The Unsweet Truth about Sugar Sweetened Beverages

Sean attended the 71st World Health Assembly in Geneva. He is currently studying a Doctorate of Medicine at Bond University.

Abstract

A leading contributor to the burden of disease and health-care costs of the Australian population is poor nutrition, as convenience is often favoured over nutritional quality in modern society. Sugar sweetened beverages such as soft drinks, hold no nutritional value in a diet, yet two out of three Australians consume at least one daily. This equates to 47% of added sugar to an individual’s diet.1The link between the consumption of sugar sweetened beverages and the development of obesity is strong. There is also a strong link between obesity’s pro-inflammatory tendency and an individuals’ susceptibility to develop disease processes, such as heart disease and cancer. This research report will propose two recommendations; a federal sugar tax and restriction of serving sizes of sugar sweetened beverages. In doing so, it will also explore the social implications and political landscape that have hindered the implementation of effective policies to combat the risks of sugar-sweetened beverages to date.  

Context and Background 

Currently, 27% of Australian children and 63% of the Australian adult population are overweight or obese (BMI >25).1Current trends predict that 80% of the Australian adult population will be overweight or obese by 2025.1This is not an issue isolated to Australia. The international obesity prevalence, as estimated by the World Health Organisation (WHO), has progressively increased throughout the past two decades to greater than 1 billion adults being overweight.2This epidemic is not isolated to high-income countries, with middle and low-income countries also impacted. The WHO revealed that rates of overweight and obesity account for 8.4% of the total deaths in high-income countries, equating to seven hundred thousand lives. Whereas, rates of overweight and obesity account for 6.7% and 3.8% of lives lost in middle and low-income countries respectively.3

Obesity is a well-established risk factor for cardiovascular disease, hypertension, depression, diabetes, and cancers, including breast, endometrial, colon and prostate.4The impact on an overweight or obese individual’s quality of life include medical, psychological and social costs.5Psychological consequences, especially low esteem, were nearly four times more likely in 13 year old Caucasian obese girls compared to their non-obese counterparts.6, 18According to the AusDiab study, the annual total direct cost of overweight and/or obesity in Australia in 2005 was $21 billion.7It should be noted that, when this study was conducted, only 40% of Australians were either overweight or obese. This has risen to 63% in 2018.1The study also only included citizens who were 30 years old or older. The study’s costing data excluded the indirect costs such as the social and mental health impacts as these are very difficult to quantify. This indicates that this figure should be considered a baseline and is likely to be much greater.7

The contribution of Sugar Sweetened Beverages

Obesity is a complex disorder to which genetic, cultural and behavioural factors contribute. In simple biological terms, obesity is a result of an imbalance favouring intake energy consumption over the expenditure of energy.8The World Health Organisation recommends, for an average male, a daily intake of 8700 kilojoules. The added sugar intake should be below 10% of the daily energy or 870 kilojoules to be cardiac protective.16In the United States of America, added sugar accounts for 15.8% of the total energy of the average American diet. Sugar sweetened beverages accounted for 47% of total added sugars.9Sugar sweetened beverages encompass carbonated soft drinks, fruit drinks, energy drinks, cordials and sweetened milk drinks. In 2011-2012, the Australian Health Survey found that on any given day two out of five Australians above the age of two consumed a sugar sweetened beverage. This statistic increases to nearly every second person for adolescents. Sweetened beverages contain little nutritional value but contribute a significant amount to daily energy intake.10

A meta-analysis conducted by The American Journal of Clinical Nutritionshowed a positive relationship between consumption of sugar sweetened beverages and weight gain and an increased risk of developing obesity in the long term for both children and adults. This meta-analysis also revealed that a reduction of sugar sweetened beverages resulted in a reduction in the prevalence of overweight and obesity.11

Recommendations

The recommendations below aim to promote and sustain healthy lifestyles through the implementation of a federal sugar tax and reducing the serving size of sugar sweetened beverages. The primary outcome of these interventions is the reduction in the mean BMI among the high-risk consumers. These recommendations target high-risk consumers, particularly: adolescents (15 to 24 year olds), Indigenous Australians and individuals from lower socio-economic backgrounds. These populations are considered high-risk due to their unique social determinants statistically making them more likely to consume sugar-sweetened beverages. Generally, these are the populations which also see the largest rates of obesity.  

Recommendation 1: Promoting and sustaining healthy lifestyles through the implementation of a federal sugar tax.

