data suggest that the tax has resulted in a decrease in SSB purchases, little is known about the longer-term impact the SSB tax will have on disease burden and healthcare costs in Mexico.
What Did the Researchers Do and Find?
We conducted a computer simulation study in order to understand the potential impact of the tax on diabetes, cardiovascular diseases, mortality, and healthcare costs associated with diabetes among Mexican adults 35–94 years of age over a period of 10 years (2013–2022).
To do this, we developed a Mexico version of an established model of cardiovascular disease in the US (the Cardiovascular Disease Policy Model) using national-level data from Mexico wherever possible.
We found that the 10% tax on SSBs will likely prevent approximately 189,300 new cases of type 2 diabetes, 20,400 incident strokes and heart attacks, and 18,900 deaths over 10 years among adults 35–94 years of age, and is expected to result in 983 million international dollars in savings in healthcare costs because of the prevention of diabetes cases.
The largest reductions in health burden and healthcare spending are projected to occur among the youngest adults included in the simulation (those 35–44 years of age).
What Do These Findings Mean?
The national tax on SSBs in Mexico is projected to have a substantial impact on the burden of diabetes, cardiovascular diseases, and mortality over 10 years.
With the largest effects of the tax observed among the youngest age group modeled, we expect the impact of the intervention to become more dramatic as the population ages.
The SSB tax may be an important component in a multifaceted strategy by the Mexican government to curb the obesity and diabetes epidemic in Mexico.
Citation: Sánchez-Romero LM, Penko J, Coxson PG, Fernández A, Mason A, Moran AE, et al. (2016) Projected Impact of Mexico's Sugar-Sweetened Beverage Tax Policy on Diabetes and Cardiovascular Disease: A Modeling Study. PLoS Med 13(11): e1002158. https://doi.org/10.1371/journal.pmed.1002158
Academic Editor: Tony Blakely, University of Otago, Wellington, NEW ZEALAND
Received: April 6, 2016; Accepted: September 16, 2016; Published: November 1, 2016
Copyright: © 2016 Sánchez-Romero et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: Data for this study come from sources detailed in the paper. Data on CVD risk factors and sugar sweetened beverage consumption come from the ENSANUT study group (http://ensanut.insp.mx/). Framingham Heart Study data are available following approval of research applications submitted through the National Heart, Lung, and Blood Institute's Biologic Specimen and Data Repository Information Coordinating Center (available at http://biolincc.nhlbi.nih.gov/studies/framcohort/?q=framingham for the Framingham Cohort and http://biolincc.nhlbi.nih.gov/studies/framoffspring/?q=framingham for the Offspring study). Health survey, vital statistics, and healthcare cost data are publicly available from government sources described in the paper. Investigators interested in working with the CVD Policy Model software can contact Dr. Bibbins-Domingo by email. Interested authors can submit a brief (1–2 page) research proposal and collaboration plan by email that will be considered by the CVD Policy Model team. The CVD Policy Model team will interact with interested researchers in order to assess the feasibility of collaboration and clarify any questions about the research question, particularly whether the CVD Policy Model is designed to address the question. The CVD Policy Model has established a Creative Commons agreement for the purpose of establishing rules for collaborations with outside researchers. The commons allows for outside researchers to use the software, ensures that the software is used appropriately, and asks collaborators to share modifications and improvements to the software with the CVD Policy Model team. A copy of the Creative Commons agreement is available online as a supplementary file (S1 File). If interested researchers propose an analysis and sign our Creative Commons agreement, and the proposal is approved by the CVD Policy Model team, the software will be shared.
Funding: Research reported in this publication was supported by the Fogarty International Center of the National Institutes of Health (http://www.fic.nih.gov/Pages/Default.aspx) under Award Number R03TW009061 (AF, KBD, SB) and by a Grant for Collaborative Projects (http://ucmexus.ucr.edu/funding/grant_collaborative.html) from the University of California Institute for Mexico and the United States (UC MEXUS) and the National Council of Science and Technology (CONACYT) Mexico (KBD, SB). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests: The authors have declared that no competing interests exist.
Abbreviations: BMI, body mass index; CHD, coronary heart disease; CVD, cardiovascular disease; CVDPM, Cardiovascular Disease Policy Model; ENSANUT, Encuesta Nacional de Salud y Nutrición; SBP, systolic blood pressure; SE, standard error; SINAIS, Sistema Nacional de Información en Salud; SSB, sugar-sweetened beverage; UI, uncertainty interval
Sugar-sweetened beverage (SSB) consumption has risen rapidly in Mexico in recent years [1,2], with one-fifth of total daily caloric intake among adults currently estimated to come from SSBs (including sugar-sweetened soda, coffee, tea, and agua fresca [flavored water]). Observational and intervention studies have demonstrated that higher SSB consumption is linked to greater risk of cardiometabolic outcomes [3–5]. Of particular concern in Mexico is the link between high SSB consumption and obesity and diabetes given the dramatic increase in these conditions over a short period of time [6]. The prevalence of obesity and diabetes in Mexico now rank among the highest in the world; approximately 70% of Mexican adults are considered overweight or obese, and 14% have diabetes [7]. Diabetes is now the leading cause of death and, in 2011, cost the Mexican government an estimated US$7.7 billion in direct and indirect costs [8,9]. As a result of recent trends, Mexico is projected to bear an ever increasing burden of health-related costs from diabetic complications including cardiovascular disease (CVD).
In response to the population's high consumption of SSBs and the diabetes epidemic, the Mexican government instituted several initiatives in 2014 guided by recommendations from its Ministry of Health [10]. Included among these initiatives was a 10% excise tax on SSBs (one Mexican peso per liter) levied on manufacturers effective January 1, 2014. Market research surveys have demonstrated that SSB purchases by Mexican households declined by an average of 6% in 2014, reaching a 12% decrease by December 2014 [11]. The expectation is that taxation will result in sustained population-wide reductions in SSB intake and downstream prevention of diabetes, CVD, and other negative health outcomes. However, epidemiologic and economic evidence demonstrating the policy's impact will take years to emerge and may be confounded by changes in medical practice and other secular trends. The purpose of this analysis is to build on current evidence in order to project the longer-term impact of SSB taxation on diabetes, coronary heart disease (CHD), stroke, mortality, and associated healthcare costs in Mexico.
