Above:  There has been a rapid increase in the rates of obesity and diabetes due to consumption of junk food in the past 15 years

As nations fight against obesity and diabetes, there is an increasing realisation that regulations can also help as increased taxes on junk food and sugary drinks can bring down their consumption

By Dr Anoop Misra and Bhavya Arora

The fight against sugar is unending and being fought globally. Recently, Singapore, which has some of the highest diabetic rates, came up with the idea to ban ads of some fizzy drinks and juices so that people would decrease their consumption of sugar. Other countries, such as Mexico and Britain, too have cracked down on ads showing high-calorie food and drinks. In India, regulations have been introduced to stem the march of diabetes, with Kerala introducing a fat tax in 2016 to bring down the high rates of obesity.

The rapid escalation of Type 2 diabetes (T2D) and urbanisation in developing countries has forced them to take these stern measures. Ethnic groups like South Asians, other Asians, and Africans develop diabetes a decade earlier and at a lower body mass index than Caucasians. They have prominent abdominal obesity and have greater acceleration from pre-diabetes to diabetes.

In India, there has been a rapid increase in the rates of obesity and diabetes during the past 15 years. Their prevalence has risen from 5.9 percent to 7.3 percent. Preventive actions still remain undeveloped in most developing countries. The quality of care is largely poor and hence, a substantial number of patients do not achieve treatment goals. To counter these challenges, a renewed political commitment and several low-cost innovative approaches need to be undertaken, including training of non-medical allied health professionals, and use of technology and telemedicine to deliver simple health messages for prevention and management of T2D.

The following are some of the contributing factors for the rapid increase in diabetes and obesity in India: consumption of refined grains, high saturated fat intake, increased consumption of sugars and sweetened beverages, low intake of fruits and vegetables, increasing “westernisation” of food habits, lack of physical activity, poor awareness about diabetes and its risk factors, increased rates of obesity in early childhood (increased feeding and excessive intake of food), low healthcare budget of developing countries and more focus on communicable diseases. There are other barriers in tackling diabetes in terms of the organisation of health systems and care, insufficient human resources, poor availability and affordability of medicines and poor support systems (e.g., nutritionists, diabetes educators).

Various low-cost approaches have been suggested to tackle diabetes and other non-communicable diseases in developing countries. These include:

• Task shifting: An innovative care model includes “task shifting”. Here, the provision of basic care and advice on medications by paramedical workers could be of great help in areas with a scarcity of physicians. Diabetes care can be delivered by pharmacists, nurses, diabetes educators and other trained non-medical individuals.
• lmHealth: Mobile phone messaging appears to be an effective and acceptable method for lifestyle modification and the prevention of diabetes. It improves medication adherence, glycosylated haemoglobin HbA1c (a marker for monitoring diabetes), self-monitoring of blood glucose and other diabetes-related behaviour.
• Mobile healthcare at the doorstep: The cost of commuting and waiting in hospitals precludes many underprivileged people from seeking adequate care. In such cases, diabetes-related healthcare could be delivered at the doorstep of the underserved population and is being done in India. Health talks about diet and lifestyle modification, random sugar monitoring, assessment of diabetes complications for eyes and feet are being provided to people at low cost.
• Nutrition and lifestyle interventions in pregnancy, early childhood, and adolescence: Balanced nutrition, starting before, during and after pregnancy and then through the neonatal period for the prevention of childhood and adolescent obesity (lifecycle approach) has been reported to improve metabolic outcomes and may prevent the onset of diabetes.
• Health system reforms: Restructuring of health policies in developing countries in the following areas will help— build political commitment and address health system constraints, develop public policies in health promotion and disease prevention, create new delivery models, ensure equity in access and payments and have consistent guidelines for the prevention and management of diabetes.
• Use legal framework and taxation: There is an increasing realisation that legal regulations may also help in the prevention of diabetes. These can be in various areas:

Trans-fatty acids (TFA): The Food Safety and Standards Authority of India (FSSAI) had drafted regulations for TFA limits at 10 percent (by weight) in 2010 and proposed to bring it to five percent in three years. However, it has still not been implemented. Labelling for TFA poses a major challenge in India. Considering the negative effects of TFA on health and the increase in formation of TFA by repeated use of oils, it should be mandatory to carry out laboratory analysis of its content in each batch of fat/oil used for frying. Finally, stringent policies regarding quality of edible fats/oils should be developed for India.

