How to approach ‘Fat-tax’ on food to tackle Non-communicable diseases in India: A Review

Ritu Rana*

Indian Institute of Public Health Gandhinagar (IIPHG), Near Lekawada Bus Stop,

Chiloda Road, Gandhinagar, Gujarat 382042

*Corresponding Author Email: rrana@iiphg.org

ABSTRACT:

Non-communicable diseases (NCDs) contributed to an estimated 61% (5.8 million) total deaths and 55% disability-adjusted life years in India in 2015. These diseases not only affect the health status of the population, but they also have social and economic implications, such as-prolonged disability and increased health-related expenditures by health systems, households, and individuals. As per recent disease burden study in India, unhealthy diet was found to be an important risk factor for NCD related mortality. Unhealthy diets, particularly those rich in fat are associated with overweight and obesity, which are an important metabolic risk factor for NCDs. Fiscal policies, such as taxation on unhealthy (fat and sugars) and subsidies on healthy (fruits and vegetables) food itemsare key population-based interventions to reduce the consumption of calorie-dense foods and address diet-related NCDs. These policies can offer both economic and health benefits. Many high-income countries, such as Hungry (packaged products with high sugar, saturated fat, and salt), Denmark (saturated fat), Finland (sweets), France (drinks with added sugar or sweeteners) and Mexico (high calorie packaged foods) have implemented health-related food taxes. Evidence from these countries suggests taxes and subsidies are effective in reducing consumption of sugary drinks and increasing the consumptions of vegetables and fruits. However, with fat taxes, a smaller effect is observed. Therefore, prior to designing a fat tax policy for India, evidence and lessons learned from other countries’ experiences must be considered. Also, the direct and indirect impact of the tax on both consumers and the food industry should be anticipated. While planning the taxation policy on fat, consumer responsiveness to the change in the price of the products that are being considered for taxation, and food industryinterests and tactics must be considered in local context. It is recommended to first have a clearly defined objective for the tax- is it for public health or economic benefits. Next step is to define the tax type and structure, followed by selecting the products to be taxed. To offset the influence of industry and to increase public and political support, earmarking the revenue from health taxes for healthcare financing or health promotion is recommended. Lastly, to tackle NCDs in India, the fat tax must be considered as one of the policy interventions and must be accompanied by other public health interventions.

KEYWORDS: Non-communicable diseases, unhealthy diets, fiscal policies, fat-tax, public health.

INTRODUCTION:

Burden of non-communicable diseases in India:

Non-communicable diseases (NCDs) contributed to an estimated 61% (5.8 million) total deaths and 55% disability-adjusted life years (DALYs) in India in 2015 (WHO, 2017). The four major NCDs, measured by leading cause of death in 2016 were- cardiovascular diseases (28%), chronic respiratory diseases (11%), cancers (8%) and diabetes (7%) (Dandona et. al., 2017, Abraham et. al., 2014). Evidence suggests that India is going through demographic, epidemiological and nutrition transition with an increase in the proportion of disease burden attributable to NCDs (Shetty, 2002, Dandona et. al., 2017). With an aging population, the burden will continue to increase during the next 25 years (FSSAI, 2017). In 1990, the top five individual causes of disease burden were Communicable, Maternal, Neonatal, and Nutritional Diseases (CMNDs), while in 2016, three of the top five cause were NCDs (Dandona et. al, 2017). In addition, diets in India are changing rapidly both quantitatively and qualitatively with small changes in energy intake but there have been large changes in consumptionof fats, animal products and sugars (Dandona et. al., 2017, FSSAI, 2017, Hait, Patel and Rajput, 2017).

Implication of high burden of NCDs:

NCDs have become a major public health problem in India. On one side, they affect the health status of the population and on other, they have social and economic implications. Within a decade, 1995-2004, NCDs accounted for an estimated 40% and 35% inpatient and outpatient burden respectively (Thakur et. al., 2011). Evidence suggests, due to NCDs, India stands to lose $4.58 trillion before 2030 (Bloom et. al., 2014). Ill health due to NCDs can affect national economy in several ways-increased health-related expenditures by health systems, households, and individuals; increased rates of early retirement, negative expectations about employment and reduced productivity (Bloom et. al., 2014, Sahu and Brahme, 2016). Similarly, the social burden associated with NCDs include- continued disability, reduced resources within the family leading to poverty and great demands on health system (Bloom et. al., 2011).