The Cardiovascular Disease Policy Model developed for Mexico
The Cardiovascular Disease Policy Model (CVDPM) is a computer-simulation state transition (Markov) model of CHD and stroke incidence, prevalence, mortality, and costs and has been used to forecast trends in CVD in the US and other countries for over 25 y [12–14]. The CVDPM models the population of adults aged 35–94 y (and excludes children and young adults under 35 y of age), with new 35-y-olds entering the simulated population each annual cycle. The CVDPM uses estimates generated from Framingham Heart Study Original Cohort and Offspring Cohort data [15–18] to predict incident type 2 diabetes, CHD, stroke, and non-CVD mortality among persons without CVD, based on age, sex, systolic blood pressure (SBP), body mass index (BMI), high-density lipoprotein cholesterol level, low-density lipoprotein cholesterol level, smoking, and type 2 diabetes mellitus. The CVDPM also predicts subsequent life years, CVD events, coronary revascularization procedures, CVD mortality, and non-CVD mortality among persons with CVD. The model is written in Fortran 95 and compiled using the Lahey Fortran 95 compiler V7.2 (Lahey Computer Systems).
The present analysis uses a newly created version of the CVDPM, the CVDPM–Mexico, adapted for analyses of epidemiology and policies in the Mexican population. The CVDPM–Mexico is based on Mexico-specific demographic and epidemiologic data and is calibrated to cardiac events and deaths among Mexicans in 2010. The CVDPM–Mexico is summarized below, and a detailed description is presented in S1 Appendix, which includes a description of the model's structure (Figure A in S1 Appendix), data sources for Mexico-specific inputs (Table A in S1 Appendix), model calibration (Figure B in S1 Appendix), and intervention simulation assumptions (Tables B and C and Figure C in S1 Appendix).
Mexico-Specific Epidemiologic Inputs
Estimates of the 2010 adult population of Mexico were obtained from the National Institute of Statistics and Geography (Instituto Nacional de Estadística y Geografía), and projections of the population through 2050 from the National Population Council (Consejo Nacional de Población) [19,20].
Age- and sex-specific means and distributions for five of six modeled risk factors (SBP, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, BMI, and diabetes) were estimated from the 2006 Mexican National Health and Nutrition Survey (Encuesta Nacional de Salud y Nutrición [ENSANUT]) [21], a nationally representative cross-sectional survey that used multi-stage cluster sampling of the Mexican population. Data on smoking prevalence was obtained from the 2009 Adult Smoking Survey (Encuesta Global de Tabaquismo en Adultos) [22], a nationally representative survey of Mexicans aged 15 y and older. Estimates of CHD and stroke prevalence were generated from ENSANUT 2006. Data on total and cause-specific mortality in 2010 are from the National Health Information System (Sistema Nacional de Información en Salud [SINAIS]) [23], and deaths were categorized according to the International Classification of Diseases (ICD-10) codes [24].
National in-hospital CHD and stroke events, deaths, and case fatality rates in 2010 were estimated based on data from three public health institutions that provide health services to 73% of Mexico's population [7]: the Mexican Social Security Institute (Instituto Mexicano del Seguro Social [IMSS]) [25], the State Employee's Social Security and Services Institute (Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado [ISSSTE]) [26], and the Ministry of Health (data acquired from SINAIS) [27,28]. Deaths occurring in other public health institutions were obtained from SINAIS 2010 mortality data [29]. The CVDPM–Mexico was calibrated to within ≤1% of national estimates of CHD and stroke events and CHD deaths in 2010 (Figure B in S1 Appendix).
Mexico-Specific Healthcare Costs
We computed age-decile-specific mean annual direct per-patient healthcare costs incurred by persons with type 2 diabetes in 2012 using methodology described previously and detailed in S1 Appendix [30,31]. We first used national expenditure data from the System of Health Accounts (Sistema de Cuentas de Salud en Mexico) [32] to determine the total 2011 expenditures separately for generalist outpatient visits, specialist outpatient visits, and hospitalizations for each of the three primary healthcare institutions (IMSS, ISSSTE, and the Ministry of Health). We then determined the average cost of each visit type for each institution by dividing the expenditure total by the count of visits and hospitalization days obtained from utilization databases [25,26,28]. Utilization data were further used to determine the average number of services used in 2011 by those with diabetes (defined as records with ICD-10 codes E11–E14 in the first or second code position) for each institution, service type, and age stratum; these values were then multiplied by the institution-specific average cost for each service and summed over service types for institution-level annual costs per diabetes patient by age. For our cost inputs, we then generated an overall mean annual cost per diabetes patient for each age group (model cost inputs) by taking a weighted average of institution-specific costs, using as weights the proportion of diabetes patients receiving healthcare at each institution as measured by ENSANUT 2012 [7]. Expenditures were converted into 2011 US dollars using a purchasing power parity rate of 7.67 Mexican pesos = 1.00 international dollar, and inflated to 2012 currency using a 3.57% inflation rate [33]. The total direct healthcare expenditure calculated for Mexicans aged 35 to 94 y and living with diabetes in 2011 was approximately 7 billion international dollars (54 billion Mexican pesos) (Table B in S1 Appendix).
Base Case Sugar-Sweetened Beverage Consumption in Mexico
Data from ENSANUT 2012 were used to estimate daily caloric intake from SSBs [7]. A one-time 24-h dietary recall administered to 13% of the ENSANUT 2012 sample assessed the type and quantity of foods and beverages consumed over the past day during meals and between meals, occurring both inside and outside the home, including measurement on weekdays and weekends [7,34]. The following were included in our definition of SSBs: industrialized flavored waters, sodas, aguas frescas, horchatas (rice waters), chocolate water, fruit juices, vegetable juices, and sports and energy drinks. Because interventions simulated in the CVDPM operate as changes in age- and gender-stratified mean values, we computed the mean and standard error (SE) of total volume (in milliliters) and number of servings (355 ml [12 fl. oz.] = 1 serving) of SSBs consumed per day for each sex and age stratum, which were in turn used to generate model inputs. The number of servings per day was also converted into average total calories from SSBs consumed per day (1 serving = 150 calories).
