tag:theconversation.com,2011:/us/topics/sugar-sweetened-beverages-35521/articlesSugar-sweetened beverages – The Conversation2022-10-27T19:26:41Ztag:theconversation.com,2011:article/1927422022-10-27T19:26:41Z2022-10-27T19:26:41ZHow taxing sugary drinks reinforces weight stigma<figure><img src="https://images.theconversation.com/files/491565/original/file-20221025-246-osvds4.jpg?ixlib=rb-1.1.0&rect=4%2C98%2C2972%2C2090&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Newfoundland and Labrador has implemented a tax of 20 cents per litre on sugary drinks.</span> <span class="attribution"><span class="source">(AP Photo/Jenny Kane)</span></span></figcaption></figure><iframe style="width: 100%; height: 100px; border: none; position: relative; z-index: 1;" allowtransparency="" allow="clipboard-read; clipboard-write" src="https://narrations.ad-auris.com/widget/the-conversation-canada/how-taxing-sugary-drinks-reinforces-weight-stigma" width="100%" height="400"></iframe>
<p>Newfoundland and Labrador made history in September as the first Canadian province to <a href="https://www.cbc.ca/news/canada/newfoundland-labrador/rethink-your-drink-campaign-1.6548570">implement a sugar-sweetened beverage tax</a>. Sugar-sweetened beverage taxes also exist outside of Canada, including in <a href="https://doi.org/10.1017/s1368980016003086">Mexico, Philadelphia, Penn. and the United Kingdom</a>. In Newfoundland and Labrador the tax amounts to <a href="https://www.gov.nl.ca/budget/2021/what-you-need-to-know/promoting-a-healthier-newfoundland-and-labrador">20 cents per litre</a> of sugar-sweetened beverage.</p>
<p>Sugar-sweetened beverage taxation is supported by many global and national health organizations, such as the <a href="https://www.who.int/europe/publications/i/item/WHO-EURO-2022-5721-45486-65112">World Health Organization</a>, <a href="https://www.diabetes.ca/advocacy---policies/our-policy-positions/sugar---diabetes">Diabetes Canada</a> and the <a href="https://www.heartandstroke.ca/-/media/pdf-files/canada/position-statement/liquidcandy-factsheet-en.ashx?la=en&hash=E21D8E5A8708FD82915931DEC2C768361D130CC7">Heart and Stroke Foundation</a>. Taxes are a popular public health policy because of associations between sugary beverage consumption and <a href="https://doi.org/10.2337/dc10-1079">Type 2 diabetes</a> and <a href="https://doi.org/10.3945/ajcn.113.058362">weight gain</a>. </p>
<p>Sugar-sweetened beverage taxes are excise taxes, or flat taxes, which also make them regressive taxes. This type of taxation has real potential to have <a href="https://theconversation.com/a-sin-tax-on-sugary-drinks-unfairly-targets-indigenous-communities-instead-of-improving-health-155108">harmful effects on equity</a> as lower-income populations will pay a higher proportion of their income through this tax. Previous critiques of sugar-sweetened beverage taxation also include the <a href="https://vocm.com/2022/09/06/opposition-fielding-questions-on-new-sugar-tax/">potential harm to small business</a> and First Nations communities.</p>
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Read more:
<a href="https://theconversation.com/a-sin-tax-on-sugary-drinks-unfairly-targets-indigenous-communities-instead-of-improving-health-155108">A sin tax on sugary drinks unfairly targets Indigenous communities instead of improving health</a>
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<h2>Weight stigma</h2>
<p>Notably absent from this list of harms is the potential of sugar-sweetened beverage taxation to create or exacerbate stigma, including weight stigma. Weight stigma in health policies has received global attention and there are <a href="https://doi.org/10.1038/s41591-020-0803-x">many calls to action</a> to end <a href="https://doi.org/10.1016/S2468-2667(19)30186-0">weight-stigmatizing policies</a>.</p>
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<img alt="Overweight parents walking outdoors with their child" src="https://images.theconversation.com/files/491963/original/file-20221026-21-c74v42.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/491963/original/file-20221026-21-c74v42.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=509&fit=crop&dpr=1 600w, https://images.theconversation.com/files/491963/original/file-20221026-21-c74v42.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=509&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/491963/original/file-20221026-21-c74v42.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=509&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/491963/original/file-20221026-21-c74v42.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=639&fit=crop&dpr=1 754w, https://images.theconversation.com/files/491963/original/file-20221026-21-c74v42.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=639&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/491963/original/file-20221026-21-c74v42.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=639&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Weight stigma includes stereotypes of laziness and stupidity, which are not supported by evidence.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
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<p>Stigma occurs, in part, when a label — such as “obesity” — is associated with negative stereotypes, <a href="https://doi.org/10.1146/annurev.soc.27.1.363">leading to discrimination and loss of status</a>. Weight stigma includes stereotypes of <a href="https://doi.org/10.1037//0278-6133.22.1.68">laziness and stupidity</a>. It can lead to <a href="https://doi.org/10.1038/oby.2008.636">discrimination in health-care and workplace settings</a>. </p>
<p>Weight stigma has negative effects on <a href="https://doi.org/10.1111/cob.12264">mental</a> and <a href="https://doi.org/10.1111/jan.13511">physical health</a>, including <a href="https://doi.org/10.1038/sj.ijo.0803105">health-care avoidance</a>, <a href="https://doi.org/10.1016/j.eatbeh.2020.101383">disordered eating</a>, <a href="https://doi.org/10.1186/s12889-021-10565-7">self exclusion from sport and exercise</a> and <a href="https://doi.org/10.1111/jan.13511">stress</a>. Contrary to what many people think, <a href="https://doi.org/10.2105%2FAJPH.2009.159491">stigma is not an effective strategy for weight loss</a>. </p>
<p>Even before Newfoundland and Labrador declared its intentions with sugar-sweetened beverage taxation, significant interest in Canada and globally led us to explore attitudes and acceptability of a tax in our province of Manitoba. We conducted an <a href="http://hdl.handle.net/1993/36863">interview-based study</a> with residents of many different locations, including a middle-to-upper class, liberal neighbourhood in the provincial capital, Winnipeg. </p>
<p>Our participants from this location were white, food secure and primarily highly educated. In our analysis, we specifically sought out instances of weight stigma in the interview transcripts. </p>
<h2>Stigmatizing messages</h2>
<p>We were interested in the language participants used because people absorb the messages they hear and the images they see. They may push back, change or repeat these messages. </p>
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<img alt="A hand pouring sugar out of a soda can" src="https://images.theconversation.com/files/491753/original/file-20221025-18-2ajurj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/491753/original/file-20221025-18-2ajurj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/491753/original/file-20221025-18-2ajurj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/491753/original/file-20221025-18-2ajurj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/491753/original/file-20221025-18-2ajurj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/491753/original/file-20221025-18-2ajurj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/491753/original/file-20221025-18-2ajurj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">People absorb the messages they hear and the images they see.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
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<p>In our analysis of the interviews, we found that many participants repeated weight-stigmatizing messages when discussing sugar-sweetened beverages. A more overt way this occurred was through the judgement of higher-weight individuals who were buying or consuming sugar-sweetened beverages. </p>
<p>Weight stigma also occurred in more covert or subtle ways. For example, some participants talked about their “disgust” and other negative emotions associated with their weight and others’ weight. Many participants also spoke of their “responsibility” to lose weight or to protect their children from becoming overweight by not consuming sugar-sweetened beverages and juice. </p>
<p>Weight dissatisfaction is <a href="https://doi.org/10.1155/2013/291371">harmful to one’s health</a>. Disgust also has justice implications for public health. Being disgusted by someone <a href="https://doi.org/10.1080/09581596.2014.885115">makes them seem less than human. It can contribute to blaming people</a> for conditions caused by multiple biological and social factors and can reinforce prejudice. </p>
<p>Participants also described higher weight individuals as a “burden” on the health-care system and that a tax on sugar-sweetened beverages would help offset these perceived costs. While this myth of obesity bankrupting the health-care system is pervasive, research suggests otherwise. In Manitoba, the health service usage for <a href="http://mchp-appserv.cpe.umanitoba.ca/reference/MCHP-Obesity_Report_WEB.pdf">individuals classified as overweight was found to be similar to those classified as normal weight</a>. Health-care usage was only marginally higher for individuals classified as obese. </p>
<h2>Policies and stigma</h2>
<p>Hearing these comments repeated in our interviews indicated to us how pervasive and widespread weight stigma was in participants’ attitudes toward sugar-sweetened beverage intake. Most importantly, these beliefs informed support or acceptability of sugar-sweetened beverage taxation. </p>
<p>This finding echoes <a href="https://doi.org/10.1016/j.socscimed.2013.09.023">existing research suggesting reciprocal processes</a> between stigma at inter- and intra-personal levels and policies. This indicates that interpersonal stigma may contribute to the creation of stigmatizing policies and that stigmatizing policies may in turn legitimize and worsen existing stigma. </p>
<p>Our specific research population was chosen because it was a good representation of the dominant social group in Canada — a white, middle-to-upper class, highly educated segment of the population. This dominant population is also likely to be similar to many policymakers, further supporting the perspectives of this group within Canadian policies. </p>
<p>Our findings demonstrate how weight-stigmatizing comments were used in support of sugar-sweetened beverage taxation. Weight stigma has <a href="https://theconversation.com/how-anti-fat-bias-in-health-care-endangers-lives-115888?">serious health consequences</a>. If Canadian <a href="https://www.canada.ca/en/public-health/corporate/publications/chief-public-health-officer-reports-state-public-health-canada/addressing-stigma-toward-more-inclusive-health-system.html">public health professionals</a> are committed to tackling weight stigma in health policies, we need to reconsider our support for this policy.</p><img src="https://counter.theconversation.com/content/192742/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Anne Katherine Anderson Waugh received Canada Graduate Scholarship-Masters funding from CIHR. She has also received funding from the University of Manitoba, Faculty of Graduate Studies. </span></em></p><p class="fine-print"><em><span>Andrea Bombak receives funding from New Brunswick Health Research Foundation, Social Sciences and Humanities Research Council, and Banting Discovery Award. </span></em></p><p class="fine-print"><em><span>Natalie Diane Riediger receives funding from the Canadian Institutes of Health Research, Canadian Celiac Association, Social Sciences and Humanities Research Council, University of Manitoba, Mitacs, and Universities Canada. </span></em></p><p class="fine-print"><em><span>Patty Thille currently receives funding from Research Manitoba. </span></em></p><p class="fine-print"><em><span>Kerstin Roger does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Taxation of sugar-sweetened drinks is not only inequitable, but also has the potential to create or perpetuate weight stigma, which has negative effects on mental and physical health.Anne Katherine Anderson Waugh, Research Coordinator, Department of Food and Human Nutritional Sciences, University of ManitobaAndrea Bombak, Associate professor, Department of Sociology, University of New BrunswickKerstin Roger, Full Professor, Department of Community Health Sciences, University of ManitobaNatalie Diane Riediger, Assistant Professor of Nutritional Epidemiology, University of ManitobaPatty Thille, Assistant Professor in Physical Therapy, University of ManitobaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1739922022-01-14T13:35:45Z2022-01-14T13:35:45ZSugar detox? Cutting carbs? A doctor explains why you should keep fruit on the menu<figure><img src="https://images.theconversation.com/files/440471/original/file-20220112-25-egh65j.jpg?ixlib=rb-1.1.0&rect=270%2C457%2C4193%2C2828&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Ripe berries and sugar crystals are both sweet, but one offers much more than just calories.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/sugar-sprinkling-down-onto-a-spoonful-of-strawberries-taken-news-photo/138203565">Chris George/PhotoPlus Magazine/Future via Getty Images</a></span></figcaption></figure><p>One of my patients – who had been struggling with obesity, uncontrolled diabetes and the cost of her medications – agreed in June 2019 to adopt a more whole-food plant-based diet.</p>
