Tag Archives: soda

Price Policies to Promote Healthy Eating: Missing the Forest for the Trees

Champagne wine and fruit salad coctail in a glassAmerican anxiety over healthcare costs and obesity continues to fuel public health advocacy for increased taxes on sugar-sweetened beverages and other unhealthy foods. Proponents of imposing higher taxes on unhealthy food products, such as soda, claim they are a necessary and effective strategy for modifying consumption behaviors and improving health outcomes. The logic is that a tax will make unhealthy foods more expensive, thereby deterring people from consuming them in excess. Advocates argue that excessive consumption of sugar-sweetened beverages not only harms individual health, but also induces increased healthcare costs that cause societal harm. Since rising healthcare costs negatively affects the public, they propose that governments are justified using fiscal policies to intervene to nudge individuals to change their dietary choices. This logic has persuaded residents of Berkeley, Seattle, and Philadelphia to vote in favor of implementing a sugar-sweetened beverage excise tax. Despite fervent support from public health advocates many people remain skeptical of imposing excise taxes on sugar-sweetened beverages as a public health solution.

I have to admit, when I was first exposed to the concept of “nudging” and soda taxes, I found them appealing. However, after in depth reflection about my values as a public health scholar, my perspective has shifted.

In late 2017, Cook County repealed its sugar-sweetened beverage tax due to intense opposition after the tax failed to live up to expectations. A major concern of using taxes to shift dietary choices is their disproportionate impact on low-income households. Higher prices on consumer goods disproportionately affect households of lower socio-economic status than wealthier households. This concern for equity was explored in a recent Lancet article, which has been touted as “a new weapon in their battle against sugar” by a review published in Fortune. The authors of the Lancet article conclude that although price policies DO often bear the largest tax burden, governments can justify this burden if the estimated health benefits of decreased consumption are likely to disproportionately benefit poorer households. This moral trade-off assumes that sugar-sweetened beverage taxes are effective at improving diet patterns and health. However, this assumption is just that-an assumption- since the evidence in support of substantial behavior changes or health impacts is weak. Even so, when it comes to public health, debating the equity of excise taxes of unhealthy food products misses the forest for trees.

The Big Neoliberal Distraction

Taxing unhealthy food items to modify individual behavior is part of a neoliberal trajectory in public health discourse. Neoliberalism is the prevailing political-economy paradigm that emphasizes free-market consumerism, individual responsibility, and minimal government spending. A variant of neoliberalsim, referred to as libertarian paternalism, legitimizes the role of private and public institutions in using market-based strategies to influence private behavior so that an individual’s freedom of choice is maintained. Fiscal policies, such as excise taxes, are a market-based strategy that nudge individuals into taking responsibility for their health are a form of libertarian paternalism in public health.

The push for increasing taxes on food items deemed unhealthy is occurring in midst of a larger political-economic wave of tax cuts for wealthy households and corporations, increased corporate consolidation, decreased public investment in education, calls to cut investment in Medicaid and privatize Medicare, restrict SNAP eligibility, threats to environmental regulations, and persecution of labor rights–all policies that contribute to increased economic insecurity that leads to stress (weight gain) and decreased ability to purchase adequate healthy food. This neoliberal agenda erodes an institutional environment that provides the greatest support for health while painting soda-drinkers as social deviants. It is within this context that The Lancet article argues that even though increased price of soda disproportionately affects people of low socioeconomic status, soda taxes may be just because these same people may realize greater health benefits than people from higher socioeconomic statuses. But is the fact that low-income individuals might benefit more in terms of health from this policy enough to claim that the policy is just?

Neoliberal public health strategies that aim to “fix” a single behavior (drinking soda or eating junk food) are reductionist in nature and ignore the underlying socio-cultural determinants of behavior and health. This paradigm of public health views solutions to complex phenomenon like health in terms of singular components isolated from the larger socio-political context. It penalizes people for “what they do wrong and what they fail to do right” while conceptualizing health as an individual responsibility rather than a right or public good. Conceptualizing health as an individual responsibility that governments can encourage through taxation distracts the public health discourse from advocating for strategies such as investment universal healthcare, public education, and living wages. Unhealthy diet patterns and poor health outcomes are in part a symptom of deeper structural factors exacerbated by neoliberal policies and cannot be resolved simply by taxing “bad” food items.

