ADSA spokesperson, Mari Pronk, updates us on the current standing of Sugar Tax.

The obesity epidemic

South Africa is facing a severe and growing obesity epidemic.According to the South African Demographic and Health Survey (2016), 68% of women, 31% of men and 13% of children are overweight or obese.¹ This makes South Africa the country with the highest overweight and obesity rate in Sub-Saharan Africa.

Sugar and health

Added sugars (added sugars are any sugars added to foods or drinks by a manufacturer, cook or consumer), particularly in beverages, are a major cause of increased weight gain and tooth decay.

The World Health Organisation (WHO) recommends that: the daily consumption of added sugars should be less than 10% of an individual’s daily energy intake. This would be equivalent to about 12 teaspoons of granular sugar per day for adults. For additional health benefits, this amount can further be reduced to 5% of daily energy intake (about six teaspoons of sugar).²

Sugar-sweetened beverages

Sugar-sweetened beverages (SSB) are non-alcoholic beverages, sweetened with added sugars. There is convincing evidence to support a positive link between the intake of SSB and the risk of obesity, diabetes and other conditions, such as stroke and heart disease.³

SSB consumption rates among urban and rural communities in South Africa have increased considerably over the past 20 years. Reports show that the total SSB consumption has risen by 68,9% from 1999 to 2012. This increase is accompanied by an increase in the rate of overweight and obesity, leading to an increased risk of non-communicable diseases, such as diabetes.⁴

Regular, high-calorie carbonated soft drinks are considered the most frequently consumed of all SSB categories. Several studies indicated that the frequent consumption of these drinks is due to habit, addiction, advertising and the wide availability of inexpensive SSB, as opposed to more expensive fruits, vegetables and wholegrain products.^3,4

What is sugar tax?

The Health Promotion Levy (HPL) on sugary beverages is a levy that was introduced, in support of the South African Department of Health’s Strategic Plan for Prevention and Control of Obesity and aims to reduce obesity by 10% by 2020⁵.

South Africa was the first country in Africa to introduce the taxation of SSB, when the tax was introduced in April 2018, with the objective of reducing SSB consumption.

In 2018, sugar tax started at a rate of 2,1 cents per gram of sugar content, which exceeds 4 grams (about one teaspoon of granulated sugar) per 100ml. The first 4 grams per 100ml are levy free.⁶

The sugar tax results in an average price increase of 11% on SSB, whereas the WHO recommends an increase of 20% or more, to be effective.⁷

In 2019, sugar tax increased from 2,1 cents to 2, 21 cents, in line with the then inflation rate of 5,2%.⁸This amount is unchanged for the 2020/2021 financial year.

A can of 300ml (current can size) Original Taste Coke (contains 33g sugar) will not be taxed on the first 12g (4g for each 100ml) of sugar. The remaining 21g of sugar will be taxed at a rate of 2,21 cents per gram. Thus, a 300ml can of Original Taste Coke is taxed by 46,41 cents. A can of 300ml Less Sugar Coke (contains 24g sugar) is taxed by 26,52 cents.

 Locally manufactured SSB are taxed at source, meaning that the tax should be paid by the manufacturer.⁶

 Effect on consumption

In countries where sugar tax has been implemented, such as Mexico, Portugal, Ireland, Canada and in some states in the USA, the impact on consumption has been greater in poorer households.⁴ Unfortunately, the same impact is expected in South Africa.

Mexico has so far been the most successful with their sugar tax levy. There was a decrease in the consumption of taxed beverages by an average of 6%, after implementation in 2014.⁷

Manufacturers

Producers of SSB have started to reduce the sugar content of their products to reduce sugar tax. Coca-Cola has reduced the sugar content of its SSB by 26%.⁸

Another strategy by manufacturers of SSB, was to reduce the volume of the product by 10%.⁷A 330ml can of SSB now only contains 300ml and a 500ml bottle now contains 440ml.

The reduction in sugar content and container size may possibly contribute to a decrease in sugar intake by consumers.

A recent study found that, since the introduction of sugar tax, there has been a significant price increase in carbonated soft drinks. It was found, however, that the price increase was similar for no sugar and high-sugar beverages, despite the underlying difference in tax liability.⁹

Effect on the sugar industry

According to the SA Cane Growers Association, the price of sugar cane is at a record low. This is due to the impact of a devastating drought; cheap sugar being imported from other countries; and a substantial drop in the demand for sugar since the implementation of the sugar tax.¹⁰

Tax income

During the first year after its introduction, sugar tax has raised almost R3 billion.⁸ Many public health experts called for this money to be specifically allocated for obesity prevention initiatives. Money generated from the HPL goes into the National Revenue Fund, to be used for general government expenditure, including health expenditure, which also include health promotion interventions.⁸

The future

Non-profit organisation, the Healthy Living Alliance (Heala), has asked Treasury to increase (to 20%) and expand (to include fruit juices which have high sugar content) South Africa’s sugar tax, as the country deals with growing health issues.¹¹

Conclusion

Studies are currently underway to determine the impact of sugar tax on the consumption of SSB, to determine its reduction of obesity.⁵

In the meantime, it is important to note that South Africa probably needs to complement sugar tax, with lifestyle and dietary change strategies. These strategies might include increasing physical activity and improving the availability and cost of healthy food choices, such as fruit, vegetables and whole grain products.