<p>Excited by the challenge, she did a remarkable job. She increased her fresh fruit and vegetable intake, stopped eating candy, cookies and cakes and cut down on foods from animal sources. Over six months, she lost 19 pounds and her HbA1c – a measure of her <a href="https://www.cdc.gov/diabetes/managing/managing-blood-sugar/a1c.html">average blood sugar</a> – dropped from 11.5% to 7.6%.</p>
<p>She was doing so well, I expected that her HbA1c would continue to drop and she would be one of our plant-based successes who had reversed diabetes.</p>
<p>Her three-month follow-up visit in March 2020 was canceled because of COVID-19 lockdowns. When I eventually saw her again in May 2021, she’d regained some of the weight and her HbA1c had climbed to 10.4%. She explained that her diabetes doctor and a diabetes nurse educator had told her that she was eating too much “sugar” on the plant-based diet.</p>
<p>She’d been advised to limit carbohydrates by cutting back on fruits and starchy vegetables and eating more fish and chicken. Sugar-free candy, cakes, cookies and artificial sweeteners were encouraged. In the face of conflicting medical advice, she fell back on conventional wisdom that “sugar” is bad and should be avoided whenever possible, especially if you have diabetes. </p>
<p>I’m a physician, board certified in preventive medicine with a <a href="https://lifestylemedicine.org/What-is-Lifestyle-Medicine">lifestyle medicine</a> clinic at Morehouse Healthcare in Atlanta. This emerging medical specialty focuses on helping patients make healthy lifestyle behavior modifications. Patients who adopt whole-food plant-based diets increase carbohydrate intake and often see reversal of chronic diseases including diabetes and hypertension. In my clinical experience, myths about “sugar” and carbohydrates are common among patients and health professionals. </p>
<h2>Fruit vs. sugar</h2>
<p>Your body runs on glucose. It is the simple sugar that cells use for energy.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/440472/original/file-20220112-19-1a13b8z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="molecular diagrams for glucose, fructose and galactose" src="https://images.theconversation.com/files/440472/original/file-20220112-19-1a13b8z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/440472/original/file-20220112-19-1a13b8z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=140&fit=crop&dpr=1 600w, https://images.theconversation.com/files/440472/original/file-20220112-19-1a13b8z.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=140&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/440472/original/file-20220112-19-1a13b8z.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=140&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/440472/original/file-20220112-19-1a13b8z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=176&fit=crop&dpr=1 754w, https://images.theconversation.com/files/440472/original/file-20220112-19-1a13b8z.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=176&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/440472/original/file-20220112-19-1a13b8z.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=176&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">These molecules are the three kinds of simple sugars, found in starches, fruit and milk.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/illustration/biology-diagram-show-structure-and-formation-royalty-free-illustration/1247905133">Trinset/ iStock via Getty Images Plus</a></span>
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<p>Glucose is a molecular building block of <a href="https://open.oregonstate.education/animalnutrition/chapter/chapter-3/">carbohydrates</a>, one of the three essential <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7468865/">macronutrients</a>. The other two are fat and protein. Starches are long, branching chains of glucose.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/440473/original/file-20220112-21-k525qd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="molecular diagram of chain of glucoses together" src="https://images.theconversation.com/files/440473/original/file-20220112-21-k525qd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/440473/original/file-20220112-21-k525qd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=78&fit=crop&dpr=1 600w, https://images.theconversation.com/files/440473/original/file-20220112-21-k525qd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=78&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/440473/original/file-20220112-21-k525qd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=78&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/440473/original/file-20220112-21-k525qd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=98&fit=crop&dpr=1 754w, https://images.theconversation.com/files/440473/original/file-20220112-21-k525qd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=98&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/440473/original/file-20220112-21-k525qd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=98&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Chains of simple sugar molecules linked together form starches and other carbohydrates.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/illustration/biology-diagram-show-structure-and-formation-royalty-free-illustration/1247905133">Trinset/iStock via Getty Images Plus</a></span>
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<p>Naturally occurring carbohydrates travel in nutrient-dense packages such as fruits, vegetables, whole grains, nuts and seeds. </p>
<p>Humans <a href="https://theconversation.com/a-taste-for-sweet-an-anthropologist-explains-the-evolutionary-origins-of-why-youre-programmed-to-love-sugar-173197">evolved to crave sweet tastes</a> to get the nutrients needed to survive. A daily supply of vitamins, minerals and fiber is needed because our bodies cannot make them. The best source of these substances for our ancient ancestors was sweet, ripe, delicious fruit. In addition, fruits contain <a href="https://fruitsandveggies.org/stories/what-are-phytochemicals/">phytonutrients</a> and <a href="https://www.nccih.nih.gov/health/antioxidants-in-depth">antioxidants</a>, chemicals produced only by plants. Phytonutrients such as <a href="https://doi.org/10.1093/fqsafe/fyx023">ellagic acid in strawberries</a> have cancer-fighting properties and promote heart health. </p>
<p>Refined sugars, on the other hand, are highly processed and stripped of all nutrients except calories. They’re a concentrated form of carbohydrates. The food industry produces refined sugars in many forms. The most common are sucrose crystals, which you’d recognize as table sugar, and high-fructose corn syrup, which is found in many processed foods and sweetened beverages. </p>
<p>If you continually satisfy your taste for sweet with foods that contain refined sugar – rather than the nutrient-rich fruits at the core of this craving passed on by evolution – you <a href="https://doi.org/10.1136/openhrt-2016-000469">may not get all the nutrients you need</a>. Over time, this deficit may create a vicious cycle of overeating that leads to obesity and obesity-related health problems. Women who eat the most fruit <a href="https://doi.org/10.3945/jn.114.199158">tend to have lower rates of obesity</a>.</p>
<h2>Sugar toxicity</h2>
<p>Refined sugars are not directly toxic to cells, but they can combine with proteins and fats in food and in the bloodstream to produce toxic substances such as <a href="https://doi.org/10.3945/an.115.008433">advanced glycation end products</a> (AGEs). High blood glucose levels may produce <a href="https://doi.org/10.1046/j.1432-1033.2002.03017.x">glycated low-density lipoproteins</a>. High levels of these and other glucose-related toxic substances are associated with an increased risk of a wide range of chronic health problems, including <a href="https://doi.org/10.2337/dc17-1740">cardiovascular disease and diabetes</a>.</p>
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<p>The disease most commonly associated with sugar is Type 2 diabetes. A surprising number of people, including health professionals, incorrectly believe that eating sugar causes Type 2 diabetes. This myth leads to a focus on lowering blood sugar and “counting carbs” while ignoring the real cause: progressive <a href="https://doi.org/10.2337/dcS13-2008">loss of pancreatic beta cell function</a>. At diagnosis, a patient may have lost between <a href="https://doi.org/10.1016/S2213-8587(20)30022-X">40% and 60%</a> of their beta cells, which are responsible for producing insulin. </p>
<p>Insulin is a hormone that controls how much glucose is in the bloodstream by blocking glucose production in the liver and driving it into fat and muscle cells. Loss of beta cell function means not enough insulin gets produced, resulting in the high blood glucose levels characteristic of Type 2 diabetes.</p>
<p>Beta cells have <a href="https://doi.org/10.1007/s00424-010-0862-9">low levels of antioxidants and are susceptible to attack</a> by metabolic and dietary oxidized free radicals and AGEs. Antioxidants in fruit can protect beta cells. Researchers have found that eating <a href="https://www.bmj.com/content/347/bmj.f5001">whole fruit decreases the risk of Type 2 diabetes</a>, with those who <a href="https://doi.org/10.1210/clinem/dgab335">eat the most fruit having the lowest risk</a>. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/440475/original/file-20220112-19-1uy72hg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="hands pouring sugar into a bowl with strawberries in the background" src="https://images.theconversation.com/files/440475/original/file-20220112-19-1uy72hg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/440475/original/file-20220112-19-1uy72hg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/440475/original/file-20220112-19-1uy72hg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/440475/original/file-20220112-19-1uy72hg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/440475/original/file-20220112-19-1uy72hg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/440475/original/file-20220112-19-1uy72hg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/440475/original/file-20220112-19-1uy72hg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">As you consume less refined sugar, you may notice more nuance in fruits’ flavors.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/christine-burns-rudalevige-pours-sugar-into-the-strawberry-news-photo/806582004">Brianna Soukup/Portland Portland Press Herald via Getty Images</a></span>
</figcaption>
</figure>
<h2>Detoxing from sugar</h2>
<p>People interested in losing weight and improving health often ask if they should do a “sugar detox.” In my opinion this is a waste of time, because it is not possible to eliminate sugar from the body. For instance, if you ate only baked chicken breasts, your liver would convert protein to glucose in a process called <a href="https://www.ncbi.nlm.nih.gov/books/NBK541119/">gluconeogenesis</a>.</p>
<p>Low-carb diets may lead to weight loss, but at the expense of health. Diets that significantly reduce carbohydrates are associated with <a href="https://doi.org/10.1186/1550-2783-7-24">nutrient deficiencies</a> and higher <a href="https://doi.org/10.1371/journal.pone.0055030">risk of death from any cause</a>. On low-carbohydrate <a href="https://www.ncbi.nlm.nih.gov/books/NBK499830/">ketogenic</a> diets the <a href="https://doi.org/10.3390/nu13020374">body will break down muscles</a> and turn their protein into glucose. The lack of fiber causes constipation.</p>
<p>Eliminating foods sweetened with refined sugar is a worthy goal. But don’t think of it as a “detox” – it should be a permanent lifestyle change. The safest way to go on a refined sugar “detox” is to increase your intake of nutrient-dense fruits and vegetables. Once you eliminate refined sugar, you’ll likely find that your taste buds become more sensitive to – and appreciative of – the natural sweetness of fruits.</p>
<p></p><hr> <p></p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/439239/original/file-20220103-48418-1p7tcpi.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/439239/original/file-20220103-48418-1p7tcpi.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/439239/original/file-20220103-48418-1p7tcpi.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/439239/original/file-20220103-48418-1p7tcpi.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/439239/original/file-20220103-48418-1p7tcpi.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/439239/original/file-20220103-48418-1p7tcpi.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/439239/original/file-20220103-48418-1p7tcpi.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption"></span>
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<p><em>This article is part of a series examining sugar’s effects on human health and culture. <a href="https://theconversation.com/us/topics/sugar-2022-114641">You can read the articles on theconversation.com.</a></em></p><img src="https://counter.theconversation.com/content/173992/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jennifer Rooke works for Morehouse School of Medicine. This is stated in the article.</span></em></p>Sugar gets a bad rap, but exactly which sugar is meant? Nutrient-dense sweet ripe fruits are a far cry from refined table sugar – and their differences can have big health implications.Jennifer Rooke, Assistant Professor of Community Health & Preventive Medicine, Morehouse School of MedicineLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1711882021-11-16T13:11:59Z2021-11-16T13:11:59ZCompanies are pushing sweetened drinks to children through advertising and misleading labels – and families are buying<figure><img src="https://images.theconversation.com/files/432039/original/file-20211115-25-kfn3p9.jpg?ixlib=rb-1.1.0&rect=63%2C31%2C2054%2C1378&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">There are dozens of options for children's drinks in most supermarkets. Choosing the healthy options is difficult.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/mother-and-daughter-shopping-in-supermarket-royalty-free-image/1210359370?adppopup=true"> ferrantraite/E+ via Getty Images</a></span></figcaption></figure><p>Walking down the drink aisle at any grocery store will take you past hundreds of drinks, from sodas to sports drinks. Children’s drink sections are filled with a vast array of products as well. Most parents want to buy what is healthy for their children, but with so many options in the drink aisle, it can be difficult to make the right choice – especially when drink companies make it hard to do so.</p>
