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IN 2014 MORE THAN 14 MILLION MEXICANS HAD
DIABETES AND THEN MEXICO IMPOSED A SUGAR TAX.
IT STARTED A TREND.

As Diabesity has become a global epidemic, governments have increasingly responded by slapping sugar taxes on fizzy drinks and certain foods too. Dot I/O Health Trends and Inquiry Partner, Nicola Gill, looks at what has worked and what’s next in slowing down this epidemic

Back in 2016 Dot I/O Health reported on the Mexican government’s seemingly (then) bold step of levying a sugar tax on sodas (as fizzy drinks are called in the Americas) in 2014 to try and stem the tide of obesity that had swept the Central American nation — as well as imposing an 8% tax on foods high in sugar, salt and fat.

At the time more than two thirds of Mexican adults and three in ten children were obese or overweight with 28% of deaths every year being obesity-related and more than 14 million Mexicans suffering from diabetes, triple the number of 1990.

Unsurprisingly, given all the above, Mexico was also the heaviest consumer of fast food and sugary drinks in Latin America — which is saying something for a continent where many workmen traditionally started their day clutching a pair of two litre coca cola bottles as their only source of hydration for their shift. Pre-sugar tax, the average Mexican drank 36 gallons a year of soda, mainly using it to wash down an average of 450 pounds of ultra-processed food to boot, as the leading consumers of fast food in Latin America.

In February 2017 the journal Health Affairs reported the immediate decline in sales of sweetened drinks seen in the first year had carried through to the second. The second-year results showed this was not a blip — as the soft drinks industry and other critics with a vested interest had claimed — but could be coming a long-term trend. The research, based on shopping data from a large sample of urban Mexican households, showed that overall sugary drink sales fell by 5.5% in 2014 compared with the previous year, and by 9.7% in 2015 compared with 2013. There was also some evidence that sales of bottled still water had increased slightly.

The study, by the University of North Carolina Gillings School of Global Public Health and the Mexican National Institute of Public Health, found that the tax, just 1 peso (4p) per litre of sugary drinks, had its biggest impact on the poorest households, where the decline in purchases was 18.8ml per person per day in 2014 and 29.3ml in 2015.

In contrast, purchases of other untaxed drinks — including water — went up on average by 2% over the two years. At the time Dr Graham Messenger, chair of pressure group Action on Sugar, believed the battle was won, if not the war. “The sugar tax has worked — soda consumption has reduced. You wouldn’t expect obesity levels to drop overnight. But they will.”

While there is no agreed universal, global definition so far of what a high-sugar drink is, the world watched and sure enough a lot of it soon followed suit. In fact, Hungary was first to act in 2011 as part of a wider tax on pre-packed sweetened products, salty snacks and condiments, followed by France in 2012, charging manufacturers the equivalent of an extra 6p per litre for any beverage containing added sugar or artificial sweeteners — but Mexico attracted by far the greatest publicity due to its huge population and dire obesity rates.

MEXICAN HOUSEHOLDS SHOWED THAT OVERALL SUGARY DRINKS HAD FALLEN 9.7% IN 2015 COMPARED TO 2013.

Mexico’s precedent was followed by Chile, Barbados and Berkeley, California by 2015, and Mauritius and Belgium by 2016. In Berkeley, studies also showed promising results and there was a 21% decrease in the consumption of sugar-sweetened beverages and a 63% increase in the consumption of water in the city’s low-income neighbourhoods, according to a study published online in the American Journal of Public Health.

In 2017, Portugal and Catalonia, United Arab Emirates, Saudi Arabia, Brunei and Thailand introduced their own versions, followed by South Africa, and there are similar plans across a number of other countries.

In April 2018 the UK Government launched its childhood obesity strategy, aiming to reduce sugar consumption by persuading companies to reformulate their high sugar brands or pay a tax levy. It was so successful that the UK Treasury department, which originally estimated it would gain £500 million in revenue from the tax, said that more than 50% of manufacturers have already changed their formulas to cut sugar and so will not be liable for the levy, and so has reduced its revenue collection estimate by around half.

One UK modelling study, published in the Lancet and advocating a gradual reduction in the sugar content in sweetened beverages, estimated that a 40% reduction in added sugars over five years would reduce the number of obese adults by roughly half a million and new cases of type 2 diabetes by around 300,000.