References

1. South African National Department of Health (2017) ‘South Africa Demographic and Health Survey 2016 – Key Indicators Report’ Available at: https://www.statssa.gov.za/publications/Report%2003-00-09/Report%2003-00-092016.pdf (Accessed: 6 March 2020). 
2. World Health Organisation (2017) ‘Sugar tax, why do it?’ Available at: https://apps.who.int/iris/bitstream/handle/10665/260253/WHO-NMH-PND-16.5Rev.1-eng.pdf?sequence=1(Accessed: 6 March 2020).
3. Bosire, E.D., Stacey, N., Mukoma, G., Tugendhaft, A., Hofman, K. and Norris, S.A. (2019) ‘Attitudes and perceptions among urban South Africans towards sugar-sweetened beverages and taxation’, Public Health Nutrition, 23(2), pp. 374-383.
4. Okop, K.J., Lambert, E.V., Alaba, O. Levitt, N.S., Luke, A., Dugas, L., Dover, R.V.H., Kroff, J., Micklesfield, L.K., Kolbe-Alexander, T.L., Smit Warren, Dugmore, H., Bobrow, K., Odunitan-Wayas, F.A. and Puoane, T. (2019) ‘Sugar-sweetened beverage intake and relative weight gain among South African adults living in resource-poor communities: longitudinal data from the STOP-SA study’, International Journal of Obesity, vol. 43, pp. 603–614. Available at: https://doi.org/10.1038/s41366-018-0216-9 (Accessed: 6 March 2020).
5. Schneider, F. (2019)‘Health Levy or Sugar Tax: Is the Pain Worth the Gain?’, Taxtalk Magazine. Available at: https://www.thesait.org.za/news/450529/Sugar-Tax.htm (Accessed: 6 March 2020).
6. South African Revenue Services (2019) ‘Health Promotion Levy on Sugary Beverages’ Available at: https://www.sars.gov.za/ClientSegments/Customs-Excise/Excise/Pages/Health%20Promotion%20Levy%20on%20Sugary%20Beverages.aspx(Accessed: 6 March 2020).
7. ‘Is sugar tax really a health measure or a tax income stream?’, https://www.bizcommunity.com,18 Feb 2019 [Online] (Accessed: 6 March 2020).
8. Pilane, P. and Green, A. (2019) ‘Sugary drinks tax turns one — amid opposition’, Health-e news, 1 April [Online]. Available at: https://health-e.org.za/2019/04/01/sugary-drinks-tax-turns-one-amid-opposition/(Accessed: 6 March 2020).
9. StaceyN., Mudara, C.,WenNg, S., Van Walbeek, C., Hofman, K. and Edoka, I. (2019)‘Sugar-based beverage taxes and beverage prices: Evidence from South Africa’s Health Promotion Levy’, Social Science and Medicine, vol. 238. Available at: https://doi.org/10.1016/j.socscimed.2019.112465 (Accessed: 12 March 2020).
10. Stainbank, G. (2019) ‘Sugar Tax: Devastating to an Industry Already on its Knees’,Taxtalk Magazine.Available at: https://www.thesait.org.za/news/450529/Sugar-Tax.htm(Accessed: 6 March 2020).
11. ‘Push to increase South Africa’s sugar tax’, Businesstech, 12 February 2020 [Online]. Available at: https://businesstech.co.za/news/finance/373280/push-to-increase-south-africas-sugar-tax/(Accessed: 6 March 2020).

MEET THE EXPERT

Mari Pronk is a registered dietitian and a spokesperson for the Association for Dietetics in South Africa (ADSA). She is currently in private practice in Pretoria. She holds a post-graduate diploma in Diabetes and has a special interest in diabetes, cholesterol, renal disease and IBS.

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Dr Carmen James educates us on the often heart-breaking mutually destructive relationship between insulin resistance and polycystic ovary syndrome (PCOS)¹.

Understanding insulin resistance

Prediabetes is a condition which occurs when your blood glucose levels are higher than normal but not high enough to be diagnosed with actual diabetes.