<p>I am a researcher at the <a href="https://uconnruddcenter.org/">UConn Rudd Center for Food Policy and Health</a>, and <a href="https://uconnruddcenter.org/person/frances-fleming-milici/">I’ve studied how food is marketed to kids and parents</a> of young children for more than a decade. Companies <a href="http://sugarydrinkfacts.org/resources/FACTS2019.pdf">spend huge sums advertising</a> children’s drinks with added sweeteners. Despite the sweeteners, companies market these drinks as healthy choices for kids.</p>
<p>In a <a href="https://doi.org/10.1016/j.amepre.2021.06.013">recent study</a> I co-authored with colleagues at the Rudd Center, we examined advertising and purchasing trends of children’s drinks from 2006 to 2017. We found, not surprisingly, that ad spending drove people to buy the drinks being advertised. The problem is that companies spend tens of millions of dollars per year promoting sweetened children’s drinks. This study was one of the first to <a href="https://www.sciencedirect.com/science/article/pii/S0749379721004098">directly tie that ad spending to household purchases</a> of unhealthy beverages. In addition, we also found that households with lower incomes were more responsive to this advertising and purchased more sweetened children’s fruit drinks than households with higher incomes.</p>
<p>Decades of research has shown that drinking too many sugary drinks can <a href="https://doi.org/10.1542/peds.2019-0282">raise the risk of heart disease, high blood pressure, type 2 diabetes and tooth decay</a>. Advertising appears to increase companies’ profits, but not children’s health.</p>
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<iframe width="440" height="260" src="https://www.youtube.com/embed/C3krPh_fTUA?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Many drink commercials are aimed at children.</span></figcaption>
</figure>
<h2>Advertising and demographics</h2>
<p>The food and beverage industry spends nearly <a href="https://uconnruddcenter.org/research/food-marketing/">US$14 billion per year</a> advertising their products, and around 80% of the spending promotes highly processed foods. This includes “fruit drinks” – fruit-flavored beverages with not much juice, like SunnyD – and flavored waters like Capri Sun Roarin’ Waters. Both are marketed as being for children, but they contain ingredients <a href="https://healthydrinkshealthykids.org/app/uploads/2019/09/HER-HealthyBeverageTechnicalReport.pdf">health experts say kids should not consume</a>, including <a href="http://sugarydrinkfacts.org/resources/FACTS2019.pdf">added sugar, diet sweeteners or both</a>. </p>
<p>In 2018, <a href="http://sugarydrinkfacts.org/resources/FACTS2019.pdf">companies spent $21 million advertising</a> these sweetened drinks across all media in the U.S. They spent $18.5 million of that promoting sweetened children’s drinks through TV ads. This was far more than the $13.6 million companies spent on TV ads for unsweetened children’s drinks like 100% juices and juice and water blends.</p>
<p>Marketing sugary drinks directly to young kids is another tactic that companies use.</p>
<p>In 2018, children 2 to 5 years old saw <a href="http://sugarydrinkfacts.org/resources/FACTS2019.pdf">twice as many TV ads for sugary children’s drinks</a> than they did for unsweetened juice products. Some fruit drink brands also disproportionately targeted advertising to <a href="http://sugarydrinkfacts.org/resources/FACTS2019.pdf">Spanish-speaking households as well as Black children</a>. Even packaging is aimed at kids, with sweetened drinks featuring more <a href="http://sugarydrinkfacts.org/resources/FACTS2019.pdf">cartoons, brand characters and wacky names</a> compared to drinks without added sweeteners.</p>
<p>This advertising can undermine parents’ efforts to serve healthy drinks.</p>
<p>To measure the effect of this advertising, my colleagues and I looked at 12 years of monthly purchase data. We found that <a href="https://doi.org/10.1016/j.amepre.2021.06.013">people living in households with lower incomes</a> purchased significantly more sweetened fruit drinks and fewer unsweetened juices than people in households with higher income. People in non-Hispanic Black and Hispanic households also purchased more sweetened fruit drinks than non-Hispanic white households. This matches research that shows that communities of color and lower-income communities drink relatively <a href="https://doi.org/10.1186/s40608-017-0178-9">more sugary drinks than other groups</a>, which contributes to disparities in diet-related disease.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/432075/original/file-20211115-21-ok6jsj.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A graph showing large increases in price for unsweetened juices and flavored waters but only small increases for fruit drinks." src="https://images.theconversation.com/files/432075/original/file-20211115-21-ok6jsj.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/432075/original/file-20211115-21-ok6jsj.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=521&fit=crop&dpr=1 600w, https://images.theconversation.com/files/432075/original/file-20211115-21-ok6jsj.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=521&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/432075/original/file-20211115-21-ok6jsj.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=521&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/432075/original/file-20211115-21-ok6jsj.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=655&fit=crop&dpr=1 754w, https://images.theconversation.com/files/432075/original/file-20211115-21-ok6jsj.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=655&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/432075/original/file-20211115-21-ok6jsj.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=655&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Prices for all children’s drinks increased over the study period, but sweetened ‘fruit drinks’ like SunnyD saw by far the smallest price increase.</span>
<span class="attribution"><span class="source">Choi, Andreyeva, Fleming-Milici & Harris, 2021</span>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
</figcaption>
</figure>
<h2>Lower prices</h2>
<p>Advertising is one thing that drives consumption, but pricing strategies also add to demographic differences in purchases.</p>
<p>I’ve conducted focus groups with parents of young children, and they say they’d like to purchase 100% juice. But when these parents compare prices in the supermarket, they end up buying cheaper sweetened drinks instead of the healthier beverages they intended to buy.</p>
<p>The recent study shows that such price disparities are getting worse. Over the 12 years we covered, prices increased for all children’s drink types, but sweetened children’s fruit drinks increased by an average of just <a href="https://www.sciencedirect.com/science/article/pii/S0749379721004098">1 cent per ounce</a>, compared to the 4 cents-per-ounce increase of unsweetened juice products.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/432043/original/file-20211115-23-1pdrs24.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A closeup of three Vitamin Water labels showing health claims." src="https://images.theconversation.com/files/432043/original/file-20211115-23-1pdrs24.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/432043/original/file-20211115-23-1pdrs24.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=346&fit=crop&dpr=1 600w, https://images.theconversation.com/files/432043/original/file-20211115-23-1pdrs24.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=346&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/432043/original/file-20211115-23-1pdrs24.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=346&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/432043/original/file-20211115-23-1pdrs24.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=435&fit=crop&dpr=1 754w, https://images.theconversation.com/files/432043/original/file-20211115-23-1pdrs24.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=435&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/432043/original/file-20211115-23-1pdrs24.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=435&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Drinks like Vitaminwater are designed to look healthy despite large amounts of added sweeteners.</span>
<span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/EarnsCocaCola/68ef61041d8a4f9398040439a9e0385a/photo?Query=vitamin%20water&mediaType=photo&sortBy=&dateRange=Anytime&totalCount=56&currentItemNo=0">AP Photo/Stephan Savoia, File</a></span>
</figcaption>
</figure>
<h2>Misleading labels</h2>
<p>Another way companies try to push sweetened drinks is to use labels that make them appear healthier than they really are.</p>
<p>This happens in two main ways. First, sweetened drink labels often <a href="https://doi.org/10.1016/j.jand.2020.08.009">highlight nutrition-related claims</a> – like “Vitamin C” or “Less sugar,” for example. Second, these drinks often use <a href="https://doi.org/10.2105/AJPH.2020.305621">pictures of fruit or words with no regulatory definitions</a> – like “water” and “natural.” Taken together, these tactics mask ingredients such as added sugars and diet sweeteners and convey the idea that these drinks are healthy choices, which likely contribute to sales. </p>
<p>Brands also often offer both sweetened and unsweetened drinks with <a href="http://sugarydrinkfacts.org/resources/FACTS2019.pdf">nearly identical packaging and claims</a>, so it is easy to see why parents <a href="https://doi.org/10.1111/ijpo.12791">misperceive what is in these drinks</a>. I challenge any reader to head down a children’s drink aisle in the supermarket and successfully separate the healthier drinks from the less healthy ones. </p>
<p>[<em>Understand new developments in science, health and technology, each week.</em> <a href="https://theconversation.com/us/newsletters/science-editors-picks-71/?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=science-understand">Subscribe to The Conversation’s science newsletter</a>.]</p>
<h2>What to do?</h2>
<p>Between the marketing, pricing and labels, it’s no wonder kids are drinking more sugary drinks. Overall, our research found that purchases of sweetened flavored waters increased by 68% from 2006 to 2017. Today, households with young children purchase <a href="https://www.sciencedirect.com/science/article/pii/S0749379721004098">three times as many ounces of sweetened fruit drinks as unsweetened juice</a>.</p>
<p>Reducing the amount of sweetened drinks kids consume when they are young could go a long way in keeping them healthy for a lifetime. Better <a href="https://bbbprograms.org/programs/all-programs/cfbai">industry self-regulation of advertising</a> is one way to reduce this overconsumption, but the U.S. Food and Drug Administration could also get involved by <a href="https://doi.org/10.2105/AJPH.2020.305621">mandating clear and consistent disclosures</a> of added sugars and diet sweeteners, as well as juice percentages, on packaging. Reducing disproportionate targeted marketing of sugary drinks to communities of color would be a step in the right direction, too.</p>
<p>If you care about the health of children, the goal should be to make the healthy choice the easy choice. Unfortunately, our research seems to show a trend in the opposite direction.</p><img src="https://counter.theconversation.com/content/171188/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Fran Fleming-Milici receives funding from The Robert Wood Johnson Foundation. The views expressed here do not necessarily reflect the views of the Foundation.</span></em></p>A new study looked at advertising and purchase data for children’s drinks and suggests that ads and pricing strategies contribute to sweetened children’s drink purchases.Fran Fleming-Milici, Director of Marketing Initiatives, Rudd Center for Food Policy and Health, University of ConnecticutLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1703402021-11-03T19:24:27Z2021-11-03T19:24:27ZPublic acceptance of sin taxes on sugar or fat not dependent on evidence<figure><img src="https://images.theconversation.com/files/430021/original/file-20211103-17-fan43j.jpg?ixlib=rb-1.1.0&rect=87%2C52%2C2576%2C1882&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">British Columbia introduced a tax on sugar-sweetened beverages in April.</span> <span class="attribution"><span class="source">(AP Photo/Elaine Thompson) </span></span></figcaption></figure><iframe style="width: 100%; height: 175px; border: none; position: relative; z-index: 1;" allowtransparency="" src="https://narrations.ad-auris.com/widget/the-conversation-canada/public-acceptance-of-sin-taxes-on-sugar-or-fat-not-dependent-on-evidence" width="100%" height="400"></iframe>
<p>It’s easy to assume that public health measures, such as taxing unhealthy foods, are most successful when they are based on the best available evidence. However, <a href="https://doi.org/10.1353/pbm.0.0085">research suggests that evidence-based policy-making</a> doesn’t always <a href="https://doi.org/10.1111/padm.12655">dictate public response</a>. Researchers have also noted tensions between different types of evidence when establishing the legitimacy of a policy. </p>