This report recommends the implementation of an additional 20% excise tax on sugar-sweetened beverages. Significantassociations have been made in the presence of state-level taxation on sugar-sweetened beverages between 1991 and 1998 and a relative decrease in obesity prevalence over the same time period.11The Cancer Council of Australia and the Obesity Policy Coalition support interventions such as a taxation to reduce consumption of sugar sweetened beverages. Twenty-eight countries around the world, including the United Kingdom in early 2018, have implemented a sugar tax.24

The most extensive efficacy report comes from the Mexican Government, where a sugar tax was placed on sugar sweetened beverages four years ago. The preliminary outcomes of the first nation-wide sugar taxation revealed a 9-12% decrease in overall consumption. Lower income families saw a reduction of up to 17%.17A study in the Journal of Nutrition noted that the populations with the greatest reduction were lower income families, residents living in urban areas, and households with children. The same study also noted a 16.2% increase in water purchases in lower and middle income families.12 These are preliminary results of Mexico’s data but the Research Triangle Institute International (RTI International) supported these outcomes. The RTI International analysis showed a uniform execution of a sugar sweetened beverage and a tobacco tax (the study’s results did not separate the two) would see a global benefit of 2,100,000 direct deaths averted and would raise US $30 billion in taxation by 2068. It will also reduce the US $6 billion annually spent on the direct consequences of tobacco use and obesity. The report concluded that a 10% increase in cost would lead to a 10% decrease in sugar-sweetened beverage consumption.7, 11

The Australian government’s hesitation to implement taxation reform on sugar sweetened beverages should be explored to better understand its hesitations. The Australian sugar industry has great influence in Canberra through the support of lobby groups and four marginal seats in North Queensland and Northern NSW where sugar cane farming is the major industry.15The major lobby groups in Canberra are the Beverage Council and Newgate Communications, which represents the Coca Cola Company in Australia. These lobby groups advocate on the behalf of their key stakeholders. It was made clear in the Beverage Council’s 2016 Annual Report that their resources were being focused on keeping the topic of a sugar taxation off the table of both political parties.15, 16In the same year, leaked internal Coca Cola Company emails revealed how executives pressured local governments, journalists and politicians against a sugar sweetened beverage tax.16In Australia, between 1999 and 2015, the Coca Cola Company donated one million dollars to both major parties over the sixteen-year period.16

The seats of Leichhardt, Herbert, Dawson and Page are known as the ‘sugar seats’. With a Federal Government with a slight majority and with the next election in 2019, the Government cannot afford to alienate these swinging seats. Sugar cane farming is one of the major industries in these seats. The implementation of a sugar tax may cause job losses and may dissatisfy a large portion of these communities and sway their votes. There are currently 40,000 individuals directly and indirectly employed by the Australian sugar industry.22There are no substantial statistics from any of the nations that have implemented a sugar tax about the extent of job losses, however, the fear of job losses appears to be much greater than the reality. For example, Coca Cola predicted a loss of 60,000 jobs in South Africa if they implemented a sugar tax. The South African Government reported after the taxation was in place that only 3,400 jobs were affected.23The South African Labour and Development Research Unit (SALDRU) produced a socioeconomic report that was presented to their government. The report explored the similarities between the sugar industry and tobacco industry (as they are both capital intensive industries) and concluded that when a predicted decrease in consumption occurs few jobs in manufacturing are lost. This occurs as these industries are not labour intensive.23This is relevant as opponents to the implementation of a sugar tax argue that job loss, particularly in manufacturing, will be lost.

Recommendation Two: Influencing the consumer of sugar sweetened beverages by making and reducing the available quantity/serving size.

It is recommended that the government places restrictions on the amount of sugar contained in sweetened beverages sold commercially. It is recommended that these beverages have less than 25 grams of added sugar per serve, which is the maximum daily sugar intake recommended by the World Health Organisation for women, while the recommendation for men is 38 grams.14

If a company or provider provides a value pack or family-sized product, they must clearly illustrate on the product a warning sticker that the product is high in sugar and display the percentage, and the amount of added sugar this product has in relation to the average recommended daily intake of added sugar provided by the World Health Organisation.14The manufacturers of the product must also demonstrate, through the marking of packaging, the volume of one serving is under the 25 grams of added sugar recommended. 