Effect of Sugar-Sweetened Beverages on Cardiovascular Disease Risk Factors
Based on review of epidemiologic studies, we modeled direct and independent effects of SSB consumption on three factors related to CVD: diabetes incidence, mean BMI, and mean SBP (Figure C in S1 Appendix) [5,35]. In addition, changes in diabetes incidence and mean SBP associated with SSB intake were assumed to be partially mediated through BMI [5,36]. Each additional serving of SSB per day (defined as 355 ml/d) was assumed to be associated with a 1.19-fold (95% CI 1.09, 1.31) increased risk of diabetes independent of changes in BMI [5]. Inputs for the increased risk of diabetes associated with increased BMI were estimated using Framingham Heart Study data [15–18]. For blood pressure, we assumed that each additional SSB serving per day is associated with an SBP increase of 0.78 mm Hg (95% CI 0.09, 1.47) in men and 0.61 mm Hg (95% CI −0.27, 1.48) in women independent of BMI and that each one-unit increase in BMI is associated with a 1.43–mm Hg and 1.24–mm Hg increase in SBP in men and women, respectively [35]. Changes in caloric consumption were translated into changes in weight (using the conversion of 3,500 kcal/lb.), and the average height reported in ENSANUT 2006 was used to calculate corresponding changes in BMI (weight [kg]/height [m]2). Because the relationship between caloric consumption and weight loss may be variable and because it is not precisely known the degree to which calories reduced through decreased SSB consumption will be replaced by calories from other sources [37,38], we include model scenarios that assume the broadest possible range in weight change (from no weight change associated with SSB consumption change to all calories reduced through decreased SSB consumption translated into weight change as described above). For a detailed description of our approach to modeling the relationship between changes in SSB consumption and CVD risk factors and outcomes, see our previous work on SSBs in the US [39,40].
Model Simulations
The CVDPM–Mexico was used to predict the impact of reductions in SSB intake on type 2 diabetes incidence, CVD incidence, CVD mortality, all-cause mortality, and healthcare costs over 10 y (2013–2022). To quantify anticipated changes in CVD risk factors expected from the SSB tax, two factors were taken into consideration: (1) the change in SSB consumption predicted to result from the 10% excise tax (price elasticity) and (2) the degree to which individuals would replace calories consumed through SSBs with calories from other sources (calorie compensation). SSB purchases by Mexican households declined by an increasing rate over 2014, reaching a decrease of 12% by December 2014 [11]. This observed effect corresponds with studies of Mexico's consumer soda price elasticity (−0.72 to −1.30), suggesting that the 10% tax on SSBs in Mexico would result in a 10%–13% decline in SSB consumption [41,42]. Our main analysis modeled a 10% decrease in SSB consumption starting in year 1 and sustained over the 10-y simulation. Colchero et al. observed an average increase in purchases of non-taxed beverages including diet soda, water, and unsweetened dairy and fruit juice in response to the tax, but whether this shift in consumption resulted in a reduction in calories consumed is unclear [11]. We therefore estimated that 39% of the calories reduced by lowering SSB intake would be replaced by calories from other sources, yielding a net 61% reduction in total calories from SSBs, based on prior work in the US context [38]. The sensitivity of results to this assumption were tested in separate analyses that assumed 0% caloric compensation (all calories reduced through decreased SSB consumption are translated into weight changes) and 100% caloric compensation (only the independent effects of decreased SSB intake on diabetes and SBP are modeled, with no changes in BMI). In addition to assuming a 10% decline in SSB consumption for primary analyses, additional simulations were performed assuming a 20% reduction in SSB intake with 0%, 39%, and 100% calorie compensation in order to evaluate benefits that might be achieved from additional interventions such as higher levels of SSB taxation or other initiatives that have been implemented by the Mexican government, including nutritional guidelines for school lunches, front-of-package food labeling, and restrictions of food and beverage advertising targeted to children [10,43].
Probabilistic and Deterministic Sensitivity Analyses
We used Monte Carlo simulations to generate 95% uncertainty intervals (UIs) around our primary outcome measures for each intervention scenario. The 95% confidence intervals for estimates of the effect of changes in SSB consumption on SBP and on diabetes risk as well as the beta inputs for model risk functions defining the relationship between risk factors and incident diabetes, incident CHD, incident stroke, and non-CVD death are included in Table C of S1 Appendix. There were 1,000 random draws from a standard normal distribution, scaled to the mean and confidence interval, for each varied parameter. The Monte Carlo program, written in Python, generated a new set of input parameters drawn from the distributions for each iteration, ran the given iteration base case and reduced SSB consumption simulations with the new parameters, and stored the outcomes for each iteration. The 95% UIs for each outcome were then calculated using Microsoft Excel 2010.
We used deterministic approaches to evaluate the sensitivity of our results to assumptions about the degree of calorie compensation and weight loss associated with reduced SSB intake (described above). To assess the health and economic impacts that could result from higher levels of taxation and/or additional public health interventions to curb SSB consumption in Mexico, we conducted a scenario analysis that assumed a 40% reduction in current levels of SSB consumption. There is a limited body of evidence suggesting that the risk of CHD, stroke, and non-CVD death may be higher among individuals with diabetes in Mexico compared to individuals with diabetes in the US [44,45]. We therefore conducted a sensitivity analysis using betas approximately 2-fold higher than those derived from the Framingham Heart Study and evaluated the effect on CVD and mortality outcomes.
Mexican men consumed an average of 1.24 (SE = 0.07) servings of SSBs per day in 2012, and women consumed an average of 0.86 (SE = 0.04) servings per day (Table 1). Men and women consumed a median 0.97 (interquartile range 0–1.68) and 0.64 (interquartile range 0–1.41) servings per day, respectively (S1 Table). Overall, younger adults had higher SSB consumption than older adults. Assuming no change in SSB consumption from that observed in 2012 and assuming current obesity rates, model simulations project 3.9 million new cases of diabetes and 1.2 million CVD deaths occurring among adults 35 to 94 y old between 2013 and 2022.
Table 1. Mean total volume and number of servings of sugar sweetened beverages consumed per person per day among Mexican adults from the 2012 Mexican National Health and Nutrition Survey (ENSANUT).
https://doi.org/10.1371/journal.pmed.1002158.t001
A population-wide 10% reduction in SSB intake (with 39% calorie compensation) is projected to reduce the number of new cases of diabetes by 189,300 (95% UI 155,400–218,100) for the time period 2013 to 2022, a 4.9% lower incidence than what is projected when assuming no change in SSB consumption (Table 2). The resulting reduction in diabetes burden would amount to a total savings in direct healthcare costs incurred by diabetes patients of about 983 million international dollars (95% UI $769 million–$1.2 billion) over 10 y (Table 2). Varying the degree of calorie compensation, a 10% reduction in SSBs could decrease the 10-y cumulative incidence by as few as 66,000 cases (95% UI 39,800–91,600), if 100% of calories reduced through lower SSB consumption were replaced by calories from other sources, or as many as 265,100 cases (95% UI 222,100–304,100), if all calories reduced through lower SSB consumption were translated into weight change. A 20% reduction in SSB intake with 39% calorie compensation would result in approximately 9.5% fewer incident diabetes cases than projected when assuming no change in SSB consumption, for a total savings of nearly 1.9 billion international dollars (95% UI $1.5 billion–$2.3 billion).