Prediabetes usually occurs in people who already have some insulin resistance³. Cells in your body use glucose for energy. Glucose in your body is transported into your cells with the help of the hormone insulin.

Insulin resistance is when cells in your muscles, fat, and liver don’t respond well to insulin and can’t easily take up glucose from your blood³. In response, your pancreas releases more insulin and as a result, both insulin and glucose begin to accumulate in the bloodstream¹.

What is PCOS?

Polycystic ovary syndrome (PCOS) is a common reproductive disorder⁴ that affects as many as 15% of the female population⁵. It is defined as a hormonal disorder common among women of reproductive age⁶.According to statistics, 60-80% of women with PCOS suffer from insulin resistance⁴.

Mutually destructive relationship 

While many of us might know insulin resistance may be a precursor to diabetes^{1, 3} and that excess weight and lack of physical activity could be at fault³, how many of us are aware of the relationship between insulin resistance and PCOS?

The relationship between insulin resistance and PCOS can be described as mutually destructive in that PCOS worsens insulin resistance and vice versa¹.

Not only are high insulin levels a feature of PCOS, they also fuel the disease. The reason for this is because insulin accumulation reduces ovulation and promotes the production of androgens or male hormones. This results in symptoms, such as a male pattern of hair growth (hirsutism), acne and, in some cases, is associated with difficulties with fertility¹.

In fact, 60% of women with PCOS suffer from hair loss, acne and unwanted hair growth and 20% have infertility problems^4.

Alarmingly, more than 50% of women with PCOS will develop diabetes or pre-diabetes before the age of 40⁷.

With so many women affected by PCOS or insulin resistance, or indeed both⁴, the effect on fertility can be heart-breaking.

How does having insulin resistance affect fertility? 

Ovulation occurs during a normal menstrual cycle where an egg is released from the ovary and passes through the fallopian tubes and into the uterus. If the egg is not fertilised, the egg, together with the uterine lining, will be shed during menstruation¹.

Because an accumulation of insulin in the bloodstream elevates androgen levels, the resulting hormone imbalance will negatively affect ovulation. When women do not ovulate, they may menstruate less frequently, have irregular cycles and, in some instances, they may not menstruate at all. If an egg is not released into the uterus, conception will not occur.

PCOS is the most common cause of irregular menstruation that leads to infertility⁴.

While it is more likely for overweight and obese women to experience insulin resistance¹ and PCOS⁶, women of a normal weight can be affected too. It is important to remember that weight alone is not an absolute representation of health.

Address the underlying root condition

It is recommended that women with PCOS and/or insulin resistance address the underlying root cause drivers of their condition. While we can’t control our genes, we can aim to live a healthy lifestyle to reduce the negative effects of both PCOS and insulin resistance.

Adopt a healthy diet, rich in plant-based foods and low in refined carbohydrates; enjoy regular physical exercise; add supplements, including myo-inositol; curcumin; powerful antioxidants, such as Alpha-lipoic acid; folate and berberine; manage stress levels and get good quality sleep. These measures will reduce inflammation, improve insulin sensitivity and begin to bring balance to the hormones to support ovulation¹.

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Geline Mare outlines the importance of annual optometrist consults if you have diabetes.

If you are newly diagnosed with diabetes, welcome. Take a deep breath. Yes, there might be a season of change starting now, but with the support from your loved ones and support groups, formed by veteran diabetes patients, you will get through this.

If you are living with diabetes, you might already know the secondary effects, the pitfalls, you need to watch out for. If this is so, this will be a reminder, a refresher and a motivator to manage your glucose levels and visit all the necessary healthcare professionals annually.

The optometrist consult questions

The following questions should be asked when a diabetic patient visits an optometrist:

1. What type of diabetes have you been diagnosed with?
2. When were you diagnosed?
3. What medication are you currently using? This will be for diabetes, but also includes any other medical conditions.
4. How often do you check your glucose levels? What is the value on average?
5. Did you check your glucose level today and what is it?

It is important for an optometrist to understand your glucose level pattern, which will influence the vision and the visual problems that you might experience.

Even though your glucose level might never be considered normal, because of certain factors, having a healthy and stable average helps us determine your vision and visual solutions, should you need anything.

High blood glucose levels

High blood glucose levels have serious effects, but so has fluctuation of your glucose level. A sudden spike can cause unwanted damage and changes in your vision.

Behind the coloured portion of the eye (iris) there is a clear and transparent lens. This lens is responsible for the focusing of images on the nerve layer (retina) so we can see the image clearly.

High glucose levels cause swelling of the lens in the eye, which in effect change the power and curvature of the lens and the image on the nerve layer gets out of focus or blurred.

Optometrists might be able to clear the image by prescribing spectacle correction. But if the glucose level drops, the power of the lens will change again, leading to a different prescription necessary.

