PANAH

Pakistan National Heart Association

The Role of Sweetened Beverages in Increasing Non-Communicable Diseases in Pakistan

Tabinda Ashraf Shahid

Ali’s mother is conscious about his school lunch, she prepares homemade sandwiches with a commercially
packed fruit juice drink which is perceived by many people as a healthy option. She does not want her
young to eat or drink unhygienic and unhealthy food from the canteen. Although the lunch is
scrumptiously homemade she is unaware of the fact that the fruit juice is accompanied by high sugar
contents. Additionally, to avoid drinking water from his school Ali often takes a soft drink while waiting
for his van way back home. These sugary sweetened juice and drink are hiding excess sugar and drinking
it five days a week means a lot of calories are consumed. Due to repetitive promotions, people don’t
categorize it as unhealthy. On the contrary, highly sweetened beverages once per day have been proved
to rise BMI [1] and accelerate 20% risk of cardiovascular disease.

KNOWING SUGAR SWEETENED BEVERAGES (SSBs)
The term SSBs signifies any beverage synthetically prepared with sugar in any form of table sugar, high
fructose corn syrup, or concentrates of fruit juice. These enriched calories with low nutritional value
beverages are available at every nook and corner of rural and urban areas of Pakistan and contribute to
obesity as a constellation of Non-Communicable Diseases (NCDs). The consumption of SSBs has flourished
due to the influence of rapid urbanization and marketing strategies [3]
Non-Communicable Diseases [4] are associated with one of 10 major causes of disease and death in
Pakistan. Internationally, SSB’s are accountable for about 184,000 [5] deaths annually from obesity,
diabetes, and cardiovascular disease.

However, the overconsumption of SSBs is associated with the
addiction of caffeine and sugar in the young generation, bringing them closer to the detrimental diseases.
The emerging cause of NCDs has subsequently elevated a threat to the health community due to weight
gain and obesity in Pakistan [6].
Internationally SSBs are accountable for about
184,000 deaths annually from obesity, diabetes,
and cardiovascular disease
FACTS AND FIGURES
The Covid-19 pandemic has not yet been over, and another pandemic is Obesity [7] [8] is a heading that
is often ignored because its effect may take time to show. The World incidence of overweight and obesity
is on the rise among children, women, and men which is responsible for Type 2 Diabetes (T2D) and other
cardiometabolic diseases [9].
The Director of WHO NCD 2016 Dr. Douglas Bettcher indicated the need for taxation on all SSBs as one of
the main sources of obesity and diabetes accountable for millions of death. Globally, the rate of obesity
fluctuated drastically in 2014 as compared to 1980 with an increase in the percentage of women than
men. While 42 Million children under 5 years were categorized as obese in 2015, more than half of the
children were from Asia and a quarter from Africa [10].
According to the statistics of WHO 2021, NCDs are responsible for more than 70% of deaths annually
worldwide within the age bracket 30 to 69. While in low middle-income countries 77% of deaths are
associated with NCDs including the highest cases of cardiovascular diseases than followed by cancers,
respiratory diseases, and diabetes [11]. The role of SSBs can be clearly understood by a study published
in 2019 on the Spanish population on the use of SSBs which suggested an increase in BMI of 0.21kg/m2
on every 100ml of SSB consumed. It has compelled the Government of Catalonia to impose Excise Tax on
SSBs [12].
Obesity is not only associated with affluent societies but an estimated 115 million people from low-income
countries [13] also suffer from this dreaded condition and its consequences. The significant factor is
recognized as the consumption of soft drinks [14] thus WHO has documented obesity as a global pandemic
[15]
Pakistan is the place where malnutrition is only considered as undernutrition typically, while people with
overweight are praised to be in a good health. In such a society advocating for weight loss sometimes
seems unimportant. But according to a recent study one out of four Pakistani above 18 are categorized as
overweight, while women [16] are more prone to overweight and obesity as compared to men. A
systematic analysis of Global Burden of Disease 2013 stated that Pakistan is at 8th number among 10
countries contributing to obesity in the world [17].
It is of major concern that the findings of the national NCD survey 2013 – 14 in two provinces of Pakistan
suggested unhealthy diet consumption in the obese and overweight population and they are at increased
risk of NCD later in their life [18].
The National Diabetic Survey 2016-2017 has revealed 35 to 38 million (16) young people aged 20 years
and above are suffering from TD2 in Pakistan.
The consumption of SSBs is becoming an indispensable commodity that is directly proportional to the
richer families. The validated research data from Pakistan shows that in 2015-16 the poor families have
spent more on SSBs than between 2006-08. This overconsumption of sugar is causing an extra disease
burden on the Pakistani population in the form of cardiovascular risk, type 2 diabetes, and hypertension.

 

 


