A worldwide discussion has been going on for years about the need of implementing a Sugar Tax as part of a plan to reduce obesity, and it has been debated extensively amongst health professionals and industry advocates. Some countries took the initiative and introduced the Sugar Tax and altered the legislation based on their consumption rates, making it more specific to their targeted population. For example, Hungary introduced the Tax on sugary drinks back in 2011 and the rates vary depending on substance and concentration (1). France followed, and applied the tax in 2012 with high rates on alcoholic and soft drinks, and lower rates on energy drinks (1). Unlike France, the UAE, and depending on its’ population demographics and consumption rates, applied the tax in 2017 with higher rates on energy drinks, and lower rates on soft drinks (1). Australia has been battling obesity as well with a multifaceted approach. The Australian community-wide approach however focuses on long term behavioural change and relies heavily on individuals and families in taking charge of their own decisions regarding the food choices they make or the level of physical activity they perform. The Australian government showed no dereliction nor negligence to this matter and addressed the issue through funding social market campaigns, sports and recreation infrastructure, and healthy eating and physical activity programs. All efforts considered, Public health professionals and the Australian Medical Association continuously support the implementation of the sugar Tax and urge the government to play its’ legislative role to face the obesity epidemic (1).
Introduction
To induce more attention, and without the support of Public health and Science Committee, the American Medical Association recognized obesity as a disease in 2013 (2). Although It is hard to find one clear inclusive definition of disease, one can safely consider that any disease is a detrimental deviation from the norm. According to recent statistics, Two-Third of Australian Adults, and one-quarter of children aged 5-17 are overweight and obese (3). Obesity plays a role in chronic disease clustering, and obesity prevalence positively correlates with multimorbidity, and it is higher among obese than non-obese (4). Not only does obesity increase the risk of having many health problems, but also it increases the health costs at an individual and societal level (5). Obesity increased simultaneously all over the world, and Australia ranks 9th amongst the OECD nations (6). In Fact, the prevalence of obesity has tripled in Australia in the last 30 years classifying it as an Epidemic (7).
While we might think that gaining weight is solely linked to eating too much and moving too little, the actual food choices that we make and eating habits we develop are determined by social trends changing globally. Another major influence on food choices are the Food Industries, Fast-Food chains, and Supermarkets - by how they market their products. One might argue that being overweight or obese relies heavily on personal responsibility and demand will be met by supply, but the market-driven food system that is based on ever-increasing consumption will do nothing but restrict choice (7).
Generally, Multiple Factors contribute to weight gain, some of them can be genetic and others can be related to physical activity levels, eating behaviours, psychosocial and environmental influencers, metabolism, and consumption trends (8). Going more in-depth, obesity was highly observed amongst smokers, processed meats consumers, and regular consumers of sweetened soft drinks (8). Coming back to Australia, the term “soft drinks”, includes all non-alcoholic carbonated beverage such as cola, lemonade, tonic or flavoured mineral waters and is also referred to as sugar sweetened beverages SSB (9). The increased prevalence of obesity in Australia was accompanied by an increased consumption of SSB, which suggested the existence of a correlation and brought the Sugar Tax card to the Australian legislation table.
SSB Consumption Patterns and Associations in Australia
The public health implications were not only related to the increased prevalence of obesity in parallel to the increased consumption of SSB, but were also related to the association of this consumption with fatty liver disease, visceral fat, kidney and renal functions, cardio-metabolic problems, and increase In dental caries among both children and adults (9). Based on a study conducted in WA and SA to explore factors associated with SSA consumption in Australia-2016, observers found that obese participants were more likely to consume SSBs. It was also found that SSB consumers were more likely to be male, have little interest in health, and would consume SSB more when purchasing a meal away from home (9).
Examining the younger generation, results of a Nepean cohort study done on Australian school aged children found a pernicious effect of soft drinks and cordial consumption on body weight in childhood and adolescence, and the findings were consistent with the published data in American children (10).