Risk factors for NCDs:

Risk factors for NCDs can be categorised into non-modifiable, modifiable behavioural risk factors and metabolic risk factors (WHO, 2017). Modifiable behaviours include-diet, physical activity, tobacco use and use of alcohol (Pujari and Pateel, 2017). Metabolic risk factors include-overweight/obesity, raised blood pressure, raised glucose level and raised lipid levels. As per recent disease burden studyfrom India, unhealthy diets were found to be an important risk factor for NCDs related mortality (Dandona et. al., 2017).

Strategies to tackle NCDs:

Several intervention packages have been developed to tackle NCDs. The most widely used is the World Health Organization’s (WHO) “best-buys” interventions (Bloom et. al., 2011). These interventions are very cost-effective, feasible and suitable to implement in a low resource setting. Some food-based interventions have also been proposed to prevent nutrition-related NCDs, such as -NOURISHING framework (Hawkes, Jewell and Allen, 2013) and smart food policy design (Hawkes et. al., 2015). NOURISHING framework is based on the understanding that food policy packages to prevent obesity and related NCDs should aim to improve dietary behaviours by improving the availability, affordability, and acceptability of healthy diets while decreasing the affordability, and acceptability of unhealthy diets (Hawkes, Jewell and Allen, 2013). Smart food policy design includes elements under three policy areas- school setting (fruit and vegetable programmes, school food standards and nutrition education), economic instruments (taxes and subsidies) and nutrition labelling (nutrition information on the food label) (Hawkes et. al., 2015). Both interventions suggest economic instruments as an important tool to tackle diet-related NCDs.

Given the rising burden of NCDs, Government of India (GoI) is committed to taking proactive actions to tackle this issue. In 2017, GoI developed National Multi-sectoral Action Plan for Prevention and Control of Common NCDs (2017-2022). One of the strategic areas under this multi-sectoral plan is health promotion through implementation of fiscal policies.

OBJECTIVES:

The objective of this review is- 1) To synthesise the evidence on fiscal policiesas key population-based interventions to reduce the consumption of calorie-dense foods and address diet-related NCDs, and 2) To provide a basis for developing guidelines on how to approach fat-tax on food to tackle NCDs in India.

METHODS:

A literature review of online resources including- systematic reviews, journal articles, WHO and GoI reports.

DISCUSSION:

Dietary habits in India, obesity, and risk of NCDs:

Unhealthy diets are one of the most important modifiable risk factors for NCDs (Singh et. al., 2014). These diets are associated with overweight and obesity, which are an important metabolic risk factor for NCDs.Prevalence of overweight or obesity in India has increased significantly over a period of 10 years, in 2005-06, it was 11%, which increased to 20% in 2015-16 (IIPS and ICF, 2017). According to NSSO, over a period of nearly two decades (1993-2012), the share of fats and oils in total energy intake has increased by about 3.5 percentage points in both rural and urban areas (NSSO, 2013). In contrast, the share of cereals has declined by nearly 10 and 7 percentage points in rural and urban areas respectively. In addition, there has been a rising trend in per capita fat intake at all-India as well as in every major state (NSSO, 2013).

Fiscal policies to address diet-related NCDs:

Fiscal policies, such as taxation and subsidies are key population-based interventions to reduce the consumption of calorie-dense foods and address diet-related NCDs (WHO, 2016). These policies can offer both economic and health benefits. They can help create incentives to reduce dietary risk factors for NCDs and can generate revenues for the government (figure 1). Fiscal policy interventions are usedwith the objective of influencing consumer behaviours at the point of purchase. These policies can also be used for manufacturinghealthy rather than unhealthy food by changing incentives (WHO, 2016).

The revenue generated from taxes can be used for healthcare and/or health promotion. Some of the fiscal policies that have been proposed for prevention of NCDs include- taxes on unhealthy nutrients (saturated/trans-fat, salt, sugar) and/or unhealthy foods (defined through nutrient profiling), and subsidies on fruits, vegetables and/or other healthy foods (WHO, 2016).

Evidence of fiscal policies and country experiences:

Most of the evidence on fiscal policies are dominatedby high-income countries. Evidence suggests taxes and subsidies are effective in reducing consumption of sugary products and increasing the consumptions of vegetables and fruits, however, with fat taxes, a smaller effect is observed (Hyseni et. al., 2017). Many high-income countries, such as Hungry (packaged products with high sugar, saturated fat and salt-2011), Denmark (saturated fat-2011), Finland (sweets-2011), France (drinks with added sugar or sweetener-2012) and Mexico (high calorie packaged foods-2013) have implemented health-related food taxes (Cornelsen et. al., 2014). To date, the evidence on the impact of these food taxes on the consumption of unhealthy food is limited. Preliminary findings from some countries (Finland, Denmark, Hungry and France) indicate a short-term impact on consumer demand; however, this impact was not sustained for a longer period (Cornelsen et.al., 2014). This highlights the importance of compressively exploring the long-term impacts of such policies.

Impact of food taxes:

Direct impact of food taxes: The economic rationale of food taxes for improving health outcomes assumes that price is an important factor influencing dietary choices (Kuriakose and Iyer, 2016) and hence, the responsiveness of the consumers to the change in price (elastic/inelastic) is crucial (figure 2). Price elasticities are different in developed and developing countries. In developed countries, the responsiveness of consumers to changes in price is relatively low as food includes only a small proportion of their total household income (<20%) and hence slight changes in food prices do not have any significant impact on consumption at the population level (Gao, 2011). Conversely, in developing countries, where most of the people are from the lower socio-economic group, they are more sensitive to prices changes as they spend a substantial amount of their household income on food (Pechey et. al., 2013).

Although food prices and incomes play a critical role, availability of alternates, complementary foods, individual habits, and preferences are other important factors that determine how the population will respond to food tax (Cornelsen et. al., 2014). On the other side, even if the demand for unhealthy food is not reduced much, there will be an increase in tax revenue (Cornelsen et. al., 2014). This revenue can be used for various purposes-providing health care, health education and/orpromotion activities. Evidence suggests if the tax is accompanied by health education activities, then therecould be added benefits (Cornelsen et. al., 2014).

Indirect impact of food taxes: Impact on the consumer-Food taxes can also have an indirect effect on consumer preferences (figure 2). In response to an increase in price, people might choose to consume less of it but then they might look for substitutions. This substitution could be healthy or unhealthy. Another possibility is consumers may continue to purchase the higher priced food and may reduce the quantity of other food items they consume, which might include healthy food options (Cornelsen et. al., 2014).

Impact on supply: The food industry might reduce the impact of the tax on consumers by lowering their margin of profitto sustain the sales (strategic pricing) (WHO, 2017) (figure 2) (Cornelsen et. al., 2014). However, this might vary for different producers- some may cut their prices, while others may not. These actions are likely to reduce the health impact of food taxing policies as the increase in price can be manipulated by the producers (Cornelsen et. al., 2014). Those producers who are willing to increase the price are likely to reformulate the product by using alternative ingredients. These alternatives can be eitherhealthy (e.g. replacing sugar with natural sweetener) or unhealthy (e.g. replacing can sugar with high fructose corn syrup). Thus, food taxes can have both positive and negative health impacts based on reformulationstrategies (Cornelsen et. al., 2014).

