This editorial briefly considers the increasing epidemic of obesity and Type 2 diabetes, the underlying drivers of junk food and sugary drinks, and the recent scientific and campaigning movements culminating in the UK Chancellor's surprise announcement of a Sugary Drinks Levy

Capewell, Simon

Lloyd-Williams, Ffion

University of Liverpool Repository

Community Dental Health (2016) 33, 174–176 © BASCD 2016 doi:10.1922/CDH_Lloyd-Williams03Selling a sugar tax: the sweet smell of success?Dr Ffion Lloyd-Williams and Professor Simon CapewellPublic Health and Policy, University of Liverpool, UK This editorial briefly considers the increasing epidemic of obesity and Type 2 diabetes, the underlying drivers of junk food and sugary drinks, and the recent scientific and campaigning movements culminating in the UK Chancel-lor’s surprise announcement of a Sugary Drinks Levy.Type 2 Diabetes, Obesity, and Public HealthType 2 diabetes is an increasing health problem in the UK, currently affecting over three million people diag-nosed (Diabetes UK, 2012; NHS Choices, 2014) and increasing to over five million people by 2025. Obesity is the most powerful driver, and accounts for 86% of the overall risk of developing Type 2 diabetes; hence the current global epidemic. Furthermore, over the last two decades, the prevalence of obesity has increased two fold globally and threefold in the UK (WHO, 2015b). The Health Survey for England (2011-2013) shows that approximately two thirds of UK adults are now overweight or obese: 66% of men, 58% of women (HSCIC, 2014). As are one in three children completing primary school: 30% of boys, 27% of girls (PHE, 2014b). Furthermore, obesity is two-fold higher in children from deprived households compared with affluent households. If recent trends continue, 60% of UK men, 50% of women and 25% of children will be obese by 2050. This would generate massive additional costs to the NHS, and also increase the burden on social care, welfare and families because obesity drastically increases a person’s future risk of cardiovascular disease, diabetes, dementia and many common cancers. The main contributors to obesity in the food system include the increased supply of inexpensive, energy-dense junks foods and sugary drinks, persistent and aggressive food marketing and physical inactivity (Health Committee, 2015; PHE, 2015a). Obesity is therefore a major public health challenge, principally reflecting an obesogenic environment with an increased consumption of energy dense, nutrient poor foods and sugary drinks (Kleinert and Horton, 2015; NICE, 2012; Swinburn et al., 2015; WHO, 2013a).The role of simple sugars in the aetiology of Obe-sity and Type 2 DiabetesThe excessive consumption of sugar hidden in fizzy drinks, fruit juices, confectionery and junk foods (Ima-mura et al., 2015) represents one of the main causes of Correspondence to: Professor Simon Capewell, Public Health and Policy, Waterhouse Building, Block B, 2nd Floor, University of Liverpool, Liverpool L69 3BX, UK. Email: capewell@liverpool.ac.ukEditorialthe increasing obesity and diabetes rates. Worse still, UK and global populations are consuming increasing amounts of these sugary drinks and junk foods high in salt, sugar and animal fats (Monteiro, 2011). Furthermore, a high-sugar diet has been linked with an increased incidence of type 2 diabetes independent of obesity. Sugar consumption also increases dental decay (SACN, 2015) and coronary heart disease (Yang et al., 2014). The recent Scientific Advisory Committee on Nutrition (SACN) Carbohydrates and Health Report reported several meta-analyses of prospective cohort studies. These indicated that greater consumption of sugar-sweetened beverages is associated with increased risk of type 2 diabetes mellitus and obe-sity. SACN concluded that drinking high-sugar beverages results in weight gain and increased body mass index (BMI) in teenagers and children and increases the risk of developing type 2 diabetes independently of obesity. What to do?If prevention was as simple as eating less and doing more, then none of us would be overweight. It is clearly not that simple. The problem is that we live in an obesogenic environ-ment (Swinburn et al., 2015). The public health priority is therefore to create an environment which supports the increasing consumption of healthy foods, and decreasing intake of sugary drinks and junk foods. There is clear scientific evidence that reducing consumption is far more effective in obesity prevention than simply increasing physical activity levels (Lim et al., 2012). Increasing consumption of healthier food can bring large benefits, as demonstrated in diverse populations in countries in-cluding Finland, France, Hungary, Latvia, the USA and Mexico (Mozaffarian and Capewell, 2011; PHE, 2015b).Healthy foods lack the financial capacity to compete with junk food and sugar sweetened beverages (Federal Trade Commission, 2008; Harris et al., 2009). Junk food and sugar-sweetened beverages are immensely profitable to the food industry. They are provided in cheap excess and are