Download Nearly two-thirds of UK adults and around 30% of UK children are

Nearly two-thirds of UK adults and around 30% of UK children are overweight or
obese. Contributing to this, both adults and children are consuming more sugar than
the Government recommends. Therefore the need to reduce the amount of sugars in
our diets is high on both the media and political agenda. Several organisations,
including medical bodies, call for the taxation of high sugar products, such as sugary
sweetened beverages (SSBs) to be combined with a range of other methods for
sugar reduction such as marketing restrictions and product reformulation.
Diets that are high in sugar can provide excess energy which can lead to weight
gain and obesity. In the UK, adults and children of all ages are consuming too
much sugar. Added to this, nearly two-thirds of adults and around 30% of children
are overweight or obese. We know that obesity is an independent risk factor for
many serious health problems including cardiovascular disease, type 2 diabetes
and certain cancers.
Therefore the BHF believes that a range of actions must be taken to reduce the
UK’s sugar intake and to decrease the rate of obesity in the UK. Health-related
food duties, where taxes are added to increase the cost of unhealthy foods to
discourage consumption, are one option. Research suggests that a 20% tax on
sugary sweetened beverages (SSB) could reduce the number of obese adults in
the UK by 180,000 and could reduce the number of obese and overweight adults
by 285,000.
The BHF, therefore, supports the introduction of an excise duty of a 20p tax per
litre of sugary sweetened beverages.
This tax is just one measure from a suite of policy interventions that should be
implemented at the same time to decrease obesity rates and improve the UK’s
diet. Policy interventions that help make healthy options cheaper should be
considered alongside the implementation of an SSB tax. Other interventions
include measures such as industry reformulation to reduce the sugar content of
their foods and restrictions on marketing to children of high sugar food and drink.
How much sugar is enough?
On 17th July 2015 the Scientific Advisory Committee on Nutrition (SACN) published
their report on carbohydrates. This report states that the UK’s recommended free
sugar intake should be halved to account for 5% of a person’s daily dietary energy
intake, this equates to 30g per day for adults.1 Free sugars are defined as all
monosaccharides and disaccharides added to foods by the manufacturer, cook or
Policy statement – Sugar
consumer, plus sugars naturally present in honey, syrups and unsweetened fruit
juices. Under this definition, lactose (milk sugar) when naturally present in milk and
milk products and sugars contained within the cellular structure of foods (particularly
fruits and vegetables) are excluded.
The UK Government has now accepted SACN’s recommendation, as an
independent advisory body, and subsequently all government advice sources
including the Eatwell plate, NHS Choices and Change4Life materials will be updated.
This new recommendation aligns with the World Health Organization’s (WHO) daily
free sugar recommended target 5% of total energy intake.2
Sugar and sugary sweetened beverage (SSB) consumption in the UK
At a population level, children and adults currently consume more sugar than is
recommended. 3 For example children aged between four and six are currently
consuming an average of 61g of free sugars per day. To bring this group’s
consumption of free sugars down to meet the new recommendations this would need
to fall to below 19g per day. Teenagers are the highest consumers, currently
consuming an average of 74g of free sugars per day, a long way off the new
recommended limit of 30g per day. The problem is similar in adults (aged 19-64
years), who currently consume an average of 59g of free sugars per day. This, again,
is well above the recommended daily intake of 30g.4 These high levels of
consumption are putting the population at risk of being overweight and obese5 and
therefore increasing the chances of developing cardiovascular disease if this
consumption continues over a period of time.
