In the first week of November, Sydney Health Law will be hosting the Food Governance Conference. The conference is a collaborative endeavor between Sydney Law School and the Charles Perkins Centre, the University of Sydney’s dedicated institute for easing the global burden of obesity, diabetes, and cardiovascular disease. The conference also has sponsorship from The George Institute for Global Health and the University’s Cancer Research Network.
The Food Governance Conference will explore the role of law, regulation and policy in addressing the key challenges associated with food and nutrition in the 21st century, including food security, food safety, and preventing diet-related disease such as diabetes and cardiovascular disease. It also engages with issues related to sustainability, equity, and justice in the food supply, with a strong focus on nutrition and diet-related health in Aboriginal and Torres Strait Islander communities.
In taking such a broad focus we hope that the Conference will highlight the interrelationships between the main challenges facing the global food system in the 21st century. The conference will also showcase the work of researchers in developing new, innovative solutions to these challenges, with the conference including presenters from across Australia, as well as from the UK, Canada, and New Zealand. Some of the issues considered at the conference include:
Taxes on sugar-sweetened beverages
Free range egg labeling
The role of business in improving nutrition and diet-related health, and
The influence of trade agreements on the global food system
We have an exciting program of events around the Food Governance Conference, including two free, public lectures to open the conference.
Professor Corinna Hawkes will be giving the opening address for the conference on Tuesday the 1st of November at 6pm at the Charles Perkins Centre Auditorium. This lecture is free and open to the public. Professor Hawkes is the Director of the Centre for Food Policy at City University London and a world-renowned expert on food and nutrition policy. She’ll be speaking on the three biggest challenges facing the food system, and how we fix them. If you’re interested in this talk, you can register at this link.
Dr Alessandro Demaio will also be giving a public lecture at 1-2pm on Tuesday the 1st of November at Sydney Law School. Dr Demaio (from the World Health Organisation) will be speaking on the links between food, nutrition and cancer, and what the nutrition community can learn from the cancer community from its fight against tobacco. Further details about his talk are available at this link.
Workshop on food advocacy
Along with the Charles Perkins Centre, the Australian Right to Food Coalition is hosting a masterclass on becoming an effective food policy advocate, featuring Professor Corinna Hawkes. The purpose of this master class is to encourage debate among academics and civil society about the role of advocacy in food and nutrition policy, what it is, and how it can be used more effectively. Registrations for the master class can be made here. Please note that the master class is now full.
We’re looking forward to the inaugural Food Governance Conference at the University of Sydney, and we hope to see you there. We welcome any questions about the conference, which can be directed to Dr Belinda Reeve: Belinda.firstname.lastname@example.org
Follow #foodgovernance2016 on Twitter for updates about the conference!
Governing Food will bring together researchers and practitioners from a range of disciplines to explore the role of law, regulation and policy in promoting a healthy, safe and sustainable food supply. The conference will be opened by a public keynote address on Tuesday the 1st of November, to be delivered by Professor Corinna Hawkes from the Centre for Food Policy at City University London. The main days of the conference will be Wednesday the 2nd of November and Thursday the 3rd of November.
The call for abstracts and further details about the conference can be found at this address. You can also contact Dr Belinda Reeve in relation to any questions about the conference: email@example.com.
The UK tax on soft drink and Jamie Oliver’s call to action
TodayBritain announced that from 2017 it would levy a tax on soft drinks containing more than five grams of sugar per 100 millilitres, as part of efforts to contain rising levels of childhood obesity. The announcement prompted Jamie Oliver to post a video on Facebook encouraging other governments to follow suit, and telling Australia and other countries to “pull your finger out” on soft drink taxes.
Should Australia introduce a sugary drinks tax? Would a tax be an effective obesity prevention measure? Or would it just be a slow and costly way of raising the ire of the food industry?
Australians drink a lot of soft drink
Around one third of Australians drink about a can of soft drink a day, making Australia one of the top ten soft-drink consuming countries in the world. Soft drink consumption among young people is particularly concerning, with around 47% of children (aged between two and 16 years) consuming sugar-sweetened beverages (SSBs) every day.
