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- Page navigation anchor for Sugary Drinks and Pediatric Health – Reflections from a Tertiary Care HospitalSugary Drinks and Pediatric Health – Reflections from a Tertiary Care Hospital
Extensive research has demonstrated the negative impacts of sugary drink intake. While the impacts of high sugary drink intake are far-reaching and include health, social and economic burdens, what is missing from the discussion by Riediger and Bombak (1) is the consideration of the further inequity and additional economic burden that inevitably arises from the evolving poor health outcomes of our pediatric patients.
While the authors acknowledge the link between sugary drinks and obesity, they minimize the other associated chronic diseases and they do not discuss how these diseases lead to greater health disparity. The authors also fail to account for how the disproportionate burden of disease among people with low-incomes impacts an individual’s quality of life. The growing rates of chronic disease burden our publicly funded health care system, which will be doubly burdened by an aging population and increasing rates of chronic disease among children at younger and younger ages.
Working with vulnerable populations in a pediatric tertiary care hospital, we observe first-hand the impacts that unhealthy diets have, including sugary drink consumption, and the resulting chronic disease they cause to our patients. With current sugary drink use and trends, it is estimated that more than 2 million new cases of obesity, almost 1 million cases of type 2 diabetes, over 100,000 cancer cases and almost 300,000 cases of cardiovascular disease will develop over the nex...
Show MoreCompeting Interests: None declared. - Page navigation anchor for A made in Canada sugary drink levy can help reduce intake while also being mindful of addressing health disparitiesA made in Canada sugary drink levy can help reduce intake while also being mindful of addressing health disparities
The authors are correct that we must ensure that any levy on sugary drinks does not create unintended consequences or significantly widen social disparities. But the sugary drinks themselves contribute exactly to those disparities because the conditions they can cause – diabetes, heart disease/stroke, cancer and obesity – are highly regressive and disproportionately impact low-income and Indigenous populations. (1-3)
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The reality for many Indigenous and northern communities is that food insecurity is high (4), and healthy options (fruit, vegetables and milk) can be more expensive and less available than energy-dense/nutrient-poor options. A head of cabbage or bunch of grapes can go for upwards of $30, (5,6) whereas a box of Kraft Dinner is more affordable at $4 (7). Cases of water can be priced around $100 (5,8) while a 12 can case of pop can be listed at $27 (9) representing a lower price per unit and more accessible option for hydration. These price differences are exacerbated by marketing practices of the sugary drink manufacturers which, as Senator Dennis Patterson of Nunavut has told the Senate of Canada, extend even to very remote areas and to children as young as five (10).
We have a responsibility to act urgently and robustly and a levy could help in a number of ways. In the United Kingdom, in anticipation the sugary drink levy, manufacturers reduced the sugar content of some beverages even before the levy took effect in April 2018 (11). In Mexico, the i...Competing Interests: The author is Director, Health Policy & Advocacy at Heart & Stroke, an organization which has declared its strong support for a levy on sugary drinks in Canada as a tool to reduce their consumption. No other conflicts declared. - Page navigation anchor for Sugar is Not the “New Tobacco”Sugar is Not the “New Tobacco”
Sugar is Not the “New Tobacco”
As an endocrinologist who is also an anti-smoking advocate, seeing the title "Are sugar-sweetened drinks the new tobacco?" on the cover of my April 2018 CMAJ immediately drew my ire. While "orange is the new black" or "fifty is the new forty" [I hope so!] may be harmless commonly-used axioms, we, as medical professionals, should be more careful when publicly drawing equivalencies in matters of public health. The increasingly common comparison of obesity and sugar (or other "unhealthy" food substances) to smoking and tobacco is an important example of such.
According to Health Canada, smoking remains the leading preventable cause of death in Canada (and worldwide) killing more than five times traffic injuries, alcohol abuse, murder and suicide combined [1]. Obesity, diabetes, dyslipidemia, and hypertension are appropriately excluded from that assessment because they are not in the same sense preventable conditions. They are continuous variables, defined using somewhat arbitrary cut-offs, and cannot be avoided via a single decision or action such as never starting to smoke, wearing a bicycle helmet or outlawing assault weapons. They are much better thought of as modifiable risk factors. Healthy eating is the sum of innumerable decisions that need to be made multiple times daily over an entire lifetime by every one of us, none of which are ever absolutely right or wrong. Making the distinctio...
Show MoreCompeting Interests: None declared. - Page navigation anchor for RE: Successful in the UK, adaptable to CanadaRE: Successful in the UK, adaptable to Canada
Riediger and Bombak argue that Canada should not implement a sugary drink tax because it won’t help reduce inequalities in obesity and highlight a number of other challenges with the tax. However their arguments fail to recognize that the impact of a sugar-sweetened beverage tax will depend on how it is constructed and implemented.
Sugary drink taxes typically have two aims: to encourage the beverage industry to change or reformulate their products and to reduce individual-level consumption of the products. Depending on how the tax is structured, the balance between these two aims can shift. In the UK, the Sugary Drink Industry Levy primarily focuses on changing industry behavior. It came into force in April 2018, and is structured as a two-tier system, with a higher level of tax for a higher level of sugar (18p/L for drinks containing at least 5g of sugar per 100ml, and 24p/L for those with more than 8g per 100ml), and is levied on manufacturers rather than individual consumers. It was announced in March 2016, and in the intervening two years, sugary drink manufacturers have already reformulated their products to avoid the higher level of tax resulting in significant reductions in sugar consumption even before the tax was officially introduced. This is evidenced by the expected revenues from the tax, which have been revised down from £500m per year to £240m per year due to reformulations in the time between the announcement in March 2016 to the finance budget in au...
Show MoreCompeting Interests: None declared. - Page navigation anchor for When the perfect is the enemy of the goodWhen the perfect is the enemy of the good
The central flaw of Riediger and Bomback‘s argument is to suggest that public health solutions are narrow in scope: no single strategy is ever universally effective or equitable. Continuing the connection between tobacco and sugar-sweetened goods, tobacco consumption has been effectively reduced in Canada as well as internationally not through the sole agency of taxes, but through a suite of measures (the WHO MPOWER framework) that impact how we interact with tobacco through every stage of the process: manufacturing, regulation, marketing, labels & warnings, retail accessibility and substitution including cessation aids.
As such, the public health community has equally recognized that taxes are ‘a’ measure, not ‘the’ measure to address obesity or chronic disease caused by poor nutrition. A sugar sweetened beverage tax must accompany other policies and programs that form a comprehensive approach to what is debatably a more wicked problem than tobacco. Indeed, through a collective set of measures, an approach may be taken that allows for emphasis of certain approaches for specific populations and locations to maximize effectiveness and minimize any potential inequities produced. Given that Indigenous Peoples, as pointed out by the authors, do suffer increased barriers to access to fresh drinking water and have higher degrees of food insecurity, efforts to limit intake of unhealthy food and beverages foods should be at minimum matched by initiatives to increa...
Show MoreCompeting Interests: None declared. - Page navigation anchor for RE: The Need for Canada to Tax Sugar-sweetened BeveragesRE: The Need for Canada to Tax Sugar-sweetened Beverages
In their analysis of the potential effects of sugar sweetened beverage (SSB) taxation Ridiger and Bombak correctly point out that we must take in to account the potential effects of such a tax on weight stigma, Indigenous populations and health inequities. They also call to our attention the lessons learned from tobacco taxation. It would be a mistake, however, for readers to conclude that Canada should not implement a levy on sugar sweetened beverages.
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SSBs are strongly linked with obesity and the associated chronic diseases , and SSB consumption is an independent risk factor for type 2 diabetes and heart disease regardless of BMI. Targeted taxation of SSBs raises their price and results in decreased consumption . Big Beverage is aware of this link and they have spent over $100 million dollars over the last 8 years fighting SSB taxation .
Weight stigma exists because excess weight gain is often misattributed to gluttony and sloth rather than to the modern obesogenic environment which promotes excess caloric intake. SSB manufacturers reinforce this misconception by stressing the role of inactivity in weight gain , deflecting responsibility from their product and implicitly labelling the obese as lazy. Placing a levy on SSB lays blame where it belongs.
Indigenous Canadians are being ravaged by excessive sugar consumption and as a result, 85% of First Nations women will go on to develop type 2 diabetes . Free, safe and reliable drinking water must be...Competing Interests: None declared. - Page navigation anchor for SETTING THE RECORD STRAIGHT ON TAXATION AND DISPARITIES IN SMOKINGSETTING THE RECORD STRAIGHT ON TAXATION AND DISPARITIES IN SMOKING
We were pleased to see the article from Riediger and Bombak[1] highlighting the importance of disparities in tobacco use. However, the suggestion that reductions in smoking have only been achieved among high socioeconomic groups — and that tobacco taxes have exacerbated inequalities — is incorrect.
Although smoking rates in Canada remain substantially higher among lower socioeconomic groups, similar reductions have been achieved among all socioeconomic groups over the past 20 years — the period with the largest absolute increases in tobacco taxes. For example, reductions in smoking prevalence among Canadians with less than a secondary school education have been comparable to those among post-secondary graduates in both of Canada’s benchmark surveys, CTUMS (1999-2012; -9.5 vs -7.0 percentage points, respectively)[2] and CCHS (2000-2014; -8.0 percentage points each).[3] Smoking is not simply a problem among socioeconomically disadvantaged Canadians: in fact, there are 2.4 times as many smokers in Canada with a post-secondary education as with less than a high school diploma (2,606,684 vs. 1,085,446, respectively).[3]
Riediger and Bombak are also incorrect to suggest that tobacco taxes have exacerbated inequalities in smoking and are less effective among the economically disadvantaged. Authoritative reviews conducted on behalf of the World Health Organization (WHO), the International Agency for Research on Cancer and other leading public health authorities dete...
Show MoreCompeting Interests: None declared.