Another study predicted that — assuming decreased sales are an accurate reflection of decreased consumption — Mexico’s 10% tax on sugary beverages would prevent nearly 190,000 new cases of diabetes over 10 years, at an average savings of $983 million (£785 million) in related health-care costs. A separate systematic review and meta-analysis showed that by also reducing the price of fruits and vegetables by 10% in tandem their consumption would also increase, with positive effects on BMI.

Commenting on the results of the worldwide taxes and levys, current Action on Sugar campaign director Katharine Jenner said, “The SDIL (Soft Drinks Industry Levy) is in its infancy with regards to measuring impact but we have already seen a 28.8% reduction in total sugar content of soft drinks (in retailer own brand and manufacturers) compared to a 2.9% reduction in a non-mandatory program. The report also found a 45.5% reduction in soft drinks with 5g to less than 8g of sugar (per 100g), and 35.1% reduction in sales of soft drinks with 8g of sugar or more (per 100g). We need to ensure that the SDIL is maintained and extended in order to better measure outcomes.”

“Current research, largely modelling studies, do show that fiscal measures have an impact on overall reduction in body mass index on a population level. More research is needed to explore the great potential of these measures but we believe it’s also imperative that the UK Government continue to lead in this area by including milk-based drinks within the SDIL framework and explore opportunities to extend the levy to calorie-dense processed foods that meet an agreed criterion set by the government.”

BUT TAXES ARE ONLY ONE PIECE OF THE PUZZLE TO REDUCE DIABETES AND OBESITY ACCORDING TO MANY ACADEMICS.

But taxes are only one piece of the puzzle to reduce diabetes and obesity rates according to many academics, who mostly now increasingly agree that there should be a more varied approach in terms of policy, including dealing with aggressive price promotion and marketing of sugary foods, particularly towards children, and providing clear information on the nutritional content in tandem with educating children to make healthy choices and be more active.

In the first study of its kind it was found that extending fiscal policies to include sweet snacks could lead to larger public health benefits, both directly by reducing purchasing and therefore consumption of these foods, and indirectly by reducing demand for other snack foods and sweet drinks.

The researchers classified household expenditure on food and drink items in 2012–13 into 13 different groups and examined them in a national representative sample of around 32,000 UK homes. They found that on average people in Britain get 17.1g of sugar daily from purchased sweet snacks, which is more than twice as much as they get on average from sugary drinks (6.9g).

As the demand for sweet snacks is price responsive (a 10% increase in the price would reduce consumption by 7%), higher prices for chocolate, confectionery, cakes and biscuits may reduce sugar consumption even more, as we consume more of it in the first place

Urban planners worldwide meanwhile are also increasingly using the principles of active design to create environments which make it easier to walk, play sport and keep active to improve health.

DOT I/O HEALTH INSIGHT — EMERGING MARKETS HAVE BECOME THE INNOVATION HUBS FOR HEALTHCARE

The dramatic global rise of diabetes and obesity in emerging markets (often low-middle income countries, as defined by WHO) is being driven by a number of factors — primarily diet and lifestyle, and increasing urbanisation. Non-communicable diseases (NCDs) have reached a tipping point in these countries and their impact now exceeds that of infectious diseases.

Mexico is an exemplar of what can be done to reverse this trend and demonstrates how an emerging market can lead others — back in 2015 the Mexican Health Minister was invited to separate meetings by the UK Health Minister and the US FDA to share how his Government and its public health policies were addressing the issue of diabetes and obesity.

This example highlights a growing trend, whereby emerging countries create next generation health systems, ignoring the more established approaches of developed nations. Whilst this is born from necessity and fewer constraints it highlights a fertile ground for innovation.

For the pharmaceutical, biotech and health industry, it means not doing business as usual, but looking at emerging markets as an ‘innovation hub’ and ‘sandbox environment’, where new value solutions incorporating regulatory, pricing, market access, and delivery can be pioneered.

Dot I/O Health’s DEEP Health Trends uses DEEP Horizon our data science driven approach to identifying and anticipating health trends, synthesised with our on the ground investigative team and analysts. To learn more, visit us at dotio.health or follow us on our Linkedin page or on twitter.

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