Moreover, the Australian Bureau of Statistics provides Data on SSB consumption among Indigenous Australians and it shows that half (50%) of Aboriginal and Torres Strait Islander people aged two years and over consumed sugar-sweetened beverages, compared with one-third of non-Indigenous people (34%). Breaking it down, Two thirds (67%) of all free sugars consumed by Aboriginal and Torres Strait Islander people came from beverages, led by soft drinks, sports and energy drinks (28%), followed by fruit and vegetable juices and drinks (12%), cordials (9.5%). Consequently, indigenous Australians exceed the WHO recommendation that children and adults should limit their intake of free sugars to less than 10% of dietary energy and consume up to 14% instead (11).
It is hard to examine the patterns, amounts, and frequency of SSB consumption among Australians as National dietary surveys are irregularly conducted in Australia and hence dietary data are limited. Alternatively, we can roughly determine levels of SSB consumption by referring to the Industry-Sale data. The worldwide Beverages industry ranks Australia 15th in terms of Revenue (12), and 10th in terms of market share (9) making Australia one of the largest consumers globally (12).
Declines in overall SSB Consumptions Australia
The calls for implementing the Sugar Tax do not suggest the failure of the existing health strategies in reducing obesity or weight gain in general. On the contrary, combatting obesity as a disease will only happen when a combination of procedures effectively take place.
Based on a National dietary Survey conducted in 2017, the ABS reported that on the day of the survey adult consumption of SSB was (30.5%) which is less than previous years (35%). On the other hand, the consumption of artificially sweetened beverages also known as Diet beverages increased from (8.4%) and reached (11.1%) (13). That decline can possibly be attributed to the increased public awareness of the presence of artificial sugar sweeteners and non-caloric alternatives.
Additionally, the evaluation of the impact of the LiveLighter sugary-drink campaign that took place in WA in 2018 showed that the overall behaviours and knowledge about soft drinks were positively impacted and consumption was dropped (14). These results suggest that changing behaviour is possible through discouraging unhealthy habits especially when the public is a responsive audience.
Most Recent Data and Statistics showed a drop in Soft Drink Manufacturing in Australia, and the industry growth was estimated to be -3% in 2020 (15). This drop is attributed to the Covid-19 Pandemic and the implications it had on social norms (15). The negative impact on the industry was due to restrictions and social distancing, as a result, more people were eating at home and avoiding restaurants and cafes anticipating a decline in demand. The profit margins of manufacturers also dropped due to closure of shopping centres, cancellation of big events, closure of theatres, and reduced aviation catering.
SSB a suitable Target
The identification of SSBs as a suitable target for Public health intervention is not a direct attack against the manufacturing industry but it is due to the nature of the product itself. Not only is this product strongly associated with obesity, but also it offers no nutritional value (16). Sugary soft drinks are full of empty kilojoules/calories and are packed with sugar without offering any nutrients (ex: a 600 ml bottle contains 16 teaspoons of sugar equivalent to 1000 kilojoules). The excess kilojoules provided by soft drinks give no feeling of satiety and people do not normally reduce the amount or portion of food consumed to accommodate for the drink (17). Consequently, one end up consuming empty calories that have no contribution to health but only a correlation to weight gain.
As part of working along with the industry to reach a common ground, Health professionals and food scientists encouraged the manufacturers to implement certain changes to reduce the total caloric content per serving. Examples of these changes can be serving size, amount of added sugar, and usage of non-caloric sweeteners.
Obesity at what cost
At an individual and societal level, a high price is being paid for being overweight and being obese comes at an economic cost. Starting with the psychological implications, going through health complications, and finally to the out of pocket expenses. The cost of obesity is rising and falls under two categories: Direct costs that result from outpatient and inpatient health services (including general surgery and weight reduction surgery), laboratory and radiological tests, and drug therapy – and the Indirect costs that are related to the loss of productivity and that includes additional Insurance charges, value of lost work, and lower wages (18).
At a national governmental level, the cost of obesity is determined by the comparison of health care costs for normal weight to overweight and obese Australians (19). Looking at Government subsidies, the mean annual payment from government subsidies was $3600 per person. Based on BMI, government subsidies per person increased from $2948 for people of normal weight to $3737 for the overweight and $4153 for the obese (19).
Cost-effectiveness for Price-Related health Interventions
To check whether the Sugar Tax is a cost-effective legislation, a cohort study was done in the US to quantify the economic benefits of the excise tax. The results showed that implementing the tax will only cost money in the first year but after that the returns will be; Reducing SSBs consumption by 20%, BMI reductions progressively with years, $23.6 billion in healthcare cost saving, and would generate $12.5 billion in annual revenue (20). More studies were done on countries who have adopted this taxation, and results were also consistent (21). For example, an analysis done on Philippines showed that a Sugar Tax of 13% on SSB promoted population level health gains (21). Furthermore, also in the Philippines, additional cost-effectiveness analysis were conducted to investigate the tax’s hypothetical impact on different income groups, results proposed that the added taxation was pro-poor and was not found to be a regressive imposition on the low and middle income quintiles (21).
Another promising approach and a form of health intervention legislation is administering the mandatory restriction on price promotions for sugar-sweetened beverages. In Australia, 40% of grocery sales are price promoted (22). Consequently, such a legislation will result in a lower percentage of the take-home sugar intake (23). A multi-state multi cohort study done in Australia concluded that mandatory restrictions on price promotions on SSBs have the potential to be cost-effective with substantial health benefits and cost-savings (23). The study also provided support for recommendations to restrict price promotions on SSBs as part of a comprehensive strategy to address obesity and unhealthy diets (23).
It comes to no surprise that the WHO endorsed the Sugar Tax and aided 26 countries worldwide to implement it (21).
Legislation and Public Support
We cannot accuse the Australian Government of taking no action in fighting obesity, but its’ response can be considered confined and limited. When it comes to nutrition, Australia plays the role of the educator not the legislator making its’ approach good, but not good enough.
The use of legal tools in the past was highly successful in reducing some public health problems such as road safety, alcohol consumption, and tobacco use (24). Promotional campaigns, recreation centres, and raising awareness can indirectly change an individuals’ behaviour, but the law has the power to change it directly. The law has the capacity to modify the social, economic, and physical environment in which people make decisions about what they eat (24). The law can have the power to regulate pricing, marketing, labelling, and even contents of products, reshaping how the public perceive food and shifting unhealthy eating habits. On top of that, sugar-sweetened beverage taxes are a way for countries to raise revenues (21). Australia can use this Tax generated income to subsidize health care, and to fund additional Public Health strategies that work alongside with legislations.
The two main opposing voices to Sugar Tax are the Public and the Beverages industry. The Publics’ main arguments is the additional household expenses while the manufacturers concern is the drop in sales. The level of Public Support started significantly changing in 2018, and that was revealed in survey findings where the majority of the Australian population recognised obesity to be a serious health problem, and supported government regulation of the food environment as a population-level preventative strategy (25).
On the other hand, the industry can continue its’ battle against the human health which is an absolute priority. Alternatively, manufacturers can cooperate with food scientists and health advocates to improve and alter their products to fit into the new healthy standards set by law and expected by the public. The good news is, with the growing recognition and awareness amongst the public about the health effects of overweight and obesity a shift in demand towards minimally processed foods, healthier products, organic, and natural foods is the recent orientation (26).
Conclusion
Australia performs well relatively when it comes to general health care, it scores high in life expectancy at 82.5 years, it has the fifth lowest infant mortality rate, and its sixth least likely to smoke. However, it ranks less well when it comes to overweight and obesity. For men, Australia ranks third behind the United States and Chile and that is excluding indigenous population which is a population struggling with obesity (27).
It is well established that sugar plays a powerful role in weight gain leading to obesity, and it is even more agreed upon that obesity comes with long term health and economic burdens (28). That given, regulating sugar intake has become a health necessity, and restricting its consumption via legislation seems to be an effective tool.
Australia succeeded dramatically in decreasing the prevalence of smoking and reducing the road death toll (3). These health achievements were only possible due to serious legislations, public policies, and health strategies enforced by the government.
Taxation of sugar-sweetened beverages is just one intervention, and it should be a component of a collective comprehensive strategy. In the face of obesity epidemic, Health advocates need to remain vigilant to ensure that sugar-sweetened beverage taxes go through and more legislations endure.