<p>We study <a href="https://www.euro.who.int/en/health-topics/noncommunicable-diseases/obesity/news/news/2012/10/can-fiscal-policies-reduce-noncommunicable-diseases2">taxes placed on foods that are deemed unhealthy</a>, and find scientific evidence has not dominated the debates over the legitimacy of these measures. Instead, a food tax’s chances of survival are based on the ability of political interests to create a successful narrative surrounding the policy’s purpose. </p>
<p>We compare Denmark, which implemented and quickly repealed a tax on saturated fats in 2011-12, and Ireland, which implemented a sugar-sweetened beverage tax in 2018 that has remained in place. </p>
<h2>A tale of two taxes</h2>
<p>Our findings demonstrate how certain public health measures are made acceptable to the public. They tell us about the importance of narratives in the successful implementation of <a href="https://www.cbc.ca/news/canada/british-columbia/b-c-tax-changes-affecting-sugary-drinks-netflix-vaping-products-come-into-effect-april-1-1.5939189">similar food taxes in Canada</a>. They also raise questions about when similar narratives may be relevant to other types of public health measures.</p>
<p>What shaped public discussion and controversy over food taxes in Denmark and Ireland? In both these countries, the success or failure of the tax depends on two factors. First, <a href="https://doi.org/10.2307/2939044">how sympathetic</a> were potential “winners and losers” under the tax? Second, did <a href="https://doi.org/10.1177%2F0010414008325283">previous policies</a> provide a template for the public to understand and potentially accept the tax?</p>
<h2>A short-lived fat tax in Denmark</h2>
<p>Denmark’s “fat tax” has been <a href="https://www.washingtonpost.com/news/worldviews/wp/2012/11/11/what-the-world-can-learn-from-denmarks-failed-fat-tax/">described as a failure</a> due to its quick repeal. The 2.3 per cent tax on foods high in saturated fats was adopted with the goal of addressing Denmark’s <a href="https://www.oecd.org/els/health-systems/49105858.pdf">obesity rates and lifestyle-related illnesses</a>. However, it faced backlash after its introduction in October 2011 and was repealed in November 2012. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/430038/original/file-20211103-27-14ry3h6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A nutrition label for potato chips lying on top of potato chips" src="https://images.theconversation.com/files/430038/original/file-20211103-27-14ry3h6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/430038/original/file-20211103-27-14ry3h6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/430038/original/file-20211103-27-14ry3h6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/430038/original/file-20211103-27-14ry3h6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/430038/original/file-20211103-27-14ry3h6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/430038/original/file-20211103-27-14ry3h6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/430038/original/file-20211103-27-14ry3h6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Denmark’s 2.3 per cent tax on foods high in saturated fat faced backlash after its introduction in October 2011, and was repealed in November 2012.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>Denmark made the decision to adopt the fat tax based on a recommendation from expert committees studying the “obesity crisis.” Experts indicated that a tax on fats would potentially have positive effects on public health. They also raised concerns about the impact on <a href="https://atv.dk/sites/atv.dk/files/media/document/Rapport_ATV_Economic_nutrition_policy_tools_December_2007.pdf">low-income groups</a>. However, the limited expert support for this policy was not a central point of discussion in the media narratives.</p>
<p>Although Denmark has historically had <a href="https://www.skm.dk/skattetal/satser/satser-og-beloebsgraenser-i-lovgivningen/satser-og-beloebsgraenser-lovfortegnelse/">high taxes on certain food products</a> to generate revenue, these taxes were not framed as health policies. The public was unfamiliar with both the idea of a health tax, and paying more for the goods the fat tax targeted. This meant the media narrative focused on the tax’s negative impacts on consumers and industry rather than its health implications.</p>
<p>The fat tax primarily targeted the meat and dairy industries in Denmark. Industry stakeholders argued that the tax would severely <a href="http://dx.doi.org/10.1038/ejcn.2014.224">impact jobs</a>, low-income households or push consumers to buy groceries outside of Denmark. The media narrative pointed to the tax targeting dietary staples, which made common purchases more expensive.</p>
<p>The dominant media narrative was that the fat tax was harmful to Denmark’s economy, essential industries and families. There were experts that supported or critiqued the public health evidence behind the tax. However, the primary reasons for backlash against the tax were unrelated to scientific evidence. Instead, they were centred on the social and economic impacts on Danes. </p>
<h2>A stable sugar tax in Ireland</h2>
<p>Ireland’s sugar-sweetened drinks tax was implemented as an effort to address what experts identified as a <a href="https://www.rcpi.ie/news/publication/the-race-we-dont-want-to-win/">childhood obesity crisis</a>. It was backed by the Royal College of Physicians of Ireland and the Irish Heart Foundation. While the expert support for a health tax was stronger in Ireland than it was in Denmark, the construction of a sympathetic narrative in support of the sugar tax did not rest on the quality of evidence.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/430051/original/file-20211103-21-1bof04s.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A row of soda cans" src="https://images.theconversation.com/files/430051/original/file-20211103-21-1bof04s.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/430051/original/file-20211103-21-1bof04s.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=150&fit=crop&dpr=1 600w, https://images.theconversation.com/files/430051/original/file-20211103-21-1bof04s.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=150&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/430051/original/file-20211103-21-1bof04s.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=150&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/430051/original/file-20211103-21-1bof04s.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=189&fit=crop&dpr=1 754w, https://images.theconversation.com/files/430051/original/file-20211103-21-1bof04s.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=189&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/430051/original/file-20211103-21-1bof04s.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=189&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Ireland’s tax on sugar-sweetened beverages was a success.</span>
<span class="attribution"><span class="source">(Pixabay)</span></span>
</figcaption>
</figure>
<p>At that time, Coca-Cola was <a href="https://www.independent.ie/irish-news/health/coca-cola-ads-target-children-aged-seven-obesity-expert-30551144.html">under fire in the media for its advertising campaigns</a> said to be targeting children during an obesity epidemic. The Irish media compared this to tobacco companies, as both “<a href="https://www.irishtimes.com/news/ireland/irish-news/not-so-sweet-news-for-the-world-s-most-iconic-brand-1.1767109">industries sell a product that is associated with a major public health risk</a>” and sometimes advertise to vulnerable populations. Ireland had previously established a tobacco tax to curb consumption, so the concept of a health tax was familiar, but also sympathetic as it could benefit children. </p>
<p>The design of the tax was also familiar because of Ireland’s existing value-added tax (VAT) system, which is a tiered system that taxes goods at different rates. Sugary drinks were already taxed at the highest rate at 23 per cent, alongside foods that are typically considered unhealthy such as alcohol or sweets. Although the tax <a href="https://www.revenue.ie/en/companies-and-charities/excise-and-licences/sugar-sweetened-drinks-tax/index.aspx">increased the price of sugar-sweetened beverages further</a>, the public was already familiar with paying more for sugary drinks as non-essential goods.</p>
<p><a href="https://assets.gov.ie/8374/69cc40ce0f764c25b9091e28d2350c94.pdf">Beverage companies reacted similarly to stakeholders in Denmark</a>. However, due to the negative perception of the beverage industry, and the sympathetic frame of the childhood obesity crisis, industry opposition was not portrayed sympathetically in the media. </p>
<p>The childhood obesity crisis was the priority in media coverage, and those critiquing the policy did not have a strong narrative to support their arguments. Overall, the beverage tax maintained longevity due to the familiar and positively framed narrative supporting the policy.</p>
<h2>Canada’s first sugar tax</h2>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/430042/original/file-20211103-23-u36732.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Soda bottles on retail shelves" src="https://images.theconversation.com/files/430042/original/file-20211103-23-u36732.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/430042/original/file-20211103-23-u36732.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/430042/original/file-20211103-23-u36732.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/430042/original/file-20211103-23-u36732.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/430042/original/file-20211103-23-u36732.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/430042/original/file-20211103-23-u36732.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/430042/original/file-20211103-23-u36732.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The scientific basis for health taxes on foods may have minimal impact on the success of these policies.</span>
<span class="attribution"><span class="source">(AP Photo/Matt Rourke)</span></span>
</figcaption>
</figure>
<p>In April 2021, British Columbia became the first Canadian province to <a href="https://www.cbc.ca/news/canada/british-columbia/b-c-tax-changes-affecting-sugary-drinks-netflix-vaping-products-come-into-effect-april-1-1.5939189">introduce a tax on sugar-sweetened beverages</a>, a move that the government described as a response to <a href="https://www.cbc.ca/news/canada/british-columbia/why-b-c-is-now-taxing-sugary-carbonated-drinks-1.5467775">advice from health professionals</a>. If B.C.’s sugary drinks tax is successful, it could inspire other provinces to follow suit. While the tax could have health benefits, the scientific basis for health taxes on foods appears to have minimal impact on whether these policies are implemented and stay in place. </p>
<p>In the media narratives surrounding the European cases, scientific evidence was unimportant. Instead, a successful narrative defending the tax rested on two factors. First was the familiarity of the tax due to existing policies. Second was the framing of the target population: the tax was seen to help children in Ireland, and hurt essential industries in Denmark. </p>
<p>Understanding the role of narratives can inform how these policy choices are designed and justified, and provide lessons for policy-makers in Canadian provinces.</p><img src="https://counter.theconversation.com/content/170340/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Katherine Boothe receives funding from the Social Sciences and Humanities Research Council of Canada and the McMaster Future of Canada Project.</span></em></p><p class="fine-print"><em><span>Nicole Fiorillo does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>B.C. recently began taxing sugary drinks. Examples from Europe show the scientific basis for taxing unhealthy foods may have little impact on whether these taxes are adopted or remain in place.Nicole Fiorillo, Research Assistant, Political Science, McMaster UniversityKatherine Boothe, Associate Professor, Political Science, McMaster UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1562302021-04-20T12:33:27Z2021-04-20T12:33:27ZAfrican countries must consider legal challenges to sugar taxes before pursuing policies<figure><img src="https://images.theconversation.com/files/388523/original/file-20210309-23-1lnr2vd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Sales of unhealthy foods and beverages in sub-Saharan Africa are skyrocketing. This is leading to an <a href="https://www.sciencedirect.com/science/article/pii/S2211912420301206">increase in obesity related conditons</a> such as diabetes, hypertension and cardiovascular disease. </p>
<p>These diseases are projected to become <a href="https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(19)30370-5/fulltext">the leading cause of death in sub-Saharan Africa by 2030</a>, overtaking communicable diseases like HIV and TB. The economic cost of noncommunicable diseases is immense. They result in significant disability, and can be very expensive to treat. In South Africa, the medical cost of diabetes was <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7012049/">R2.7 billion in 2018</a>. </p>
<p>But noncommunicable diseases are preventable. The economic and societal impact can be mitigated if governments take decisive action to reduce the availability of harmful products such as unhealthy food, alcohol and tobacco.</p>
<p>Sugar-sweetened beverages are among the most harmful food products to consumers. This is because <a href="https://www.sciencedirect.com/science/article/abs/pii/S1043276012001191?casa_token=mkh_7xDvoqUAAAAA:54Fjyj7MH3XZAsDWKBdWzLq9GvUIYEkYtrL1ruRSrlcE5nf3Bqf_OfhP7aenNpumeNMGtHtNfZE">liquid sugar is especially toxic</a> and these drinks have no nutritional value.</p>