When arguing in support of increased soda taxes, public health advocates often lament the power of “Big Sugar” or “Big Soda” and suggest that the increased cost to consumers, and theoretical decrease in purchases, will shift enough revenue away from large beverage corporations to curb their control over people’s dietary choices. Again, this deflects the public health discourse away from more effective strategies for curbing corporate power like enforcement of anti-trust laws or support for labor rights and casts the individual in the role of starving the beast. It also overlooks the role crop subsidy policies play in making sugar so cheap to begin with. Focusing attention on taxing soda instead of the root causes of extreme corporate power feeds into the neoliberal agenda of deregulation at the macro level that further increases concentration and power in the food industry. The exact opposite of what public health advocates claim they are fighting for.

Beyond Soda Taxes: Seeing the Public Health Forest

Wellness, and not the individualized form of it popularized by self-help health gurus, offers an alternative paradigm through which to think about public health policy. It is a holistic and affirming process that focuses on cultivating factors that support human health and well-being, rather than on just preventing factors that cause disease (i.e., drinking soda). Wellness is a function of, and must be understood in the context of, justice at the interpersonal, organizational, and community (national) level. This goes beyond merely debating the equity burden of a soda tax and forces us to look at soda taxes within a larger institutional environment that determines resource distribution among members of a society. Public health professionals should concern themselves with the wellness implications of sugar taxes in terms of justice and systems that support people to have healthy lifestyles rather than penalizing them for the choices they make within the context of systems or environments that are unsupportive of healthy lifestyles.

Procedural justice is concerned with how resources are distributed to members of society. It is possible that resources can be distributed to low-income households in paternalistic ways that do not affirm dignity. Penalizing low-income individuals for their soda consumption with additional taxes may raise revenues for public institutions to provide nutrition education or fruit and vegetable subsidies to “benefit” these households. But who has the power to determine what constitutes a benefit, or which benefits are valued more highly than others? This resource allocation decision is often made by powerful individuals or institutions to serve their own agendas rather than by the individuals most affected by poor health and/or soda taxes. Therefore, imposing soda taxes to nudge low-income soda-drinkers into changing their behavior and justifying it by “giving” them nutrition programs do not cultivate wellness in the big picture. To truly promote wellness, resources should be distributed to those most in need through procedures that are just. Soda taxes do not meet this criterion.

The current discourse on soda taxes as a desirable public health strategy shifts conceptualization of health away from being a public good that is supported by an institutional environment consistent with standards of distributive and procedural justice. Viewing health as an individual responsibility divorced from one’s social environment further marginalizes disadvantaged populations and reinforces current health inequities. Public health advocates should consider the following wellness-oriented guidelines when supporting public health policies:  (1) look at the public health data differently: instead of looking at populations who have succumbed to a problem like diabetes to find out what they are doing wrong, look at those who are succeeding and try to find out why they are doing well; (2) persuade policy-makers to consider outcomes related to success (e.g., greater consumption of fruits and vegetables), not just outcomes related to problem reduction (e.g., decreased soda consumption); (3) elevate the importance of social justice and consider the harmful effects to health and wellbeing of reductionist policies that penalize or demonize people for health-related lifestyle choices; and finally (4) stimulate the development of innovative policies that cultivate the environmental and institutional conditions for these desired outcomes to occur. Public health advocates need to look beyond soda taxes and use their political capital to advocate for investment in systems like universal health care, public education, and living wages if they are truly concerned about health and equity.

 

 

 

 

 

What Health Professionals Need to Know about Sugar Taxes

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Calls for taxes on sugar-sweetened beverages (SSB) by health professionals and advocates continue to occupy news headlines. Many of these commentaries rely extensively on emotional justifications for implementing these taxes as a public health measure to prevent weight gain, diabetes and cavities.