Data from the National Diet and Nutrition Survey show that one of the main sources
of free sugars in our diets, in particular within children’s and teenagers’ diets, are
sugary sweetened beverages (SSBs).6, 7 SSBs account for 29% of total free sugar
intake for teenagers aged between 11-18 years and 16% for children aged between
four and ten.8
The BHF defines SSBs as soft drinks that have added sugars, syrups or other
sweetening ingredients that add energy. We take soft drinks to be cold, non-alcoholic
beverages with any amount of added sugar. They may be carbonated or not
carbonated. This includes energy drinks, but does not include pure fruit juices,
without added sugar. SSBs generally offer no nutritional benefit other than energy
and are therefore not an essential part of a healthy diet and should be viewed as an
occasional treat product. To put this into context, under the new daily intake of free
sugar recommendations, one can of regular Coca-Cola contains 36g of free sugars,
which if the entire can consumed, would take both adults and children over their
entire daily allowance.9
Survey data also shows a health inequality angle to sugar, with consumption typically
reducing as household income increases. The Family Food Survey, based on
household food purchases, found that the proportion of energy coming from free
sugars in the household diet was higher in the lowest income group compared with
the highest.10
Sugar, SSBs and cardiovascular disease
The high consumption of both sugar and specifically SSBs as non-necessary drinks
is concerning due to their contribution to obesity. Research has shown diets that are
2
Policy statement – Sugar
high in energy tend to be higher in sugar intake and subsequently over time can lead
to weight gain.11 Findings from randomised control trials conducted in children and
young people show that consumption of SSBs results in greater weight gain than
drinking non-calorically sweetened beverages. 12,13,14 It has been estimated that the
contribution of SSBs to our energy intake amounts to 50kcals a day for adults and
100kcals a day for children.15 The strength of this evidence base has led to the
SACN recommending that consumption of SSBs is minimised in both children’s and
adults’ diets in order to reduce the UK’s sugar intake and as a step to reduce the
prevalence of obesity.16
Although preliminary evidence has suggested a direct causal link between sugar
consumption and a range of coronary heart disease or indicators for coronary events,
the evidence remains contested. 17,18 The Framingham study demonstrated that an
increase of more than one SSB per day increased the odds of developing high blood
pressure, yet results remain unclear.19 A sugar dense diet has also been associated
with evidence of increased inflammation, oxidative stress,20 and increased
triglyceride levels.21
The SACN found no significant association between sugar consumption and
incidence of coronary events, blood pressure, triacylglycerol concentration or
cholesterol. 22 The SACN conclude that more evidence is required to link increased
consumption of sugar directly to the incidence of coronary heart disease. However,
SACN does confirm a clear relationship between energy dense diets, such as those
high in sugar, and an increase in energy intake. If an excess energy intake continues
over time, this can lead to weight gain and obesity. Obesity is a risk factor for many
serious health problems including cardiovascular disease, type 2 diabetes and
certain cancers.23 24
Health related food taxes
In the light of high levels of consumption and obesity, there are growing calls within
the UK for the Government to reduce the population’s sugar consumption through
fiscal measures. One option is a ‘health-related food tax.’25
Health-related food taxes are designed to increase the price of unhealthy foods to
discourage their consumption. Such a tax is a population level intervention which
would apply to every person who consumes a product. This means that the health
gains are likely to be the greatest amongst the groups which consume most of these
foods (such as the most deprived).
It is important to be aware that health-related food taxes like all indirect taxes,
including taxes on tobacco and alcohol, could have a regressive effect on the income
of lower income consumers.26
The role of Government to intervene in public health through health-related
consumption taxes is well established. Current examples in the UK context are taxes
on tobacco and alcohol, which have proved successful in driving consumption down.
The UK Government has two options for the type of tax that could be introduced on
SSBs;
1) Sales tax
Foods sold in the UK are already subject to Value Added Tax (VAT) – a sales
tax. Although most food is zero-rated for VAT, some food items, such as
confectionery, carbonated drinks, as well as all food supplied in cafés and
3
Policy statement – Sugar
restaurants, and hot take-away food, already attract VAT at the standard rate.
There is no nutritional profiling used to determine which products should be
charged at standard rate VAT or be VAT free, therefore healthier products
such as bottled water are subject to VAT yet unhealthy products such as
cakes and biscuits are not.27
2) Excise duty
Excise duties are taxes tailored to particular groups of products – such as
tobacco, alcohol and petrol – and are set at levels higher than general sales
taxes. They are generally levied on a certain volume or weight of goods.
Food-related excise duties can be applied in a number of ways:
 as a tax on a specific nutrient, such as saturated fat or sugars
 as a tax on a combination of nutrients using nutrient profiling, or
 as a tax on a category of food or beverage, such as SSBs.
Taxing a specific nutrient such as sugar in its entirety could have unforeseen impacts
on foods that offer other nutritional benefits that are an important part of a healthy
diet such as dairy products, like yoghurt. Moreover administering a tax on products
that contain sugar or allocating tax on the basis of a nutritional profiling model would
require the current system of tax on food to be overhauled and would be
complicated.
