In addition to the series of article on long-term outcomes in bariatric surgery, the 2018 special issue of JAMA on obesity, also features several articles discussing the potential role of taxing or otherwise regulating the use of sugar-sweetened beverages (SSB) as a policy measure to address obesity.
In a first article, Jennifer Pomeranz and colleagues discuss whether or not governments can in fact require health warnings on advertisements for sugar-sweetend beverages. The discussion focuses on an injunction issued by the Ninth Circuit Court on the enforcement of San Francisco’s requirement that sugar-sweetened beverage (SSB) advertisements display a health warning statement, finding that this law likely violated the First Amendment rights of advertisers of SSBs.
The background for this court decision was the fact that San Francisco passed a law requiring SSB advertisers to display: “WARNING: Drinking beverages with added sugar(s) contributes to obesity, diabetes, and tooth decay. This is a message from the City and County of San Francisco.”
In its decision, the court felt that the proposed warning label was not scientifically accurate, as it focussed exclusively on “added sugar(s)” rather than sugars overall. It appears that there is no scientific evidence suggesting that “added sugars” are any more (or less) harmful than the “natural” sugar occurring in any other foods or beverages).
However, as the authors argue, warning on SSB may well be warranted as
“In addition to being a major source of added sugar in the US diet, the liquid form of SSBs could enable rapid consumption and digestion without the same satiety cues as solid foods. SSBs also contain no relevant ingredients to provide offsetting health benefits, in comparison with sweetened whole grain cereals, nut bars, yogurt, or other foods with added sugars, which can have healthful components. Furthermore, the associations of SSBs with weight gain, obesity, type 2 diabetes, and heart disease are each stronger and more consistent than for added sugars in solid foods. In addition, compared with other foods containing added sugars, SSBs are the only source for which randomized controlled trials have confirmed the observational link to weight gain.”
Another point of contention identified by the court was related to the fact that the warning stated harm irrespective of quantity and would have been more accurate had it included the term “overconsumption” or at leas the qualifier “may”.
Here, the authors argue that,
“health risks of SSBs increase monotonically. Thus, use of the word “overconsumption” would not be scientifically accurate because there is no clear threshold effect between SSB consumption and harm. Yet, due to potential individual variation in responses, incorporating the word “may” or “can” would be scientifically accurate and are used in alcohol and smokeless tobacco warnings.”
The third objection by the court was related to the proposed size and rectangular border requirements of the warning, which was considered to be “unduly burdensome” – a point that the authors concede could be dealt with by modify formatting requirements by slightly reducing size, permitting “hairline” borders, or using other methods to ensure prominence and conspicuousness.
.In a second article on the issue of SSBs, Lisa Powell and Matthew Maciejewski discuss the case for taxing SSBs, noting they are the largest contributor of added sugar in the US diet, accounting for approximately 6.5% of total daily calories among adults and 7.3% among youth (ages 2-19 years) and approached 8% to 9% of daily calories among minority populations and 9% to 10% among low-income households. In addition consumption of SSBs have been associated with obesity as well as type 2 diabetes, cardiovascular disease, dental caries, and osteoporosis.
As the authors point out, for SSB taxes to be effective, the increased cost of SSBs has to be passed on to the consumer (“pass-through) and the consumer has to respond by decreasing their consumption (“price elasticity”). In places where SSB taxes have been implemented (e.g. Mexico), both effects have been seen, suggesting that an SSB tax can indeed change consumer behaviours.
However, as the authors also note, so far there is little evidence directly demonstrating that such changes have translated into actual health outcomes (for obesity or otherwise).
Nevertheless, the authors feel that an SSB tax can effectively decrease the overall consumption of these beverages and should perhaps be extended even further to include all forms of sugary drinks including 100% fruit juice. For this approach to be broadly acceptable, it would also be important to dedicate any revenue from these taxes to specific educational or public health purposes.
Finally, a third article on this issue by John Cawley deals with an interesting “quasi experimental” pass-through effect of SSB taxes at the Philadelphia International Airport, which happens to straddle the city border, with some terminals in Philadelphia that are subject to the beverage tax (1.5 cents per ounce), and other terminals in Tinicum that are not.
