Royal Colleges call for “duty” on sugary drinks in action plan against obesityBMJ 2013; 346 doi: https://doi.org/10.1136/bmj.f1146 (Published 19 February 2013) Cite this as: BMJ 2013;346:f1146
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We read the recent report published by the Academy of Medical Royal Colleges highlighting a 10-point plan of action to tackle the growing obesity epidemic with interest. Statistics published by the World Health Organisation (WHO) in 2008 estimated that the prevalence of obesity worldwide is close to 500 million . More worrying still is the rate of increase; by 2015, the WHO have predicted that over 700 million people will be defined as clinically obese (body mass index >30kg/m2) . Therefore a robust and effective action plan to manage this epidemic is crucial.
We were particularly interested by the suggestion of a 20% levy (or ‘sugar tax’) on sugary soft drinks. Although anti-obesity measures such as the “five a day” nutritional diet and “traffic light” food labelling have had some success, the overall obesity programme, as quoted by the news article published in the British Medical Journal in 2013, is “disappointingly ineffective” . How effective will such tax measures be on the consumption of sugary beverages?
In the case of cigarettes, Chaloupka et al., posited that increased taxation on cigarette prices in America resulted in significant reductions in smoking, particularly among the younger generation . Using estimates of ‘price elasticity’ to predict the impact of cigarette consumption caused by price changes, it was estimated that an increase of 10% in cigarette cost caused a 2.5%-5% drop in consumption. This is attributed to both a drop in the number of cigarettes consumed and the number of smokers. It appears that the same also applies to alcohol. In 2009, Waagenar et al., conducted a meta-analysis of 112 separate studies and concluded that there was a significant reduction of alcohol consumption when prices were increased. This inverse relationship applies for a variety of alcoholic beverages, including beer, wine and spirits .
These studies provide a powerful rationale for the use of increased taxation to curb the consumption of harmful products, such as cigarettes, alcohol and soft drinks. However, a caveat is that the harmful agent in soft drinks (i.e. sugar) can be obtained from other sources. Will tax changes lead to substitution of sugary drinks for other unhealthy consumer products or food groups? Will this be followed by a ‘fat tax’, or ‘fast food tax’? So far there is a paucity of research investigating the effects of price changes on overall diets . Thus there is a key question yet to be answered: would an increase in tax on soft drinks have an impact on obesity rates by reducing calorific intake? We think probably not.
1. World Health Organisation. Obesity and overweight. Factsheet, http://www.who.int/mediacentre/factsheets/fs311/en/index.html (Accessed 9 March 2013).
2. The Information Centre. Statistics on obesity, physical activity and diet: England, January 2008. http://www.ic.nhs.uk/pubs/opadjan08 (Accessed 9 March 2013).
3. Limb H (2013), Royal Colleges call for “duty” on sugary drinks in action plan against obesity. BMJ 2013;346:f1146
4. Chaloupka FJ, Cummings KM, Morley CP, Horan JK. (2002), Tax, price and cigarette smoking: evidence from the tobacco documents and implications for tobacco company marketing strategies.Tobacco Control, 11 Suppl 1:I62-72.
5. Wagenaar, A. C., Salois, M. J. and Komro, K. A. (2009), Effects of beverage alcohol price and tax levels on drinking: a meta-analysis of 1003 estimates from 112 studies. Addiction, 104: 179–190. doi: 10.1111/j.1360-0443.2008.02438.x
6. Popkin BM, Adair LS, Ng SW. (2012), Global nutrition transition and the pandemic of obesity in developing countries. Nutrition Reviews. 70(1):3-21. doi: 10.1111/j.1753-4887.2011.00456.x.
Competing interests: No competing interests
There can no doubting that obesity and its medical sequelae are now the leading healthcare burden not only in the UK, but in the entire western world. But what can be done about this growing pandemic?
Whilst the Academy of Royal College's efforts in proposing solutions to this ever-expanding problem are laudable, I do question some of their recommendations.
The 20% levy on sugary drinks may well work, and strikes a chord with the minimum price on alcohol as a means of tackling an out of control situation. But is this fair? Does it not simply penalise the least wealthy? Is there a possibility that these people eat more processed, high fat food (washed down by sugary drinks) because they simply cannot affords healthier alternatives? When I have tried to lose weight through dieting and healthy eating, I cannot help but notice that 'healthier' options are often more expensive than their normal counterparts. How about encouraging supermarkets and even fast food outlets to incentivise healthier eating by reducing the prices of low fat orow sugar options, rather than focussing on hiking up the prices of unhealthy food? Unless there is a hidden agenda behind taxing sugar, just as there may be in the case of alcohol-revenue.
Additionally, the academy proposes a ban on advertising foods high in fat, sugar and salt before 9pm. Is this a reasonable and rational proposal, let alone practicable?! They will call it the watershed for good reason-water will be the only thing which will be allowed to be advertised before 9pm!! It suggests reducing fast food outlets near schools too. I can't help but wonder whether these aspects of their recommendations are somewhat myopic? It seems to suggest that if these unhealthy consumables are out of sight, then they are out of mind. Can we really hide all the bad food and drink from people, and then hope they will simply forget that it exists?! I remain to be convinced about the role censorship and concealment will play in the battle of the bulge.
Aside from these issues, what happened to the concept of free will? At the end of the day, people have a right to choose what they eat and drink (alcohol included). All we can do is try to educate them as best we can, and in so doing empower them to make fully-informed decisions. But the choice they then make is down to themselves-they have capacity after all! The Mental Capacity Act states that an individual should not be deemed to lack capacity simply because their choice is considered to be unwise-and so it is with the things we choose to consume. It would not surprise me if at some point in the not to distant future, psychiatrists will end up labelling morbidly obese individuals who are unable to control the amount of food they consume as 'mentally ill,' just as we do with those who restrict their food intake to levels which are life-threatening. Once detained under the Mental Health Act, we really would be able to control our obese patients' consumption within the auspices of a legal framework. We could wire their jaws shut, we could strap them down to their beds for prolonged periods of enforced starvation-the possibilities are endless. Of course, my statements are a tad facetious, and I do not mean to belittle the serious condition that is anorexia nervosa. My point is this-how far can we go in exerting control over people's behaviours when they have the capacity and indeed the right to make their own choices.
I believe we must focus on educational strategies and the promotion of sensible eating as just one facet of an all-round healthy lifestyle. Changing people's lifelong eating habits involves changing their attitudes towards food, which can take time, and so we must be patient. Our role as doctors is to educate and to advise as best we can, but not to control, censor or conceal.
Competing interests: No competing interests