Policy Memo for Masters in Public Healthreneo.kena87
OPTIONS TO REDUCE SUGAR SWEETENED BEVERAGE (SSB) CONSUMPTION IN NEW ZEALANDPOLICY BRIEF
PACIFIC HEALTH DIALOG98 MARCH 2014 . VOLUME 20 . NUMBER 1
POLICY BRIEF : Options to reduce Sugar Sweetened Beverage (SSB) consumption in New Zealand
P O L I C Y B R I E F
PURPOSE The purpose of this document is to identify key policy recommendations to relevant settings that impact on the
availability, marketing. price, and knowledge of SSBs and ultimately the consumption of SSBs in New Zealand,
particularly in youth. These recommendations will provide achievable goals to various stakeholders and settings
of infl uence, aiming to reduce SSBs intake. The ideal outcome is that water and milk (unfl avoured) become
preferred beverage options for New Zealand children and adults. These goals align to the vision articulated by the
advocacy group ‘FIZZ’ to achieve a Sugary Drink Free New Zealand by 2025.1,2 This means that SSBs should be only
rarely consumed, and comprise less than 5% of total population beverage intake. Addressing SSBs in particular is
an important step to addressing New Zealand’s obesity epidemic, especially among children.
The United States Beverage Guidance Panel (USBGP) was the fi rst of these panels and was established by Barry Popkin, Professor of Nutrition, University of North Carolina in 2006.3
The intention of this panel was to develop guidance to govern- ment and community groups to limit the intake of SSBs, which had broad societal support from relevant interest groups. The USBGP panel had the eff ect of raising the profi le of SSB intake to both nutritionists and policymakers. Since then, similar groups have formed in China, Mexico, Spain, the United Kingdom, and this one in New Zealand. These panels are similar to those that were formed in response to the harms of tobacco in the lead-up to the Framework Convention on Tobacco Control.4
“The Beverage Guidance Panel was assembled to provide guidance on the relative benefi ts and risks for health of
various categories of drink.”
DEFINITION of SSB: Any beverage that contains added caloric sweetener usually sugar. The main categories of sugary drinks include soft-drinks/ fi zzy-drinks, sachet mixes, fruit drinks, cordials, fl avoured milks, cold teas/coff ees, and energy/sports drinks.
WHAT IS THE ISSUE? SSBs are very popular in New Zealand like many countries around the world. In New Zealand, SSBs are one of the two leading contributors of sugar to the diets of adults and chil- dren.5,6 Their consumption is known to cause dental diseases, increase the risk of developing unhealthy weight gain, type-2 diabetes, gout, and non-alcoholic steatohepatitis.7-11
There is evidence that a reduction in SSB consumption will reduce the likelihood of developing the health conditions identifi ed above and that with policy/regulation, a signifi cant reduction in consumption can be achieved.12,13 Furthermore, policy options are known to be highly cost-eff ective in terms of public health interventions.14
Studies have shown that energy consumed in SSBs are not well compensated for by a reduction in energy consumed in food, meaning they have an additive eff ect on energy in- take.15 Furthermore, there is a growing body of evidence to show that sugar and SSBs have addictive like characteristics among high consumers. High sugar intake is known to stim- ulate the same parts of the brain as ‘drugs of abuse’, and peo- ple coming off high sugar diets describe feelings of withdrawal similar to coming off other addictive substances.16-19
New Zealand Beverage Guidance Panel
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Health eff ects of SSB consumption The association between free sugars and dental caries has also been established beyond reasonable doubt.20 Furthermore the impact on dental caries is experienced in very young and vul- nerable children. Dietary sugars have been widely accepted as a cause of weight gain and obesity.21,22 In addition, dietary sugar particularly that consumed in SSBs, has been associated with:
• cardiovascular disease23,24 • type-2 diabetes25-30 • raised blood pressure31 • dyslipidaemia32 • gout8,33 Since 2006, there have been 5 systematic reviews of ob-
servational studies that have found a positive relationship be- tween SSB consumption, unhealthy weight and related health consequences.21,22,35-37 Two randomised controlled trials con- ducted with children and adolescents found that masked sub- stitution of SSBs with their sugar free equivalents, resulted in signifi cantly less weight gain and fat accumulation in the sug- ar free group.12,13
These SSB-related diseases are major contributors to New Zealand’s burden of disease, with cardiovascular disease, for example, accounting for a quarter of New Zealand’s disability adjusted life years lost due to illness.38
There is also increasing evidence that demonstrates a likely link between high SSB intake and stroke, cancer, and impaired cognitive development.39-41 The positive relationship between SSB intake and unhealthy weight also indirectly increases the risk of cancer, as adiposity is a signifi cant risk factor for many cancer. In response the increasing evidence that high intake of sugar has on health, the World Health Organisation (WHO) have released a draft guideline that has continued to recom- mend that free sugars comprise no more than 10% of total en- ergy intake, however, indicated that there are added benefi ts in achieving a reduction to 5% of total energy intake.42