The study included 31 stores: 21 on the taxed side of the airport (Philadelphia) and 10 on the untaxed side (Tinicum).
As the authors found, following the implementation of the SSB tax in Philadelphia, the average price of SSBs increased on both the taxed and untaxed side of the airport (albeit more so on the taxed side). Using only data for taxed stores, the percentage of the tax passed on to consumers was 93%. Overall, however, the price difference between the taxed and untaxed stores was about 0.83 cents per ounce (a 55% relative pass-through rate).
Thus, while the tax did have a significant effect on SSB pricing in Philadelphia, it appears that the non-taxed stores simply went along to increase their profit margins accordingly.
Whether or not these changes in pricing had any impact on actual SSB sales or consumption was not reported.
Together, these studies certainly support the statement by Powell and Maciejewski that
“SSB taxes are likely to remain controversial for some time and policy makers will have a number of issues to consider as they formulate and implement fiscal policies.”
“SSB taxation can only be one approach to what must be a multipronged public health strategy to reduce obesity via improved diets and increased activity. The fact that intake of SSBs has declined over the past decade and the obesity epidemic has continued unabated suggests that reducing SSBs alone is not the sole solution. Adults and youth who frequently consume SSBs are more likely to engage in other unhealthy behaviors (eg, inactivity, greater fast-food consumption), so population-based policies specifically targeting these behaviors need to be designed in concert with SSB taxes. Although SSB consumption remains high in the United States, particularly among vulnerable populations, and taxation is a viable tool for curbing its consumption, the long-run intended and unintended effects of SSB tax policy are yet to be determined. The debate on its merits as an effective tool to improve health outcomes will be greatly informed by rigorous evidence on consumption, sugar intake, and body weight both on average and within vulnerable populations (children, minorities, low-income individuals).”
This week, JAMA revisits obesity with a dedicated theme issue, which includes a range of articles on obesity prevention and management (including several on the impact of taxing sugar-sweetened beverages and five original long-term studies on bariatric surgery).
In an accompanying editorial, Edward Livingston notes that,
“The approach to the prevention and treatment of obesity needs to be reimagined. The relentless increase in the rate of obesity suggests that the strategies used to date for prevention are simply not working.”
“From a population perspective, the increase in obesity over the past 4 decades has coincided with reductions in home cooking, greater reliance on preparing meals from packaged foods, the rise of fast foods and eating in restaurants, and a reduction in physical activity. There are excess calories in almost everything people eat in the modern era. Because of this, selecting one particular food type, like SSBs, for targeted reductions is not likely to influence obesity at the population level. Rather, there is a need to consider the entire food supply and gradually encourage people to be more aware of how many calories they ingest from all sources and encourage them to select foods resulting in fewer calories eaten on a daily basis. Perhaps tax policy could be used to encourage these behaviors, with taxes based on the calorie content of foods. Revenue generated from these taxes could be used to subsidize healthy foods to make them more affordable.”
Over the next few days, I will be reviewing about the individual articles and viewpoints included in this special issue.
In the meantime, the entire issue is available here.
The following is a guest post from my Australian colleague Dr. Georgia Rigas, who reports on the recent recognition of obesity as a disease by the Royal Australian College of General Practice (RACGP).
Last week, the Royal Australian College of General Practice (RACGP) President, Dr Seidel recognised obesity as a disease. The RACGP is the first medical college in Australia to do so.
This was exciting news given that we have just observed World Obesity Day a few days ago.
According to the Australian Bureau of Statistics1, over 60% of Australian adults are classified as having overweight or obesity, and more than 25% of these have obesity [defined as a Body Mass Index (BMI) ≥30] (ABS2012). Similarly in 2007, around 25% of children aged 2–16 were identified as having overweight or obesity, with 6% classified as having obesity (DoHA 2008). These are alarming statistics.
The recent published BEACH data for 2015-162, showed that the proportion of Australian adults aged 45-64yo presenting to GPs has almost doubled in the last 15+ years. Worryingly the numbers are predicted to continue rising, with 70% of Australians predicted to have overweight or obesity by 2025. Embarrassingly, the BEACH data also indicated that <1% of GP consultations centred around obesity management.