Over the last 50 years, the size of containers for sweetened beverages has increased by between two and three times. The New South Wales (NSW) government produced a report which saw a parallel in the increased portion sizes of sugar sweetened beverages and the increased prevalence of obesity.21A standard serving size in 1950 was a 200 ml container. Now, the common containers seen in the market are 390 ml and 600 ml containers. Interestingly, the cost of a 600 ml container is not significantly higher its smaller counterpart but results in the consumption of an extra 378 kilojoules.20, 21This can easily push people over the recommended daily consumption of 870 kilojoules.16This illustrates the complexity of the issue as simple price increases may not persuade a consumer to drink a lesser volume per serving. This policy would then compliment a taxation by providing a maximum volume of added sugar per serving.

The logic of the recommendation is twofold; it provides valuable education for and insight to the consumer of sugar sweetened beverages about how much they are consuming and the harm of added sugar causing obesity. For example, many members of the population would be surprised to know that a medium sized McDonald’s Coke Cola has 17g of sugar, whereas, a medium sized McDonald’s Minute Maid Orange Juice contains 41g of sugar.13This recommendation is not about restricting the autonomy of consumers but providing critical information to all consumers to create an informed opinion of a product. 

Secondly, this recommendation impacts manufacturers. Restricting the serving sizes of sugar sweetened beverages will unlikely impact the beverage companies as it targets particular products and not product lines. It also provides an incentive for beverage companies to create and market healthier alternatives with lower added or no sugar. The SALDRU report noted how, in Mexico, while there was a 10% decrease in consumption, there was a 7% increase in consumption of untaxed beverages. This included a 13% increase in bottled water consumption.12, 23The beverage industries have understood this trend and have started reforming their recipes. In Britain, after a sugar sweetened beverage tax was implemented, Coca Cola reduced the amount of added sugar in Fanta by a third. Ribena’s content was also reduced by half.15, 16, 20These trends would likely occur in Australia. 

Conclusion

Rates of overweight or obesity are continually rising in Australia, leading to an increased burden of disease and significant strain on the public health system. Currently, 27% of Australian children and 63% of the Australian adult population are overweight or obese. There is sufficient evidence that suggests that sugar sweetened beverage consumption contributes to increased rates of overweight and obesity and that reducing the consumption of sugar sweetened beverages provides multiple health benefits.

This paper proposes two reform policies; a taxation on sugar sweetened beverages; and reform of serving sizes of sugar sweetened beverages. A 20% taxation is cost effective to implement, raises revenue, and will contribute to the reduction in the consumption of sugar sweetened beverages. Restricting the serving size, or at least clearly informing a consumer of the sugar contained in a serving size, is easy to implement, does not cost taxpayers, and will provide manufacturers with an incentive to create and promote low sugar or zero sugar alternatives. This will also help inform consumers of their sugar intake and promote greater awareness and understanding of how their sugar intake affects their weight and overall health.

Evidence shows that both recommendations will reduce the consumption of sugar sweetened beverages. They are easily implemented with minimal risks politically, economically or to job security and have the potential to benefit the majority of society and hence should be seriously considered.    

 

References

 

1.     Australian Bureau of Statistics. 2013. Australian Health Survey: Consumption of added sugars, 2011-12. Australian Bureau of Statistics.[ONLINE] Available at: http://www.abs.gov.au/australianhealthsurvey. [Accessed 9 July 2018].

2.     World Health Organization. Obesity and overweight fact sheet.  Geneva, Switzerland: World Health Organization, 2003. [ONLINE] Available at: http://www.who.int/dietphysicalactivity/media/en/gsfs_obesity.pdf

3.     Health, W., 2009. Global Health Risks: Mortality and Burden of Disease Attributable to Selected Major Risks.World Health Organization.[ONLINE] Available at: http://www.who.int/healthinfo/global_burden_disease/GlobalHealthRisks_report_part2.pdf

4.     Allison DB, Fontaine KR, Manson JE, Stevens J, VanItallie TB. Annual deaths attributable to obesity in the United States. JAMA1999; 282: 1530–8.

5.     Allison DB, Zannolli R, Narayan KM. The direct health care costs of obesity in the United States. Am J Public Health 1999; 89: 1194–9.

6.     Dietz WH.Health consequences of obesity in youth: childhood predictors of adult disease. Pediatrics1998;101:518–25.  

7.     Tanamas SK, Magliano DJ, Lynch B, Sethi P, Willenberg L, Polkinghorne KR, Chadban S, Dunstan D, Shaw JE. The Australian Diabetes, Obesity, and Lifestyle Study. (2012) Baker IDI Heart and Diabetes Institute. ISBN: 0-9578310-3

8.     Morrill AC, Chinn CD. The obesity epidemic in the United States. J Public Health Policy2004; 25: 353–66.

9.     Guthrie JF, Morton JF. Food sources of added sweeteners in the diets of Americans. J Am Diet Assoc  2000; 100: 43–51.