marketed aggressively. Companies are able to employ the best marketing agencies, buy multiple outlets and sponsor high profile sports. In contrast, healthy foods are less ubiquitous and can be more expensive or require valuable time to prepare (Faculty of Public Health, 2013).175The UK has been steadily moving towards a tax on sugar sweetened beverages since Action on Sugar (AoS) launched its campaign in January 2014. AoS involved lead-ing experts uniting to tackle and reverse the obesity and diabetes epidemic (AoS). Action on Sugar’s initial aims were: 1. to achieve a reduction in free sugars intake in the UK and ensure it contributes to less than 5% of total energy intake2. to ensure the body of scientific evidence about the dangers of excessive refined free sugars consumption becomes translated into policy by the Government and relevant professional organisations. Since then, AoS has been successfully working to reach a consensus with the food industry and Government over the harmful effects of a high sugar diet, and bring about a reduction in the amount of sugar in processed foods. In 2014, AoS began by highlighting the vast and unnecessary amounts of sugar currently being added to junk food and soft drinks. This very successful and effective strategy has continued. For instance, their most recently survey targeted hot drinks available in popular coffee shop outlets. They found that 98% of hot flavoured drinks would receive a ‘red’ (high) label for excessive levels of sugars per serving, with a third containing more sugar than a can of cola (AoS, 2016). Recent DevelopmentsThe World Health Organization (WHO) Global Action Plan 2013-2020 set a global target of a 25% relative reduction in non-communicable diseases by 2025 (WHO, 2013). This included policies to reduce the content of free and added sugars in non-alcoholic beverages, as well as reducing the impact on children of marketing of non-alcoholic beverages high in free sugars (WHO, 2013).Scientific evidence to support substantial reductions in sugar consumption, has been steadily increasing, with notable reports by WHO, SACN, Public Health England (PHE) Faculty of Public Health and other agencies (AoS, 2014; 2016; Faculty of Public Health, 2013; Mozaffarian and Capewell, 2011; PHE, 2014a;b; SACN, 2015). PHE, SACN and WHO recently recommended substantially reducing the intake of free sugars from the current level of approximately 15% of total energy intake in adults and children, (almost 20 teaspoons of sugar a day) to less than 10% initially, then 5%. That 10% recommendation for children would equate to six teaspoons per day for chil-dren aged 5-11 years and four per day for children aged 4-6years (WHO, 2015a). The subsequent target of less than 5% of daily energy (Faculty of Public Health, 2013; Mozaffarian and Capewell, 2011; SACN, 2015) would equate to a reduction to just six teaspoons in an adult, and three in a nine year old child. This is the equivalent of a small glass of fruit juice and a flavoured yoghurt per day. Powerful and persuasive scientific evidence has therefore accumulated in leaps and bounds in the last two years. Fearing a threat to their profits, the processed food and beverage industries have bitterly opposed any form of regulation or taxation. The parallels with tobacco industry tactics have thus become increasingly clear, hence the suggestion that Sugar is the New Tobacco. However, in spite of this bitter corporate opposition, public awareness and support for action have grown steadily in England and the devolved countries. Thus in December 2015, the Welsh Assembly Government sup-ported the idea of introducing a tax on sugary drinks in Wales to cut rates of obesity and diabetes (The Guardian, 2015). Northern Ireland did likewise in February 2016, and a tax has also been recently discussed in Scotland. In England, the Parliamentary Health Select Committee recently reviewed extensive evidence and then urged the UK government to finalise and publish their comprehensive, evidence-based Childhood Obesity Strategy. One which ideally included bold and brave measures to reduce the consumption of sugar-sweetened carbonated soft drinks (AoS, 2014). Initially promised in early 2016, that strategy launch was postponed and eventually published ion 18th August 2016 ,raising accusations of industry lobbying and government backsliding. The HSC and myriad of charities recently working together as the Obesity Health Alliance also continued to highlight the urgent necessity of introducing a sugary drinks tax in the UK (Health Committee, 2015). This was initially without any apparent effect. And then suddenly, out of the blue, on the 16th March 2016, the Chancellor included in his Budget an announcement of a levy on sug-ary drinks manufacturers equivalent to a 10% excise tax. However, implementation would be delayed until 2018 “to give the industry time to respond and reformulate”. 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Editorial: Selling a sugar tax: the sweet smell of success?

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