Table 2. Number of incident cases of diabetes prevented and diabetes healthcare costs saved under intervention scenarios compared to the base case scenario among Mexican adults aged 35–94 y for 2013–2022.
The effect of decreasing SSB intake on diabetes incidence and associated costs would be greater for men than women regardless of scenario (S2 Table). The youngest age group modeled (ages 35–44 y) had the largest absolute and relative reductions in diabetes incidence, with roughly half of all cases averted over the 10-y simulation occurring in this age group (Fig 1; S3 Table).
Fig 1. Incident cases of diabetes prevented during 2013–2022 under different intervention scenarios, with results for each scenario stratified by age group.
Results for intervention simulations assuming a 10% decrease (A) or 20% decrease (B) in SSB intake and varying levels of calorie compensation. The y-axis values represent the absolute number of diabetes cases prevented by the intervention compared to the base case simulation, which assumes no change in SSB consumption. The base case simulation projects a 10-y cumulative incidence of diabetes of 1,565,600 for individuals aged 35–44 y, 1,741,600 for individuals aged 45–54 y, and 580,900 for individuals aged 55–94 y. The labels on each bar represent the percent of the total number of incident cases predicted by the base case simulation that is reduced under the intervention assumptions. SSB, sugar-sweetened beverage.
https://doi.org/10.1371/journal.pmed.1002158.g001
In addition to reducing diabetes, declines in SSB consumption would lower the number of CVD events and deaths (Table 3). A 10% reduction in SSB consumption with 39% calorie compensation would lower incident CHD cases by approximately 46,300 (95% UI 40,900–51,800), stroke by 6,200 (95% UI 4,600–8,100), CHD and stroke deaths by 10,900 (95% UI 9,400–12,500), and deaths from all causes by 18,900 (95% UI 15,500–22,700). The projected decreases in CVD events and deaths over the 10-y simulation were distributed unequally over age groups (Fig 2). For all CVD and mortality outcomes, the events avoided with reduced SSB consumption were concentrated among those under 65 y of age (Fig 2A); the percent decrease in events relative to the base case (which assumes no change in SSB consumption) was highest among individuals aged 35–44 y and decreased progressively with each increasing age group (Fig 2B; S4 Table).
Fig 2. Age-stratified decrease in cardiovascular disease events and deaths predicted for a 10% reduction in sugar-sweetened beverage consumption with 39% caloric compensation, compared to a base case simulation assuming no change in consumption.
(A) Total events and deaths prevented over 10 y under the intervention scenario. (B) The fraction of the total events predicted under the base case scenario that are prevented under the intervention scenario. The total counts of events and deaths for each age decile under the base case scenario and the change in events under the 10% and 20% SSB reduction scenarios are presented in S4 Table. CHD, coronary heart disease; CVD, cardiovascular disease.
Table 3. Total number of cardiovascular disease events and deaths avoided over 10 y among Mexican adults aged 35–94 y under different assumptions about sugar-sweetened beverage consumption reduction and replacement with calories from other sources.
Cardiovascular disease and mortality results were sensitive to assumptions about the level of SSB reduction and degree of calorie compensation (Tables 3 and S5). For example, depending on the range of calorie compensation (from 100% [all calories replaced] to 0% [no calories replaced]), a 10% decrease in SSB consumption may prevent as few as 1,500 myocardial infarctions (95% UI 500–2,300) or as many as 22,200 myocardial infarctions (95% UI 19,800–24,600) (Table 3). Assuming a higher CVD event rate and mortality rate associated with diabetes for Mexicans compared with rates predicted from Framingham Heart Study data resulted in somewhat higher estimates for events averted (S6 Table).
Mexico's SSB consumption has increased in recent years such that SSB calories now account for a substantial proportion of overall caloric intake [2]. Our population modeling of CVD and diabetes in Mexico suggests that if Mexico's SSB tax leads to population-wide reductions in SSB intake, as suggested by declines in SSB purchases already observed since the initiation of the tax [11], the policy will have a profound impact on disease burden in Mexico. We project that substantial health gains and cost savings are likely to result from reduced SSB consumption stemming from the current 10% excise tax, particularly among younger Mexicans, who are the highest consumers of these beverages.
The recent acceleration of obesity and diabetes rates among Mexicans—particularly young Mexicans—has led to a rapid increase in the chronic disease burden associated with diabetes and its complications. Our main policy simulations estimate that the SSB tax alone could prevent 189,300 cases of diabetes and save about 983 million international dollars in direct healthcare costs attributable to diabetes over the time period 2013–2022, with the overwhelming majority of the benefit occurring among adults under the age of 55 y. Because of the high consumption of SSBs and prevalence of obesity, as well as the young population structure, Mexico can expect a 2.6-fold larger diabetes rate reduction compared to simulations of SSB taxation in the United States using nearly identical assumptions over the same timeframe [39,40]. In addition to a reduction in diabetes incidence, we also observed reductions in CVD events and deaths with SSB tax simulations, with the reduced burden again occurring most prominently among the younger age groups. Preventing new cases of diabetes and CVD among young Mexicans will yield substantial additional benefits over a life course, as measured by years of life lived free of these chronic conditions; these health benefits are not fully captured by our 10-y simulations and highlight that our estimates are likely a conservative description of the true health benefits of this intervention. Comparisons of similar policy strategies in different population contexts highlight the importance of understanding the demographics and epidemiology of a particular population when choosing a public health strategy for maximal impact. This comparison also underscores the large anticipated health benefits from policies aimed at obesity and diabetes in Mexico, where the obesity and diabetes epidemic is particularly striking.