<p>One of the key ways to address the growing public health impact of sugary drinks is by introducing laws, policies and regulations. These measures could limit the availability of unhealthy products and make it easier to encourage people to eat healthy food. But they must be implemented as a combined effort. </p>
<p>There are a number of <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/obr.12580">proven interventions</a> to reduce the consumption of sugary drinks. These include limiting portion sizes, banning them from schools and checkout isles of supermarkets and taxing sugar-sweetened drinks. </p>
<p>But these measures have been challenged legally and by other means by the companies that produce and sell sugary drinks. </p>
<p>In 2012, then New York City mayor Michael Bloomberg introduced a regulation limiting the portion sizes of sugar-sweetened drinks sold around the city. The beverage industry and retailers <a href="https://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2015.302862">challenged this decision in court</a> and the policy was rolled back. South Africa’s efforts to introduce a tax on sugar-sweetened beverages <a href="https://globalizationandhealth.biomedcentral.com/articles/10.1186/s12992-020-00647-3">faced threats of legal challenges</a>. These were based on a range of technicalities from a lack of public participation to challenging the purpose of the tax. In this case, the objections only delayed the tax rather than stopping it. </p>
<p>Even if these law suits are unsuccessful, they can have a chilling effect on other actions to prevent noncommunicable diseases. Legal challenges to government efforts to address the availability of unhealthy food and drinks can seriously undermine public health.</p>
<p>This is why countries must carefully consider the legal feasibility of an intervention before deciding how to implement it. We <a href="https://www.tandfonline.com/doi/full/10.1080/16549716.2021.1884358">developed</a> a way in which countries can consider doing this. It involves an assessment of the potential legal barriers to, and as well as the facilitators of, the proposed intervention.</p>
<h2>The landscape</h2>
<p>Our <a href="https://www.tandfonline.com/doi/full/10.1080/16549716.2021.1884358">study</a> looked at the legal feasibility of introducing a tax on sugar-sweetened beverages in seven sub-Saharan African countries: Botswana, Kenya, Namibia, Rwanda, Tanzania, Uganda, and Zambia. We looked at four different types of sugary drinks taxes that had been introduced around the world and whether these could be introduced in each of these countries.</p>
<p>We assessed each country’s legal barriers and facilitators. These included their legal and taxation regimes. We also examined broader regional agreements and the infrastructure needed to implement such a tax. </p>
<p>We considered <a href="https://openknowledge.worldbank.org/bitstream/handle/10986/33969/Support-for-Sugary-Drinks-Taxes-Taxes-on-Sugar-Sweetened-Beverages-Summary-of-International-Evidence-and-Experiences.pdf?sequence=6&isAllowed=y">taxes implemented in various countries around the world</a> and chose to evaluate the four taxes adopted in Mexico, Colombia, the UK and South Africa under this study. The tax introduced in Mexico added a fixed amount on each litre of soft drink. The taxes in South Africa and the United Kingdom link the amount of tax payable to the sugar content of a drink. And Colombia decided to remove a value added tax exemption from sugar-sweetened beverages. With the exception of Colombia’s approach, most of these taxes are introduced as an excise tax.</p>
<p>Our research showed that all seven sub-Saharan African countries had existing excise tax legislation. And five countries already taxed sugar-sweetened beverages. However, these existing taxes worked to generate revenue for governments rather than improve public health as the taxes did not differentiate between sugary and non-sugary drinks. For example, Rwanda had a tax of 39% on carbonated beverages but sugary drinks remained a cheap beverage option.</p>
<p>In addition, countries have an obligation to introduce measures to protect the health of their citizens. These obligations are set out in treaties like the <a href="https://www.achpr.org/legalinstruments/detail?id=49">African Charter on Human and Peoples’ Rights</a> and domestic constitutions which contain rights to nutritious food or health. </p>
<p>Our research also showed that there were existing laws that could be used as a foundation to adopt a sugar-sweetened beverage tax to improve public health. For example, <a href="https://www.theguardian.com/global-development/2018/oct/26/tax-on-drinks-to-raise-funds-for-hiv-treatment-in-uganda">Uganda</a> had a dedicated HIV fund which was funded entirely by a 2% levy on drinks (including soft drinks and bottled water). Both <a href="https://www.kilimo.go.tz/index.php/en/stakeholders/view/sugar-board-of-tanzania-sbt">Tanzania</a> and <a href="http://kenyalaw.org/kl/fileadmin/pdfdownloads/bills/2019/TheSugarBill_2019.pdf">Kenya</a> had an agricultural levy on sugar, the proceeds of which were used to support sugar farmers. </p>
<p>The existence of supportive legal frameworks such as human rights could also be used to defend against potential challenges to a public health measure like this. </p>
<p>The introduction of taxes on sugar-sweetened beverages in <a href="https://www.cambridge.org/core/journals/public-health-nutrition/article/did-high-sugarsweetened-beverage-purchasers-respond-differently-to-the-excise-tax-on-sugarsweetened-beverages-in-mexico/37DBC66A6F1E19F74942888814EB1EA3">Mexico</a> and <a href="https://www.cambridge.org/core/journals/public-health-nutrition/article/abs/assessing-sugarsweetened-beverage-intakes-added-sugar-intakes-and-bmi-before-and-after-the-implementation-of-a-sugarsweetened-beverage-tax-in-south-africa/050AA9D1D8F9B12026C0F7836D1B4F09">South Africa</a> resulted in the reduced consumption of sugar and sugary drinks consumption within a year or two after the implementation of the tax. These reductions can lead to significant <a href="https://www.cambridge.org/core/journals/public-health-nutrition/article/assessing-sugarsweetened-beverage-intakes-added-sugar-intakes-and-bmi-before-and-after-the-implementation-of-a-sugarsweetened-beverage-tax-in-south-africa/050AA9D1D8F9B12026C0F7836D1B4F09">health benefits</a>, particularly in people who consume a lot of sugary drinks. In addition, these taxes are a particularly good intervention because they can help governments generate additional tax revenues. </p>
<h2>Looking ahead</h2>
<p>Our research shows that sugar-sweetened beverage taxation in the seven countries is legally feasible. Existing laws can provide a strong starting point for the introduction of a sugar-sweetened beverage tax. In addition, the adoption of such a tax is a way for governments to meet their human rights obligations without having to worry about legal challenges undermining the intervention.</p>
<p>Legal feasibility and the health impact of these interventions are only one part in the complex political economy of adopting noncommunicable disease prevention interventions. Research has shown that <a href="https://www.tandfonline.com/doi/abs/10.1080/23288604.2019.1669122">the political environment</a> and <a href="https://globalizationandhealth.biomedcentral.com/articles/10.1186/s12992-020-00647-3">industry pushback</a> against measures like sugar taxation are also important hurdles that need to be overcome. </p>
<p>Governments must take urgent action to prevent noncommunicable diseases from becoming an uncontrollable epidemic in sub-Saharan Africa. Sugar-sweetened beverage taxation offers a potential solution.</p><img src="https://counter.theconversation.com/content/156230/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Safura Abdool Karim is supported by the South African Medical Research Council Centre for Health Economics and Decision Science - PRICELESS SA. The research referenced in this article was supported by the International Development Research Centre, Canada.</span></em></p><p class="fine-print"><em><span>Karen Hofman is supported by the South African Medical Research Council Centre for Health Economics and Decision Science - PRICELESS SA. The research referenced in this article was supported by the International Development Research Centre, Canada.</span></em></p>Governments must take urgent action to prevent noncommunicable diseases from becoming an uncontrollable epidemic in sub-Saharan Africa. Sugar-sweetened beverage taxation offers a potential solution.Safura Abdool Karim, Senior researcher, University of the WitwatersrandKaren Hofman, Professor and Programme Director, SA MRC Centre for Health Economics and Decision Science - PRICELESS SA (Priority Cost Effective Lessons in Systems Strengthening South Africa), University of the WitwatersrandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1563162021-04-20T12:27:18Z2021-04-20T12:27:18ZZambia must find a way to balance the economy and public health in tax policy<figure><img src="https://images.theconversation.com/files/394740/original/file-20210413-17-9xp7jr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>The burden of noncommunicable diseases is <a href="https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(19)30374-2/fulltext">growing rapidly</a> across sub-Saharan Africa. The conditions, which include obesity and diabetes, are now <a href="https://www.who.int/nmh/countries/2018/zmb_en.pdf">leading causes</a> of premature deaths. In Zambia, noncommunicable diseases account for <a href="https://www.who.int/nmh/countries/2018/zmb_en.pdf">29% of all deaths</a>.</p>
<p>The consumption of <a href="https://www.sciencedirect.com/science/article/abs/pii/S0140673612620893">unhealthy commodities</a> – tobacco, alcohol and ultra-processed foods high in sugar, salt and fats – is a major risk factor for these conditions. </p>
<p>To regulate the availability of unhealthy commodities, the World Health Organisation (WHO) recommends cost-effective, evidence-based interventions. One such measure is a <a href="https://www.who.int/dietphysicalactivity/publications/fiscal-policies-diet-prevention/en/">tax on sugar-sweetened beverages</a>. Sweetened beverages are associated with a number of <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/obr.12868">health complications</a>. These include an increased risk of <a href="https://www.bmj.com/content/351/bmj.h3576">type 2 diabetes</a>, <a href="https://pubmed.ncbi.nlm.nih.gov/26869455/">cardiovascular diseases</a> and other obesity‐related diseases.</p>
<p>The aim of such a tax is to discourage people from buying these drinks. </p>
<p>Zambia is one of the African countries that has acted to regulate the environment for products linked to obesity. In January 2019 the country introduced an excise tax on all non-alcoholic beverages except water. A <a href="https://extranet.who.int/nutrition/gina/sites/default/filesstore/ZMB%202018%20Customs%20and%20Excise%20%28amendment%29%20%20Act%20No.%2019%20of%202018.pdf">tax rate</a> of K0.30 (US$ 0.02) per litre was levied. This 3% tax is well below the <a href="https://gh.bmj.com/content/bmjgh/5/4/e001968.full.pdf">recommended rate</a> of 20% required to reduce noncommunicable disease risk factors like obesity. Because of the low rate, health sector stakeholders are suggesting that the tax no longer focuses on public health. Instead, it’s a general source of government revenue. </p>
<p>In our recent <a href="https://www.tandfonline.com/doi/full/10.1080/16549716.2021.1872172">study,</a> my colleagues and I looked for opportunities to strengthen this tax policy in Zambia. Our focus was on sugar-sweetened beverage taxation. We reviewed policy documents and spoke to nutrition advocates, industry representatives and policymakers. We wanted to understand the context in which policies about nutrition-related diseases are developed. We also wanted to explore the potential use of revenue from tax on sugary drinks to support improved nutrition.</p>
<p>Our findings showed tension between the government’s economic and public health priorities. The government has <a href="https://health-policy-systems.biomedcentral.com/articles/10.1186/s12961-017-0195-7">intentions of regulating</a> production of harmful food products like sugar-sweetened beverages. But it also <a href="https://www.mcti.gov.zm/?page_id=5176">commits to growing the economy</a> by investment in the manufacturing sector, which includes the food and beverage sub-sector. </p>
<p>This has prevented stronger fiscal measures to address noncommunicable diseases related to nutrition. But we believe the tension need not hurt the public health objectives. There are opportunities to strengthen existing taxation of sugary drinks by ensuring policies take local economic context into account.</p>
<h2>Our research</h2>
<p>The policy <a href="https://extranet.who.int/ncdccs/Data/ZMB_B3_NCDs%20Strategic%20plan.pdf">documents</a> we <a href="https://www.mndp.gov.zm/wp-content/uploads/2018/05/7NDP.pdf">reviewed</a> and stakeholder interviews we conducted recognised the increasing problem of noncommunicable diseases in Zambia. </p>
<p>The diseases were linked to lifestyle factors such as physical inactivity and unhealthy diet. But none of the policies we reviewed identified sugary beverages as a driver of noncommunicable diseases in Zambia. </p>
<p>Our interviews also highlighted existing misperceptions. The people we interviewed linked affluence to sugary drinks consumption. They believed wealthier populations were more affected by nutrition-related diseases. But <a href="https://bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-9-465">research suggests</a> it’s poorer populations who tend to consume more unhealthy food. Unhealthy foods, including processed foods high in salt, fat and sugar, are cheaper than healthier food options but have attracted high status. </p>