10.  Australian Bureau of Statistics. 2013. Australian Health Survey: Biomedical Results for Chronic Diseases, 2011-12. Australian Bureau of Statistics.[ONLINE] Available at: http://www.abs.gov.au/australianhealthsurvey. [Accessed 9 July 2018].

11.  Malik VS, Schulze MB, Hu FB, 2006. Article Navigation Intake of sugar-sweetened beverages and weight gain: a systematic review. The American Journal of Clinical Nutrition, [Online]. Volume 84, Issue 2, Pages 274–288,. Available at: https://doi.org/10.1093/ajcn/84.2.274 [Accessed 7 July 2018].

12.  Colchero, Arantxa M, Molina, Mariana, Guerrero-López, Carlos M. 2017. "After Mexico Implemented a Tax, Purchases of Sugar-Sweetened Beverages Decreased and of Water Increased: Difference by Place of Residence, Household Composition, and Income Level"The Journal of Nutrition. 147: jn251892. doi:10.3945/jn.117.251892ISSN 0022-3166

13.  McDonald's. 2018. Nutrition Calculator. McDonald’s Company. [ONLINE] Available at: https://www.mcdonalds.com/us/en-us/about-our-food/nutrition-calculator.html. [Accessed 11 July 2018].

14.  World Health Organization. Guideline: Sugars intake for adults and children. Geneva: World Health Organization. 2015. [ONLINE] Available at: http://apps.who.int/iris/bitstream/handle/10665/149782/9789241549028_eng.pdf;jsessionid=F87E24908328A1E4B1FA368FA9B94A57?sequence=1

15.  O'Reilly L. The End of the Coke Era. Business Insider Australia. 2015. [ONLINE] Available at: https://www.businessinsider.com.au/what-is-the-future-for-the-coca-cola-brand-soda-sales-decline-2015-4?r=US&IR=T. [Accessed 5 July 2018].

16.  Australian Broadcasting Company: Four Corners. Tipping the Scales. 2018. [ONLINE] Available at: http://www.abc.net.au/4corners/tipping-the-scales/9712342

17.  DinsaGD. GoryakinY. FumagalliE. SuhrckeM. Obesity and Socioeconomic Status in Developing Countries: a Systematic Review. National Centre for Biotechnology Information. 2012: 1067–1079.doi:  10.1111/j.1467-789X.2012.01017.xPMCID: PMC3798095 PMID: 22764734[ONLINE] Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3798095/

18.  Reilly JJ. Methven E. McDowell ZC. Hacking B. Alexander D. Stewart L. Kelnar CJH. Community Child Health, Public Health, and Epidemiology. British Medical Journal. [ONLINE] Available at: https://adc.bmj.com/content/88/9/748?etoc=

19.  Heo M. Allison DB. Faith MS. Zhu S. Fontaine KR. Obesity and Quality of Life: Mediating Effects of Pain and Comorbidities. Wiley Online Library. 2012. [ONLINE] Available at: https://onlinelibrary.wiley.com/doi/full/10.1038/oby.2003.33

20.  Lobstein T. Reducing Consumption of Sugar-Sweetened Beverages to Reduce the Risk of Childhood Overweight and Obesity. World Health Organization. 2014. [ONLINE] Available at: http://www.who.int/elena/bbc/ssbs_childhood_obesity/en/

21.  Hector D, Rangan A, Louie J, Flood V, Gill T (2009). Soft drinks, weight status and health: a review. Sydney: A NSW Centre for Public Health Nutrition. ISBN 978 1 74187 356 6. [ONLINE] Available at: http://www.health.nsw.gov.au/heal/Publications/soft-drinks-report.pdf

22.  Industry Information. 2018. Sugar Australia Company Ltd.[ONLINE] Available at: http://www.sugaraustralia.com.au/sugar-australia/about/industry-information/

23.  Wilkinson K. Bhardwaj V. (2018) SA’s Proposed Sugar Tax: Claims about Calories & Job Losses Checked. Africa Check. [ONLINE] Available at: https://africacheck.org/reports/sas-proposed-sugar-tax-claims-calories-job-losses-checked/

24.  Baker P. Lawrence M. (2018) Sweet Power: the Politics of Sugar, Sugary Drinks and Poor Nutrition in Australia. The Conversation. [ONLINE] Available at: https://theconversation.com/sweet-power-the-politics-of-sugar-sugary-drinks-and-poor-nutrition-in-australia-95873