Taxes on sugar sweetened beverages are not new and have been implemented in many areas in many different ways. In theory, this sounds like a great idea, but what is the actual evidence that they meaningfully impact public health?

Theoretically, given a large enough excise tax on SSB, consumption levels decrease, leading to significant improvements in weight and obesity rates. In Mexico for example, one analysis estimates that a SSB excise tax may have resulted in a 7.5% average reduction in SSB consumption, with the greatest decrease among households at the lowest socio-economic level, while an analysis of 15 cities in the United States that have implemented an excise tax on SSB estimates that the incidence of diabetes could potentially decrease by 6% within a year of the tax reaching its full effect. However, the estimates from these economic models only predict a decrease of less than one pound of body weight, with no real improvement in health. Furthermore, empirical evidence of self-reported soda consumption did not significantly change after Berkeley, CA, implemented its tax on SSB as people shifted their purchases to neighboring counties or online vendors. This may be because demand for sugar-sweetened beverages tends to be slightly inelastic among the general population when prices increase, meaning that price does not significantly influence a consumers decision to purchase them.

But at what cost? Are the actual changes in consumption or health outcomes substantial enough to be considered worthwhile? How sustainable or long-lasting are these improvements? And are there other programs or policies that would lead to more significant health outcomes and have a societal or individual cost that is equivalent to or lower than a sugar tax?

It is important to remember that while sugar taxes may be associated with improved weight status at the population level, there is no evidence that they cause improvements in actual health status. One reason may be because lifestyle choices contribute to less than a quarter of one’s of current health status and sugar-sweetened beverage consumption is just one of many lifestyle variables. A greater proportion of an individual’s health risk is due to social determinants of health such as one’s social environment, physical environment/total ecology, and health services/medical care.

Focusing the health conversation on taxing sugar-sweetened beverages may actually be distracting efforts to take action in addressing more substantial causes of poor health like low wages, poor housing conditions, access to affordable healthy food, violence and trauma, systemic oppression, and quality healthcare. Increasing the price of SSB may deter consumption of these products, but it does nothing to increase access to affordable healthy food or healthcare services in the communities that are affected most by food insecurity and diet-related health issues. Policy alternatives, like subsidizing the cost of fruits and vegetables, and investing in community-based food systems would do more to improve access to healthy choices–without the need to penalize people for taking pleasure in a sugary beverage now and then.

While the case of Mexico shows that a SSB tax may reduce consumption of the taxed beverages, they also estimated a 2.1% increase in purchases of un-taxed beverages due to the substitution of SSB with other products like juice, milk, diet soda, and even alcohol. While certain substitutions may be beneficial, a focus on decreased consumption of SSB and changes in BMI are too narrow to be meaningful. Without empirical evaluations of the SSB tax impacts on actual health outcomes, it is difficult to determine if the tax is actually worthwhile in achieving anything more than imposing administrative costs on society and placing an unnecessary burden on the individual autonomy of both healthy and unhealthy individuals.

Unfortunately, few studies have empirically evaluated the effects of taxes on sugar-sweetened beverages and the evidence that they improve public health measures is limited. Many studies in this area rely on econometric modeling rather than measuring peoples’ actual behavioral response to the tax. Before getting on the SSB tax band-wagon, health professionals should advocate for more extensive empirical research in this area as a way to promote evidence-based policy decisions in public health.

Related: Junk-food Taxes: Do They Work?

Junk Food Taxes: Do They Work?

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The Navajo nation recently became the first place in the United States to impose a tax on junk food in an effort to address concerns about obesity in their communities. A “sin tax” to disincentivize the consumption of foods associated with health risks is not new, but it is gaining momentum as communities recognize the need to create food environments that are health promoting. So far, soda and sugar-sweetened beverages have been the primary targets.

Soda and sugar-sweetened beverages have been implicated as a major source of excess calories, leading to weight gain.  Nationally, Americans consume an average of 1 gallon of soda each week, or about 1000 calories completely void of nutrients.  Sugar-sweetened beverages account for roughly half of the 250-300 additional calories American are consuming compared to 60 years ago.  In response, taxes have been proposed in many states to discourage the purchase and consumption of sugar-sweetened beverages.  Thirty-four states currently have a sales tax imposed on soda sold in grocery stores, and 39 states tax vending machine sales.