However, limiting the tax to an excise duty per litre of SSBs could be beneficial for
two reasons. First, it would target a non-essential product and therefore minimise
unintended consequences. Second, it would target the primary source of free sugar
in children’s diets and one of the main sources of free sugars in adults’ diets. As an
SSB tax would be an excise tax, this would increase the baseline cost of SSBs,
whereas a sales tax would apply a tax on purchases regardless of amount bought.
Therefore an excise duty negates the risk associated with other types of taxation that
would make buying bigger volumes cheaper as a way to avoid the tax.
A number of other countries across the globe have introduced SSB taxes to reduce
consumption of SSBs in an effort to combat obesity and incidence of Type 2
diabetes, including France, Finland, Hungary and Mexico.28 In America 39 states and
3 cities29 30have some form of taxation on SSBs either sold in food premises and/or
vending machines, the most recent being introduced in November 2014 in Berkley,
California. It has been reported in the media and from other sources that the Irish
Government is actively considering introducing a tax on SSBs.31
Would an SSB tax work?
While in the short-term a tax will raise revenue, the intended long-term impact of a
tax on SSBs is to reduce the UK’s sugar intake to help tackle obesity levels. A
literature review compiled by the UK Health Forum states that the effectiveness of an
SSB tax should be evaluated against the impact on the consumption of SSBs and
similar products in the context of price elasticity and cross-price elasticity.32 I.e.
whether the tax leads to reduced consumption of SSBs and whether consumers
move towards healthier alternative products as a result.
There are a number of modelling studies that suggest that an SSB tax is a beneficial
policy intervention for governments to adopt to reduce SSB consumption and obesity
4
Policy statement – Sugar
levels. The majority of this research suggests that a 20% tax (or above) should be
adopted to deliver noticeable reductions in consumption.
When applied to the UK it is estimated that a 20% tax would deliver a 15% reduction
in consumption of concentrated SSBs and 16% in non-concentrated SSBs.33
Economic analyses show that when the price of SSBs increase, the demand for
SSBs declines and that there is an increase in demand for other drinks such as milk,
fruit juice, tea and coffee as substitutes. It is therefore reasonable to suggest that the
introduction of an SSB tax would reduce demand.
The modelling studies also show an SSB tax to be an effective policy intervention to
reduce obesity levels. Research conducted by the University of Oxford estimates that
a 20% tax on SSBs would reduce obesity in the UK by 180,000 people and reduce
the number of those overweight by 285,000 people.34
Longitudinal research from the US showed that the odds of children becoming obese
increased 1.6 times for each daily additional can or glass of SSB that they
consumed.35 One possible explanation for the link between SSBs and weight gain is
that as they are a high energy product in liquid form, the consumer does not reduce
their calorie intake at their next meal to compensate and also does not feel full,
despite the high calorie content.36
SSB taxes are a relatively new policy intervention; hence robust data on their effect
on consumption outside of modelling studies is not widely available. However, early
results are emerging from Mexico, where a 10% per litre SSB tax was introduced in
January 2014 to combat the country’s obesity problem. These figures show that the
tax has had the intended effect on reducing sugary drink sales. Sales data figures
show a 10% decrease of SSBs purchased, compared to the previous year. A rise in
purchase of healthier alternatives like water has also been seen.37
It is important to note that an SSB tax alone will not solve the problem of obesity. It
must be part of a suite of policy interventions to reduce obesity levels within the UK.
In particular the Government should also consider reformulation targets to industry,
subsidies to fruit and vegetables,38, 39and restrictions in marketing of products high in
saturated fat, salt and sugar to children online and on TV.
It remains a slight possibility that SSB companies would decide to absorb the excise
tax and therefore offer the products at the same price. However, it is also a possibility
that an SSB tax could drive more of the industry to develop zero sugar versions of
their products or to focus marketing budget on healthier drinks which do not contain
added sugar. It is important to note that an SSB tax would not apply to soft drinks
that do not contain any added sugar, thereby giving consumers a more suitable
alternative.