New Zealand’s SSB consumption The most recent national nutrition surveys show that SSBs con- tribute 26% of total sugar intake to the diets of children and 17% of total sugar intake to the diets of adults.5,6 Furthermore, 29% of children consumed 4 or more SSBs per week and this was markedly higher for boys (33% as opposed to 24% for girls), and Pacifi c (49%) and Mãori (39%) children.44 Scragg et al using the 2002, National Children’s Nutrition Survey found a positive relationship between SSB consumption and BMI in children.44 Children who drank more than one SSB per day had a signifi - cantly higher BMI compared to those children who drank less than one SSB per week (BMI: 19.7 verses 18.8 kg/m2). Findings from the Obesity Prevention in Communities study showed that compared to non-SSB consumers, children who consumed one can of SSB per day had a mean higher weight of 3.3kg, and those who consumed two cans had a higher mean weight of 5.3kg.45
Key stakeholders and settings This document identifi es six broad groups of stakeholders and settings that can have a signifi cant infl uence on SSB consump- tion. The six stakeholder groups/settings include: i) government, ii) whanau, and community/workplace groups, iii) school and early childhood education (ECE) communities, iv) health pro- fessionals, v) industry, vi) advocacy and non-governmental
1. Government (Local & National) Leadership and action from governments, in terms of programs and policies, to promote and create healthier food environ- ments are urgently required. A number of plausible policy op- tions that the government can consider to infl uence the SSB environment include pricing options, restrictions, regulation and policies that impact onavailability and access as well as marketing, sponsorship and the media. Strong Government leadership, both local and national, is vital to foster meaning- ful change in this area.
NZ specifi c activity An example of strong government leadership in this area saw the inclusion of a clause into the National Administration Guidelines by the then Minister of Education. The clause required that
‘only healthy foods be sold in schools’.46 This clause was intro- duced in 2007 and saw the elimination of SSBs from school can- teens and school premises. This clause was revoked in 2009.46
RECOMMENDATIONS: GOVERNMENT • Introduce a 20% excise tax on SSBs with funding used for
• Strengthen the National Administration Guidelines that schools only provide foods and beverages which meet the dietary guidelines.
• Implement eff ective social marketing campaigns that sup- port healthy beverage choices and discourage unhealthy beverage choices.
• Implement eff ective restrictions of marketing to chil- dren of unhealthy foods and beverages, including SSBs.
2. WHANAU AND COMMUNITY/ WORKPLACE GROUPS Community groups such as sports clubs, churches, social clubs, and community centres/hubs are in positions where they may be able to encourage healthier beverage intake of their respec- tive membership, and develop or adopt healthy beverage poli- cies/guidelines themselves.
NZ Specifi c activity Networks of churches in some regions have developed strong relationships with their respective District Health Board (DHB) and are sites for much health promotional activity. Many mem- ber churches have adopted nutrition policies that may address SSBs within them, and some have a specifi c policy on SSBs.48-50
RECOMMENDATIONS: WHANAU AND COMMUNITY/ WORKPLACE GROUPS • Develop/adopt organisational healthy beverage policy,
making them SSB free; • Work with local DHB, Public Health services and NGOs
to tailor education and awareness approaches on healthy eating and drinking for organisations eg Marae.
• For organisations which receive sponsorship from a bev- erage company, ensure that it is only related to a sug- ar-free product, and that any marketing related to this sponsorship strongly promote the sugar-free aspect of the agreement/deal.
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3. SCHOOLS AND ECE COMMUNITIES Children are the highest consumers of SSBs therefore schools and ECEs are important organisations that can promote healthy beverage consumption. Schools may address SSB consumption in a number of ways including implementing their own SSB pol- icy to restrict what beverages are available on school grounds and providing guidelines on whether vending machines have any place in schools. Schools can educate children and parents on the amount of sugar in SSBs, the health implications and al- ternative options to SSBs. Schools can actively promote health- ier drink options using promotional material on school grounds.
NZ Specifi c activity The ‘Beverage Guidelines Project’, led by Waitemata District Health Board (WDHB) in collaboration with a number of or- ganisations including the Auckland Regional Public Health Service, the National Heart Foundation,and more than twen- ty schools, was launched in 2005. It informed and encouraged schools to replace SSBs withhealthier beverages options. In one school alone, this project saw 125kg of sugar per week (or greater than1 tonne per term) being removed from the school canteen in the form of SSBs.51 Project Energize is another cur- rent example that educates primary school children about nu- trition and SSBs in the Waikato region.52,53
RECOMMENDATIONS: SCHOOLS & ECE COMMUNITIES • ECE centres adopt a policy to ensure SSBs are not con-
sumed in the setting. • Boards of Trustees ensure that ‘healthy food and bever-
age guidelines’ are implemented in their schools wheth- er the guidelines are mandatory or not.