HOW DIFFERENT COUNTRIES ARE TAKING THE LOAD OF SSB
As the cost of soda and colas are nominal and in the reach of the general public its use has been increased,
hence, in 2017 WHO suggested a 20% tax on SSB as an effective tactic to overcome SSB usage (19).
About 50 countries including the USA imposed different types of taxes on SSBs products including Excise
tax and Value-added taxes. The UK has also introduced a two-tier tax in 2014 depending on the amount
of sugar content used in preparation. SSBs having more sugar contents than 8g/100ml and 5gm/100ml
are taxed, accordingly. In 2014 Mexico started tax rates subject to the volume of sugar-sweetened drinks
while the Pacific Island countries also imposed SSB taxes (20).
It has been seen that additional taxes contributed
to generating more revenue once imposed. While
generated money can be utilized for the
betterment of the healthy community and
awareness campaign for NCDs.
According to research in Zambia (21) when low-middle-income countries increased taxation on SSBs it
showed a decreasing trend in BMI and obesity-related diseases, especially in women. A prospective effect
of SSBs in Ireland, Germany, South Africa, the Philippines and India exhibited a successful reduction in
SSBs practices (22).
According to the Tribune (23), the preference and demand for soft drinks have increased after Covid-19
and people like to buy family packs which is more economical instead of bottles with one serving which
shows that the money is the main reason which compels people to buy the product. Due to the
westernized trend, local home drinks like lemonade and lassi which have more nutritive value are not
preferred by many.
Observational studies (24) endorsed taxation policies on SSBs and specify that they can reduce excess
weight by about 200 million pounds around the world. It will not only affect the household budget
situations but it will save money to be used on other health care projects while increasing the life
expectancy and will increase the workforce for the community to boost the economy.
It has been noted that 25% sin tax in Zambia (25)
on alcohol, tobacco, and SSBs has abridged the
intake of calories, has reduced weight, BMI and
subsequently NCD diseases burden.
Many countries adopted health encouraging policies like Latin America by the introduction of warning
signs on labels of SSBs about the sugar contents of the drink to get customers aware of their negative
impact on health proved to be a practical solution (26).

POLICY SOLUTIONS FOR PAKISTAN

1. On the advice of WHO SSB’s tax implementation by
25% as in Zambia has restricted the buying ability of
consumers which has contributed to the reduction of
weight, BMI, and NCD burden. Health authorities
from Pakistan can also take similar action to
eradicate NCDs to some extent.
2. Initiation of federal NCD policy to control the surge
of these diseases.
3. Pakistan National Heart Association (PANAH) has
suggested FBR impose a 20% Tax on all SugarSweetened Drinks (27).
4. Cheap and readily available SSBs are a source of increased consumption of unhealthy diet which
should be increased under Taxation.
5. Reduced Sugar Beverages (28) should be introduced with enhanced warning labeling.
6. There is a need for awareness campaigns about the consumption of healthy options like the
inclusion of fruits and vegetables in the diet and the importance of exercise to motivate people
to become active individuals.
7. Excise tax and value-added tax should be constantly reviewed for SSB products.
8. A two-tier tax must be imposed depending on the amount of sugar used in the preparation of
each SSBs. While the volume of the drink should also be considered and should be taxed
accordingly.

9. Tax generation will aid in increasing the
revenues (29) which can be used for
nutritional or educational interventions
as many studies have revealed.

10. Schools should be free from sugarsweetened beverages for more healthy
options.
11. In schools at every parent-teacher
meeting, a dietitian/ Nutritionist should
be available to give 15 minutes lecture
on the healthy school lunch program.

 

 

 


The nutritional assessment of all children
in school should be arranged under a
dietitian/nutritionist annually.
12. Taxation on SSBs will impact by reducing the NCD cases in any society which will save money spent
on hospital care and will increase the work output hours.
13. It has been noted that increased taxes (29) helps in the prevention of addiction to SSBs which can
control weight and cardiometabolic disorders related to diet.

14. It will impact the purchasing power of the consumer and they will buy other healthy food instead.
It has been observed that a 10% increase (30) in tax will reduce a 10% drop in usage.
15. Some easy-to-read and follow info-graphics should be present on the SSBs labels to aware the
customers whether they drink they are buying is healthy or not. Like traffic light signals red-orange
and green are often best to depict.
16. Use of water should be emphasized for hydration where ever possible as an alternative of SSBs
(31).
References:
1. https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-019-7908-5
2. https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.111.067017
3. https://www.hsph.harvard.edu/nutritionsource/healthy-drinks/sugary-drinks/
4. http://www.emro.who.int/emhj-volume-24-2018/volume-24-issue-1/prevalence-of-risk-factorsfor- noncommunicable-diseases-in-adults-key-findings-from-the-pakistan-steps-survey.html
5. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7377978/
6. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6488513
7. https://pubmed.ncbi.nlm.nih.gov/15601956/
8. https://pubmed.ncbi.nlm.nih.gov/15601956/
9. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3828681/
10. https://www.who.int/news/item/11-10-2016-who-urges-global-action-to-curtail-consumptionand-health-impacts-of-sugary-drinks
11. https://www.who.int/news-room/fact-sheets/detail/noncommunicable-diseases
12. https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-019-7908-5
13. https://www.who.int/activities/controlling-the-global-obesity-epidemic
14. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3828681/
15. https://pubmed.ncbi.nlm.nih.gov/16326822/
16. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7118000/
17. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4624264/
18. https://pubmed.ncbi.nlm.nih.gov/29658619/
19. https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0105287
20. https://www.obesityevidencehub.org.au/collections/prevention/countries-that-haveimplemented-taxes-on-sugar-sweetened-beverages-ssbs
21. https://gh.bmj.com/content/5/4/e001968#ref22. https://www.who.int/news/item/11-10-2016-who-urges-global-action-to-curtail-consumptionand-health-impacts-of-sugary-drinks
23. https://tribune.com.pk/story/2277439/beverages-sector-recovers-as-preferences-shift)
24. https://openknowledge.worldbank.org/handle/10986/33970?locale-attribute=en
25. https://gh.bmj.com/content/5/4/e001968
26. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6520104/
27. https://tribune.com.pk/story/2305772/pakistan-a-diabetes-disaster-in-the-making
28. https://www.hsph.harvard.edu/nutritionsource/healthy-drinks/beverages-public-healthconcerns/#ref62
29. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7377978/
30. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5442881/
31. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6723421/
32. https://unsplash.com/ (all pictures)