<p>Nutrition advocates and government representatives suggested that the lack of diversity in people’s diets could be a contributor to the rise of noncommunicable diseases. Maize porridge – <em>nshima</em> – is a staple in the country and is consumed several times a day. But there’s a lack of evidence in this regard. </p>
<p>Policymakers felt the government was well prepared to address the health problem. They pointed to policies such as the strategic plan for nutrition-related noncommunicable diseases and related <a href="https://extranet.who.int/ncdccs/Data/ZMB_B3_NCDs%20Strategic%20plan.pdf">risk factors</a> as an example. The <a href="https://www.lusakatimes.com/2019/02/02/exercise-is-best-health-practice-president-lungu/">president’s active engagement</a> in promoting healthy lifestyles in mainstream media was seen as good leadership. </p>
<p>In contrast, respondents representing civil society felt that the current leadership and policies were insufficient. Marketing of unhealthy food products remained unregulated and nutrition programmes were poorly funded. They also felt the sugar-sweetened beverage tax was inadequate to curb consumption and hence noncommunicable diseases. </p>
<p>The sugary drinks tax in Zambia was initiated and championed by the Ministry of Health. Initially, a tax rate of 20% was proposed. But this met strong pushback from the government’s economic sector and industry stakeholders. They argued this would contribute to a high cost of doing business. Industry <a href="http://zam.co.zm/download/zam-submission-proposed-regulatory-reform-to-improve-nutrition/">attempted</a> to discredit evidence supporting the tax. Some suggested that the Zambian government was bowing to international pressure without considering the implication of the tax in the domestic context. Such strong lobbying against the tax likely contributed to the low rate of 3% that was eventually adopted.</p>
<p>Respondents suggested that revenues from the tax should finance nutrition and noncommunicable disease prevention programmes. These would include health promotion and education, regulation of the marketing of unhealthy foods, improved food labelling, and incentives for production of healthy foods. </p>
<p>These suggestions reflected a perception among all respondents that the population was largely unaware of causes, prevention and impact of nutrition related noncommunicable diseases. Therefore, raising awareness should be an immediate priority for Zambia.</p>
<h2>Way forward</h2>
<p>Our findings show that there is an opportunity to strengthen policies addressing noncommunicable diseases in African countries through measures like sugar-sweetened beverage taxes. But policy measures should be contextualised to the needs of the country. The priority of most African governments is economic growth. This is evident in policies that encourage growth of industries that produce unhealthy commodities. This context should not be ignored as it bears on the success of policy measures that protect population health. </p>
<p>A differential tax that distinguishes between international and local producers and manufacturers may be a feasible starting point to balance economic interest with public health objectives.</p>
<p>Taxation could also support public health by providing subsidies for fruit and vegetables, or the provision of safe drinking water. To achieve this, the revenues from the tax could be earmarked for health promotion.</p>
<p>Health problems have their origins and consequently solutions outside the health sector. This is why consultation must expand beyond the health sector during the development of policies addressing noncommunicable diseases. </p>
<p>Such consultation will go a long way to improve policy coherence between the health and economic sectors of governments. Policy measures should be contextualised to strike a balance between public health and the economic needs of countries.</p><img src="https://counter.theconversation.com/content/156316/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Mulenga Mary Mukanu, received support for this work from International Development Research Centre, Ottawa
Canada under grant number 108648-001. </span></em></p>Tension between the government’s economic and public health priorities is preventing stronger fiscal measures to address nutrition-related noncommunicable diseases.Mulenga Mary Mukanu,, PhD Candidates, University of the Western CapeLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1579082021-04-20T08:08:01Z2021-04-20T08:08:01ZKenya doesn’t have a stand-alone tax on sugary drinks: we set out to find out why<figure><img src="https://images.theconversation.com/files/395266/original/file-20210415-20-r25nse.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The consumption of a lot of soft drinks is linked to increased obesity. </span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Kenya is <a href="https://www.health.go.ke/wp-content/uploads/2016/04/Steps-Report-NCD-2015.pdf">experiencing a rise</a> in obesity. Overweight and obesity among women increased from 25% in 2008 to 33% in 2014. An estimated one in four Kenyan urban children are <a href="https://www.dhsprogram.com/pubs/pdf/sr227/sr227.pdf">overweight or obese</a>. At the same time there has been a rise in associated <a href="https://globalnutritionreport.org/resources/nutrition-profiles/?country-search=kenya">noncommunicable diseases</a>. These include diabetes, cardiovascular diseases and cancer. Noncommunicable diseases now account for over <a href="https://www.health.go.ke/wp-content/uploads/2016/04/Steps-Report-NCD-2015.pdf">50% of hospital admissions</a> in the country.</p>
<p>Globally, the rise in noncommunicable diseases has been attributed to the growing consumption of unhealthy foods such as sugar-sweetened beverages. Between 2018 and 2019 Kenya registered a 30% spike in <a href="https://apps.fas.usda.gov/newgainapi/api/report/downloadreportbyfilename?filename=Sugar%20Annual_Nairobi_Kenya_4-12-2018.pdf">sugar production</a> and an <a href="http://www.parliament.go.ke/sites/default/files/2019-08/Report%20on%20the%20Crisis%20Facing%20the%20Sugar%20Industry%20in%20Kenya%20%28%20Annexures%29.pdf">increase</a> in sugar consumption from the growth of retail, industrial and food service sectors. </p>
<p>To control the rising burden of obesity and noncommunicable diseases the World Health Organisation (WHO) <a href="https://www.who.int/dietphysicalactivity/publications/fiscal-policies-diet-prevention/en/">recommends</a> a tax on sugar-sweetened beverages. It views such taxes as a population-level, cost-effective measure to discourage consumption of sugar-sweetened beverages. </p>
<p>The approach has been widely used in several countries including South Africa. However, to date, Kenya has no standalone sugar-sweetened beverage tax policy.</p>
<p>We undertook <a href="https://www.tandfonline.com/doi/full/10.1080/16549716.2021.1902659">research</a> into the possibility of implementing a sugar-sweetened beverage tax in Kenya. </p>
<p>The study entailed a desk review of existing evidence on noncommunicable diseases and sugar-sweetened beverages. We also conducted interviews with a wide range of experts to explore the policy and political context as well as the enablers of and barriers to such a policy.</p>
<p>We identified a number of barriers to adopting a tax on sugary drinks in Kenya. These included limited evidence on sugar-sweetened beverages as a risk factor for noncommunicable diseases in Kenya. We also found industry interference in the development of sugar-sweetened beverage taxation policy. </p>
<p>But we also found that existing policies provided an opportunity to pursue a sugar tax in the country. These include the <a href="http://publications.universalhealth2030.org/uploads/kenya_health_policy_2014_to_2030.pdf">Kenya Health Policy</a> and the <a href="https://www.who.int/nmh/ncd-task-force/kenya-strategy-ncds-2015-2020.pdf?ua=1">National Strategy for Control and Prevention of Noncommunicable diseases</a>. </p>
<h2>Barriers</h2>
<p>A number of factors accounted for the fact that Kenya hasn’t pursued a tax on sugar-sweetened beverages.</p>
<p>The first was a dearth of up-to-date publicly available information on sugary drinks sales and consumption in Kenya. Data are essential to guide the decisions and process of development and adoption of a stand alone sugar-sweetened beverage tax. </p>
<p>Interviewees also cited lack of information in the general population about sugar-sweetened beverages and how they affect health. They attested to the fact that tobacco and alcohol are widely recognised risk factors for noncommunicable diseases. Not so with sugar-sweetened beverages.</p>
<blockquote>
<p>An important barrier when we are dealing with sugar-sweetened beverages is the fact that the public does not appreciate that this is a problem. What do respectable old men and women in the village, church elders, take when they go for a meeting? It is tea, Coca-Cola, Sprite, Fanta. I think it presents a subtle challenge that we don’t have when we are dealing with tobacco or alcohol. Nobody argues about the adverse consequences of tobacco or of alcohol.</p>
</blockquote>
<p>A second barrier we identified was that government ministries held different and sometimes opposing interests. </p>
<p>For instance, the ministry of health was interested in improving health and discouraging the trade, production and marketing of sugary drinks. But the ministry of industry, trade and cooperatives promoted the sugar and food processing industries as major revenue for government. </p>
<p>Our key informants felt that these opposing priorities might get in the way of a sugar-sweetened beverage taxation policy being developed. </p>
<p>A third factor we identified was industry lobbying against sweet drinks taxation. The sugar-sweetened beverage companies were described by key informants as having major influence over government decision making. This was because of the power they wielded in terms of their operations, and their contribution to the government revenues. They also use industry alliances and formations to fight sugar-sweetened beverage taxes, which may overwhelm an under-resourced government like Kenya’s. </p>
<p>As one interviewee put it: </p>
<blockquote>
<p>… unfortunately, there’s a lot of industry interference with policy (on sugary drinks). This is a big industry; very big in terms of capital and also in terms of influence. They pay a lot of tax to government and they have a lot of leverage … An industry like that of course has a lot of policy interference because they have big money they can compete with us.</p>
</blockquote>
<p>Kenya does charge an excise tax on all soft drinks of 10 Kenya shillings (0.10 USD) per litre. This includes sugar-sweetened beverages. And in <a href="http://kenyalaw.org/kl/fileadmin/pdfdownloads/bills/2018/FinanceBill__2018.pdf">2018</a> an excise tax of 20 shillings (0.20 USD) per kilogram was imposed on sugar confectionery and chocolate. </p>
<p>But these taxes were introduced as a revenue generation strategy, not as a means to manage noncommunicable diseases. They are likely to have only a minimal impact on the consumption of sugary drinks.</p>
<h2>Going forward</h2>
<p>We made a number of recommendations on how a sugar-sweetened beverage tax could be developed and implemented in Kenya.</p>
<p>First, public and policymaker education is critical to challenge the prevailing attitudes to sugary drinks.</p>
<p>Second, strategies to develop industrial growth should be critically examined to understand how they could undermine the government’s commitment to addressing noncommunicable diseases. This will require wide stakeholder engagement beyond the ministry of health in policy development.</p>
<p>Third, civil society needs to be involved in sustained advocacy to ensure that Kenyans understand the issues at hand.</p>
<p>And more research evidence is needed to support an explicit sugar-sweetened beverage taxation policy. Kenya also needs to gather local and regional or international evidence to inform and guide its decisions in the development and adoption of a standalone tax on sugary drinks.</p><img src="https://counter.theconversation.com/content/157908/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>This work was carried out with support from the International Development Research Centre (IDRC),Ottawa Canada (grant number 108648-001)</span></em></p><p class="fine-print"><em><span>Gershim Asiki does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Between 2018 and 2019 Kenya registered a 30% spike in sugar production and an increase in sugar consumption.Milka Wanjohi, Research officer, African Population and Health Research CenterGershim Asiki, Research Scientist, African Population and Health Research CenterLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1583202021-04-09T12:19:09Z2021-04-09T12:19:09ZNew research shows South Africa’s levy on sugar-sweetened drinks is having an impact<figure><img src="https://images.theconversation.com/files/393983/original/file-20210408-19-1e44z8a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Photo by Peter Kovalev\TASS via Getty Images</span></span></figcaption></figure><p>Three years ago South Africa introduced Africa’s <a href="https://www.diabetessa.org.za/sugar-tax-an-update-where-are-we-at-currently/#:%7E:text=South%20Africa%20was%20the%20first,of%20granulated%20sugar%20per%20100ml.">first major tax on sugar-sweetened beverages</a> based on grams of sugar. The tax now stands at about 11% of the price per litre. </p>
<p>We assessed the impact in recently published <a href="https://www.thelancet.com/journals/lanplh/article/PIIS2542-5196(20)30304-1/fulltext">research</a>. We found that the health promotion levy coincided with large reductions in purchases of taxable beverages, in terms of both volume and sugar quantities. We didn’t find significant changes for non-taxable beverages. </p>