• Professional organisations (i.e. PPTA (Post Primary Teachers’ Association), NZEI (New Zealand Educational Institute) support the implementation of ‘healthy food and beverage guidelines’ in schools.
• Strengthen curriculum and education about SSBs. • Schools and ECEs ensure that a suffi cient number of qual-
ity water fountains are available ‘at arm’s reach’ on school grounds and promoted by school to students.
4. HEALTH PROFESSIONALS In the health sector a number of organisations have an obvious affi nity to the vision of eliminating SSB intake.These include but are not limited to the Ministry of Health, DHBs, Hospitals, primary care organisations generally, Public Health Units, and local councils.
NZ specifi c activity Some DHBs have provided leadership in working with other sec- tors including Industry and Education to bring about action on SSBs. These initiatives include Project Energize with Waikato DHB, the Sprite Zero substitution with Counties Manukau DHB, and the ‘Beverage Guidelines Project’ with Waitemata DHB and local schools.51- 54
RECOMMENDATIONS: HEALTH PROFESSIONALS
• Identify SSBs as a priority for action by actively asking,
assessing, and advising clients on the issues related of SSB intake and health.
• Ensure SSBs are not be sold on health care premises and display/provide educational recourses as to why.
• Provide leadership on this issue and actively facilitate collaboration with other secttings (i.e. schools,commu- nity and industry) to develop solutions.
5. industry Relevant industry players that have infl uence on consumption of SSBs include: the beverage industry (soft-drink and water producers), supermarkets, retailers, and fast food/hospitality. Meaningful engagement with industry may facilitate progress in promoting sugar free beverage choices.
NZ specifi c activity In 2006, as part of the ‘Let’s Beat Diabetes’ programme – led by Counties Manukau DHB a trial was undertaken with McDonalds and Coca-Cola would replace the beverage Sprite with its sugar free version Sprite Zero for a 26 week period in all 21 McDonald restaurants in the area. A 17% reduction of SSBs consumption occurred; and importantly, the change did not prompt negative consumer feedback or impact business viability. Such positive outcomes saw Sprite Zero become the default lemonade served in all their respective restaurants throughout New Zealand.54
RECOMMENDATIONS: INDUSTRY • Beverage companies promote the sugar-free beverages as
their fl agship products with the aim of these sugar-free products being the majority share of beverage sales.
• Supermarkets and retail chains in stocking, placing, and promoting beverages in the store, favour sugar-free bev- erages over SSBs.
• Fast food chains make the majority of their beverages sugar free and make these the default beverage option, as well as actively promoting their sugar-free beverag- es over the SSBs.
6. Advocacy and non- government organisations The harmful consequences SSBs have on health are not well known by many parts of society. A common strategic direction and message issued by advocacy groups that work in this area
– is likely to be useful in giving a stronger combined voice with a clear call to action. Advocacy groups that may be sympathet- ic to this health issue include groups concerned with: obesity, poverty, youth, nutrition, Mãori and Pacifi c health, oral health, cancer, diabetes, youth education, cardiovascular disease risk factors, and gout. Promotion of healthier beverages/alternatives (tap water and milk) need to accompany any messages that re- strict options. Many non-government organisations also work in this area including the National Heart Foundation, Diabetes NZ, the NZ Dental Association, Sport NZ, regional sports trusts, Mãori and Pacifi c health providers.
NZ Specifi c activity In August 2013 an advoc acy organisation solely de- voted to SSBs called FIZZ which stands for Fighting S u g a r i n S o f t - d r i n k s w a s e s t a b l i s h e d w h i c h i s
OPTIONS TO REDUCE SUGAR SWEETENED BEVERAGE (SSB) CONSUMPTION IN NEW ZEALAND POLICY BRIEF
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modelled off another very successful advocacy organisation ASH – Action on Smoking and Health.1 FIZZ aims to ensure SSBs become a health priority for action by recruiting politi- cal support, engaging with community, leading solutions based research, and responding to any threats that are contrary to re- alising the vision of a sugary drink free New Zealand by 2025. Other advocacy groups are important to this issue including FOE (Fight the Obesity Epidemic), Parents Voice, Public Health Association, Health Promotion Forum, and Child Poverty Action
Group. Furthermore, in 2013, the Health Promotion Agency identifi ed reducing SSB consumption as one of their key pro- gramme focus areas to address in their new strategic objectives.55
RECOMMENDATIONS: ADVOCACY AND NON-GOVERNMENT ORGANISATIONS • Support this six point policy brief. • Champion key aspects of this document.
THE NEW ZEALAND BEVERAGE GUIDANCE PANEL: Dr Gerhard Sundborn,
Professor Boyd Swinburn,
Professor Jim Mann,
Professor Cliona Ni Mhurchu,
Dr Rob Beaglehole,
Dr Lisa Te Morenga,
Professor Elaine Rush,
Dr Robyn Toomath,
Dr Colin Tukuitonga.
ORGANISATION SUPPORT or ENDORSEMENT*
New Zealand Inc.
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