Our estimates are likely conservative. We modeled the impact of reduced SSB consumption for those 35 y of age and older due to limitations in epidemiologic data for CVD for those of younger ages. Given the high consumption of SSBs and prevalence of obesity in children and young adults [1,2], a larger impact might be expected as the younger generation ages. While our estimate of non-CVD deaths captured deaths from diabetes-related complications like renal disease, we did not capture changes in event rates for diabetic nephropathy and end-stage renal disease. These complications may be particularly common in Mexico and represent additional health burdens that may improve with reduced SSB consumption.
For calculations of healthcare costs, we included direct costs of hospital days and outpatient consultations for those with diabetes and estimated the savings that can be expected over the 10 y following intervention. Due to data limitations, we did not take into consideration the incremental savings from preventing CHD, stroke events, chronic kidney disease, or other conditions not captured in hospital records under diabetes codes. This likely resulted in substantial underestimation of savings, given that CVD and chronic kidney disease currently rank among the most prominent contributors to financial burden and causes of mortality in Mexico [46,47]. We also did not measure the savings that would result from the reduced need for healthcare infrastructure to deliver prevention and management services for diabetes and associated complications. Others have reported on the inadequacy of the current Mexican healthcare system to address the rising rate of diabetes, citing low rates of screening and limited capacity for chronic disease management [48]. In addition to the direct economic benefits we project in our modeling, the SSB tax might be expected to yield indirect cost savings associated with having a healthier workforce and reduced out-of-pocket expenditures absorbed by individual households [49,50]. Prior research suggests that indirect social and productivity costs could represent between 52% and 55% of the total cost of diabetes and CVD [8,49,51]. Finally, we included only revenue associated with reductions in healthcare utilization, while the revenue generated by the tax itself was not considered. Tax revenue that is invested in additional efforts to reduce diabetes risk would be expected to additionally increase the health benefits modeled here. Indeed, the Mexican government has planned to allocate a portion of SSB tax revenue to programs aimed at preventing and controlling diabetes as well as programs aimed at increasing access to drinkable water in schools and public spaces (including installation and maintenance of drinking water fountains) and decreasing undernutrition [52,53], which could magnify the health benefits described here.
The 10% SSB tax is the cornerstone of Mexico's National Strategy for the Prevention and Control of Overweight, Obesity, and Diabetes. Though our findings suggest that the tax could bring considerable health and economic benefits, large and sustained declines in SSB consumption will likely require a combination of strategies including mass media campaigns, healthy food consumption subsides, nutritional labeling, and marketing restrictions, in addition to taxation [54]. The Mexican government has implemented other initiatives that could enhance the effects of the tax, including school-based guidelines for serving healthy foods and beverages, mandatory front-of-package labeling, and regulations around marketing foods and beverages to children [43]. We chose to focus on the SSB tax because it is a national policy of global interest and has a sufficient research base to define its effects on consumption and health. We conducted additional simulations reflecting declines in consumption larger than those expected from the current tax in order to understand what might be achieved from additional public health interventions.
The strengths of our projections include the use of a validated CVD simulation model adapted to describe the population of Mexico, using multiple Mexican national data sources to define inputs on SSB consumption and post-tax change in SSB consumption and the occurrence of diabetes and CVD outcomes. However, the study has several limitations. We defined SSBs according to methods developed by the Global Burden of Disease Study 2010 [55]. It is possible to include or exclude other beverages in this group, and misclassification could have led us to over- or underestimate average pre-tax SSB consumption in Mexican adults [1,2]. SSB consumption is based primarily on self-report, a measure that has been shown by others to likely underestimate consumption, again supporting the likely conservative nature of our estimates of potential health benefits. For our main simulations, we assumed that consumers reducing their consumption of SSBs would replace 39% of SSB calories with calories from other beverage types, but this assumption was based on reports from the US and may not apply equally in the Mexican population. Nonetheless, we tested the sensitivity of our finding and still found an important health benefit when varying the percentage of caloric compensation from other beverages and, importantly, found significant health benefits even under the assumption that all of the calories from SSB consumption are replaced. Only one elasticity parameter linking taxation with downstream effects on consumption was considered, an assumption that was validated by Mexican market research surveys [11]. However, as the same study showed, price elasticity varies by socioeconomic status and geographic location, with larger reductions in purchasing among poorer households [11]. The average effect we report here is likely to be heterogeneous across population subgroups, with greater effects in cities and among poor individuals. Importantly, while lower-income populations may bear a disproportionate burden from taxation, they are also likely to accrue the health and economic benefits from prevention of diabetes and CVD [11]. Finally, we model theoretical reductions in consumption based on taxation; one industry-funded study—limited by the generalizability of the study sample and interpretation of results—reported minimal impact of the SSB tax in Mexico [56], but a larger study reporting on a representative population in Mexico found substantial reductions in purchases following the initiation of the tax that are compatible with the effects we model here [11].
In conclusion, our findings suggest that Mexico's SSB tax has the potential to substantially cut back SSB consumption, reducing downstream diabetes and CVD morbidity and mortality. Healthcare savings resulting from reduced SSB consumption could be reallocated toward other public health promotion programs and toward the augmentation of personnel and infrastructure to improve care for diabetes, CVD, and other diseases.
S1 Appendix. Supporting information for the Cardiovascular Disease Policy Model–Mexico structure, inputs and calibration, and simulation assumptions.
https://doi.org/10.1371/journal.pmed.1002158.s001
(DOCX)
S1 Table. Daily volume in milliliters of sugar-sweetened beverages consumed per person per day among Mexican adults estimated from the 2012 Mexican National Health and Nutrition Survey (ENSANUT).
S2 Table. Cumulative number of avoided events and deaths (percent difference) in three different scenarios of reduced sugar-sweetened beverage consumption (10%, 20%, and 40% reduction) for 2013–2022 among Mexican adults aged 35–94 y, reported separately for men and women.
S3 Table. Cumulative number of incident cases of diabetes avoided and diabetes cost savings for 2013–2022 under two scenarios of sugar-sweetened beverage consumption reduction (10% and 20%; both with 39% calorie compensation), stratified by age decile.
S4 Table. Cumulative number of cardiovascular disease events and deaths avoided for 2013–2022 under two scenarios of sugar-sweetened beverage consumption reduction (10% and 20%; both with 39% calorie compensation), stratified by age decile.
S5 Table. Cumulative number of incident diabetes cases, cardiovascular disease events, and deaths prevented for 2013–2022 among Mexican adults aged 35–94 y, assuming a 40% reduction in sugar-sweetened beverage consumption and 39% caloric compensation.