So obviously what we, as GPs have been doing..,or rather not doing…isn’t working!
The RACGP’s General Practice: Health of the Nation 2017 3report found Australian GPs identified obesity and complications from obesity as one of the most significant health problems Australia faces today and will continue to face in coming years as the incidence of obesity continues to rise.
But what are we doing about it?…. I think the answer is evident… clearly not enough!
Thus, we can only hope that this announcement by the RACGP will have a ripple effect, with other medical colleges in Australia and then the Australian Medical Association following suit.
So what does this mean in practical terms?
For those individuals with obesity (BMI ≥30) with no “apparent” comorbidities or complications from their excess weight…[though you could argue they will develop (if not already) premature osteoarthritis of the weight bearing joints…..] would be eligible for a chronic care plan [government subsidized access to a limited number of consultations with allied health services] given the chronic and progressive nature of the disease.
It also highlights the need for GPs to start screening ALL patients in their practice-young and old;
- for children their parameters need to be plotted on a BMI-for-age chart;
- for adults BMI & waist circumference, taking into account their ethnicity (as different cut- offs for different ethnic groups) and physical activity levels (if they are muscular or not) are important
This powerful statement should help clear any ambivalence.
Why is there a therapeutic inertia when it comes to treating people with obesity?
People with obesity suffer significant degrees of stigma, discrimination and weight bias and as a result may be reluctant to access healthcare. Today, we are giving these patients a voice.
As health care professionals, let’s not forget that the health message needs to change from “lose weight” to “gain health” in recognition that obesity is about more than body weight.
In closing, to effectively and equitably work towards reducing obesity in our communities, we need a balanced combination of both individual and public health measures. This media release by the RACGP shows their commitment to both the primary prevention and the treatment of this life- threatening disease, to ensure better health outcomes and quality of life for all Australians.
Dr Georgia Rigas, MBBS FRACGP
SCOPE certified obesity doctor
Bariatric Medical Practitioner
Yesterday (World Obesity Day), the European Regional Office of the World Health Organisation released a brief on the importance of weight bias and obesity stigma on the health of individuals living with this condition.
The brief particularly emphasises the detrimental effects of obesity stigma on children:
“Research shows that 47% of girls and 34% of boys with overweight report being victimized by family members. When children and young people are bullied or victimized because of their weight by peers, family and friends, it can trigger feelings of shame and lead to depression, low self-esteem, poor body image and even suicide. Shame and depression can lead children to avoid exercising or eatng in public for fear of public humiliation. Children and young people with obesity can experience teasing, verbal threats and physical assaults (for instance, being spat on, having property stolen or damaged, or being humiliated in public). They can also experience social isolation by being excluded from school and social activities or being ignored by classmates.
Weight-biased attitudes on the part of teachers can lead them to form lower expectations of students, which can lead to lower educa onal outcomes for children and young people with obesity. This, in turn, can affect children’s life chances and opportunities, and ultimately lead to social and health inequities. It is important to be aware of our own weight-biased attitudes and cautious when talking to children and young people about their weight. Parents can also advocate for their children with teachers and principals by expressing concerns and promo ng awareness of weight bias in schools. Policies are needed to prevent weight-victimization in schools.”
The WHO Brief has important messages for anyone working in public health promotion and policy:
Take a life-course approach and empower people:
Monitor and respond to the impact of weight-based bullying among children and young people (e.g. through an -bullying programmes and training for educa on professionals).
• Assess some of the unintended consequences of current health-promo on strategies on the lives and experiences of people with obesity. For example:
- Do programmes and services simplify obesity?
- Do programmes and services use stigmatizing language?
