Contrary to common belief, obesity doesn’t only afflict the couch potatoes of the wealthy world. Over the last two decades a growing number of low and middle income countries (LMICs) have seen their populations’ waistlines expand to unhealthy dimensions. In fact, nine out of the ten highest ranking countries in terms of prevalence of adult obesity are small island nations in the Pacific.
Obesity is classified according to BMI (Body Mass Index) and is defined as having excessive fat accumulation. Being obese is more than a matter of vanity; there is a raft of comorbidities and health impairments associated with obesity. The societal burden of obesity is felt in terms of DALYs — Disability-Adjusted Life Years, i.e. years of healthy life lost — and their related influence on the community. Meanwhile, the financial cost is observed via increased healthcare expenditure on obesity management and treatment of the comorbidities — borne by both the individual’s household and by government healthcare systems (aka society at large) — as well as productivity loss due to absenteeism and presenteeism.
Image from the ‘NCDs are Killing Us’ Campaign in Tonga [Cam Sugden]
Diversion of resources to deal with obesity related illness is a weighty concern for LMICs who are now grappling with the double burden of disease. Obesity and other non-communicable diseases (NCDs) are substantial development issues that undermine public health gains of the last few decades. The impact is so extreme that Tonga’s life expectancy has fallen due to these chronic morbidities: By the millennium, the life expectancy for Tongan women had increased to 72.8 years, and 11 years later, it had dropped again to 70.5 years.
The global epidemic of obesity (“globesity”) is attributable to a multifactorial complex of influences. One of the most significant factors in the Pacific is the rapid socioeconomic transition from low income to middle income in a few short decades. Due to industrial activities that took hold without supporting community development to sustain healthy lifestyles, there has been a shift in gear of Pacific Islander’s village cultures.
As part of industrialisation, multinational food producers — the likes of Nestlé, Coca Cola and McDonalds — quickly poured into places where they could see affluence increasing. Regulation of Big Food activities has been slow to occur in response to the relatively sudden switches from traditional local produce and active daily lives to highly processed foods and more sedentary occupations.
Big Food is infamous for blaming the obesity epidemic on the individual for making poor lifestyle choices in food consumption and physical activity behaviours. This takes the focus away from social and corporate influences to alleviate industry responsibility. The solution to the burden of obesity, according to industry, is to educate society about nutrition.
This approach is certainly positive, and all stakeholders agree that education is part of the solution. Interestingly though, nutritional education is well delivered in schools in many Pacific Islands. Pacific Islanders are aware that too much sugar is bad and that they should be getting their ‘5+ a day’. And yet the Health Ministries struggle to turn this knowledge into behaviour change.
One of the biggest challenges is that, although they have been told that they should avoid sugar-laden diets, Pacific Islanders remain unaware of the amount of sugar contained in the imported foods they eat. To combat this, Tonga Health Promotion Foundation created the Mouthful of Sugar campaign to demonstrate to Tongans how much sugar they consume without realising. That was a constructive initiative for health education, however education is only one component of the health promotion strategy to fight obesity.
Recognising this fact, in 2014 the Mexican government enacted an excise tax of one peso (US$0.08) per litre on sugar-sweetened beverages (SSBs) to discourage sugary drink consumption and help curb the surge in obesity in their country. Unsurprisingly, the fizzy drink industry’s reaction was “apoplectic”. They are scared stiff that this tax may set a precedent.
Similar in developmental status to Pacific Island countries such as Tonga, Tuvalu and Fiji, Mexico is also buckling under el peso of having 33% of the population suffering from obesity. In 2013, Consumption of SSBs in Mexico was alarmingly high at 163L per person per year and soft drinks are one of the major contributors of excessive calorie intake in Mexico.
2L bottles are the most purchased size of bottled drink in Mexico [Gregory Bittan]
One year on since the introduction of the tax in Mexico, surveys suggest that SSB purchases dropped by 6% from the same period in 2013 and there was a 7% rise in purchase of beverages not subject to the new tax, such as plain water and milk. While this is yet to be translated to a measurable effect on health outcomes, there is biological, behavioural and contextual rationale to suggest that reducing consumption of SSBs can reduce the risk of unhealthy weight gain. What’s more, it provides positive evidence that taxation measures reduce consumption of obesogenic foods in middle-income countries to contend with other evidence that similar measures in OECDs have had limited impact on consumption rates.
Returning to the Pacific, looking at the limited data available, Polynesian countries appear to consume lower volumes of SSBs than Mexico. Nevertheless, Dr Wendy Snowden, coordinator of the Pacific Research Centre for the Prevention of Obesity and Non-communicable Disease reports that access to drinking water in a lot of the Pacific Island communities is a problem, so bottled drinks are relied on. Given that soft drinks are heavily marketed, widely available and generally cheaper than bottled water, there’s “good reason that people drink a lot of them”, although it is to the detriment of their health.
There is irony in the Australian government’s recent proposal to partner with companies such as Coca Cola to deliver medical aid to countries in the Pacific. This suggestion has been slated as Boomerang Aid, one critic making the tongue-in-cheek comment that “it’s the perfect solution; the truck that brings your supply of soft drink also brings your supply of insulin injections.”
The Big Food industry is a crucial provenance of the demand for medical aid in Pacific Island countries. Taking the capitalist approach of involving them in the ‘solution’ is unlikely to achieve sustainable results. In actual fact, this tactic is more likely to lead these nations down a slippery slope of reliance on foreign aid, bolstering Big Food industry presence and inflating the obesity epidemic further. It’s the proverbial “give a man a fish and feed him for a day” scenario.
The alternative proverb, teach a man to fish and feed him for a lifetime, should involve collaborative preventative health initiatives from health, finance, infrastructure and education sectors, both government and private, to improve the sense of societal responsibility for health. As an example, Australian Aid funds could be better spent providing advice and guidance for implementation of taxes on SSBs.
Mexico presents compelling evidence in favour of taxing SSBs to reduce the risk of obesity in a middle income country. But caution must be taken; in health there is no one-size-fits-all approach. When considering the enactment of a tax on SSBs in the Pacific, each nation would require funding to research case studies of SSB taxation already piloted in the Pacific; to gather and analyse baseline data on obesity rates, healthcare expenditure, SSB consumption rates etc. in their country; to construct evaluation frameworks to measure impact; to determine how to collect and reallocate revenue raised from the tax; to advocate for public support of the tax; and to plan programmes to support the SSB tax initiative, such as a drinking water infrastructure improvement project.
An integrated and considered development approach like this puts the tools and methods to take responsibility of reducing the risk of obesity in the hands of the Pacific Island community itself. It would deliver ongoing revenue and community empowerment to enhance the Pacific nations’ ability to continue their socioeconomic transition as proud, healthy people. In other words, this type of approach ensures them a proverbial lifetime supply of fish.