S6 Table. Cumulative number of cardiovascular disease events and deaths avoided for 2013–2022 among Mexican adults aged 35–94 y under two sets of assumptions about the association between diabetes and the risk of coronary heart disease, stroke, and non-cardiovascular disease death.
S1 File. Cardiovascular Disease Policy Model software commons developer project participation agreement.
(DOC)
We gratefully acknowledge Dr. Aremis Villalobos, for providing estimates related to diabetes costs, and Julio Montañez, for his support with the Mexican hospitalization databases.
The content is solely the responsibility of the authors and does not necessarily represent the official views or positions of the National Institutes of Health, the University of California, or the US Preventive Services Task Force (of which K. B.-D. is the chair).
Conceptualization: LMSR AF AMo SB KBD.
Data curation: LMSR JP PC LA.
Formal analysis: LMSR JP AM MO KBD.
Funding acquisition: AF KBD SB.
Investigation: LMSR JP SB LA KBD.
Methodology: PC JP AM MO KBD.
Project administration: JP KBD.
Resources: KBD LMSR JP PC LA.
Software: PC.
Supervision: KBD SB.
Validation: LMSR PC JP KBD.
Visualization: KBD PC JP.
Writing – original draft: LMSR JP PC AM MO KBD.
Writing – review & editing: LMSR JP PC AF AM AMo LA MO SB KBD.
1. Barquera S, Hernandez-Barrera L, Tolentino ML, Espinosa J, Ng SW, Rivera JA, et al. Energy intake from beverages is increasing among Mexican adolescents and adults. J Nutr. 2008;138:2454–2461. pmid:19022972
PubMed/NCBI
2. Stern D, Piernas C, Barquera S, Rivera JA, Popkin BM. Caloric beverages were major sources of energy among children and adults in Mexico, 1999–2012. J Nutr. 2014;144:949–956. pmid:24744311
3. Malik VS, Popkin BM, Bray GA, Despres JP, Hu FB. Sugar-sweetened beverages, obesity, type 2 diabetes mellitus, and cardiovascular disease risk. Circulation. 2010;121:1356–1364. pmid:20308626
4. Malik VS, Popkin BM, Bray GA, Despres JP, Willett WC, Hu FB. Sugar-sweetened beverages and risk of metabolic syndrome and type 2 diabetes: a meta-analysis. Diabetes Care. 2010;33:2477–2483. pmid:20693348
5. Imamura F, O'Connor L, Ye Z, Mursu J, Hayashino Y, Bhupathiraju SN, et al. Consumption of sugar sweetened beverages, artificially sweetened beverages, and fruit juice and incidence of type 2 diabetes: systematic review, meta-analysis, and estimation of population attributable fraction. BMJ. 2015;351:h3576. pmid:26199070
6. Villalpando S, Shamah-Levy T, Rojas R, Aguilar-Salinas CA. Trends for type 2 diabetes and other cardiovascular risk factors in Mexico from 1993–2006. Salud Publica Mex. 2010;52 Suppl 1:S72–9. pmid:20585732
7. Gutiérrez J, Rivera-Dommarco J, Shamah-Levy T, Villalpando-Hernández S, Franco A, Cuevas-Nasu L, et al. Encuesta Nacional de Salud y Nutrición 2012: resultados nacionales. Instituto Nacional de Salud Pública. 2012 [cited 2014 Jan 20]. Available: http://ensanut.insp.mx/informes/ENSANUT2012ResultadosNacionales.pdf.
8. Arredondo A, Reyes G. Health disparities from economic burden of diabetes in middle-income countries: evidence from Mexico. PLoS ONE. 2013;8:e68443. pmid:23874629
9. Secretaría de Salud. Programa Nacional de Salud 2007–2012. Por un México sano: construyendo alianzas para una mejor salud. Secretaría de Salud. 2007 [cited 2016 Jul 25]. Available: http://www1.paho.org/hq/dmdocuments/2010/Politicas_Nacionales_Salud-Mexico_2007-2012.pdf.
10. Secretaría de Salud. Estrategia Nacional para la prevencion y el control del sobrepeso, la obesidad y la diabetes. Secretaría de Salud. 2013 [cited 2016 Jun 10]. Available: http://promocion.salud.gob.mx/dgps/descargas1/estrategia/Estrategia_con_portada.pdf.
11. Colchero MA, Popkin BM, Rivera JA, Ng SW. Beverage purchases from stores in Mexico under the excise tax on sugar sweetened beverages: observational study. BMJ. 2016;352:h6704. pmid:26738745
12. Bibbins-Domingo K, Chertow GM, Coxson PG, Moran A, Lightwood JM, Pletcher MJ, et al. Projected effect of dietary salt reductions on future cardiovascular disease. N Engl J Med. 2010;362:590–599. pmid:20089957
13. Moran AE, Odden MC, Thanataveerat A, Tzong KY, Rasmussen PW, Guzman D, et al. Cost-effectiveness of hypertension therapy according to 2014 guidelines. N Engl J Med. 2015;372:447–455. pmid:25629742
14. Weinstein MC, Coxson PG, Williams LW, Pass TM, Stason WB, Goldman L. Forecasting coronary heart disease incidence, mortality, and cost: the Coronary Heart Disease Policy Model. Am J Public Health. 1987;77:1417–1426. pmid:3661794
15. Framingham Heart Study-Cohort (FHS-Cohort). Biologic Specimen and Data Repository Information Coordinating Center. National Heart, Lung, and Blood Institute. 2013 [cited 2013 Apr 2]. Available: http://biolincc.nhlbi.nih.gov/studies/framcohort/?q=framingham.
16. Framingham Heart Study-Offspring (FHS-OS). Biologic Specimen and Data Repository Information Coordinating Center. National Heart, Lung, and Blood Institute. 2013 [cited 2013 Apr 2]. Available: http://biolincc.nhlbi.nih.gov/studies/framoffspring/?q=framingham.
17. Dawber TR. The Framingham Study: the epidemiology of atherosclerotic disease. Cambridge (Massachusetts): Harvard University Press; 1980.
18. Feinleib M, Kannel WB, Garrison RJ, McNamara PM, Castelli WP. The Framingham Offspring Study. Design and preliminary data. Prev Med. 1975;4:518–525. pmid:1208363
19. Intituto Nacional de Estadística y Geografía. Población, hogares y vivienda. Intituto Nacional de Estadística y Geografía. 2014 [cited 2014 Jan 20]. Available: http://www3.inegi.org.mx/sistemas/temas/default.aspx?s=est&c=17484.