In order to strengthen its fight against transfats and limit their percentage in food products, FSSAI decided to put forth a regulation through an amendment in the Food Safety and Standards (Prohibition and Restriction on Sales) Regulations, 2019. The apex food regulator had issued a draft notification saying that from January 1, 2022, the limit of trans-fats in the food products shall not be more than two percent.

• Sugar-sweetened beverages (SSBs): Strategic controlling of price can be instrumental in lowering the consumption of unhealthy foods which can minimise the negative effects of the nutrition transition. A study in the US showed that price increases of 10, 15, and 20 percent on SSBs were associated with fewer purchases of juice drinks. A study on the Indian population done in 2014 suggests that a 20 percent soda tax may lead to a reduction of 3 percent in obesity, and a 1.6 per­cent decrease in the prevalence of T2D from 2014 to 2023. This data will lead to reformulation of strategies for curbing non-communicable diseases by enhancing taxation on SSBs. Mexico introduced an SSB tax in 2014 and projected that there would be a 10 percent reduction in SSB consumption with a 39 percent calorie compensation resulting in a decrease in incidence of T2D, stroke, myocardial infarctions and fewer deaths. Overall, a high tax rate on sales of SSBs or a reduction in sugar content could be effective in reducing obesity and diabetes.
• Fat tax: In July 2016, a fat tax (tax on burgers, pizzas and other junk food) of 14.5 percent was introduced in Kerala. It is estimated that the tax would add Rs 100 million (Rs 10 crore) annually to the state’s funds and also make people more conscious of their food choices. In 2011, Hungary put a four percent tax on packaged foods and drinks that contain high levels of sugar and salt in certain product categories, including soft drinks, candy, salty snacks, condiments and fruit jams. In 2013, Mexico passed an eight percent tax on foods including snacks, sweets, nut butters, and cereal-based prepared products. Within these categories, foods that surpass a calorie density threshold (more than 275 calories per 100 grams) are taxed. The World Health Organisation (WHO) looked at the tax in Hungary, and found that junk food consumption decreased both because of the price increase and also the educational campaigns around the tax, an effect also seen with soda taxes. “Consumers of unhealthy food products responded to the tax by choosing a cheaper, often healthier product (7 to 16 percent of those surveyed), consumed less of the unhealthy product (5 to 16 percent), changed to another brand of the product (5 to 11 percent) or substituted some other food (often a healthier alternative).” The Mexico and Hungary junk food tax seemed to have the greatest effect among low-income groups and people who were big consumers of junk food prior to the tax. As low-income people tend to consume the most junk food and are also at the greatest risk of diet-related disease, “this suggests a junk food tax might be regressive on income and progressive on healthfulness of food purchases”, said WHO.
• Palm oil: Its consumption is high in India. A modelling study in India (published in 2014) proposed that 20 percent tax on palm oil purchases was projected to avert approximately 3,63,000 deaths from CVDs over 2014–23.
• Other governmental interventions: Policy evidence from existing food tax implementation suggests that taxes need to be paralleled by subsidies on healthier foods like fruits and vegetables and other interventions to encourage healthy eating. Such dual methods would be helpful for changing consumer behaviour and improved nutrition outcomes.

So, it is not just the individual who has to fight obesity and diabetes but governments too in order that they have healthier and more productive work forces.

—Dr Anoop Misra is Chairman, Fortis-C-DOC Centre of Excellence for Diabetes, Metabolic Diseases and Endocrinology and Chairman, National Diabetes, Obesity and Cholesterol Foundation (N-DOC); Bhavya Arora is a clinical nutritionist and certified diabetes educator at Fortis C-DOC Hospital