A frequent counterargument to the introduction of an SSB tax is that that it is
regressive, disproportionately affecting lower income consumers. However, research
published in the New England Journal of Medicine, suggests that this is outweighed
by the potential health gains for this group if an SSB tax were to be implemented.40
This is because consumption figures show higher consumption of SSBs in lower
income households (although the differences are small).41 Furthermore, research
from the University of Oxford has shown that as a 20% tax is a relatively low level of
taxation, the impact would be minimal across socio-economic groups.42 The Food
Research Collaboration (an academic group) states that on its own, an SSB tax is
5
Policy statement – Sugar
regressive. However, accompanying policy interventions can help address this, such
as healthier options becoming cheaper or an extension of the Healthy Start
programme, which distributes vouchers to low income households to claim against
fruit and vegetables.43 This highlights the need for implementing an SSB tax
alongside other policy interventions, such as providing support for people to reduce
their weight and making healthy options cheaper, to go some way in redressing the
regressive nature of such a tax.
Public Health England is due to publish an in-depth evidence review into the
implementation of an SSB tax in the autumn and the BHF awaits this publication.
Support for an SSB tax
There is a significant and growing body of health organisations calling for an SSB tax
to be introduced within the UK. Reputable organisations such as the British Medical
Association, Royal College of Paediatrics and Child Health, the Academy of Medical
Royal Colleges, the UK Health Forum, the Royal Society for Public Health, the British
Dental Health Foundation and Sustain all support the introduction of an SSB tax.44 At
a local level, Food Active, an organisation of Directors of Public Health in the North
West of England, launched the Give Up Loving Pop campaign in February 2015. The
aim of this campaign is to encourage people to stop consuming SSBs as a way to
improve their health. The Action on Sugar coalition also calls for a sugary drinks
duty and a reduction of sugar in food and drinks by 40 per cent by 2020.45 In
September 2015, celebrity chef Jamie Oliver announced that he would introduce a
sugary drinks tax in all his restaurants as well as launching a petition to Government
to introduce a tax, supported by Sustain. As of September 23rd this petition had been
signed over 144,000 times, however the Government responded by saying they have
no plans to introduce a sugary drinks tax.46
Alongside the health sector, individual retailers are taking it upon themselves to
commit to sugar reduction strategies. Examples include Tesco which announced in
May 2015 that they will be embarking on a sugar reduction strategy across their SSB
range.47 Coca Cola have also committed to aiming for at least 50% of the cola they
sell in the UK to be lower or no-calorie options by 2020. 48
Politically, however, the current Conservative Government has ruled out the
introduction of a sugar tax or SSB tax49,50 and has explicitly stated that this is not an
option they are considering in the development of their childhood obesity strategy,
due to be published in Autumn 2015. Similarly, before the General Election the
Labour Party confirmed that they do not support the implementation of so called ‘sin
taxes’ and have publically opposed a sugary drinks tax.51 The only political party to
support an SSB tax is Plaid Cymru, even although the fiscal measures needed to
introduce an excise tax are currently reserved to Westminster.52
For more information please contact [email protected]
1
Scientific Advisory Committee on Nutrition (2015) Carbohydrates and Health Available from: www.sacn.gov.uk
http://www.who.int/mediacentre/news/releases/2015/sugar-guideline/en/
Public Health England and Food Standards Agency (2014). National Diet and Nutrition Survey: Headline results
from Years 1 to 4 (combined) of the rolling programme from 2008 and 2009 to 2011 and 2012. Available from:
https://www.gov.uk/government/publications/national-diet-and-nutrition-survey-results-from-years-1-to-4-combinedof-the-rolling-programme-for-2008-and-2009-to-2011-and-2012
4
Public Health England (2015) ‘Why 5%?’ An explanation of SACNs recommendations about sugars and health.’
https://www.gov.uk/government/publications/sacns-sugars-and-health-recommendations-why-5
5
Jebb S. Dietary determinants of obesity. Obesity Reviews 2007; 8(1): 93–97
2
3
6
Policy statement – Sugar
6
Department of Health (1991). Dietary Reference Values for Food Energy and Nutrients for the United Kingdom
Report of the Panel on Dietary Reference Values of the Committee on Medical Aspects of Food Policy. Report on
Health and Social Subjects 41. London: HMSO
7
Public Health England and Food Standards Agency (2014). National Diet and Nutrition Survey: Headline results
from Years 1 to 4 (combined) of the rolling programme from 2008 and 2009 to 2011 and 2012. Available from:
https://www.gov.uk/government/publications/national-diet-and-nutrition-survey-results-from-years-1-to-4-combinedof-the-rolling-programme-for-2008-and-2009-to-2011-and-2012
8
Public Health England (2015) ‘Why 5%?’ An explanation of SACNs recommendations about sugars and health.’
