However, according to Fairfax Press, Dr Nabarro has “stepped into the ring to slap down calls for sugar taxes, saying there is not enough evidence on what drives over-eating to justify blunt levies on the ingredient”.
According to Fairfax Press, Dr Nabarro cautioned against “blunt regulations” like a sugar tax and noted that the state should only intervene where the intervention has a proven effect in changing behavior.
Well that would depend on the rate of the tax. A growing body of research – examples here, and here – argues that dietary taxes could both raise revenue and improve health outcomes. In ways that subsidised gym memberships, education, personal responsibility and good intentions are unlikely to.
Dr Nabarro also distinguished between contagious epidemics, which engage the “pure health sector” and non-communicable diseases, which require inter-sectoral responses across a number of sectors.
The suggestion is that special caution is warranted with non-communicable diseases.
I’m not sure I take the point. Outside of sub-Saharan Africa, the world overwhelmingly dies from non-communicable diseases.
People are not less dead, and prior to death they are not less disabled because the condition crept up on them slowly, due to lifestyle factors that have multiple determinants.
So can we put this down to WHO politics, or is Dr Nabarro foreshadowing a softer line on “big food” and “big soda” if he is elected Director-General?
These are questions he may be asked when he is in Australia later this month.
By the way, in a recent report the Australian Institute of Health and Welfare has estimated that 7% of the burden of disease in Australia is attributable to overweight and obesity (63% of which is fatal burden). Overweight and obesity are responsible for 53% of Australia’s diabetes burden, and 45% of the burden of osteoarthritis.
The Grattan Institute report estimates that such a tax would reduce the consumption of sugary drinks by about 15% and generate up to half a billion dollars that could help to pay for a broad array of obesity-related programs.
Imagine! A public health policy that fights obesity, diabetes and tooth decay AND generates revenue.
The National Party hate the idea. Deputy Prime Minister and Leader of the Nationals, Barnaby Joyce told reporters:
“If you want to deal with being overweight, here’s a rough suggestion: stop eating so much, and do a bit of exercise. There’s two bits of handy advice and you get that for free. The National Party will not be supporting a sugar tax”.
Well that’s what he said.
But here’s what I heard: “We know that obesity and diabetes are out of control. But we have ideological objections to being part of the solution”.
The same day that Minister Joyce shared these thoughts with reporters, the Australian Food and Grocery Council issued a press release saying that it was seeking a “constructive response to obesity”.
“Obesity is a serious and complex public health issue with no single cause or quick-fix solution”, explained the AFGC, but “it is not beneficial to blame or tax a single component of the diet”.
With most complex issues, you start somewhere. You come up with evidence-informed policies and you try them out. You rigorously evaluate their performance, and learn by doing.
But not with obesity. “Complexity” is the new enemy of action. Since the causes of obesity are complex, every “single” policy advanced in response can be dismissed as a dangerously simplistic solution to a complex problem.
Welcome to obesity, the problem we’re not allowed to start to fix.
Except with personal responsibility, of course.
Personal responsibility…the answer to obesity, traffic accidents, terrorism, Zika virus, perhaps everything?
In a limited sense, Barnaby Joyce is right.
The only cure for personal obesity is personal responsibility.
But personal responsibility has turned out to be a spectacularly poor solution to “societal obesity”.
By societal obesity, I am referring to the trend towards overweight and obesity that has arisen over the past few decades and now affects the majority of adult men and women (and more than one in four children).
Since each of us is an individual, and because we live in a culture that prizes individual autonomy, it’s easy to fall into the trap of believing that individual effort, personal motivation, is the solution to the world’s ills.
But just as the global epidemics of obesity and diabetes were not caused by a catastrophic, global melt-down in personal responsibility, personal responsibility is equally unlikely to provide the magic solution.
That’s where public policies come in.
Governments know all this, but with the exception of tobacco control, they seem reluctant to apply their knowledge in the area of preventive health.
The fact is, from road traffic accidents to terrorism, smart governments:
acknowledge the complexity of the factors that contribute to societal problems;
They acknowledge that multiple interventions are needed, in many settings;
They acknowledge that possible solutions need to be trialled now, under conditions of uncertainty, instead of handing the problem to future generations.