Why is soft drink bad for our health?
A large number of studies show that soft drink consumption increases the risk of obesity, diabetes, heart disease and dental caries, and soft drink consumption has been linked to approximately 184,000 deaths per year globally.
Soft drink has a large of amount of added sugar (when it’s not artificially sweetened), making it a key source of added sugar in our diets. Drinking soft drink displaces the consumption of healthier beverages, and we tend not to compensate for the calories we drink by reducing our food intake. Drinks that are high in sugar have been shown to reduce appetite control, which also contributes to weight gain.
Around 60% of Australian adults and 25% of children are either obese or overweight and obesity has overtaken smoking as the leading cause of preventable death and illness. Reducing soft drink consumption could be one way of reducing the burden of obesity and chronic disease, and its impact on Australia’s health care system.
Soft drink taxes are gaining momentum
Public health experts recommend soft drink taxes as one component of a comprehensive obesity prevention strategy, and a number of countries have taken this recommendation on board.
In September 2013 the Mexican congress passed an excise tax on SSBs of one peso per litre – a price increase of approximately 10%. Mexico also introduced an ad valorem tax of 8% on a defined list of non-essential energy-dense foods.
The US city of Berkeley passed a one cent per ounce excise tax on SSBs in November 2014, becoming the first US city to levy a targeted health-related tax on soft drink.
Since January 2015 Chile has levied an 18% ad valorem tax on drinks with a sugar content of more than 6.25 g of sugar per 100 mL, including energy drinks and sweetened waters. Sugary drinks with less than 6.25 g of sugar per 100 mL are taxed at 10%.
These are just a few examples of jurisdictions with soft drink taxes; others include France, Mauritus, and Barbados. Countries are also experimenting with taxes on other unhealthy food products, or on specific nutrients such as fat or salt, often in tandem with taxes on sugary beverages.
Are soft drink taxes effective?
Soft drink taxes are a relatively new initiative, meaning that there’s not much ‘real world’ evidence of their impact. However, modelling studies suggest that tax increases are effective in reducing consumption of SSBs, and a recent evaluation of Mexico’s soft drink tax provides more concrete evidence of the effectiveness of taxes in shifting consumption patterns. The study found that the average volume of taxed beverages purchased monthly was 6% lower after the tax was implemented, with reductions accelerating over time, and reaching a 12% decline by December 2014.
The effects of soft drink taxes on diet-related health are less certain, but there is some evidence for this relationship too. One review of the evidence found a statistically significant association between “substantial” food taxes and weight outcomes, particularly in relation to children, adolescents, low socioeconomic status populations, and those at risk for overweight.
Other studies are more equivocal, but keep in mind that this a recurring problem in public health – the difficulty of showing that one initiative in isolation will lead to significant weight reductions. Experts agreed that a number of complementary measures will be required if we are to see meaningful reductions in obesity and overweight.
What are some of the criticisms of soft drink taxes?
One of the main concerns about soft drink taxes is that they are regressive. In theory, SSB taxes have a larger impact on lower socioeconomic groups, given that such groups pay a higher proportion of their income towards soft drink purchases. However, the evaluation of Mexico’s soft drink tax found that reductions in soft drink purchasing were greatest among low SES households (averaging 9.1%), suggesting that low SES groups were the most price elastic and thus benefited the most from the tax.
Governments can also take steps to offset the regressive nature of soft drink taxes, for example by targeting subsidies for healthy foods and beverages to low-income households, which could be paid for using the revenue generated by soft drink taxes. Alternatively, tax revenue could be used to address disparities in health or socioeconomic status more broadly.
The effectiveness of an excise tax in reducing SSB consumption hinges on the extent to which the tax is passed on to consumers in the form of higher retail prices. Distributors or retailers may “under shift” the tax by absorbing its cost, thus lowering their profit margins, but sustaining sales. Lower than expected price increases may undermine the tax’s public health benefit. However, evaluations of SSB taxes in Berkeley and Mexico find that manufacturers and distributors have mostly passed on the costs of the taxes to consumers, suggesting that these taxes will have the desired effect.
What’s the situation in Australia?
Australia’s GST exempts many foods that are a core component of a healthy diet, such as fresh fruits and vegetables. Sugary drinks are subject to the GST, meaning that there is a kind of differential tax on soft drinks. However, the GST is not intended for this purpose and operates differently to a specific, health-related soft drink tax.
In 2008 the National Preventative Health Taskforce recommended that the government commission a review of economic policies and taxation systems, and use economic incentives to decrease the production and consumption of unhealthy foods and beverages. It cautiously recommended a soft drink tax, given the uncertain impact of these taxes on consumer health.
In its response to the Taskforce, the then federal Labor Government stated that it had already commissioned an independent review of the Australian taxation system, i.e., the Henry Tax Review in 2010. This review did not recommend health-specific taxes on foods and beverages (despite recommending tax hikes for tobacco and alcohol) and the Government said that it would not consider another review. Instead, the Government pointed to voluntary food reformulation efforts taking place through the Food and Health Dialogue.
Should Australia introduce a soft drink tax?
Jamie Oliver’s right. The Australian government does take a “weak, pathetic” approach to obesity prevention, and we could do better.
The evidence shows that an SSB tax could have a real impact on Australian’s soft drink consumption habits, as does the effectiveness of tobacco taxes and other food taxes such as Denmark’s tax on saturated fat. Soft drink has no nutritional value, making it one of the more uncomplicated food products to tax.
As well as shifting consumption patterns, soft drink taxes could prompt companies to reformulate drinks to reduce their sugar content, or to introduce new, healthier products. Taxes could also generate significant revenue for health promotion activities, preferably targeted at the most vulnerable populations.
The health outcomes of SSB taxes need further research, but this should not stop the Government from “pulling its finger out” as suggested by Jamie Oliver, and introducing a tax on soft drink, as many other countries are doing. An SSB tax would send a clear message that the government is committed to protecting the health of Australians, even if it means taking on the powerful multinational companies that dominate the beverage industry.
We’ve now had a few weeks to chew over the latest report linking food and cancer. Only this time it wasn’t a puff-piece in your Sunday newspaper, but an extremely comprehensive report from IARC, the World Health Organization’s International Agency for Research on Cancer. After a systematic review, IARC’s findings on the links between red and processed meat consumption, and cancer, were published in a press release and in The Lancet in late October (the full findings will be published later as a monograph).
In brief, red meat (“all mammalian muscle meat, including, beef, veal, pork, lamb, mutton, horse, and goat”) was classified as being probably carcinogenic to humans. Processed meat (“meat that has been transformed through salting, curing, fermentation, smoking, or other processes to enhance flavour or improve preservation”) was classified as carcinogenic to humans. This means that, based on epidemiological studies, IARC found “convincing evidence” that meat products like ham, sausages, corned beef and biltong cause colorectal cancer.
Is meat the “new tobacco”?
Despite widespread media reporting that red and processed meats were now “as big a threat as cigarettes”, IARC did not actually make this comparison. Rather, it rated the strength of the evidence for the link as “Group 1”, meaning that the evidence is strong. So, the evidence linking tobacco and lung cancer is equally persuasive (Group 1) but this does not mean that eating meat is as dangerous as smoking. (This classification system is widely used in systematic assessments of nutritional evidence, including in the Australian Dietary Guidelines.)
Among those who denounced the comparison between eating meat and smoking cigarettes was Australia’s Agriculture Minister, Barnaby Joyce. Clearly, Mr Joyce has an interest in dampening any concerns that might threaten Australia’s reputation as a nation of meat-eaters – but in this case his assessment of the evidence was correct.
Regulation of bacon: the next frontier for public health law?
All in all, you may want to consider throwing a few extra vegetable skewers on your next barbeque. But more interestingly for our purposes, what – if any – are the implications for law and regulation?
As countries such as India and China undergo rapid social and nutritional transitions, the demand for meat will only grow – worldwide, meat-eating is correlated with greater wealth. This has environmental as well as health implications. Together, these implications may eventually prompt countries to take regulatory action.
While there are currently no jurisdictions that regulate the consumption of meat, the following developments may be indicative of an early trend:
“Meatless Mondays” or “meat-free Mondays” campaigns have been springing up around the world since the early 2000s. These tend to be grassroots civil society initiatives aimed at making vegetarian food more acceptable and available.
In 2009, the Belgian city of Ghent became the first in the world to proclaim an official “Veggie Thursday”.
The most recent iteration of the US government’s dietary guidelines, “MyPlate”, refers to daily “protein” rather than “meat” consumption.
In the early 1990s, Ghana introduced food standards setting maximum fat limits for pork, beef, mutton and poultry, in response to concerns about diet-related NCDs. While not a curb on meat consumption per se, this regulatory response does speak to some of the concerns raised by IARC.
Perhaps most tellingly, the food industry has come to recognise the commercial potential of vegetarian foods, which are now said to have “gone mainstream” after decades on the hippie fringe.
This is where the comparison with tobacco control may be more salient. The evidence linking tobacco to cancer was recognised by some governments as early as the mid-1950s, but the WHO’s Framework Convention on Tobacco Control was not enacted until 2003. Biltong regulation will no doubt require a similar fermentation period. But the mix of voluntary, regulatory and commercial developments above suggests that the goal of curbing meat consumption is not far-fetched or conceptually unappealing. More controversial perhaps will be the methods of achieving that goal. Warning labels on a pack of sausages? A tax on bacon? A ban on quarter-pounders? We’ll get back to you in 30 years…
New York City’s Board of Health last week unanimously agreed to require ‘salt-shaker’ warning symbols on menu items with more than an entire day’s recommended limit of 2300mg of sodium. That’s around one teaspoon of salt.
Restaurants with more than 15 outlets nationally will display warnings from 1 December 2015.
Industry groups and the National Restaurant Association have been as swift in their (predictable) opposition as public health advocates have been to welcome the move. The Center for Science in the Public Interest has even begun a Pinterest board of qualifying items – a salt shaming parade of sorts.
Surrounding public debate has renewed attention on the health impact of salt. Sugar may have received more publicity of late, but population salt reduction is a World Health Organization ‘best-buy’ for public health.
Cardiovascular disease is now the world’s biggest killer, and high blood pressure the leading risk factor for these deaths. Links between salt and high blood pressure are so well established that in 2011, countries agreed to pursue a 30% relative reduction in population salt intake, aiming towards an average of less than 5 grams a day (approx. 2000mg of sodium) by 2025. In Australia, a 30% reduction could save around 3400 lives each year – that’s three times the national road toll.
Many are aware of salt’s potential harms, but it appears most people are failing to personalise their own risk – and thereby failing to modify their behaviour accordingly.
New York’s measure is built on figures that just 1 in 10 Americans are abiding by current guidelines. Most Australians aren’t aware of the daily recommended amount, yet believe their own intake of salt to be ‘about right’ (spoiler: it’s not!) People may not realise around 75% of salt intake comes from processed and restaurant foods – making it hard for even motivated individuals to reduce consumption alone, particularly without user-friendly information available on labels or menus. Ironically the source of the problem is not the salt-shaker itself. Not the one you keep at home, anyway.
Introducing a warning icon is a step in the right direction. Graphic and simple, it aligns with growing evidence from a packaging context that interpretive labelling helps consumers make healthier choices. Such measures also have broader impact by driving reformulation. If you were the maker of Jersey Mike’s Buffalo Chicken Cheesesteak – currently containing an astounding 7795mg of sodium – would you continue to invite adverse publicity via online ‘worst-of’ lists and in-store warning labels, or instead dial down salt, perhaps even phasing out the item from sale? Reformulated recipes rolled out by national chains may benefit millions of fast food customers far beyond New York City. Even before the potential ‘domino effect’ when emboldened health authorities elsewhere copy the measure, the little salt-shaker icon could have significant flow-on effects.
But what is an amount of salt worth warning us about? Burger industry representatives have been quick to proclaim most burgers in NYC wouldn’t be slapped with warnings under the current threshold. One whole teaspoon is a high bar if applied only to individual items. If a similar measure were applied in Australia, we may not see too many salt-shakers appear, though KFC’s Zinger Stacker burger comes dangerously close. Thankfully the law also applies to advertised meal combinations – in case you needed it, one more incentive not to ‘super-size me’.
Perhaps an entire day’s total is still an unreasonably high benchmark. If we allow food companies to market packaged foods as a ‘good source’ of positive nutrients like protein or fibre when containing just 20% of the daily recommended intake, and an ‘excellent’ source at 50% – why not apply a similar metric to a warning when the reverse is true?
Even if items don’t qualify for a salt-shaker, few would argue most products sold by these chains are ‘good for you’. Some point to limitations of focusing on single nutrient warnings, but such critiques miss the intervention’s place as only one component of a suite of complementary measures (including voluntary salt reformulation programs and trans-fat bans) which operate together to improve the food environment and enable consumers to make healthier choices.
In NYC – just as in New South Wales – total energy content is already displayed for all menu items. Results from NSW have been encouraging: the Food Authority found a 15% decrease in average kilojoules purchased. Despite a recent high-profile breach by McDonalds’ on its new digital menu boards, compliance has generally been high. Laws exist only in NSW, South Australia and the ACT, but many national chains have rolled out kilojoule information nationwide, delivering benefits to countless Australians.
As NSW considers extending menu labels to cover additional nutrients, New York’s salt-shaker provides global leadership. Perhaps better still, Australia has already developed a system combining information on a variety of risk factors (salt, sugar and saturated fat) with positive nutrients and total energy content into a single interpretive symbol. If ‘Health Star Ratings’ prove popular on front-of-pack of packaged foods in our supermarkets, why not extend them to fast food?
Writing in the Sydney Morning Herald, Stephen Simpson (Director of the Charles Perkins Centre at the University of Sydney) and Rosemary Calder (health policy Director at the Mitchell Institute for Health and Education Policy at Victoria University), call for community-based action to prevent chronic disease. They point to communities like Broken Hill, which has high rates of obesity, but also a strong self-identity and good social cohesion, offering exciting opportunities for a community-led approach to prevention.
Steven Simpson and Rosemary Calder contrast community-led initiatives to government action, but maybe we could have both. Legislation and regulation could be much better used to support existing local initiatives, encourage community action, and improve local-level obesogenic environments. This is a relatively unexplored area in Australia, but there is growing interest in local level action in obesity prevention in some regions of the country. The City of Sydney encourages active transport, which it links to improving health in the city. The City of Marion, in Adelaide, implemented an obesity prevention program that included community meals and physical activity sessions, targeted to at-risk populations. And some states governments have moved to strengthen the role of local governments in health promotion through legislative measures. For example, South Australia’s Public Health Act 2011 makes local governments responsible (for the first time) for taking action to preserve, protect and promote public health within their area.
The US is much further ahead than Australia in local level prevention efforts, with states and municipal governments around the country trialling innovative obesity prevention policies. A US national prevention policy framework encourages local obesity prevention policies, as do federal grants for community-based initiatives. Local efforts in obesity prevention in the US could provide some lessons for Australian local governments that want to take action in obesity prevention, but they also illustrate some of the challenges that our local governments may face in taking legislative action.
High profile initiatives in the US have attracted significant media attention, as when the former Mayor of New York City, Michael Bloomberg, attempted to ban large sized sodas sold by food service establishments in the city. However these kinds of controversial initiatives are just the tip of iceberg. A range of state and local governments are experimenting with measures to improve the obesogenic environment and encourage physical activity, including Californian legislation that reduces taxes for landowners who make their land available for urban agriculture, and laws in Maine that require grocery stores to stock a minimum number of ‘staple foods.’ Some localities have introduced broad-ranging programs that combine infrastructure development, improved urban design, and health education. In this TED talk, Mayor Mike Cornett describes his obesity prevention strategy for Oklahoma City, and how it resulted in the loss of over one million pounds by city residents. Mayor Cornett also attributes his initiatives with encouraging economic revitalisation in the city.
There are many benefits to local level action. In both Australia and America, the division of powers between state, local, and federal governments enables local governments to act as ‘laboratories of innovation,’ i.e., to trial innovative policies without facing the political barriers that would impede federal-level initiatives (e.g., aggressive industry lobbying). Local governments use their legislative and administrative powers to develop policies that are tailored to the social, economic, and demographic features of their region, and which can diffuse ‘horizontally’ to other localities and ‘vertically’ – upwards to states and national government levels. Local leaders are closer to their constituents, allowing them to be more responsive to community needs, and facilitating ‘bottom-up’ initiatives that are built on a base of community consultation and ownership.
However, local policy making in the US illustrates some of the challenges that local governments in Australia may face in preventing obesity. As in Australia, local governments in the US are creatures of state government. Some US municipalities have expansive rule-making authority, but other states delegate only narrow powers, constraining local action and creating variation in the extent to which local governments can pursue obesity-prevention measures. Popular and media discourse frame obesity mainly as the result of individual’s poor consumption choices, meaning that government intervention to encourage healthy eating and drinking are often seen as paternalistic. Critics of the soda ban referred to Mayor Bloomberg as Nanny Bloomberg, and the soda portion rule was eventually declared invalid following a legal challenge.
Another concern is that some obesity-prevention strategies disproportionately impact vulnerable communities. Like tobacco taxes, soft drink taxes can be seen as regressive because they fall more heavily on lower-income groups who drink more soft drink and have fewer resources to absorb tax increases. Policies that actively target at-risk communities may also be discriminatory when they are based on ethnicity or race, as opposed to targeting neighbourhoods or communities with poor health indicators. Effective policies can also fail to reduce – or even exacerbate – health inequalities. Redesign of the urban landscape can increase gentrification, pushing low-income residents out of the inner city into areas with fewer amenities.
A final issue is that community-level prevention policies are a relatively new area of intervention and the results of evaluating studies are still emerging. Supporters of local-level innovation argue that policies such as the soda portion rule are supported by evidence linking soft drink consumption to diabetes and obesity, for example. However, many policies lack causal evidence to support their effectiveness in producing tangible obesity prevention outcomes. Yet some local initiatives have produced demonstrable changes in health-related behaviour and weight status, with particularly good evidence for school-based initiatives.
Despite these challenges, local government action could form the centrepiece of a revitalised approach to obesity and chronic disease prevention in Australia. Local government action is particularly important in Australia, where the current federal government appears entirely disinterested in chronic disease prevention (having recently cut funding for prevention efforts, including for local policies and programs), and some state governments are withdrawing from health promotion, and actively devolving preventive efforts to local governments.
Further, local government law making could be designed to address some the barriers outlined above. Health law academics in the US call for a participatory, inclusive approach to the design of public health law and regulation, where local communities are involved in identifying areas for action, as well as in processes of policy design and implementation. Their argument is that inclusive law-making processes are more likely to produce initiatives that reflect community interests, and have a strong base of community support, potentially ameliorating the concerns about nanny statism that attach to initiatives championed by public health’s ‘elites,’ such as Michael Bloomberg. Inclusive law making that is tailored to local concerns could also help to address health inequalities, while preventing initiatives from being perceived as discriminatory.
Local governments may provide a route for stronger action on prevention in Australia, particularly in light of the apathy of the current Liberal federal government. But if we are to frame obesity as a collective problem requiring community-based solutions, we need to reconceptualise public health law as a democratic, participatory and collaborative project that ensures recognition and supports self-determination for marginalized communities. Public health doesn’t need nannies; it needs local champions, facilitators, mediators, guides and leaders.