20. Secretaría de Gobernación. Proyecciones de la población 2010–2050. Secretaría de Gobernación. 2014 [cited 2014 Jan 20]. Available: http://www.conapo.gob.mx/es/CONAPO/Proyecciones.
21. Olaiz-Fernández G, Rivera-Dommarco J, Shamah-Levy T, Rojas R, Villalpando-Hernández S, Hernández-Ávila M. Encuesta Nacional de Salud y Nutrición 2006. Instituto Nacional de Salud Pública. 2006 [cited 2014 Jan 20]. Available: http://ensanut.insp.mx/informes/ensanut2006.pdf.
22. Reynales Shigematsu L, Shamah T, Méndez I, Rojas R, Lazcano E. Encuesta Global de Tabaquismo en Adultos: México 2009. Organización Panamerica de la Salud. 2010 [cited 2014 Jan 20]. Available: http://www.who.int/tobacco/surveillance/gats_rep_mexico.pdf.
23. Dirección General de Información a la Salud. Bases de datos sobre defunciones. Defunciones generales (INEGI/SALUD): 2010. Secretaría de Salud. 2012 [2012 Aug 11]. Available: http://www.dgis.salud.gob.mx/contenidos/basesdedatos/std_defunciones.html.
24. World Health Organization. ICD-10 version: 2010. 2010 [cited 2016 Sep 27]. Available: http://apps.who.int/classifications/icd10/browse/2010/en.
25. Instituto Mexicano del Seguro Social. Memorias estadística 2011. Instituto Mexicano del Seguro Social. 2016 [cited 2016 Jun 14]. Available: http://www.imss.gob.mx/conoce-al-imss/memoria-estadistica-2011.
26. Instituto de Seguridad Social y Servicios para los Trabajadores del Estado. Estadística: anuarios 2011. Instituto de Seguridad Social y Servicios para los Trabajadores del Estado. 2012 [cited 2016 Jun14]. Available: http://www.issste.gob.mx/datosabiertos/anuarios/anuarios2011.html.
27. Sistema Nacional de Infromación en Salud. Bases de datos egresos hospitalarios. Secretaría de Salud. 2016 [cited 2016 Sep 27]. Available: http://www.dgis.salud.gob.mx/contenidos/basesdedatos/std_egresoshospitalarios.html.
28. Direccion General de Información en Salud. Cubos dinámicos-egresos hospitalarios. Mexico: Secretaría de Salud. 2016 [cited 2016 Sep 27]. Available: http://www.dgis.salud.gob.mx/contenidos/basesdedatos/bdc_egresoshosp_gobmx.html.
29. Direccion General de Información en Salud. Cubos dinámicos-defunciones (mortalidad). Secretaría de Salud. 2016 [cited 2016 Sep 27]. Available: http://www.dgis.salud.gob.mx/contenidos/basesdedatos/bdc_defunciones_gobmx.html.
30. Burgos LÁ, Hurtado LC, editors. Cuentas en diabetes mellitus, enfermedades cardiovasculares y obesidad: México 2006. Secretaría de Salud. 2009 [cited 2016 Jul 10]. Available: http://www.insp.mx/images/stories/Produccion/pdf/101203_cdiabetes.pdf.
31. Villalobos Hernández A, Ham Chande R. Gasto por diabetes en el sistema público de salud en México, 2010–2030. 2014 [cited 2016 Jul 10]. Available: http://colmex.alma.exlibrisgroup.com/view/delivery/52COLMEX_INST/1264973160002716.
32. Secretaría de Salud. Boletín de información estadística. Volumen IV. Recursos financieros. Número 31, Año 2011. 2016 [cited 2016 Jul 10]. Available: http://www.dgis.salud.gob.mx/contenidos/publicaciones/p_bie.html.
33. Instituto Nacional de Estadística y Geografía. Calculadora de inflación. Instituto Nacional de Estadística y Geografía. 2014 [cited 2014 Jan 1]. Available: http://www.inegi.org.mx/sistemas/indiceprecios/calculadorainflacion.aspx.
34. Romero-Martinez M, Shamah-Levy T, Franco-Nunez A, Villalpando S, Cuevas-Nasu L, Gutierrez JP, et al. [National Health and Nutrition Survey 2012: design and coverage.] Salud Publica Mex. 2013;55 (Suppl 2):S332–S340. pmid:24626712
35. Chen L, Caballero B, Mitchell DC, Loria C, Lin PH, Champagne CM, et al. Reducing consumption of sugar-sweetened beverages is associated with reduced blood pressure: a prospective study among United States adults. Circulation. 2010;121:2398–2406. pmid:20497980
36. Wilsgaard T, Schirmer H, Arnesen E. Impact of body weight on blood pressure with a focus on sex differences: the Tromso Study, 1986–1995. Arch Intern Med. 2000;160:2847–2853. pmid:11025795
37. Hall KD, Sacks G, Chandramohan D, Chow CC, Wang YC, Gortmaker SL, et al. Quantification of the effect of energy imbalance on bodyweight. Lancet. 2011;378:826–837. pmid:21872751
38. Stookey JD, Constant F, Gardner CD, Popkin BM. Replacing sweetened caloric beverages with drinking water is associated with lower energy intake. Obesity (Silver Spring). 2007;15:3013–3022.
39. Mekonnen TA, Odden MC, Coxson PG, Guzman D, Lightwood J, Wang YC, et al. Health benefits of reducing sugar-sweetened beverage intake in high risk populations of California: results from the Cardiovascular Disease (CVD) Policy Model. PLoS ONE. 2013;8:e81723. pmid:24349119
40. Wang YC, Coxson P, Shen YM, Goldman L, Bibbins-Domingo K. A penny-per-ounce tax on sugar-sweetened beverages would cut health and cost burdens of diabetes. Health Aff (Millwood). 2012;31:199–207. pmid:22232111
41. Cahuana L. Heterogeneidad de la demanda por refresco en México. Efecto de un impuesto a bebidas azucaradas para el financiamiento de una política de prevención de la obesidad en México. Cuernavaca (México): Escuela de Salud Pública; 2013.
