Global SSB and Sugar Consumption Patterns, Policies, Taxes, and Other Issues

Barry Popkin Department of Nutrition School of Public Health and Medicine Department of Economics The University of North Carolina at Chapel Hill

THE W RLD IS FAT “Over 2 billion people in the world are overweight” Outline: Why is This Occurring? 1. In-depth look first: added sugar in modern food supply, 2. Key ignored issue: the maldistribution of intake of added sugar 3. Global SSB consumption patterns 4. Fruit Juices: are they any different than SSB’s in their health effects? 5. Policies being utilized: taxes, labeling, marketing controls, restrictions in selected environments • Mexico • Berkeley • Chile

“Over 2 billion people in the world are overweight” Remarkably Short History for Caloric Beverages: Might the Absence of Compensation Relate to This Historical Evolution?

Earliest possible date US Soda Intake 52/gal/capita Definite date (2004) US Coffee Intake 46 gal/capita (1946) Juice Concentrates (1945)

US Milk Intake 45 gal/capita

present (1945)

- 10,000 BCE 10,000

- Coca Cola (1886) Homo SapiensHomo

- Pasteurization (1860-64)

Origin of of Humans Origin

Pre 10,000 BCE BCE 10,000

Modern Beverage Era ModernBeverage Carbonation (1760-70) 200,000BCE

Liquor (1700-1800)

Lemonade (1500-1600)

Coffee (1300-1500)

Brandy Distilled (1000-1500) (206 AD) Tea (500 BCE) Wine, Beer, Juice Wine (5400 BCE) (8000 BCE) Beer (4000 BCE) Milk (9000 BCE) 2000 BCE Water, Breast Milk

200000 BCE Homo Sapiens 100000 BCE

0

of of Time

Beginning

200000 BCE 200000

10000 BCE 10000

AD BCE 1. Sweeteners in Our Food Supply • About 550,000 foods and beverages exist in our consumer packaged food and beverage system in the US. • About 100,000 have unique ingredients. Using these data from a nationally representative sample of about 60,000 households who daily scan all food purchases’ bar codes, we can identify the foods with sweeteners. • Two sets of data—older published paper on difference from US NHANES data and our data with ingredients searched. • Then new results—in press only

“Over 2 billion people in the world are overweight” Sweeteners in Our Food Supply

• Key word searches at the ingredient list of each product – Low-calorie sweeteners: artificial sweetener, aspartame, saccharin, sucralose, cyclamate, acesulfame K, stevia, sugar alcohols (i.e. xylitol) and brand name versions of each sweetener (i.e. Splenda) – Caloric sweeteners: fruit juice concentrate (not reconstituted), cane sugar, beet sugar, sucrose, glucose, corn syrup, high fructose corn syrup, agave-based sweeteners, honey, molasses, maple, sorghum/malt/maltose, rice syrup, fructose, lactose, inverted sugars

Caloric Sweetener Low-calorie Sweetener Sources of Sweeteners

Caloric Low calorie LCS and CS sweetener sweetener

All Foods and Beverages that Contain Any Sweetener

A. NHANES, 2007-2010 B. HOMESCAN, 2007-2010

LCS CS LCS CS LCS+CS 500 500 stores stores 400 400

15 % from from 73 % 300 300

59 % 7 %

200 200

capita total store purchases purchases store total capita

capita total intake intake total capita Per Per Per Per 100 100 92 % 27 % 95 % 26 % 5 % 1 % 0 0 Beverage Food Beverage Food • Means per capita for beverages (mL/d) and foods (g/d). LCS, low-caloric sweetened beverages or foods; CS, caloric-sweetened beverages or foods • Piernas et al, Pediatrics Obesity 8:294-306 The % of Uniquely Formulated Foods and Beverages in the US Food Supply Containing Sweeteners (Mutually Exclusive Categories)

100% 3 2 2 2 4 5 7 9 90% 15 80% Any FJC 70% 63 58 63 60 55 66 66 51 Both NS and NNS

60% 45 by by weight 50% NS only 40% NNS only 5 9 14 12 sweeteners 30% 3 6 No added sweeteners 20% 34 % of unique formulations containingformulationsuniqueof % 30 32 31 31 29 28 26 28 10%

0%

2000 (N= 4,666) (N= 2000 9,371) (N= 2006

2013 (N=16,512) 2013

2000 (N= 40,562) (N= 2000 76,971) (N= 2006 35,896) (N= 2000 67,600) (N= 2006

2013 (N=113,015) 2013 2013 (N= 129,527) (N= 2013 All CPG Foods & Beverages Foods only Beverages only

NS= Nutritive/Caloric Sweetener, NNS= Non-nutritive/non-caloric sweetener, FJC= Fruit Juice Concentrate (excluding lemon/lime and when reconstituted) (not for use or quotation) (Popkin and Hawkes, Lancet Diabetes for fall/winter) % of Uniquely formulated CPG Purchases by Weight in Grams Containing Sweeteners (Weighted to Be Nationally Representative)

100% 1 3 1 2 2 1 5 6 10 90%

80% 39 47 34 Any FJC 70% 57 51 48 70 69 65 60% Both NS and NNS

50% NS only 21 17 40% 9 18 NNS only sweeteners 12 10 30% No added sweeteners

20% 39 36 33 35 31 32 29 28 32

% of purchases by weight containing by weight purchasesof % 10%

0% 2000 2006 2013 2000 2006 2013 2000 2006 2013 All CPG Foods & Beverages Foods only Beverages only

NS= Nutritive/Caloric Sweetener, NNS= Non-nutritive/non-caloric sweetener, FJC= Fruit Juice Concentrate (excluding lemon/lime and when reconstituted) (not for use or quotation) (Popkin and Hawkes, Lancet Diabetes for fall/winter) % of CPG Purchases by Calories Containing Sweeteners Weighted to be Nationally Representative (Excludes Low Calorie Sweeteners by Using Kcal)

100% 0 0 1 2 1 1 1 2 5 90%

80% Any FJC 70% 55 53 47 66 69 69 72 71 68 60% Both NS and NNS

50% NS only

40% NNS only sweeteners 30% No added sweeteners 48 20% 42 44 32 29 29 27 27 30

% of purchases by containingby caloriespurchasesof % 10%

0% 2000 2006 2013 2000 2006 2013 2000 2006 2013 All CPG Foods & Beverages Foods only Beverages only

NS= Nutritive/Caloric Sweetener, NNS= Non-nutritive/non-caloric sweetener, FJC= Fruit Juice Concentrate (excluding lemon/lime and when reconstituted) (not for use or quotation) (Popkin and Hawkes, Lancet Diabetes for fall/winter) 2. United States: Added Sugar and Beverages: Patterns and Trends

• US trends overall • Changes in the distribution

“Over 2 billion people in the world are overweight” Hook consumers early, gain a consumer for life:

“Babies who drink soda during their early formative period are much more likely to fit in during those awkward preteen and teen years”

“Over 2 billion people in the world are overweight” Adjusted Mean Calories of Daily Added Sugars by US Individuals for Foods and Beverages

1977 to 2003 change 2003 to 2012 change 1977 to 2003 change 2003 to 2012 change • Beverages:+3.6kcal/year • Beverages:-5.6 kcal/year • Beverages:+3.5kcal/year • Beverages:-3.9 kcal/year • Foods: +.6kcal/year • Foods: -1.2 kcal/year • Foods: +.9kcal/year • Foods: -.3kcal/year

400 Foods 350 Beverages

300 198 179 142 250 163 168 147 138 144 163 200 163 122 119 150

100 192 208 199 165 157 165 162 164 136 50 112 109 121

0 1977-1978 1989-1991 1994-1998 2003-2004 2009-2010 2011-2012 1977-1978 1989-1991 1994-1998 2003-2004 2009-2010 2011-2012 Children 2-18 Adults 19 and Older

Adjusted by Gender, Race, Income and Education, Weighted to Be Nationally Representative Trends in Quintiles of Added Sugar Distribution in the US (Excludes Fruit Juice Concentrate), Kcal/Day. Note the large skewed distribution.

A. Children aged 2-18 B. adults 19 and older

794 800 741 722 712 705 708 700 673

613 620 587 600 565 557

500

412 411

400 354 356 355 357 342 336

Kcal/day 302 310 301 306 300 266 266 226 232 224 227 213 208 198 192 198 193 200 158 153 129 118 129 136 117 132 106 108 99 102 100 58 52 53 52 47 41 37 44 29 26 26 20 0 1977-1978 1989-1991 1994-1998 2003-2004 2009-2010 2011-2012 1977-1978 1989-1991 1994-1998 2003-2004 2009-2010 2011-2012

q1 q2 q3 q4 q5

Powell et al, (not for use or quotation) 3. Global Trends— Both in Kcal by Region and Country and Volume

• Euromonitor passport data: excellent on trends, levels appear to be under-reported as expected as they do not obtain data from all companies. Pilot study worked with them. they obtain kcal from each country for most beverages. • Kcals based on calories from beverages in each country. They get this off websites and nutrition facts panels. If anything, these are a major undermeasurement as many local companies underreport their kcal, total sugar and other data.

“Over 2 billion people in the world are overweight” Daily Calories Sold per Capita per Day from all Sugar-Sweetened Beverages in 2014 by Region (Weighted by Population)

North America

Latin America

Australasia

Western Europe

Middle East and Africa

World

Eastern Europe

Asia Pacific

0 20 40 60 80 100 120 140 160 kcal/d per capita

Source: Euromonitor Passport International with country-specific kcal data added (not for use or quotation) (Popkin and Hawkes, Lancet Diabetes for fall/winter) Caloric Trends in Sugar-Sweetened Beverage Sales by Region, 2009-2014

180

160 Sports and Energy Drinks Juice Drinks 140 Caloric Soft Drinks

120

100

80 kcal/d per capitaperkcal/d 60

40

20

0

2013 2010 2013 2009 2010 2011 2012 2013 2014 2009 2010 2011 2012 2013 2014 2009 2010 2011 2012 2014 2009 2010 2011 2012 2013 2014 2009 2010 2011 2012 2013 2014 2009 2011 2012 2013 2014 2009 2010 2011 2012 2013 2014 2009 2010 2011 2012 2014 North America Latin America Australasia Western Europe Middle East and Eastern Europe World Asia Pacific Africa

Source: Euromonitor Passport International with country-specific kcal data added (not for use or quotation) (Popkin and Hawkes, Lancet Diabetes for fall/winter) Calories Sold per Capita per Day from Sugar-Sweetened Beverage by Country, 2009-2014

200

180 Sports and Energy Drinks Juice Drinks 160 Caloric Soft Drinks 140

120

100

80 kcal/d per capitaperkcal/d 60

40

20

0

2010 2011 2012 2013 2009 2011 2012 2013 2014 2009 2010 2011 2012 2013 2014 2009 2010 2012 2013 2014 2009 2010 2011 2012 2013 2014 2009 2010 2011 2013 2014 2009 2010 2011 2012 2013 2014 2009 2010 2011 2012 2014 2009 2010 2011 2012 2013 2014 Chile United States Mexico Brazil United Kingdom Colombia Thailand China

Source: Euromonitor Passport International with country-specific kcal data added (not for use or quotation) Supplemental Figure 1. Daily Calories Sold per Capita from all Sugar-Sweetened Beverages in 2014, Highest Selling Countries

Chile Mexico USA Argentina Saudi Arabia Germany Netherlands Slovakia Austria Brazil Belgium Israel Ireland Canada Australia Poland United Arab Emirates Denmark South Africa Norway Venezuela Finland Czech Republic Portugal Peru New Zealand Turkey 0 20 40 60 80 100 120 140 160 180 200 Calories sold per capita per day

Source: Euromonitor Passport International with country-specific kcal data added (not for use or quotation) (Popkin and Hawkes, Lancet Diabetes for fall/winter) Daily Calories Sold per Capita from all Sugar-Sweetened Beverages in 2014, Lowest Selling Countries

Sweden United Kingdom Hungary Colombia Spain Romania France Thailand Russia Italy Philippines Bulgaria Japan Switzerland South Korea Taiwan Ukraine Singapore Greece Malaysia China Morocco Egypt Hong Kong, China Vietnam Indonesia India 0 50 100 150 200 250 Calories sold per capita per day

Source: Euromonitor Passport International with country-specific kcal data added (not for use or quotation) (Popkin and Hawkes, Lancet Diabetes for fall/winter) Trends 2000-2010 in Calories per Ounce Sold: Global, the US, Brazil, and China

A. Calories per Ounce Sold B. Calories per Ounce Sold The Coca-Cola Company - Carbonates PepsiCo - Carbonates 14

12

10

8

6

4

2

0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

World US Brazil China

Source: Kleiman et al (2011) Obesity Reviews 4. Fruit Juices: a major concern • The biology is simple: really sugar water with little long- term research showing any benefit • The few long-term studies with adequate sample sizes or variability of fruit juice consumption (US, Singapore, Aust., Europe) find significant effects of fruit juice intake on weight gain and particularly risk of diabetes. • Fruit juice consumption is high among those consuming it in many countries. It has the aura of natural, healthy; however 5-a-day and all major dietary guidelines are trying to reduce intake—schools,etc allow only half portions. (4 oz or 120ml) • Be aware: the beverage industry controls an increasing number of juice bar franchises and juice companies. • New Zealand: high fruit juice intake now. “Over 2 billion people in the world are overweight” 5. Large-Scale Regulatory Options

• Taxation of sugar - ideal, Chile planning now. • Taxation at the manufacturer level of kcal in SSB’s • Marketing controls • Front-of-the-label profiling linked with marketing controls • Controls in selected institutions, e.g. schools • Food system changes

“Over 2 billion people in the world are overweight” Taxation • Barbados 10% tax began Aug 1, 2015 • France and Mexico SSB: about 10% tax, Mexican evaluation strong positive results but cannot reveal details until we publish. On website showed release: . Preliminary results show a 6 percent average decline in purchases of taxed beverages over 2014 compared to pre-tax trends. This difference accelerated over 2014 and the reduction compared to pre-tax trends reached 12% by December 2014. All socioeconomic groups reduced purchases of taxed beverages. Reductions were higher among lower socio-economic households, averaging 9% decline over 2014 compared to pre-tax trends and up to a 17% decline by Dec 2014. Results also show roughly a 4 percent increase in purchases of untaxed beverages over 2014, mainly driven by an increase in purchased bottled plain water (tap water intake is not collected). • Hungary—no evaluation • Chile: 8% SSB began Jan 1, 2015 coupled with marketing and FOP controls which will slowly be instituted over 4 years. • Selected Pacific Islands

“Over 2 billion people in the world are overweight” Berkeley California: too early for impact • US 1 cent/ounce. Implementation began March 1, 2015 • Prices: 26 supermarkets, corner stores, pharmacies and gas stations in Berkeley, CA in Dec 2014 and June 2015 for 68 beverages (751 prices in Dec 2014; 801 in June 2015) plus sales-weighted prices using retailer scanner data from Jan 2013-June 2015 of 71.9 million transactions, 9 million from beverages • SSB price per ounce rose at large (+1.32₵) and small (+1.65₵) chain supermarkets, and chain gas stations (+2.71₵). Not implemented yet small stores. • Scanner data: April 2015 (+0.52₵ April, +0.87₵ May, and +1.34₵ June 2015). The pass-through also occurred in neighboring cities.

“Over 2 billion people in the world are overweight” The Food Environment: Labeling and Claims • Front-of-the-package—confusing GDA’s of industry vs. – positive health food labeling: Singapore, Malaysia, Mexico, Thailand, China have or are finalizing. India is beginning. Law in Netherlands/Czech/others E Europe, Scandanavian Tick, new Healthy Stars Australia and New Zealand – negative logo: Ecuador exists as law (now planning implementation with its own version of negative logo) and Chile (identify foods with unhealthy levels added sugar, sodium, saturated fat, total energy). Complex traffic lights. Negative on multiple items, positive on others. – ban images: Ecuador banned animal characters, cartoon personalities, celebrities to promote junk food. • Ideal: Link labeling with marketing and later taxation. Some countries are doing this.

