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“Over 2 billion people in the world are overweight”
Global SSB and Sugar Consumption Patterns, Policies, Taxes, and Other Issues
THE W RLD IS FAT
Barry Popkin
Department of Nutrition
School of Public Health and Medicine
Department of Economics
The University of North Carolina at Chapel Hill
“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
Remarkably Short History for Caloric Beverages:
Might the Absence of Compensation Relate to This Historical Evolution?
AD
BC
E
10
00
0 B
CE
20
00
00
BC
E
Beg
inn
ing
of
Tim
e
100000 BCE
200000 BCE
Homo Sapiens
Pre
-Ho
mo
Sa
pie
ns
20
0,0
00
BC
E -
10
,00
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CE
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gin
of
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ma
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de
rn B
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rag
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10
,00
0 B
CE
-p
res
en
t
0
Earliest possible date
Definite date
Water, Breast Milk2000 BCE
Milk (9000 BCE)
Beer (4000 BCE)
Wine (5400 BCE)Wine, Beer, Juice
(8000 BCE)
(206 AD)Tea (500 BCE)
Brandy Distilled (1000-1500)
Coffee (1300-1500)
Lemonade (1500-1600)
Liquor (1700-1800)
Carbonation (1760-70)
Pasteurization (1860-64)
Coca Cola (1886)
US Milk Intake 45 gal/capita
(1945)
Juice Concentrates (1945)
US Coffee Intake 46 gal/capita
(1946)
US Soda Intake 52/gal/capita
(2004)
“Over 2 billion people in the world are overweight”
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
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
• 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
26 %
1 %
59 %
92 %
15 %
7 %
0
100
200
300
400
500
Beverage Food
Per
cap
ita
tota
l sto
re p
urc
has
es
B. HOMESCAN, 2007-2010
LCS CS LCS+CS
27 %
5 %
73 %
95 %
0
100
200
300
400
500
Beverage Food
Per
cap
ita
tota
l in
take
fro
m s
tore
s
A. NHANES, 2007-2010
LCS CS
Caloric
sweetener
Low calorie
sweetenerLCS and CS
All Foods and Beverages that Contain Any Sweetener
The % of Uniquely Formulated Foods and Beverages in the US Food
Supply Containing Sweeteners (Mutually Exclusive Categories)
30 29 32 31 31 3428 26 28
3 65 9 14 12
63 60 55 66 6663 58 51
45
3 5 72 2 2 4
915
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%2
00
0 (
N=
40,5
62
)
200
6 (
N=
76,9
71
)
201
3 (
N=
129
,52
7)
200
0 (
N=
35,8
96
)
200
6 (
N=
67,6
00
)
201
3 (
N=
113
,015
)
200
0 (
N=
4,6
66)
200
6 (
N=
9,3
71)
201
3 (
N=
16,5
12)
All CPG Foods & Beverages Foods only Beverages only
% o
f u
niq
ue
fo
rmu
lation
s c
on
tain
ing
sw
ee
ten
ers
by w
eig
ht
Any FJC
Both NS and NNS
NS only
NNS only
No added sweeteners
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)
31 32 3629 28 32 33 35
39
1012 9 18
21 17
57 51 48
70 69 65
47 3934
1 3 61 2 2 1 5
10
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
2000 2006 2013 2000 2006 2013 2000 2006 2013
All CPG Foods & Beverages Foods only Beverages only
% o
f p
urc
ha
se
s b
y w
eig
ht
co
nta
inin
g
sw
ee
ten
ers
Any FJC
Both NS and NNS
NS only
NNS only
No added sweeteners
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)
29 29 3227 27 30
42 4448
69 69 66 72 71 68
55 53 47
0 1 2 0 1 1 1 2 5
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
2000 2006 2013 2000 2006 2013 2000 2006 2013
All CPG Foods & Beverages Foods only Beverages only
% o
f p
urc
ha
se
s b
y c
alo
rie
s c
on
tain
ing
sw
ee
ten
ers
Any FJC
Both NS and NNS
NS only
NNS only
No added sweeteners
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)
“Over 2 billion people in the world are overweight”
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”
Adjusted Mean Calories of Daily Added Sugars by
US Individuals for Foods and Beverages
112136
192208
165 157
163
163
198 179
163 168
0
50
100
150
200
250
300
350
400
1977-1978 1989-1991 1994-1998 2003-2004 2009-2010 2011-2012
Foods
Beverages
109 121
165199
162 164
119122
147
142
138 144
1977-1978 1989-1991 1994-1998 2003-2004 2009-2010 2011-2012
1977 to 2003 change• Beverages:+3.6kcal/year• Foods: +.6kcal/year
2003 to 2012 change• Beverages:-5.6 kcal/year• Foods: -1.2 kcal/year
1977 to 2003 change• Beverages:+3.5kcal/year• Foods: +.9kcal/year
2003 to 2012 change• Beverages:-3.9 kcal/year• Foods: -.3kcal/year
Children 2-18 Adults 19 and Older
Adjusted by Gender, Race, Income and Education, Weighted to Be Nationally Representative
37 26 2052 44 47
11799 102
153129 132
198 193208
266
224 227
301 306
336
411
355 357
557
587
705
794
722708
1977-1978 1989-1991 1994-1998 2003-2004 2009-2010 2011-2012
41 29 26
58 52 53
118 106 108
158129 136
198 192213
266
226 232
302 310
342
412
354 356
565
613
712741
673
620
0
100
200
300
400
500
600
700
800
1977-1978 1989-1991 1994-1998 2003-2004 2009-2010 2011-2012
Kca
l/d
ay
Trends in Quintiles of Added Sugar Distribution in the US
(Excludes Fruit Juice Concentrate), Kcal/Day.
Note the large skewed distribution.
q1 q2 q3 q4 q5
A. Children aged 2-18 B. adults 19 and older
Powell et al, (not for use or quotation)
“Over 2 billion people in the world are overweight”
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.
0 20 40 60 80 100 120 140 160
Asia Pacific
Eastern Europe
World
Middle East and Africa
Western Europe
Australasia
Latin America
North America
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)
Daily Calories Sold per Capita per Day from all Sugar-Sweetened
Beverages in 2014 by Region (Weighted by Population)
0
20
40
60
80
100
120
140
160
180
20
09
20
10
20
11
20
12
20
13
20
14
20
09
20
10
20
11
20
12
20
13
20
14
20
09
20
10
20
11
20
12
20
13
20
14
20
09
20
10
20
11
20
12
20
13
20
14
20
09
20
10
20
11
20
12
20
13
20
14
20
09
20
10
20
11
20
12
20
13
20
14
20
09
20
10
20
11
20
12
20
13
20
14
20
09
20
10
20
11
20
12
20
13
20
14
North America Latin America Australasia Western Europe Middle East andAfrica
Eastern Europe World Asia Pacific
kca
l/d
pe
r ca
pita
Sports and Energy Drinks
Juice Drinks
Caloric Soft Drinks
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
0
20
40
60
80
100
120
140
160
180
200
20
09
20
10
20
11
20
12
20
13
20
14
20
09
20
10
20
11
20
12
20
13
20
14
20
09
20
10
20
11
20
12
20
13
20
14
20
09
20
10
20
11
20
12
20
13
20
14
20
09
20
10
20
11
20
12
20
13
20
14
20
09
20
10
20
11
20
12
20
13
20
14
20
09
20
10
20
11
20
12
20
13
20
14
20
09
20
10
20
11
20
12
20
13
20
14
Chile United States Mexico Brazil United Kingdom Colombia Thailand China
kca
l/d
pe
r ca
pita
Sports and Energy Drinks
Juice Drinks
Caloric Soft Drinks
Source: Euromonitor Passport International with country-specific kcal data added (not for use or quotation)
Calories Sold per Capita per Day from Sugar-Sweetened
Beverage by Country, 2009-2014
0 20 40 60 80 100 120 140 160 180 200
TurkeyNew Zealand
PeruPortugal
Czech RepublicFinland
VenezuelaNorway
South AfricaDenmark
United Arab EmiratesPoland
AustraliaCanadaIreland
IsraelBelgium
BrazilAustria
SlovakiaNetherlands
GermanySaudi Arabia
ArgentinaUSA
MexicoChile
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)
Supplemental Figure 1. Daily Calories Sold per Capita from all
Sugar-Sweetened Beverages in 2014, Highest Selling Countries
0 50 100 150 200 250
IndiaIndonesia
VietnamHong Kong, China
EgyptMorocco
ChinaMalaysia
GreeceSingapore
UkraineTaiwan
South KoreaSwitzerland
JapanBulgaria
PhilippinesItaly
RussiaThailand
FranceRomania
SpainColombiaHungary
United KingdomSweden
Calories sold per capita per day
Daily Calories Sold per Capita from all Sugar-Sweetened
Beverages in 2014, Lowest Selling Countries
Source: Euromonitor Passport International with country-specific kcal data added (not for use or quotation) (Popkin
and Hawkes, Lancet Diabetes for fall/winter)
0
2
4
6
8
10
12
14
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
A. Calories per Ounce SoldThe Coca-Cola Company - Carbonates
Trends 2000-2010 in Calories per Ounce Sold:
Global, the US, Brazil, and China
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
B. Calories per Ounce SoldPepsiCo - Carbonates
World US Brazil China
Source: Kleiman et al (2011) Obesity Reviews
“Over 2 billion people in the world are overweight”
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)
Special Programs for Controlling
Overweight and Obesity Problems
• Sweet Enough Network
• Thai People Flat
Belly Network
“Over 2 billion people in the world are overweight”
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
Remarkably Short History for Caloric Beverages: Recent Transition to the Water Revolution
AD
BC
E
10
00
0 B
CE
20
00
00
BC
E
Beg
inn
ing
of
Tim
e
200000 BCE Homo Sapiens
Pre
-Ho
mo
Sap
ien
s
20
0,0
00
BC
E -
10
,00
0 B
CE
Ori
gin
of
Hu
man
s
Mo
der
n B
ever
age
Era
10
,00
0 B
CE
-p
rese
nt
0Earliest possible date
Definite date
Water, Breast Milk2000 BCE
Milk (9000 BCE)
Beer (4000 BCE)
Wine (5400 BCE)Wine, Beer, Juice (8000 BCE)
(206 AD)Tea (500 BCE)
Brandy Distilled (1000-1500)
Coffee (1300-1500)
Lemonade (1500-1600)
Liquor (1700-1800)
Carbonation (1760-70)
Pasteurization (1860-64)
Coca Cola (1886)
US Milk Intake 45 gal/capita(1945)
Juice Concentrates (1945)
US Coffee Intake 46 gal/capita (1946)
US Soda Intake 52/gal/capita (2004)
100000 BCE
THEWATER
REVOLUTION
WATER
TEA
COFFEE