Keeping your glucose stable will keep your vision stable. And that will make it possible to accurately determine the power of your visual system.

High and fluctuating glucose levels can ultimately lead to faster changes in the structure of the eye and may cause secondary cataracts, glaucoma and diabetic retinopathy.

Cataracts: hardening of the lens

The lens inside the eye is soft and transparent to let light pass through on to the retina. Think of the white portion of an egg, it is soft and transparent, but as soon as you bake the egg, it becomes white and hard.

Similarly, the lens in the eye becomes white and hard, and that is what we call a cataract, that hardening. But, thankfully it’s a much slower process than with an egg. It becomes more difficult for light to pass through the hardened lens and thus you’ll have blurry vision. Some people compare the vision to a dirty window.

Glaucoma: damage to the nerve layer due to pressure

The eyeball is soft, with no bones, and has fluid inside to keep it in the shape that it should be in. Constantly new fluid is being produced and old fluid is drained out. If the amount of fluid being produced is more than the amount of fluid draining, there will be too much fluid in the eyeball. Unfortunately, the eyeball can’t expand like a water balloon, and the pressure will build up. If that pressure starts damaging the nerve layer (retina) at the back of the eye, we call it glaucoma.

Sadly, the damaged nerve layers can’t be fixed and loss of visual field is permanent. Glaucoma is silent, as there are usually no symptoms to warn you, but thankfully it’s preventable if high pressure is picked up soon enough. If you have high eye pressure, you won’t necessarily get glaucoma (damage). But once you have glaucoma (damage), it cannot be reversed. 

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Diabetic retinopathy: damage to the nerve layer due to uncontrolled glucose levels

The nerve layer (retina) at the back of the eye is super important. It is made up of all kinds of nerves, light and colour receptors, and blood vessels. This layer receives the information from our outside world in light form, collects all the data and sends it to the brain for interpretation.

High and fluctuating glucose levels causes changes to the blood vessels that feeds the retina with oxygen and nutrients, which leads to damage to that nerve layer. This damage is called retinopathy.

Applied knowledge is power

All these conditions might not give you initial symptoms and cause for alarm; for this reason, a yearly eye examination is recommended for people living with diabetes.

Remember as Eric Thomas says, “Knowledge isn’t power, applied knowledge is power.” All we can do is give you information and instruction. What you do with it, is the most important aspect. Seek help if you can’t get your glucose levels under control and stable. Don’t give up.

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We learn how the RetinaRisk app eliminates diabetic blindness through empowerment and predictive analytics.

The RetinaRisk app is a unique and novel tool that empowers persons with diabetes to monitor their individualised risk of developing sight-threatening diabetic retinopathy, which is one of the most common causes of blindness worldwide.

It is designed by an Iceland-based company, founded by academics and healthcare providers with over 30 years’ experience in screening, for persons with diabetic retinopathy and treating diabetes.

Diabetes stats

The global diabetes epidemic has tripled since 2000, to some 430 million persons worldwide, and is expected to exceed 600 million by 2045.

Two-thirds of persons with diabetes develop diabetic retinopathy and one-third develop sight-threatening diabetic retinopathy over twenty years. These patients are at high risk of vision impairment or even blindness if not diagnosed and treated in a timely manner.

How the RetinaRisk app works

Systematic eye screening and preventive treatment are known to dramatically reduce diabetic blindness. The RetinaRisk app is a clinically-validated risk calculator that allows people with diabetes to assess, in real-time, their individualised risk for sight-threatening diabetic retinopathy, based on their risk profile, and to track the progression of the disease over time.

The app includes detailed guidelines and useful information on diabetes, diabetic retinopathy and improved self-care, which allows patients to better understand their condition and become an active participant in their own wellness journey.

The RetinaRisk app empowers persons with diabetes to become more involved in their healthcare decision-making. It supports patient self-management by demonstrating the importance of regular eye examinations and seeking timely medical assistance.

It motivates persons with diabetes to become more responsible and better-informed patients. The app’s easy-to-visualise, effective and efficient patient education tools vividly demonstrate how improvement of modifiable risk factors (e.g., blood glucose, HbA1c, blood pressure) could significantly lower the risk of potentially blinding diabetic eye disease and expensive interventions.

The algorithm at the core of the RetinaRisk app is based on extensive international research on risk factors known to affect the progression of diabetic retinopathy, such as duration of diabetes, gender, blood pressure and blood glucose (HbA1c) levels.

Clinical validation in 20 000 persons with diabetes is robust and the results have been published in several respected medical journals.

The RetinaRisk app is free of charge and our goal is to get it in the hands of as many persons with diabetes as possible around the world.

The RetinaRisk App can be downloaded using the following links: