BRUSSELS, (Parliament Times) :To whom it may concern,
We are writing to you on behalf of the International Diabetes Federation (IDF) in support of our member, the Diabetic Association of Pakistan (DAP) and their request made to you in a letter from DAP Secretary General Professor Abdul Basit last month (dated April 13th). IDF is an umbrella organisation of over 240 national diabetes associations in 168 countries and territories. Our organisation represents the interests of the growing number of people affected by diabetes and those at risk.
Respectfully, we would like to raise our concern about the high number of people living with diabetes in Pakistan (currently estimated to be 19.4 million, though this is thought to be a conservative estimate) and the many more at high risk of developing diabetes. More than a third of adults in Pakistan are either obese or overweight and therefore at increased risk of diabetes and other health problems.
We write to encourage the government of Pakistan to take action to tackle diabetes in the country through measures designed specifically to reduce the burden of diabetes on individuals and families affected by diabetes and to do more to prevent diabetes in the population.
We are cognisant that, on the 31st of May, the Federal Board of Revenue (FBR) will submit its proposals to the Ministry of Finance for the forthcoming budget. We would like to propose the government give serious consideration to fiscal policies that can help reduce the consumption of goods detrimental to health and encourage citizens to make healthier choices. Specifically, we would recommend serious consideration be given to increased taxation on sugar-sweetened beverages (SSBs). We support the request of the Diabetic Association of Pakistan to increase excise duty on SSBs to 20% and to broaden the category beyond its current definition to include juices, energy drinks, flavoured milk, iced tea and other drinks sweetened with added sugars.
Taxation to reduce the consumption of SSBs has proved a highly effective tool to reduce the burden of obesity and type 2 diabetes. To date, around 50 countries have introduced such measures, including examples in South-East Asia the IDF Middle East and North African Region (India, Maldives, Bahrain, Oman, Saudi Arabia and United Arab Emirates and Qatar).
In every region, diabetes is spiralling out of control and has become a global health emergency. It presents a significant threat to economic advancement, particularly in low and middle-income countries, where more than three in four of all people with diabetes now live. Almost two-thirds (63%) of people with diabetes are of working age. The life-changing complications of diabetes place a heavy burden on individuals, families and economies. Consistently high blood-glucose levels can lead to serious diseases affecting the heart and blood vessels, eyes, kidneys, nerves and teeth. Diabetes is a leading cause of cardiovascular disease, blindness, kidney failure, and lower-limb amputation. Over the past year, the COVID-19 pandemic has hospitalised and claimed the lives of people living with diabetes disproportionately, underscoring the elevated risk from infectious diseases to people living with the condition.
At a global level, we have seen the number of people with diabetes more than quadruple in 30 years, from an estimated 108 million in 1980 to 463 million adults aged 20–79 years today. This is fast approaching one in ten (9.3%) of the world’s population in this age group. Without sufficient action to bend the curve, the total number is predicted to rise to 578 million (10.2%) by 2030 and to 700 million (10.9%) by 2045. IDF estimates for 2019 suggest diabetes was responsible for 4.2 million deaths worldwide, of which close to half (46.2%) were premature (occurring in people under 60 years old) and preventable through a healthy, balanced diet and regular physical activity.
At the country level, a 2019 population-based study in Pakistan estimated that 17% of adults older than 20 years have type 2 diabetes and a further 11% have elevated levels of blood glucose levels, placing them at high risk for developing diabetes. Other studies have suggested the figure could be higher, perhaps affecting as many as one in four adults. Figures to be published by IDF later in the year will incorporate data from more recent studies than the 2019 figures. Early analysis suggest the prevalence estimates will indeed be higher.
Behind the rising trend is a complex interplay of socio-economic, demographic, environmental and genetic factors. Poor nutrition and sedentary lifestyles are driving weight gain and obesity rates worldwide, and are among the main risk factors for type 2 diabetes. The increasing availability of ultra-processed and sugary foods, reduced physical activity, and higher incomes, which often go hand-in-hand with a higher consumption of unhealthy foods, are significant contributing factors and key areas where policy intervention can help make a difference.
The above figures highlight the urgency for national governments to develop and deploy strategies to either slow or stop the diabetes pandemic and underscore a need to provide the best possible care for citizens living with diabetes. The only way to achieve the former is by reinforcing efforts to prevent the onset of new cases of type 2 diabetes. This will require governments to do more to drive awareness to support the prevention, early detection and treatment of diabetes and its complication. Achieving the latter will require investment in capacity to provide diabetes care and education for those already living with the condition and by increasing the availability of diabetes services. All of this will require additional funding allocation, which is where the taxation of sugar-sweetened beverages can play its part.
Fiscal policy offers governments an opportunity to help make a difference for diabetes. We strongly recommend considering the taxation of SSBs to support heathier habits that will be of financial benefit to individuals, in terms of reducing expenditure on products detrimental to their health and beneficial to societies in terms of savings from reduced healthcare costs and lost productivity. A recent study of the consumption trends for SSBs in Pakistan (Datta and Husain, 2020) shows that carbonated beverages have become an integral part of the Pakistani diet, with SSBs constituting as much as 70% of non-alcoholic beverages consumed. This is true at both ends of the income spectrum: for wealthier households SSBs have, seemingly, become a must-have consumable, while in poorer households an increasing amount of expendable income is spent on carbonated beverages – income that could be better spent on consumables more beneficial to family wellbeing.
Compelling evidence has demonstrated a strong association between the consumption of sugar-sweetened beverages and an increased risk of type 2 diabetes. WHO guidelines recommend children and adults limit their consumption of free sugars to less than 10% of their daily energy intake in order to prevent obesity (this is the equivalent of 12 teaspoons of table sugar). The guidelines suggest reducing this amount by half to gain additional health benefits. There are 40 grams of free sugars (10 teaspoons of table sugar) in a can of sugary drink. Studies indicate that people who consume 1-2 cans of SSBs or more each day have a 26% higher risk of developing type 2 diabetes (Malik et al., 2010).
Type 2 diabetes accounts for the vast majority (around 90%) of diabetes worldwide but can be effectively managed through education, support and the adoption of healthy lifestyles, combined with medication as required. Evidence exists that type 2 diabetes can be prevented and there is accumulating evidence that remission of type 2 diabetes may be possible for some people.
For a clear presentation of the case to deploy fiscal strategies to curb sugar consumption and thereby address the increasing impact of diabetes on individuals and the economy, we refer you to the World Bank Group 2020 publication “Taxes on Sugar-sweetened Beverages: International Evidence and Experiences on the impact”. In summary, the publication explains how taxing SSBs leads to increased prices that act as a deterrent to their consumption and how the policy plays an important role in helping raise public awareness of the detrimental health effects of over-consuming SSBs. It also shows how industry players, in response to taxation and a downward pressure on sales, have reformulated their products, by lowering sugar content for example, and taken other measures to address increased taxation. Finally, increased tax revenues can, of course, serve to provide additional revenue for investment in encouraging healthy habits by incentivising the consumption of products that promote health and supporting action to encourage increased physical activity.
We sincerely hope you will give serious consideration to our request to take action to prevent diabetes by responding positively to the proposal of the Diabetic Association of Pakistan to increase excise duty on a wide range of sugar sweetened beverages.
Andrew Boulton, MD, DSc (Hon), FACP, FICP, FRCP, President
Akhtar Hussain, MD, M.Phil, MPH, Ph.D, DSc President-elect