42. Colchero MA, Salgado JC, Unar-Munguia M, Hernandez-Avila M, Rivera-Dommarco JA. Price elasticity of the demand for sugar sweetened beverages and soft drinks in Mexico. Econ Hum Biol. 2015;19:129–137. pmid:26386463
43. Barquera S, Campos I, Rivera JA. Mexico attempts to tackle obesity: the process, results, push backs and future challenges. Obes Rev. 2013;14(Suppl 2):69–78. pmid:24103026
44. Hunt KJ, Gonzalez ME, Lopez R, Haffner SM, Stern MP, Gonzalez-Villalpando C. Diabetes is more lethal in Mexicans and Mexican-Americans compared to non-Hispanic whites. Ann Epidemiol. 2011;21:899–906. pmid:21840730
45. Wei M, Mitchell BD, Haffner SM, Stern MP. Effects of cigarette smoking, diabetes, high cholesterol, and hypertension on all-cause mortality and cardiovascular disease mortality in Mexican Americans. The San Antonio Heart Study. Am J Epidemiol. 1996;144:1058–1065. pmid:8942437
46. Figueroa-Lara A, Gonzalez-Block MA, Alarcon-Irigoyen J. Medical expenditure for chronic diseases in Mexico: the case of selected diagnoses treated by the largest care providers. PLoS ONE. 2016;11:e0145177. pmid:26744844
47. Lozano R, Gómez-Dantes H, Pelcastre B, Ruelas M, Montañez J, Campuzano J, et al. Carga de la enfermedad en México, 1990–2010. Nuevos resultados y desafíos. Cuernavaca (México): Instituto Nacional de Salud Pública; 2014.
48. Tapia-Conyer R, Gallardo-Rincon H, Saucedo-Martinez R. CASALUD: an innovative health-care system to control and prevent non-communicable diseases in Mexico. Perspect Public Health. 2015;135:180–190. pmid:24285554
49. Arredondo A, Barcelo A. The economic burden of out-of-pocket medical expenditures for patients seeking diabetes care in Mexico. Diabetologia. 2007;50:2408–2409. pmid:17879080
50. Barquera S, Campos-Nonato I, Aguilar-Salinas C, Lopez-Ridaura R, Arredondo A, Rivera-Dommarco J. Diabetes in Mexico: cost and management of diabetes and its complications and challenges for health policy. Global Health. 2013;9:3. pmid:23374611
51. Arredondo A, De Icaza E. [The cost of diabetes in Latin America: evidence from Mexico.] Value Health. 2011;14(5 Suppl 1):S85–S88. pmid:21839907
52. Centro de Estudios de las Finanzas Públicas. Medidas fiscales y extra fiscales para contrarrestar el consumo de bebidas saborizadas en México. Centro de Estudios de las Finanzas Públicas. 2015 [cited 2016 Jun 28]. Available: http://www.cefp.gob.mx/publicaciones/nota/2015/abril/notacefp0142015.pdf.
53. Secretaría de Educación Pública. Sistema de bebederos. Secretaría de Educación Pública. 2015 [cited 2016 Jun 28]. Available: http://escuelas.transparenciapresupuestaria.gob.mx/es/PRE/bebederos#funciona.
54. Cecchini M, Sassi F, Lauer JA, Lee YY, Guajardo-Barron V, Chisholm D. Tackling of unhealthy diets, physical inactivity, and obesity: health effects and cost-effectiveness. Lancet. 2010;376:1775–1784. pmid:21074255
55. Lim SS, Vos T, Flaxman AD, Danaei G, Shibuya K, Adair-Rohani H, et al. A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012;380:2224–2260. pmid:23245609
56. Aguilar A, Gutiérrez E, Seira E. Taxing calories in Mexico (preliminary and incomplete draft). Instituto Tecnológico Autónomo de México. 2015 [cited 2016 Jul 24]. Available: http://cie.itam.mx/sites/default/files/cie/15-04.pdf.
PubChase
For more information about PLOS Subject Areas, click here.
We want your feedback. Do these Subject Areas make sense for this article? Click the target next to the incorrect Subject Area and let us know. Thanks for your help!
Is the Subject Area "Diabetes mellitus" applicable to this article?
Mexican people
Is the Subject Area "Mexican people" applicable to this article?
Is the Subject Area "Cardiovascular diseases" applicable to this article?
Is the Subject Area "Mexico" applicable to this article?
Is the Subject Area "Beverages" applicable to this article?
Is the Subject Area "Epidemiology" applicable to this article?
Is the Subject Area "Obesity" applicable to this article?
Public and occupational health
Is the Subject Area "Public and occupational health" applicable to this article?
Archived Tweets


text:
Songs For Judy
Decrease quantity for Songs For Judy
Increase quantity for Songs For Judy
Neil Young had a turbulent 1976. Still digging himself out of the dark period that produced his "Ditch Trilogy" -- the weird, gnarled records he made when he decided to steer away from the middle of the road that was a possible tributary from the success of "Heart of Gold" -- Young began to see a new dawn on Zuma, a 1975 reunion with Crazy Horse. Not long after its release, Young reunited with his old Buffalo Springfield bandmate Stephen Stills to record Long May You Run, an album credited to the Stills-Young Band, but this union proved to be short-lived. Young ditched Stills a month into their tour, headed back to California to record an acoustic album called Hitchhiker, which he decided not to release. Instead, he took Crazy Horse out that November, acting as his own opening act via an acoustic set that preceded the electric blowout.
Released 42 years after that November jaunt, Songs for Judy collects 23 highlights curated by journalist Cameron Crowe and photographer Joel Bernstein, who tagged along on the tour. Bernstein recorded the concerts for his own pleasure and that provides the source material for Songs for Judy. What's striking about these performances is how loose and relaxed -- even happy -- Young seems. A far cry from the haunted, hazy Hitchhiker, Songs for Judy is spry and sly, the songs sounding charged and muscular even when they're sung with no greater support than an acoustic guitar (and, on occasion, an organ). Young cracks jokes and sings with vigor, alternating between staples from his songbooks and test-driving new tunes. Among the latter is "White Line," which later showed up on 1990's Ragged Glory, and "No One Seems to Know," which sees its first official release on this album. That alone makes Songs for Judy of interest for Young diehards, but what really makes this collection worthwhile is how these robust performances put the lie to the notion that acoustic Neil is sad, sensitive Neil. ~ Stephen Thomas Erlewine
RSD Release Date: n/a