Table 2a: Key aspects of designing a fiscal policy on diet

Key aspects	Explanation
Tax Type	Excise tax is a tax levied on manufacture, sale, use, or distribution; this can also include a fixed fee or levy on a vendor. Another tax, value added tax (VAT) is applied on the production and distribution of goods. VAT is considered as a consumption tax as the ultimate cost is borne by the consumers at point of purchase.
Tax structure	A tax can be of two kinds- specific or ad valorem. Specific tax is levied based on product amount and size, whereas ad valorem is a percentage of the product value. Evidence from WHO’s tobacco taxation policy showed specific taxes (set amount of tax on a given quantity of product/ingredient) are likely to be more effective.
Products to be taxed	The core component of a tax design is responsiveness of the consumers to the change in price (elasticity) of the food products that are being considered for taxation. Careful designing of the tax base (range of products to be taxed) is essential to prevent consumers from undesirable substitutions and direct them towards healthy alternatives.
Tools for taxation	Several taxation tools are available, however, each one has its advantages and disadvantages. The choice of tool should depend on the overall aim of the tax and the context in which it is to be implemented.

Source: Wright et. al., 2017

Table 2b: Advantages and disadvantages of taxation tools

Tools	Explanation
Clearly prioritizing the objectives when designing taxes	If the purpose of the tax is to achieve health gains via behavioural change, it must be set at a sufficiently high level (>20%) If the aim is to generate revenue, then taxes set at a rate that is high enough to incentivize behavioural changes may be less desirable and a low rate may be appropriate
Expanding the number of unhealthy commodity products that are taxed	This is a concern as public support for new commodity taxes tends to be low and we need high public and political support to initiate and sustain this type of tax. These policies are likely to be challenged by strong industry interests (e.g. short-lived Danish fat tax)
Earmarking the revenue from health taxes for specific purposes (healthcare funding or obesity prevention)	These can increase public and political support for taxes This may help offset the influence of industry interests It is essential that government abide by initial earmarking commitments once tax is implemented
Potential mechanisms for reducing regressive nature of health taxes on consumer products	Using the revenue raised from taxes to subsidize healthier products Targeting ingredients used in the production of certain products, instead of product itself

Source: Wright et. al., 2017

Fat sectorin India:

Fat and fatty acid content of foods in India is regulated under the Food Safety and Standards (FSS) Act 2011. This act is regulated by Food Safety Standards Authority of India (FSSAI) and Ministry of Health and Family Welfare (MoHFW) is the administrative authority for implementation. As per FSSAI total fat intake in the daily diet should be between 20-30% of total calories. Of the total energy intake per day, saturated fatty acids (SAFA) levels should be less than 10%; polyunsaturated fatty acids (PUFA) should be 6-10%, monounsaturated fatty acids (MUFA) should be 5-8% and trans fatty fats (TFA) must be less than 1% (FSSAI, 2017). For health benefits, FSSAI recommends limited use of foods rich in SAFA, and foods containing partially hydrogenated vegetable oil and deep-fried foods (source of trans fat) (FSSAI, 2017).

Health is a state subject in India; hence, local political dynamics can play a major role in the adoption of fat tax (Basu, Dahiya and Bachani, 2017). Those states having significant revenue generation from fat products consumption could be less inclined to impose excess taxation compared to states with lower per capita consumption(Basu, Dahiya and Bachani, 2017).However, with the Goods and Services Tax (GST) being implemented by Government of India, states may not have much independence in this policy(Basu, Dahiya and Bachani, 2017).While selecting products with higher levels of SAFA for taxation both branded as well as food produced by local, informal sector should be considered. Taxing only branded foods may encourage consumers to shift from ‘branded’ to ‘local’unhealthy food products (Basu, Dahiya and Bachani, 2017).

The FSSAI, MoHFW and academic institutions, such as Public Health Foundation of India (PHFI) are key stakeholders in promoting diet-related strategies for NCDs (Arora et. al., 2014). These stakeholders should be involved in effective health education and promotion activities; assessing public opinion on fat-tax and the knowledge, attitude and practices related to consumption; and evaluating the short and long-term impact of this policy.

CONCLUSION AND RECOMMENDATIONS:

Evidence suggests fat tax has a small effect on consumption compared to tax on other unhealthy food items. This evidence is based on short-term impact and more research is needed to study the long-term impact of a fat tax. However, we know even if the demand for unhealthy fat consumption is not reduced much, there would still be an increase in tax revenue. This revenue can be used in multiple ways- providing subsidies on healthy items, providing healthcare and promoting healthy foods through nutrition education.

Based on the available evidence, the following guidelines can be used for planning a fat tax in India-

1. The objective of the fat tax should be defined clearly.

· Since the main aim is health gains through behaviour change, the primary focus should be on health benefits. Hence, the fat tax should be targeted at a higher level (>20%).

2. The tax type, structure, and products to be taxed should be planned carefully.

· Excise tax (structure-specific) of approximately INR 100 per kg of saturated fat in products (both branded and local) with more than 2.3 g of saturated fat per 100 grams should be applied, a fat-tax similar to Danish fat-tax. However, exact amount of tax should be fixedafter consulting the revenue department, FSSAI, and MoHFW.

3. Before finalising the exact amount, the direct and indirect impact of the fat tax on consumers as well as on food industry should be anticipated in advance.

· Consumer response-Price elasticities among different socio-economic classes.

· Industry response- Product price manipulations and reformulations.

4. Earmarking the revenue from food taxes for exact purposes, such as healthcare financing or health promotion.

· This can increase public and political support and may help offset the influence of industry interests. However, it is vital that government abide by initial earmarking commitments once the tax is implemented.

5. Identify potential mechanisms for reducing regressive nature of taxes on the consumer.

· By targeting ingredients rather than the product itself.

· Using the revenue raised from taxes to subsidise healthier products.

6. Key stakeholders such as FSSAI, MoHFW, and academic institutionsshould be involved in planning, implementation, monitoring and evaluation. Impactevaluation of this fat-tax policy programme is critical for assessing short and long-term health outcomes.

7. Other strategies should also be considered in addition to fat tax.

· Sugars and salt are other food items which are associated with high level of NCDs.

· Fat tax should be accompanied by nutrition education and promotion interventions.

ACKNOWLEDGEMENT:

This research work was supported by INSPIRE research grant of Department of Science and Technology, Ministry of Science and Technology, Government of India.

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Abbreviations

CMNDs	Communicable, Maternal, Neonatal, and Nutritional Diseases
DALYs	Disability Adjusted Life Years
FSS	Food Safety and Standards
FSSAI	Food Safety Standards Authority of India
GST	Goods and Services Tax
MoHFW	Ministry of Health and Family Welfare
MUFA	Monounsaturated Fatty Acids
NCDs	Non-Communicable Diseases
NOURISHING	N: Nutrition label standards and regulations on the use of claims and implied claims on foods O: Offer healthy foods and set standards in public institutions and other specific settings U: Use economic tools to address food affordability and purchase incentives R: Restrict food advertising and other forms of commercial promotion I: Improve the quality of the food supply S: Set incentives and rules to create a healthy retail environment H: Harness supply chain and actions across sectors to ensure coherence with health I: Inform people about food and nutrition through public awareness N: Nutrition advice and counselling in health care settings G: Give nutrition education and skills
NSSO	National Sample Survey Organization
PHFI	Public Health Foundation of India
PUFA	Polyunsaturated Fatty Acids
SAFA	Saturated Fatty Acids
SSB	Sugar Sweetened Beverages
TFA	Trans Fatty Acids
VAT	Value Added Tax
WHO	World Health Organisation

Domain	Comment
Rationale	The aims were to raise additional revenue to reduce the income tax burden, and to reduce the consumption of saturated fats.
Mechanism	Excise tax of DKr 16 (€2.15) per kg of saturated fat in products with more than 2.3 g of saturated fat per 100 g.
Revenue Collection	DKr 1 billion (€134 million) between November 2011 and August 2012.
Impact on consumption/health	Econometric analysis suggests that in the short-term consumption of some products subject to the tax dropped by 10–15%.
Unintended consequences	Speculated but unconfirmed cross-border shopping, job losses and negative profit impacts for producers.