20% Sugar-Sweetened Drink Tax in India Would Slash Obesity

Becky McCall

January 10, 2014

Tax on sugar-sweetened beverages (SSB) at a rate of 20% could significantly mitigate rising obesity and type 2 diabetes among consumers in India, a new economic-epidemiologic study suggests.

In the study, published online January 7 in PLOS Medicine, the researchers estimate that according to the current rate of increase in SSB sales in India, 11.2 million cases of overweight/obesity and 400,000 cases of type 2 diabetes could be prevented between 2014 and 2023 if a sustained 20% taxation on SSBs was implemented.

Furthermore, if predicted SSB sales increases were factored into the model, estimated potential health benefits of 20% taxation would avert 15.8 million cases of overweight/obesity and 600,000 cases of incident type 2 diabetes over the same time period.

Study coauthor Shah Ebrahim, BMBC, FRCP, from the London School of Hygiene and Tropical Medicine, United Kingdom, said the finding that a 20% tax rate would be the most effective in reducing obesity and diabetes represents a "penny-per-ounce" tax, which has proven effective in reducing consumption in the United States.

"A tax at this level is predicted to reduce overall calorie intake and thereby reduce obesity and diabetes in statistical models. Lower tax rates would be less likely to be effective," he said.

Marketing Turns to Low- to Middle-Income Countries

Previously, SSB taxation has been proposed as a way to lower the risk of obesity and type 2 diabetes in high-income countries, but not in low- and middle-income nations.

In the current study, researchers based their model on consumers in India, a middle-income country, where SSB consumption and chronic disease is rising rapidly but where risk varies greatly between population subgroups and where people are likely to turn to other sugar-rich beverages — for example, fresh fruit juices — if SSBs are taxed.

SSB consumption in India has been rising at a rate of 10% each year since 1998. "This reflects the marketing strategies of manufacturers of SSBs toward low- and middle-income countries as consumption has declined in North America and Europe," remarked Dr. Ebrahim.

It is estimated that 101.2 million people in India will have diabetes by 2030, nearly double the current number.

"In urban and more affluent Indians, obesity and diabetes are becoming an increasing problem. Reducing consumption of SSBs might be a way of reducing these current trends," he told Medscape Medical News in an interview.

But Largest Effect Would Be in Rural Populations of Young Men

The study combined data on how price changes affect the demand for SSBs with historical data on SSB sales trends, body mass index (BMI), and new cases of diabetes. These findings were used to estimate the effect that a 20% SSB tax would have on caloric intake, the prevalence of obesity, and the incidence of diabetes among the various Indian subpopulations.

The largest effects of SSB taxation on obesity and diabetes would be seen in rural populations of young Indian men, the authors say.

"Effect sizes of the tax varied notably among different demographic groups... The largest relative declines in overweight and obesity prevalence were observed among young rural men, as this group with lower current BMI more easily maintained itself below the BMI threshold of 25 kg/m2 in scenarios with SSB taxation than without such taxation," they write.

SSB Taxes Worldwide and Other Obesity Interventions

Hungary, Finland, and France, as well as nearly half of the states in the United States, have introduced or increased taxes on SSBs, the researchers note.

"Taxes of around 20% do seem to reduce consumption of SSBs, but one issue is substitution of other calorific beverages that are not taxed," highlighted Dr. Ebrahim. "It is important to note that SSB taxes have the potential to raise funding for preventive health services and healthcare in general."

Also commenting on SSB taxes in a linked perspective piece, Tony Blakely, MBChB, from the department of public health, University of Otago, New Zealand, and colleagues discuss the real-world implications of this type of mathematical modeling study.

They note that, "in real-life settings, such as most states in the US, taxes on SSBs appear to be too small to achieve a measurable impact." Newly introduced SSB taxes, such as the ones in France and Hungary, "have not yet been evaluated for health impacts in published studies, though reductions in SSB consumption have been reported after such taxes."

In their discussion, the article's authors, led by Sanjay Basu, MD, from the Stanford Prevention Research Center, Stanford University, California, note that their new findings compare favorably with other population-level obesity interventions — for example, nutrition labels and consumer education studied previously.

These other interventions "typically result in less than 1% reductions in overweight and obesity and nonsignificant changes in diabetes rates; this implies a comparatively large population-level impact from SSB taxation."

They also note that, to date, the array of large-scale interventions to address increased obesity and diabetes being implemented in low- to middle- income countries has not so far led to sustained reductions in BMI.

"Sugar is the New Tobacco"

Dr. Blakely and colleagues also point out that "a feature of SSBs is how much they 'stand out' as an unnecessary health risk — they tend to have little or no nutritional value, leading to labels such as 'empty calories.' " They add that adequately addressing these future challenges would require different policies from today. "One potential policy is taxing foods (like SSBs) that produce costs to public-health systems and that are not required for nutritional needs."

Separately, in reports in British newspapers this week, sugar is being hailed as the new tobacco, with the formation of a new United States–United Kingdom campaign group called Action on Sugar that aims for food manufacturers to reduce sugar content by around 30%. A study by the new campaign group found high sugar levels in some of the least suspect foods, for example, savory and healthy options such as low- or zero-fat yogurts.

Dr. Ebrahim's research in India is funded by Wellcome Trust. Disclosures for the coauthors are listed in the article. Dr. Blakely is funded under the Burden of Disease Epidemiology, Equity and Cost Effectiveness Program, funded by the Health Research Council of New Zealand. He and his coauthors have reported no relevant financial relationships.

PLOS Med. Published online January 7, 2014. Article Perspective


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