They monitor the actions they take, because healthy public policy is a dynamic, ongoing process; and finally
They give a damn. Meaning that they recognise they are accountable to the community for helping to solve difficult, societal problems, and for the performance of the public policies they administer.
Imagine if Australia’s government took that approach with obesity.
The debate about a sugary drinks tax is here to stay: it will never go away
A tax on sugary drinks will get National Party politicians in trouble with sugar producers, and Liberal Party politicians in trouble with big food.
Despite batting it away, a tax on sugary drinks is on the public agenda, and it’s here to stay. I don’t see the sugary drinks industry winning on this issue indefinitely.
Partly because Australian health researchers will keep it on the agenda.
It will come back, and back. Especially as evidence of its success accumulates overseas.
One conversation worth having is how revenues from a sugary drinks tax might support agricultural producers in rural Australia, helping to cushion them from the adverse effects (if any) of the tax and creating incentives for the production of a sustainable and healthy food supply.
In the meantime, Australian health advocates need to broaden their base.
Advocacy for public policy action on obesity needs to become more closely integrated with advocacy on food security. And advocacy in both areas needs to be linked more closely to action on reducing health inequalities.
But enough about all that. You really came here for Barnaby, didn’t you?
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: firstname.lastname@example.org.
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.
The World Health Organisation’s Commission on Ending Childhood Obesity, appointed by WHO Director-General Dr Margaret Chan in 2014, has now formally presented its final report.
The Commission was co-chaired by Sir Peter Gluckman, the Chief Science Advisor to the Prime Minister of New Zealand, and Dr Sania Nishtar, the founder and President of Heartfile, a health policy think tank based in Pakistan.
The Commission held hearings in all 6 WHO regions, and was supported by two technical working groups: the Ad Hoc WG on Science and Evidence, and the Ad Hoc WG on Implementation, Monitoring and Accountability.
In 2014, an estimated 41 million children under 5 years of age were either overweight or obese (this is defined as the proportion of children whose weight for height scores are more than 2 standard deviations, or more than 3 standard deviations, respectively, from the WHO growth standard median).
The Commission’s strategic approach rests on three categories of interventions:
interventions to tackle the obesogenic environment in order to improve the healthy eating and physical activity behaviours of children;
interventions targeting critical stages of the lifecourse; ie (i) preconception and pregnancy; (ii) infancy and early childhood; and (iii) older childhood and adolescence;
interventions to treat obese children in order to improve their current and future health.
A number of the Commission’s recommendations addressing the obesogenic environment, and critical stages of the lifecourse, in particular, confirm the role for law and regulation in improving the food and physical activity environment for children.
In a move sure to thrill the fizzy drinks industry, the Commission has called on countries to implement an effective tax on sugar-sweetened beverages, and noted that some countries may also consider a tax on foods high in fats or sugar.
The Commission has called for a standardised global nutrient labelling system, as well as the implementation of interpretive front-of-pack nutritional labelling supported by public education to improve nutritional literacy. Interpretive food labelling has consistently been a highly contested area of food law and policy. For example, the European Food Industry reportedly spent 1 billion euro to ensure that front-of-pack traffic light labeling did not become a Europe-wide standard. Traffic light labels interpret the quality of the nutrition of food by means of highly visible red, amber and green symbols that correspond to the amount of saturated fat, salt and added sugar in the product.
The Commission’s recommendation that schools, child-care settings and children’s sports facilities should be required to create healthy food environments may also require legislation or regulations for successful implementation in some countries. The Commission has also specifically recommended that countries eliminate the sale or provision of unhealthy foods, such as sugar-sweetened beverages and energy-dense, nutrient-poor foods, in schools.
The Commission’s report will be presented to the members of the WHA in May 2016, where further actions may be taken to support the implementation of the Commission’s recommendations.
Those with an interest in obesity should also keep an eye out for the report of the Lancet Commission on Obesity, co-chaired by Professor Boyd Swinburn (University of Auckland), and Professor Bill Dietz (George Washington University). In this paper, Professors Swinburn and Dietz outline the work of their Commission.
Christopher Snowdon is a Research Fellow for the UK-based Institute of Economic Affairs, a think tank that receives tobacco funding. He is an opponent of plain tobacco packaging, keeper of the pure flame of libertarianism etc.