The most prevalent argument in support of a sugar-sweetened beverage tax (SSB) is the effect on public health.  Health care costs for Americans with obesity are 36% higher than for Americans with a normal weight and prescription drug costs are 77 % higher.  Current estimates suggest a loss of $30 billion in productivity on the job each year due to lifestyle related health issues. Taxes are currently imposed on cigarettes and alcohol in an attempt limit their consumption and encourage healthy behavior.  Many public health advocates believe that a SSB tax would be reasonable and effective as well because consumers generally respond to higher prices by decreasing consumption.  The funds from taxes would ideally be used in nutrition and health education programs, and this is exactly what the Navajo nation plans to do.

The theory that increased price of SSB would reduce obesity rates is not currently well supported by the research.  Most taxes on soda are a sales tax that consumers do not see when they are making the purchase decision.  Current sales tax rates of 3-4% in participating states has not significantly affect the weight status of adolescents.  In addition, one study found only a 0.16% reduction in BMI in states with a sales tax on soda. Due to consumers’ propensity to substitute consumption choices, other studies show that any reduced soda consumption increases consumption of not only water, but milk, alcohol and juice.  Therefore, it is not clear that a tax on SSB would reduce BMI for overweight and obese individuals.

Current academic research fails however to present a holistic picture of the SSB tax, focusing specifically on weight loss.  While substitution of milk and juice for soda may not reduce weight, it will contribute necessary micronutrients that are typically inadequate to the diet of Americans like potassium, magnesium and calcium. We also know that BMI is not a strong indicator of health, as people with BMI scores in the overweight and obese categories can achieve positive health outcomes through health-promoting lifestyles, while people in the normal BMI category are at risk of poor health outcomes if they pursue health-detracting lifestyles (HAES cite). Viewing the tax through a health-based evaluation paradigm, rather than a weight-based paradigm may show more desirable outcomes.

As suggested in the research studies, current sales tax rates are too low and not visible enough to significantly impact consumer choices.  A higher rate in the form of an excise tax is another way to influence SSB consumption.  One study suggests it would take a 10% increase in price to produce an 8% reduction in soda purchases.  An excise tax (included in shelf price vs. at the register) of this magnitude, might be a more effective strategy for directing consumers away from soda.  This is more than double the tax rate imposed in participating states, and 5 times that of the Navajo nation. Furthermore, the increased price would be visible at the point of selection (when purchasing decisions are made) rather than at the point of payment.

While taxes are not the comprehensive solution to changing health-detracting behaviors, they can help shape the food environment to be more health promoting. If the Navajo nation looks beyond weight-based measures of success to health-based measures, their policy for shaping the food environment may ultimately become a model for other places in the United States to emulate.

 

1. http://time.com/3762922/junk-food-tax-obesity-navajo-nation/

2. Pratt, Katherine. A Constructive Critique of Public Health Arguments for Antiobesity Soda Taxes and Food Taxes. Tulane Law Review [online]. 2012; 87 (1): 73-140. Available from: LexisNexis Academic.

3. Kiviat, Barbara. Tax and Sip. Time [online]. 2010;176 (2): 51-52. Available from: EBSCOhost.

4. Powell, LM. Associations between state-level soda taxes and adolescent BMI. Journal of Adolescent Health.

5. Bacon, L. (2010). Health at every size: The surprising truth about your weight. BenBella Books.

6. Wansink, B., Hanks, A. S., Cawley, J., & Just, D. R. (2014). From coke to coors: a field study of a fat tax and its unintended consequences. Wansink, Brian, et al.” From Coke to Coors: a field study of a sugar-sweetened beverage tax and its unintended consequences.

7. Andreyeva, T., Long, M. W., & Brownell, K. D. (2010). The impact of food prices on consumption: a systematic review of research on the price elasticity of demand for food. American journal of public health, 100(2), 216.

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