“Over 2 billion people in the world are overweight” Labeling Unhealthy Foods—just legally shifted and will be ‘Alto’ [high]

10 % of front surface of the package One for each high “critical nutrient”

“Over 2 billion people in the world are overweight” The Food Environment: Marketing Controls Hampered by Big Food and Beverage Politics • Chile: implementation of law to ban toys, control marketing of unhealthy foods high in saturated fat, energy, added sugar and sodium in all child media channels; a 3-year implementation in phases begins July 1, 2016. Will extend law all programming 6am-10pm • Brazil: comprehensive exemplary law held up by attorney general and legal challenges • Peru and Ecuador: strong laws, implementation not complete • Industry voluntary self-regulation seems to be the major approach and no evaluation has shown this to be successful in any LMIC or any high income country. • South Korea: ban for TV and internet specific food categories during kids’ programs and 5-7pm. • Thailand planning marketing ban linked with FOP labeling “Over 2 billion people in the world are overweight” The Food Environment: School Restrictions Major Institution

• Ideal—ban/allow same healthy/unhealthy foods and beverages • Schools: banning of junk foods/SSBs completely (Peru, Ecuador, Costa Rico, UAE, Singapore, Western Pacific), mainly (Mexico, Thailand) • In-school marketing: banned • Mexico: reformulation of milk from full fat to 1.5% fat for all government programs (≈ 20 million affected). • Brazil: most exemplary. Note below under food systems. Also ban SSB’s and snacks in many states. Indonesian snack law like Brazil law. • Philippines: banned SSB’s

“Over 2 billion people in the world are overweight” Food Systems

• Brazil: most effective but needs serious impact evaluation. Schools must purchase 30% of food from local smaller family farms/cooperatives. Also 70% of food must be a basic unprocessed food. No evaluation so unclear impact. • Singapore: put all hawkers into centers when can control the environment, have access to them for various programs. • The push for farmers markets and farm to household sales minimal in LMIC’s (a high income country phenomena mainly) • Urban and school gardening: limited systematic efforts • Mainly ignoring retail sector and restaurant/fast food other than the Singapore effort and the front of the package labeling efforts

“Over 2 billion people in the world are overweight” Information and Education

• To date no evidence from any country that large-scale nutrition education has affected either what people eat or drink or how they move. Thailand appears the strongest. • Large-scale: Thailand unique effort at the village level with a focus on reducing waist circumference (Flat Belly Network), also reducing sugar and fat • Dominant media today: food industry and retailers and food service sector. Trivial level of public health-related nutrition education • Nutrition education in schools in many countries pushed. No focus on cooking or other skills and minimal impact shown to date. • Few countries push for healthy food in hospitals and clinical diet and physical activity counseling (e.g. Brazil, Thailand) • Workplace: limited efforts (e.g. Singapore) “Over 2 billion people in the world are overweight” Special Programs for Controlling Overweight and Obesity Problems

• Sweet Enough Network • Thai People Flat Belly Network LMIC’s Are Beginning to Take Serious Large-Scale Action • The need and the will to take action is increasing among LMIC’s • Mexico, Ecuador, Chile, Peru, Thailand, Singapore, and the Western Pacific Islands are just the beginning of this. • Chile most systematic: with sugar tax on top of SSB tax plus FOP and marketing controls we will learn what its impact will be of a total set of laws once all passed and evaluated. Done iteratively. • Evidence is needed: serious push for rigorous evaluation is essential. • A need to create one food and beverage standard and use across all controls: marketing, front-of-packing profiling, taxation

“Over 2 billion people in the world are overweight” Remarkably Short History for Caloric Beverages:

Recent Transition to the Water Revolution AD BCE 0 Earliest possible date Definite date US Soda Intake 52/gal/capita (2004) COFFEE US Coffee Intake 46 gal/capita (1946)

Juice Concentrates (1945)

US Milk Intake 45 gal/capita(1945)

present

- 10,000 BCE - Coca Cola (1886) THE

WATER Homo Homo Sapiens

- Pasteurization (1860-64) Origin Humans of

Pre REVOLUTION

10,000 BCE Carbonation (1760-70)

Modern Beverage Era Modern Beverage 200,000BCE Liquor (1700-1800)

Lemonade (1500-1600)

Coffee (1300-1500)

Brandy Distilled (1000-1500) (206 AD) Tea (500 BCE) TEA Wine (5400 BCE) Wine, Beer, Juice (8000 BCE) Beer (4000 BCE) Milk (9000 BCE) 2000 BCE Water, Breast Milk WATER

200000 BCE Homo Sapiens 100000 BCE

of Time of

Beginning

200000 BCE 10000 BCE