https://www.gov.uk/government/publications/sacns-sugars-and-health-recommendations-why-5
9
Public Health England (2015) ‘Why 5%?’ An explanation of SACNs recommendations about sugars and health.’
https://www.gov.uk/government/publications/sacns-sugars-and-health-recommendations-why-5
10
Family Food Survey, www.gov.uk/government/collections/family-food-statistics
11
Scientific Advisory Committee on Nutrition (2015) Carbohydrates and Health Available from: www.sacn.gov.uk
11
http://www.who.int/mediacentre/news/releases/2015/sugar-guideline/en/
12
‘Scientific Advisory Committee on Nutrition (2014) Carbohydrates and Health Available from: www.sacn.gov.uk
13
2. Malik VS, et al (2013) ‘Sugar-sweetened beverages and weight gain in children and adults: a systematic review
and meta-analysis.’ American Journal of Clinical Nutrition. 2013; 98(4):1084-102.
14
de Ruyter J et al.(2012) ‘A trial of sugar-free or sugar-sweetened beverages and body weight in children.’ New
England Journal of Medicine. 2012; 367(15):1397-406.
15
Ng SW, Ni Mhurchu C, Jebb SA, Popkin BM, 2012. Patterns and trends of beverage consumption among children
and adults in Great Britain, 1986-2009. Br J Nutr 108(3), 536-51
16
Public Health England (2015) ‘Why 5%?’ An explanation of SACNs recommendations about sugars and health.’
https://www.gov.uk/government/publications/sacns-sugars-and-health-recommendations-why-5
17
De Koning et al (2012) ‘Sweetened Beverage Consumption, Incident Coronary Herat Disease and Biomarkers Risk
in Men.’ Circulation March 12.
18
Fung T et al (2009) ‘Sweetened Beverage Consumption and Risk of Coronary Heart Disease in Women.’ American
Journal of Clinical Nutrition 89 No 4.
19
Dhingra R (2007) ‘Soft drink consumption and risk of developing cardio metabolic risk factors and the metabolic
syndrome in middle aged adults in the community.’ Circulation 116
20
For example: Lui S et al (2002) ‘Relation between a diet with a high glycaemic load and plasma concentrations of
high sensitivity C reactive protein in middle aged women.’ American Journal of Clinical Nutrition 75
21
De Koning et al (2012) ‘Sweetened Beverage Consumption, Incident Coronary Herat Disease and Biomarkers Risk
in Men.’ Circulation March 12.
22
Scientific Advisory Committee on Nutrition (2014) ‘Carbohydrates and Health Report.’ Available at
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/445503/SACN_Carbohydrates_and_H
ealth.pdf
23
Malik VS (2010) ‘Sugar-sweetened beverages and risk of metabolic syndrome and type 2 diabetes: a metaanalysis. Diabetes Care 33, pages 2477-83.
24
Hofman, KJ. (2013) ‘Evidence that a tax on sugar sweetened beverages reduces the obesity rate: a metaanalysis.’ BMC Public Health 13:1072
25
The definition of a ‘health related food tax used by the British Heart Foundation is ‘a tax placed against a product
determined to be unhealthy.’
26
Mytton, O T et al (2012) ‘Taxing unhealthy food and drinks to improve health’. British Medical Journal 344
27
HMRC (Feb 2014) ‘VAT Notice 701/14: food.’ https://www.gov.uk/government/publications/vat-notice-70114food/vat-notice-70114-food
28
World Cancer Research Fund International (2015) ‘Economic tools’ available at
http://www.wcrf.org/int/policy/nourishing-framework/use-economic-tools
29
Center for Science in the Public Interest (2011) ‘Existing Soft Drink Taxes.’
(http://cspinet.org/liquidcandy/existingtaxes.html
30
The Telegraph (2014) ‘The American Way: It is time to curb the great American sugar rush.’ Available at
http://www.telegraph.co.uk/news/worldnews/northamerica/usa/11233057/American-Way-It-is-time-to-curb-the-greatAmerican-sugar-rush.html
31
Irish Times (2014) ‘Reilly sought 20% tax on sugary drinks in Budget, record show.’
http://www.irishtimes.com/news/politics/reilly-sought-20-tax-on-sugary-drinks-in-budget-records-show-1.1689263
32
UK Health Forum (2014) ‘Options for action to support the reduction of sugar intakes in the UK.’
http://nhfshare.heartforum.org.uk/RMAssets/UKHFreports/UK%20Health%20Forum%20Discussion%20document%2
0-%20prepared%20for%20PHE%20June%202014.pdf
33
Scarborough P (2013) ‘Overall and income specific effect on prevalence of overweight and obesity of 20% sugar
sweetened drink tax in UK: econometric and comparative risk assessment modelling study.’ BMJ 347:F6189
34
Scarborough P (2013) ‘Overall and income specific effect on prevalence of overweight and obesity of 20% sugar
sweetened drink tax in UK: econometric and comparative risk assessment modelling study.’ BMJ 347:F6189
35
Gortmaker, L (2001) ‘Relation between consumption of sugar-sweetened drinks and childhood obesity: a
prospective, observational analysis.’ The Lancet 357
36
Gortmaker, L (2001) ‘Relation between consumption of sugar-sweetened drinks and childhood obesity: a
prospective, observational analysis.’ The Lancet 357
37
http://www.ibtimes.com/mexicos-sugary-drink-tax-turns-1-year-old-us-health-proponents-hope-it-can-sway1779632
38
Nnoaham, K. E., Sacks, G., Rayner, M., Mytton, O., & Gray, A Gray A eta al (2009) ‘Modelling income group
difference in health and economic impacts of targeted food taxes and subsidies.’ International Journal of
Epidemiology, 38 1324-1333.
39
Windmeijer F et al (2011) ‘Economic instruments for obesity prevention: results of a scoping review and modified
Delphi survey.’ Journal of Behavioural Nutrition and Physical Activity, 8:109
40
Brownell KD, Farley T, Willett WC, Popkin BM, Chaloupka FJ, Thompson JW, et al. The public health and
economic benefits of taxing sugar-sweetened beverages. N Engl J Med 2009;361:1599-605.
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Policy statement – Sugar
41
Cornelsen L and Carreido A (2015) ‘Health Related taxes on foods and beverages.’ Food Research Collaboration.
Scarborough P (2013) ‘Overall and income specific effect on prevalence of overweight and obesity of 20% sugar
sweetened drink tax in UK: econometric and comparative risk assessment modelling study.’ BMJ 347:F6189
43
Cornelsen L and Carreido A (2015) ‘Health Related taxes on foods and beverages.’ Food Research Collaboration.
44
Full list of supportive organisations to Sustain sugary drink tax campaign
http://www.sustainweb.org/childrenshealthfund/supporters/
45
Action on Sugar (2015) ‘Action on Sugar Manifesto.’ http://www.actiononsugar.org/
46
UK Government Petitions (2015) ‘Introduce a tax on sugary drinks in the UK to improve our children’s health.’
https://petition.parliament.uk/petitions/106651
47
BBC News (2015) ‘Tesco to cut soft drink sugar content.’ http://www.bbc.co.uk/news/health-32835245
48
Coca Cola ltd. ‘Tackling obesity: Choice and Information.’ http://www.coca-cola.co.uk/stories/health/choice-andinformation/tackling-obesity-choice-and-information/
49
The Guardian (2015) ‘No10 pours cold water over junior health minister sugar tax proposal.’
http://www.theguardian.com/society/2015/may/22/no-10-junior-health-ministers-sugar-tax-proposal-cost-obesityprime-minister
50
UK Government Petitions (2015) ‘Introduce a tax on sugary drinks in the UK to improve our children’s health.’
https://petition.parliament.uk/petitions/106651
51
The Grocer (2014) ‘Labour says no to a tax on high- sugar food and drink.’
http://www.thegrocer.co.uk/home/latest-news/labour-says-no-to-a-tax-on-high-sugar-food-and-drink/354576.article
52
Plaid Cymru (2013) ‘Leanne Wood on the sugary drinks levy.’ https://www.partyof.wales/theslate/2013/11/14/leanne-wood-on-the-sugary-drinks-levy/
42
8