- Is there an opportunity to promote body positivity/confidence in children and young people in health promotion while also promoting healthier diets and physical activity?• Give a voice to children and young people with obesity and work with families to create family-centred school health approaches that strengthen children’s resilience and consider positive outcomes including but not limited to weight.• Create new standards for the portrayal of individuals with obesity in the media and shift from use of imagery and language that depict people living with obesity in a negative light. Consider the following:
- avoiding photographs that place unnecessary emphasis on excess weight or that isolate an individual’s body parts (e.g. images that dispropor onately show abdomen or lower body; images that show bare midri to emphasize excess weight);
- avoiding pictures that show individuals from the neck down (or with face blocked) for anonymity (e.g. images that show individuals with their head cut out of the image);
- avoiding photographs that perpetuate a stereotype (e.g. ea ng junk food, engaging in sedentary behaviour) and do not share context with the accompanying wri en content.
Strengthen people-centred health systems and public health:
• Adopt people-first language in health systems and public health care services, such as a “patient or person with obesity” rather than “obese patient”.
• Engage people with obesity in the development of public health and primary health care programmes and services.
• Address weight bias in primary health care services and develop health care models that support the needs of people with obesity.
• Apply integrated chronic care frameworks to improve pa ent experience and outcomes in preventing and managing obesity. In addition:
- recognize that many patients with obesity have tried to lose weight repeatedly;
- consider that patients may have had negative experiences with health professionals, and approach patients with sensitivity and empathy;
- emphasize the importance of realistic and sustainable behaviour change – focus on meaningful health gains and
- explore all possible causes of a presenting problem, and avoid assuming it is a result of an individual’s weight status.
- Acknowledge the dificulty of achieving sustainable and significant weight loss.
Create supportive communities and healthy environments:
- Consider the unintended consequences of simplistic obesity narratives and address all the factors (social, environmental) that drive obesity.
- Promote mental health resilience and body positivity among children, young people and adults with obesity.
- sensitize health professionals, educators and policy makers to the impact of weight bias and obesity stigma on health and well-being.
Hopefully, these recommendations will find their way into the work of everyone working in health promotion and clinical practice.
The whole brief is available here.
This morning, I am presenting a plenary talk in Berlin to about 200 colleagues involved in childhood obesity prevention.
The 1-day symposium is hosted by Plattform Ernährung und Bewegung e.V. (Platform for Nutrition and Physical Activity), a German consortium of health professionals as well as public and private stakeholders in public health.
Although, as readers are well aware, I am by no means an expert on childhood obesity, I do believe that what we have learnt about the complex socio-psycho-biology of adult obesity in many ways has important relevance for the prevention and management of childhood obesity.
Not only do important biological factors (e.g. genetics and epigenetics) act on the infant, but, infants and young children are exposed to the very same societal, emotional, and biological factors that promote and sustain adult obesity.
Thus, children do not grow up in isolation from their parents (or the adult environment), nor do other biological rules apply to their physiology.
It should thus be obvious, that any approach focussing on children without impacting or changing the adult environment will have little impact on over all obesity.
This has now been well appreciated in the management of childhood obesity, where most programs now take a “whole-family” approach to addressing the determinants of excess weight gain. In fact, some programs go as far as to focus exclusively on helping parents manage their own weights in the expectation (and there is some data to support this) that this will be the most effective way to prevent obesity in their offspring.
As important as the focus on childhood obesity may be, I would be amiss in not reminding the audience that the overwhelming proportion of adults living with obesity, were normal weight (even skinny!) kids and did not begin gaining excess weight till much later in life. Thus, even if we were somehow (magically?) to completely prevent and abolish childhood obesity, it is not at all clear that this would have a significant impact on reducing the number of adults living with obesity, at least not in the foreseeable future.
Let us also remember that treating childhood obesity is by no means any easier than managing obesity in adults – indeed, one may argue that effectively treating obesity in kids may be even more difficult, given the the most effective tools to managing this chronic disease (e.g. medications, surgery) are not available to those of us involved in pediatric obesity management.
Thus, I certainly do not envy my pediatric colleagues in their struggles to provide meaningful obesity management to their young clients.
I am not sure how my somewhat sobering talk will be received by this public health audience, but then again, I don’t think I was expected to fully toe the line when it comes to exclusively focussing on nutrition and activity (as important as these factors may be) as an effective way to prevent or even manage childhood obesity.