My sin – contained in a paper forming part of a symposium on public health regulation and the “nanny state”, was to reflect on a self-confessed “crime spree” Hitchens took in New York City in late 2003.
During the course of an autumn day, Hitchens broke as many of the city’s “petty ordinances” as he could, particularly its smoke-free laws.
At the time, Michael Bloomberg was in the second year of his first, 4-year term as NYC Mayor. He went on to serve 3 full terms, introducing tobacco control laws that saw the adult smoking rate fall by 28% between 2002 and 2012, and the youth smoking rate fall by 52% between 2001-2011 .
Which is a terrible result, if you’re a tobacco company, but a magnificent result for New Yorkers – with changed life trajectories and longer, healthier lives for hundreds of thousands of people.
You can read about Michael Bloomberg’s public health legacy here.
Apparently embittered at the constraints on his smoking, Hitch lashed out, reflecting on the “shriveled core of the tiny Bloombergian mind”, and ending with:
“Who knows what goes on in the tiny, constipated chambers of his mind? All we know for certain is that one of the world’s most broad-minded and open cities is now in the hands of a picknose control freak.”
The editor of Vanity Fair, Graydon Carter, who at the time was being serially fined by the NYC Health Department for flouting its smoke-free laws and smoking in his office, published the whole account.
Then, in June 2010, at the height of his powers, Hitchens announced he had cancer of the oesophagus. As one journalist wrote, “The celebrated drinker and smoker who once claimed that “booze and fags are happiness” had succumbed to a cancer most often associated with drinking and smoking.”
Like his hero Hitchens, Snowdon believes that smoke-free laws are anti-libertarian. The mind boggles at this point, given that globally, one in ten people who die from tobacco are non-smokers who are unintentionally harmed (poisoned) by smokers….
However, to my mind the more interesting theme that excites Snowdon is the question of whether Hitchens’ diagnosis challenged his libertarian convictions. Snowdon assumes that the rationale for discussing this issue was to concoct some sort of contrived, deathbed confession:
“Magnusson clearly thinks that Hitchens got his comeuppance when he died of cancer and wants to believe that he renounced his principles on his death bed.”
The record shows that Christopher Hitchens castigated those who promoted effective tobacco control, yet spoke frankly and publicly about his own cancer, acknowledging that it was probably caused by his smoking and drinking.
Hitchens made his choices, and talked about them freely. He made his private life a public matter.
So we have permission, I think, to talk about Hitchens – who I suspect would have approved of being the topic of conversation.
“I’ve come by this particular tumor honestly”, he told Anderson Cooper on CNN in August 2010. “If you smoke, which I did for many years very heavily with occasional interruption, and if you use alcohol, you make yourself a candidate for it in your sixties.” “I might as well say to anyone who might be watching – if you can hold it down on the smokes and the cocktails you may be well advised to do so”.
Cooper responded “That’s probably the subtlest anti-smoking message I’ve ever heard”.
“The other ones tend to be more strident”, Hitchens replied, “and for that reason, easy to ignore”.
“Even if this weren’t incredibly tasteless” Snowdon writes, “Magnusson could hardly have found a less fitting person to use as an example.”
Snowdon seems to think that the point of discussing Hitchens is to trip him up on his words, seek to make an object lesson out of him, or worse, to gloat.
But there are other reasons why Hitchens’ account of his illness is worth reflecting on.
Certainly, it was a compelling story. Statistics are easy to brush off: just ask a smoker. But stories are a little harder.
Here comes this libertarian prophet – as sure as any libertarian ever was about the infantilising effect of public health laws – suddenly forced to come face to face with his own premature (and probably preventable) death. Did he have conflicting feelings, second thoughts? It’s not an unfair question.
“In whatever kind of a ‘race’ life may be”, Hitchens wrote in 2010, “I have very abruptly become a finalist….In one way, I suppose, I have been ‘in denial’ for some time, knowingly burning the candle at both ends … .[F]or precisely that reason, I can’t see myself smiting my brow with shock or hear myself whining about how it’s all so unfair … . Instead, I am badly oppressed by a gnawing sense of waste. I had real plans for my next decade and felt I’d worked hard enough to earn it. Will I really not live to see my children married? To watch the World Trade Center rise again?”
Through his story, we catch a glimpse of the public interest that public health laws and policies are intended to protect.
The public interest in tobacco and alcohol control laws does not exist for the sake of some abstracted, disembodied “public”, but ultimately for the sake of all those individuals who might otherwise die prematurely, or just as frequently, as Simon Chapman writes, live long in distress and isolation due to the disintegrating impacts of their illness.
Bloomberg’s tobacco control laws were intended to help prevent the kind of death Hitchens died. To say that is not to gloat.
Consequences tend to be trivialised or absent when libertarians set out their plans for how the world ought to be.
The narrative we tend to get is the one written by the be-suited Hitchens in 2003, flying through Central Park with his feet off the bicycle pedals, witty, cancer-free, not the man 7 years later, who writes “The chest hair that was once the toast of two continents hasn’t yet wilted, but so much of it was shaved off for various hospital incisions that it’s a rather patchy affair. I feel upsettingly de-natured. If Penélope Cruz were one of my nurses, I wouldn’t even notice”.
How should public health advocates talk about consequences?
In the United States, gun enthusiasts have become so highly proficient at ignoring consequences that anyone who dares link the most recent gun-related massacre [insert dates & details] with that shocking, leftist, evil thing called “gun control” – is howled down for seeking to “politicise a personal tragedy“.
Plenty of compelling stories, it seems, but never a teachable moment.
But for the rest of us, prevention matters because people matter. Their needless suffering or death is relevant to how we evaluate the wisdom of government actions, laws and policies.
The nanny state conspiracy theorists overstate their case. Hitchens’ freedom to make choices about smoking, drinking, diet and lifestyle were his for the taking. No one stood in his way.
Hitchens had no Damascus conversion over tobacco, or anything else for that matter, but his public expressions of regret were no less powerful for their subtlety.
This is the view when you look out the front gates of the World Health Organisation’s regional headquarters in Manila.
A few blocks away, in the processed food aisles of the supermarket, parents are encouraged to purchase “nutrition power for kids”.
The Western Pacific Region, which includes Australia, is home to 138 million adults with diabetes, and includes a number of Pacific Island countries where more than one third of the population have diabetes, and around one half of the population are obese. [See separate blog post]
The consultation was co-chaired by Professor Stephen Colagiuri (Boden Institute of Obesity, Nutrition, Exercise & Eating Disorders), Professor Roger Magnusson (Sydney Law School), and Mr David Patterson (IDLO). The background paper and meeting report were written by the rapporteur for the consultation, Ms Jenny Kaldor, who is a PhD candidate at Sydney Law School.
The report illustrates the variety of legal issues that overweight, obesity and diabetes are causing for countries within the Western Pacific WHO region, as well as how law might be used to improve health outcomes. These include the problems of diabetes-related disability discrimination, discrimination in access to diabetes medications, and good practices in legislation to improve food environments and opportunities for physical activity, from across the region. The report discusses the opportunities for, and obstacles to, using law effectively, as well as the challenge of ensuring that trade agreements and trade laws do not work at cross-purposes to health policies on obesity and diabetes.
The meeting report highlights several important conclusions:
There is a strong need to build the evidence-base on legal interventions relating to obesity, diabetes and population diets. Case studies, feasibility studies, guidelines, summaries and other tools can assist countries to share their knowledge and experience with legal and regulatory interventions. Researchers and academics have an important role to play. Networks need to be built across the region to better facilitate information sharing.
Developing local expertise in public health law and in particular, law related to obesity, overweight and diabetes, is a priority.
In-depth technical advice is needed on promising interventions. These include a tax on sugar-sweetened beverages; restrictions on unhealthy marketing of food and beverages to children; requirements for interpretive, front-of-pack labelling; and legislation to create environments that facilitate and encourage physical activity.
Civil society has a vital role to play in the development, implementation and enforcement of innovative legal approaches to overweight, obesity and diabetes.
Addressing the interference of the food and drinks industries in policy development and implementation in countries across the region is a priority. Clear guidelines are needed to avoid conflicts of interest and to ensure that government interactions with the food industry are transparent and constructive, and do not jeopardise public health goals.
Law needs to be better integrated into the agenda of the World Health Organisation. Law is central to advancing the goals of WHO, and can enable countries to protect, respect and fulfil the right to health.