<p>This isn’t the first research to show positive outcomes from the levy. A national <a href="https://www.sciencedirect.com/science/article/abs/pii/S0277953619304599">study</a> one year after it was introduced found households in urban areas halved the volume of sugary beverages they bought, cutting their sugar intake by nearly a third. Similar results were found regionally in <a href="https://www.cambridge.org/core/journals/public-health-nutrition/article/abs/assessing-sugarsweetened-beverage-intakes-added-sugar-intakes-and-bmi-before-and-after-the-implementation-of-a-sugarsweetened-beverage-tax-in-south-africa/050AA9D1D8F9B12026C0F7836D1B4F09">Soweto</a> in Gauteng.</p>
<p>The new research is the first evaluate this particular tax design. At a national level, we measured changes in household purchases of taxable and non-taxable beverages in terms of volume, sugar and calories. We also assessed changes in the purchasing behaviour of households stratified by household socioeconomic status. We assessed changes between the period before the levy to after its announcement and through the first year of its implementation period. </p>
<p>Research <a href="https://pubmed.ncbi.nlm.nih.gov/30882235/">shows</a> that excess sugar, particularly in <a href="https://pubmed.ncbi.nlm.nih.gov/31398911/">liquid form</a>, is a major cause of obesity and is a risk factor for diseases like type 2 diabetes, hypertension, heart disease, many common cancers and tooth decay. Recognising this danger, the World Health Organisation (<a href="https://www.who.int/news/item/04-03-2015-who-calls-on-countries-to-reduce-sugars-intake-among-adults-and-children">WHO</a>) has recommended that individuals should consume no more than 10% of total calories from added sugar, and preferably less than 5%.</p>
<p>Carbonated sugary drinks play a major role in making these numbers hard to attain. A <a href="https://heala.org/wp-content/uploads/2021/02/HEALA-Fact-sheet-Evidence-to-support-increasing-South-Africas-Health-Promotion-Levy-to-20percent-in-2021.pdf">250ml cooldrink contains upwards of 26g of sugar</a> – more than half the daily recommended limit.</p>
<p>Sub-Saharan Africa faces a tidal wave of diet-related noncommunicable diseases, with rapidly rising intake of <a href="https://pubmed.ncbi.nlm.nih.gov/23488503/">sugar-sweetened beverages</a> and other <a href="https://pubmed.ncbi.nlm.nih.gov/24102801/">ultra-processed foods</a>. South Africa, in particular, has <a href="https://pubmed.ncbi.nlm.nih.gov/31537368/">a heavy burden</a> of these noncommunicable diseases. </p>
<p>While other countries in sub-Saharan Africa have levied sugar-sweetened beverage taxes, South Africa is the first country in the region to evaluate such a policy.</p>
<p>Our results clearly show positive changes that could offer useful public health gains across the region. The reductions in sugar from taxable beverage purchases suggest a potential role for sugar-based taxes more broadly. </p>
<h2>To tax, or not to tax</h2>
<p>More than 50 jurisdictions across the globe have used taxes to curb the consumption of sugar-sweetened beverages. </p>
<p>For example, in 2014, Mexico introduced a tax of one peso per litre on beverages containing added sugar. Research has <a href="https://www.bmj.com/content/352/bmj.h6704">shown that</a> it resulted in a 6% reduction in purchased volume relative to pre-tax trends over the first year of the tax, and a 7.6% reduction over the first two years of the tax. </p>
<p>Tax policies in other countries such as the <a href="https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-019-1477-4">UK</a> and several subnational jurisdictions in the <a href="https://pubmed.ncbi.nlm.nih.gov/27552267/">US</a> have also resulted in statistically significant reductions in purchases of sugar-sweetened beverages.</p>
<p>South Africa has led the continent firstly by introducing the tax, and secondly by making the levy about <a href="https://pubmed.ncbi.nlm.nih.gov/31472286/">sugar content rather than volume</a>. </p>
<p>Given that sugar-sweetened drinks contain variations in sugar levels, taxing them according to their sugar content is a more precise way of targeting the source of these products’ harm. It also gives beverage <a href="http://www.treasury.gov.za/public%20comments/Sugar%20sweetened%20beverages/POLICY%20PAPER%20AND%20PROPOSALS%20ON%20THE%20TAXATION%20OF%20SUGAR%20SWEETENED%20BEVERAGES-8%20JULY%202016.pdf">manufacturers</a> an incentive to reduce the sugar content of their products. This strategy formed the basis of South Africa’s 2018 tax policy.</p>
<h2>Unfinished business</h2>
<p>South Africa’s levy showed that in 2018 the country was prepared to put the health of the public in first place.</p>
<p>But the government has failed to capitalise on these early gains, despite the <a href="http://www.treasury.gov.za/public%20comments/Sugar%20sweetened%20beverages/POLICY%20PAPER%20AND%20PROPOSALS%20ON%20THE%20TAXATION%20OF%20SUGAR%20SWEETENED%20BEVERAGES-8%20JULY%202016.pdf#page=18">evidence that’s been presented</a> to it about the impact of the levy on consumption patterns. An example of this is that it has not raised the rate at which the tax is imposed. </p>
<p>Health experts had been lobbying for an increase to 20% – the levy recommended by the WHO. No country in the world has reached this benchmark. Nations are only getting part of the benefits in terms of preventing obesity. This matters to the future health of children, in particular. South Africa has seen a rise in <a href="https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-019-1449-8">childhood obesity rates since 1994</a>. And some forecasts suggest that the country will have the <a href="https://www.worldobesity.org/membersarea/global-atlas-on-childhood-obesity">10th highest level of childhood obesity</a> in the world by 2030, affecting over 4 million children aged 5 to 19 years. </p>
<p>The campaign to get the levy increased is based on the growing body of research showing that <a href="https://theconversation.com/fact-or-fiction-is-sugar-addictive-73340">sugar is addictive</a>, that it is harmful to people’s health and that it is overwhelming the country’s health system. </p>
<p>Earlier this year the government made it clear that it had no intention of raising the 11% after the subject <a href="https://www.dailymaverick.co.za/article/2021-02-26-sugar-tax-stays-sweet-for-the-industry-but-mboweni-receives-praise-from-a-surprising-quarter/">was left out</a> of the February budget.</p>
<p>Yet, the country is paying a heavy <a href="https://pubmed.ncbi.nlm.nih.gov/31282315/">cost to treat type 2 diabetes</a> and <a href="https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(18)30450-9/fulltext">hypertension</a>. </p>
<p>Government has the power to make healthy choices the easy choice. Healthy food like fresh fruit and vegetables is <a href="https://theconversation.com/food-systems-need-to-change-to-promote-healthy-choices-and-combat-obesity-150966">often not available or affordable</a> for many living in rural or urban areas. People eat what is available and cheap. </p>
<p>The government can save lives and reduce the numbers of people who develop diseases by taking three very simple steps.</p>
<p>Firstly, it needs clear regulations. </p>
<p>Secondly, it needs preventative strategies. </p>
<p>Thirdly, it needs watertight policies for reducing consumption of unhealthy foods.</p>
<p>Increasing the health promotion levy, introducing mandatory front of package labelling and banning the marketing of unhealthy products to children should be at the very top of the priority list.</p><img src="https://counter.theconversation.com/content/158320/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Karen Hofman receives funding from IDRC Canada, the SA MRC and Bloomberg Philanthropies through The University of North Carolina. </span></em></p>The results are in: South Africa’s ground-breaking health promotion levy, introduced in 2018, is working.Karen Hofman, Professor and Programme Director, SA MRC Centre for Health Economics and Decision Science - PRICELESS SA (Priority Cost Effective Lessons in Systems Strengthening South Africa), University of the WitwatersrandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1551082021-02-21T12:05:53Z2021-02-21T12:05:53ZA sin tax on sugary drinks unfairly targets Indigenous communities instead of improving health<figure><img src="https://images.theconversation.com/files/385316/original/file-20210219-15-2hg8nd.jpg?ixlib=rb-1.1.0&rect=99%2C46%2C3941%2C3122&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A water bottle sits on the table in front of Chief and NDP candidate Rudy Turtle during a visit by NDP Leader Jagmeet Singh on Oct. 5, 2019 on the Grassy Narrows First Nation, where industrial mercury poisoning in its water system has seriously affected the health of the community.</span> <span class="attribution"><span class="source">THE CANADIAN PRESS/Paul Chiasson</span></span></figcaption></figure><p>“Sin taxes” are a tried, <a href="https://knowledge.wharton.upenn.edu/article/do-sin-taxes-really-change-consumer-behavior/">although not necessarily true</a>, strategy for reducing harm connected to alcohol and tobacco. Calls for a tax on sugar-sweetened beverages are supported by a large body of evidence linking weight gain and Type 2 diabetes, to excess consumption of these drinks. <a href="https://apps.who.int/iris/bitstream/handle/10665/260253/WHO-NMH-PND-16.5Rev.1-eng.pdf?sequence=1&isAllowed=y">This response is supported by the World Health Organization</a>, among others, <a href="https://www.heartandstroke.ca/-/media/pdf-files/canada/media-centre/the-health-and-economic-impact-of-a-sugary-drink-tax-in-canada-summary.ashx">to offset negative health and economic effects</a>. </p>
<p>The <a href="https://greenparty.mb.ca/news/manitoba-greens-sugar-tax-proposal-would-save-36-million-in-health-care-costs/">idea of taxing sugar-sweetened beverages</a> has <a href="https://www.cbc.ca/news/politics/liberals-ontario-soda-tax-proposal-federal-election-campaign-katie-simpson-1.5136724">caught the attention of political leaders</a> <a href="https://www.fin.gov.nt.ca/en/services/have-your-say-proposed-nwt-sugar-sweetened-drinks-tax">in Canada</a>, too. However, this paternalistic “we know best” approach ignores the most obvious needs and rights of Indigenous Peoples. Rather than seeing the harms of colonization to Indigenous Peoples, governments are fixating on how to tax the Coke in their hands. </p>
<p>Imposing a sugary beverage tax on Indigenous consumers would <a href="https://www.economist.com/the-economist-explains/2018/08/10/do-sin-taxes-work">be unethical</a>, contravene tax law and undermine Indigenous rights to self-determination. Even the <a href="https://www.cbc.ca/news/canada/manitoba/indigenous-forced-labour-sugar-beet-farms-1.4165272">production of sugar in Canada</a> has exploited Indigenous people, who were used essentially as forced labour. </p>
<h2>Health and mental health gaps</h2>
<p>The connection between lack of employment, education and family supports, to poorer health outcomes <a href="https://www.wellesleyinstitute.com/wp-content/uploads/2015/02/Full-Report-FPSCT-Updated.pdf">is well documented</a>. For Indigenous peoples, who often occupy the worst end of wellness measures, this is directly connected to the legacy of colonization. </p>
<p>Moreover, the health gap is profound and getting worse. <a href="http://mchp-appserv.cpe.umanitoba.ca/reference/FN_Report_web.pdf">The Manitoba Centre for Health Policy</a> found the life expectancy gap between First Nations persons and all other Manitobans has widened to 11 years from eight years since 2002. </p>
<p>It comes as no surprise then that Indigenous Peoples also experience diabetes at much higher rates. In Canada, treating diabetes <a href="https://www.diabetes.ca/media-room/press-releases/new-data-shows-diabetes-rates-and-economic-burden-on-families-continue-to-rise-in-ontario--">costs upwards of $30 billion per year</a>. It seems unlikely that a tax on sugary drinks can set this crisis right.</p>
<figure class="align-center ">
<img alt="Close-up of an Indigenous woman with grey hair in a blue shirt" src="https://images.theconversation.com/files/385307/original/file-20210219-21-kmf6x0.jpg?ixlib=rb-1.1.0&rect=238%2C8%2C2757%2C1985&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/385307/original/file-20210219-21-kmf6x0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/385307/original/file-20210219-21-kmf6x0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/385307/original/file-20210219-21-kmf6x0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/385307/original/file-20210219-21-kmf6x0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/385307/original/file-20210219-21-kmf6x0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/385307/original/file-20210219-21-kmf6x0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Laura Green, a resident of Shoal Lake 40 First Nation, was photographed while speaking about water and access issues in her community on Feb. 25, 2015. The boil water advisory at Shoal Lake 40 has lasted more than two decades, beginning in 1997.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/John Woods</span></span>
</figcaption>
</figure>
<p>Similarly, for those struggling with addiction, eating disorders or other challenges, adding more tax provides no support for better “lifestyle choices.” There is <a href="https://doi.org/10.1016/j.ypmed.2021.106447">evidence linking adverse childhood experiences</a> and trauma to higher intake of sugar-sweetened beverages both in childhood and later in life, as well as <a href="http://doi.org/10.3390/nu12051485">calls to include sugar-sweetened drinks within addiction models</a>, including for survivors of <a href="https://doi.org/10.1016/j.ypmed.2020.106176">childhood maltreatment</a> who disproportionately use food to cope.</p>
