The public health threat from sugary drinks in IndiaBMJ 2014; 349 doi: https://doi.org/10.1136/bmj.g6216 (Published 21 October 2014) Cite this as: BMJ 2014;349:g6216
- Soumyadeep Bhaumik, clinician-scientist and public health commentator, Kolkata, India
In February this year Anand Grover, the United Nations’ former special rapporteur on the right to health, held a consultation in Mumbai as part of the groundwork for his report on unhealthy foods, non-communicable disease, and the right to health. The report, submitted in April 2014 to the UN Human Rights Council, highlighted the need for fiscal policies, particularly higher taxes on sugar sweetened beverages, to control non-communicable disease in India.1
In July 2014 the government of India announced the introduction of an extra 5% excise tax on aerated sugary drinks.2 Higher taxes on sugar sweetened beverages are already used as a public health measure in some countries, including France and Mexico.
Empty calories and obesity
Sugar sweetened beverages are said to contain only “empty calories” because they provide little nutritional value. Multiple meta-analyses have shown a consistent, specific, and dose related association between the intake of sugar sweetened drinks and diabetes, cardiovascular disease, and obesity.3 4 5 6 7 The association with type 2 diabetes exists among all age groups even after the results are adjusted for body mass index and total energy consumption.
In one European study adults who drank more than one can of sugary soda a day had a 22% higher risk of developing type 2 diabetes than those who drank less than one can a month.8 Analysis of the Framingham Heart Study found that adults who consumed at least one soft drink a day were 1.4 times more likely to develop metabolic syndrome, 1.3 times more likely to be obese, and 1.2 times more likely to develop hypertension than those who did not.9
Indian people are more susceptible
India has one of the highest burdens of diabetes in the world—there were about 61.3 million cases in 2011 and the number is expected to rise above 100 million by 2030.10 Cardiovascular disease is also increasing and is currently India’s leading cause of death.11 Coronary heart disease affects people from the Indian subcontinent an average of 5-6 years earlier than it does their Western counterparts.11 12 Indian people are also more susceptible to harm from obesity, premature cardiovascular disease, and diabetes because insulin resistance is more common in this population, even in those with a normal body mass index (<25).12
Thus the cut-offs for abdominal obesity are lower for people of South Asian origin (80 cm for women and 90 cm for men, recommended by the International Diabetes Federation) than for Western populations (88 cm and 102 cm, respectively, recommended by the US National Institutes of Health). In this context sugar sweetened beverages might be more detrimental to the health of South Asian populations than others.
Consumption is increasing
Sugar sweetened drinks are estimated to be the primary source of added sugar consumption in the United States.5 And although the consumption of sugar sweetened beverages per capita in India is reported to be about 11 litres a year, which is low compared with other nations,13 a 2013 report from the global marketing research firm Euromonitor International found that consumption is increasing by 13% a year.14 It found that growth in the consumption of sugar sweetened beverages is strong throughout India, with small shops responsible for most of the sales.
“Sugar sweetened beverages are available in nukkad kirana shops [small independent groceries] in metropolitan areas, and they are equally available in village kirana shops, the most accessible places,” Sutapa Agrawal, a research fellow at the South Asia Network for Chronic Disease in New Delhi, told The BMJ. She thinks that sugary drinks pose a problem because they are popular among all sections of Indian society—all ages and all socioeconomic groups, in rural as well as urban areas.
A modelling study that used longitudinal consumption trends estimated that a 20% excise tax on sugar sweetened beverages would reduce the prevalence of overweight and obesity in India by 3% and the incidence of type 2 diabetes by 1.6% by 2023.15 Modelling studies, however, cannot predict how consumers will actually behave in response to a rise in price—for example, richer consumers might be able to absorb such a price rise.
Modelling studies also neglect the possible effects of other risk factors for obesity, type 2 diabetes, and cardiovascular disease and the effects of new marketing strategies that the manufacturers of sugary drinks may devise when such taxes are rolled out. US manufacturers are now required by law to display the energy content of their products on vending machines, but this has not been replicated in India. Some sugary drink manufacturers also run anti-obesity campaigns.16
“One of the mistakes made in public health in the era of increasing tobacco use was to focus on high income countries such as the US and ignore lower income countries where tobacco companies later established their largest markets. We should not repeat that mistake in nutrition,” explained Sanjay Basu, assistant professor at Stanford University, California, and lead author of the modelling study.
“It is the state’s responsibility to respect, protect, and fulfil the right to health and the right to food,” Amit Khurana, programme manager for food safety and toxins at the Centre for Science and Environment (a non-profit think tank in New Delhi), told The BMJ. “[Federal] state policies, therefore, should be designed to provide an environment where the availability, accessibility, and affordability of healthy food is ensured to all.”
One of the obstacles to putting public health measures related to overconsumption into place is that they are likely to damage manufacturers’ profits and might be labelled “paternalistic” because they over-ride personal autonomy.
Right to health
Some people advocate a “right to health approach” that gives individual freedom more prominence. Grover said, “The right to health approach holds the individual’s health related decision-making paramount. It requires, therefore, that individuals be provided [with] all the information that is required for them to make a health impacting decision.”
He added that in the context of food the right to health obligations of the central government would require the government to ensure that appropriate nutritional information is available and that healthy foods are made affordable and physically accessible.
“It is open to individual states to adopt a policy of promoting healthy foods and providing information about unhealthy foods—or regulate (not ban) them—in the interest of public health. In doing so, states are not banning the consumption of unhealthy foods or preventing people who choose to eat unhealthy foods from doing so. This would counter the charge of paternalism, which is a commonplace argument made in free economies where government interference, even in public interest, is frowned upon,” Grover said.
In addition to extra taxes on sugar sweetened beverages other legislative interventions may be needed to reduce consumption—for example, the banning of sales in educational institutions, mandatory nutritional labelling, or statutory warnings on packaging. Evidence from a Cochrane review indicates that measures that aim to create environments and cultural practices in schools to support healthier eating habits are successful in preventing obesity.17
The government of India has broken the status quo on sugar sweetened beverages by introducing a higher tax on them. This needs to be coupled “with a policy that increases the affordability and accessibility of healthy alternatives such as fruits and vegetables,” said Khurana.
The UN report by Grover also calls for efforts to make healthy food cheaper than unhealthy food, with measures such as withdrawal of subsidies on unhealthy food and tax breaks and other incentives for fruit and vegetable production.1 It seems that most people agree that India needs a more comprehensive policy for food to stave off non-communicable disease.
Cite this as: BMJ 2014;349:g6216
Competing interests: I have read and understood BMJ policy on declaration of interests and have no interests to declare.
Provenance and peer review: Commissioned; not externally peer reviewed.