<p>Indigenous Peoples are also more likely to live with <a href="https://www.fnha.ca/what-we-do/mental-wellness-and-substance-use">mental illness and addiction</a>, largely due to <a href="http://www.nccah-ccnsa.ca/Publications/Lists/Publications/Attachments/142/2015-04-28-AguiarHalseth-RPT-IntergenTraumaHistory-EN-Web.pdf">intergenerational trauma</a>. This raises ethical questions about taxing addiction or behaviours associated with trauma, particularly in light of its colonial roots.</p>
<h2>Taxes, food and water</h2>
<p>One obvious problem with taxing sugar-sweetened beverage consumption by First Nations persons is their <a href="https://www.canada.ca/en/revenue-agency/services/aboriginal-peoples/indians.html">tax-exempt status</a> for all purchases made on reserves. There is no Canadian tax scheme that can avoid this exemption, thus a tax on sugary beverages has no impact on those who are at highest risk for Type 2 diabetes. With the growing presence of <a href="https://www.ictinc.ca/blog/what-are-urban-reserves">urban reserves</a> in many Canadian cities, buying tax-exempt sugar-sweetened beverages is increasingly easy. </p>
<p>Taxation also doesn’t address <a href="https://theconversation.com/canadas-food-guide-is-easy-to-follow-if-youre-wealthy-or-middle-class-114963">underlying issues of food insecurity</a>, prevalent in communities with high Indigenous populations. In urban areas, the <a href="https://doi.org/10.1186/s12937-019-0488-5">2015 Canadian Community Health Survey</a> found Indigenous populations to have the highest intake of sugar-sweetened beverages of any racial or ethnic group. This often reflects a <a href="https://doi.org/10.3390/ijerph17238818">lack of healthy and affordable food in neighbourhoods</a> with large Indigenous populations.</p>
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<p>Canada’s historic approach to resource development and wildlife management has been to ignore the needs and rights of Indigenous communities. Industry was allowed to pollute water bodies, <a href="https://pulitzercenter.org/projects/generations-activism-grassy-narrows-first-nations-fight-clean-water">including with mercury</a>, and destroy food sources relied upon by Indigenous Peoples. For <a href="https://doi.org/10.1503/cmaj.181617">northern</a>, <a href="http://www.fnfnes.ca/docs/FNFNES_draft_technical_report_Nov_2__2019.pdf">rural, remote</a> and <a href="https://proof.utoronto.ca/wp-content/uploads/2020/03/Household-Food-Insecurity-in-Canada-2017-2018-Full-Reportpdf.pdf">urban populations</a>, food insecurity continues to be a problem. Increasing food prices wouldn’t fix this.</p>
<p>A tax on sugar-sweetened beverages implies that Indigenous Peoples can either make better food choices, or choose to pay the tax. Yet <a href="https://canadians.org/fn-water">safe drinking water</a> and <a href="https://www.rcinet.ca/eye-on-the-arctic/2019/03/29/canada-nutrition-north-food-security-iqaluit-grocery-price/">affordable food</a> are not within reach of many Indigenous Peoples. </p>
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Read more:
<a href="https://theconversation.com/water-crisis-in-first-nations-communities-runs-deeper-than-long-term-drinking-water-advisories-148977">Water crisis in First Nations communities runs deeper than long-term drinking water advisories</a>
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<p>The disconnect here is how taxing sugary drinks will help reduce diabetes and other health problems for this group. There is a serious credibility gap when governments demand consumers pay extra when choices are limited, and then promise tax revenue will be used to benefit their health. Despite promises by the federal government to fix all boil water advisories in five years, <a href="https://globalnews.ca/news/7497223/indigenous-services-minister-says-trudeau-government-wont-end-boil-water-advisories-by-march-2021/">it failed to deliver</a> on this basic human right. </p>
<h2>Shifting responsibility</h2>
<p>The solution, it seems, shifts responsibility for wellness from addressing inequality, to imposing a sugar-sweetened beverage tax on those most affected by poverty and lack of clean water, and for whom <a href="https://theconversation.com/joyce-echaquans-death-how-a-decolonizing-approach-could-help-tackle-racism-in-health-care-148517">racism in health care</a> is a daily reality. By framing the “problem” just the right way, the “solution” is easy to sell to a nation struggling to accept responsibility for the continuing harms of colonization.</p>
<p>As a young nation, Canada signed Treaty agreements to share land and resources. Instead of honouring those promises, Canada enacted the <a href="https://indigenousfoundations.arts.ubc.ca/the_indian_act/"><em>Indian Act</em></a>, essentially stripping First Nations of even the most basic human rights. Since then, Canadian governments have rarely acted in the best interests of Indigenous Peoples. </p>
<p>Today, Canada is considering <a href="https://parl.ca/DocumentViewer/en/43-2/bill/C-15/first-reading">Bill C-15</a> to adopt minimum standards of Indigenous rights as set out in the <a href="https://www.un.org/development/desa/indigenouspeoples/wp-content/uploads/sites/19/2018/11/UNDRIP_E_web.pdf">United Nations Declaration on the Rights of Indigenous Peoples</a>. This includes the right to self determination. Rather than taxing sugar-sweetened beverages, a better solution is to end paternalism and to provide real choices by confronting inequality and racism.</p><img src="https://counter.theconversation.com/content/155108/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Myra J Tait receives funding from Canadian Institutes of Health Research.</span></em></p><p class="fine-print"><em><span>Natalie Diane Riediger receives funding from Canadian Institutes of Health Research. </span></em></p>A tax on sugar-sweetened beverages may be intended to improve health, but for Indigenous consumers, such a tax would be unethical, contravene tax law and undermine Indigenous rights.Myra J Tait, Assistant Professor, Governance, Law and Management, Athabasca UniversityNatalie Diane Riediger, Assistant Professor of Nutritional Epidemiology, University of ManitobaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/720102017-02-02T10:43:30Z2017-02-02T10:43:30ZSouth Africa’s sugar tax: a bold move, and the right thing to do<figure><img src="https://images.theconversation.com/files/155321/original/image-20170202-3388-1fivyqk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>South Africa’s planned sugar tax has come under severe scrutiny from its parliamentarians. The questions they’re grappling with are whether the country needs <a href="http://www.timeslive.co.za/sundaytimes/businesstimes/2017/01/31/Parliament-hears-pros-and-cons-of-a-sugar-tax-in-SA1">a tax and how effective it will be</a>.</p>
<p>The tax is planned to take effect on April 1 2017. It’s designed to reduce sugar intake from sugar-sweetened beverages by upping the price with a 20% fiscal tax. </p>
<p>The South African health authorities’ plan to issue a sugar tax must not be seen in isolation. It is part of the South African National Department of Health’s <a href="http://www.hsrc.ac.za/uploads/pageContent/3893/NCDs%20STRAT%20PLAN%20%20CONTENT%208%20april%20proof.pdf">strategic plans</a> to prevent and control non-communicable disease, and <a href="http://cdn.24.co.za/files/Cms/General/d/4776/e9776ca8f6a44f3099dbde892bb0afbb.pdf">obesity</a>. </p>
<p>These strategies have set the ambitious target of reducing obesity by 10% by 2020. And they include <a href="https://theconversation.com/south-africas-bold-move-on-salt-gets-off-to-a-shaky-start-42256">salt reduction legislation</a>, <a href="http://www.gov.za/documents/foodstuffs-cosmetics-and-disinfectants-act-regulations-trans-fat-foodstuffs">trans-fat regulations</a>, and stricter <a href="http://gabisteenkamp.co.za/food-labeling/">label and advertising regulations</a>. </p>
<p>The reality is that the move to introduce the sugar tax is necessary because of the scourge of non-communicable diseases and obesity in the country. </p>
<h2>The rise of non-communicable diseases</h2>
<p>It is not unusual for populations that <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3257689/">modernize</a> as a result of socioeconomic development to have changes in their dietary patterns. </p>
<p>But the move from traditional foods to more processed and convenience foods is linked to weight gain and an increased risk of developing diet-related non-communicable diseases such as high blood pressure, heart disease and diabetes. </p>
<p>Non-communicable diseases have become the leading causes of death in low- and middle-income countries. South Africa is no exception. It has the highest rates of overweight and obese adults in Africa. Nearly one in every seven <a href="https://www.google.co.za/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&cad=rja&uact=8&ved=0ahUKEwjN-J3f8O7RAhVpJcAKHcQJC3kQFggYMAA&url=http%3A%2F%2Fwww.hsrc.ac.za%2Fuploads%2FpageNews%2F72%2FSANHANES-launch%2520edition%2520(online%2520version).pdf&usg=AFQjCNHdRIYV90o8iKA66KGa6kVRhuFn1w&sig2=u1aQoNpzN1mxbWXZSARSfw&bvm=bv.145822982,d.d24">South African women</a> is affected. And <a href="http://www.afro.who.int/en/south-africa/country-health-profile.html">40% of deaths</a> from non-communicable conditions among men occur before they turn 60. </p>
<p>In its <a href="http://www.samj.org.za/index.php/samj/article/view/10674">second National Burden of Disease Study</a> South Africa’s Medical Research Council tracked mortality levels and trends for non-communicable diseases between 1997 and 2012. It found that by 2010 non communicable diseases had become one of the top causes of death in the country. They accounted for <a href="http://thelancet.com/journals/langlo/article/PIIS2214-109X(16)30113-9/fulltext">39%</a> of all fatalities putting them on par with the number of people dying from HIV/AIDS and tuberculosis combined. </p>
<p>The World Health Organisation predicts that by 2020 these diseases will account for 80% of the global burden of disease. They will be responsible for seven of every 10 deaths in <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4267750/">developing countries</a>.</p>
<p>Currently, a third of these premature deaths in lower income countries occur in people under the age of 60. In high income countries the proportion is only 13%.</p>
<p>The impact of non-communicable diseases has a significant impact on economic development. The accumulated loss to South Africa’s gross domestic product between 2006 and 2015 from diabetes, stroke and heart disease was estimated at <a href="http://www.samj.org.za/index.php/samj/article/view/8727/6218">US$1.88 billion</a>. The <a href="https://www.pwc.pl/en/publikacje/business_rationale.pdf">World Economic Forum</a> has estimated that other industrialised countries such as Brazil, China, India and the Russia lose more than 20 million productive life years annually to non-communicable diseases. </p>
<h2>An obese nation</h2>
<p>In addition to sharp increase in non-communicable diseases, obesity has also risen at an exponential rate. The number of <a href="http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0038-23532012000300011">overweight and obese children</a> in South Africa has increased from 1.4% in 1994 to more than 15% in 2004. </p>
<p>And the obesity phenomenon has come about before South Africa has been able to win the battle against <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3257689/">under-nutrition</a>. While there has been a rise in the number of <a href="http://www.hsrc.ac.za/uploads/pageNews/72/SANHANES-launch%20edition%20(online%20version).pdf">overweight and obese people</a>, many are still undernourished because their food choices deprive their bodies of essential nutrients (energy, vitamins and minerals). </p>
<p>The <a href="https://www.ncbi.nlm.nih.gov/pubmed/22254104">changes in South Africans’ dietary patterns</a> over time have included: </p>
<ul>
<li><p>more foods rich in total and saturated fats, </p></li>
<li><p>less legumes and vegetables, and </p></li>
<li><p>more energy-dense, micronutrient-poor snack foods, convenience foods, vegetable oils, and </p></li>
<li><p>more sweetened products and beverages. </p></li>
</ul>
<p>Adding salt, sugar, fats and oils during food preparation has also increased. Although studies show that people are eating more fruit and meat than 10 years ago, people are still <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3257689/">not consuming enough</a> variety of foods to meet all the recommended macro- and micro-nutrients for optimal health and well being. </p>
<h2>Global commitments</h2>
<p>As the world continues to win battles against HIV/AIDS and other communicable diseases, the national burden of disease attributed to non-communicable diseases is expected to intensify. </p>
<p>In the next 10 years it is <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4267750/">estimated</a> that the global non-communicable disease burden will increase by 17%. In Africa, this figure will be closer to 27%. </p>
<p>Globally governments are being forced to pay more attention and intensify their actions against these diet related diseases. As a member state to the United Nations, South Africa has signed various global resolutions and commitments on food and nutrition. By implementing the sugar tax, South Africa is simply heeding to its international commitments.</p><img src="https://counter.theconversation.com/content/72010/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The reality is that the move to introduce a sugar tax in South Africa is necessary because of the scourge of non-communicable diseases and obesity in the country.Hettie Carina Schönfeldt, Associate Professor of Human Nutrition at the Institute of Food, Nutrition and Wellbeing, University of PretoriaBeulah Pretorius, Reseacher in Human Nutrition and Food Composition, University of PretoriaNicolette Hall, Researcher & Post-doc in Human Nutrition, University of PretoriaLicensed as Creative Commons – attribution, no derivatives.