Taxing By The Pound

As Asia transitions from battling infectious microbes to battling the bulge, can a controversial ‘fat tax’ in Japan keep waistlines under control?

AsianScientist (Jun. 12, 2015) – After generations of attention on infectious diseases and malnutrition, Asia is finally gaining the upper hand. According to the recent Levels and Trends in Child Mortality Report by the United Nations, the infant mortality rate across Asia dropped from 67 to 39 deaths per 1,000 live births between 1990 and 2013. This positive trend has been attributed to general economic growth as well as political commitment towards reducing preventable deaths.

But an even more sinister threat looms in the horizon. Today, non-communicable diseases such as diabetes and heart failure are reaching epidemic proportions in many Asian countries, driven largely by a sharp rise in obesity. A 2011 study published in The Lancet predicted that cardiovascular disease would account for 36 percent of all deaths in India by 2030, which the World Health Organization (WHO) estimates will cost the government US$237 billion between 2005 to 2015.

This sudden and massive transition from diseases of poverty to those of affluence has left many epidemiologists bewildered. Although the Western world is currently afflicted with a similar burden, how could the transition between the two spectrums of disease happen so quickly in Asia?

A story of genetic and environmental factors

Despite ongoing research to understand the exact mechanisms of obesity-related chronic diseases, there is still much that scientists do not know. Many believe that genetic differences between ethnic populations may be a crucial piece of the puzzle. A 2010 genome-wide association study on a population of Han Chinese uncovered two novel genetic susceptibility loci associated with Type II diabetes in Chinese populations but not in Caucasians.

More fundamentally, the PLOS Genetics study revealed the possibility of chronic diseases having varying pathogenesis in different races. This finding means that chronic diseases like diabetes can arise through alternate pathological mechanisms and behave very differently from our current understanding.

Apart from underlying genetic differences, there are more obvious factors at play, that of a Westernizing diet and sedentary lifestyles. This is especially so in China, a country which recently surpassed America to become the epicenter of the world’s largest diabetes epidemic. According to a 2013 nationwide survey for diabetes in China carried out by Chinese researchers and published in the Journal of the American Medical Association, 11.6 percent of adults, or 114 million, have the disease. In other words, almost one in three diabetics globally lives in China.

With Western fast-food companies thriving in China, the high incidence of diabetes comes as no surprise. The Wall Street Journal reported that the number of McDonald’s outlets in China grew from one in 1990 to an astounding 1,000 outlets in 2006. Furthermore, daily per capita sales of Coca Cola in China rose by 145 percent between 2010 and 2011. The shift away from a low cholesterol, traditional diet for one high in saturated fats and simple carbohydrates could have played a role in the large increase in metabolic disease in China.

Are fats and sugar like cigarettes?

Regardless of the underlying causes of obesity, managing its burden foreshadows a costly future for health systems in Asian countries. In addition, most of these countries are witnessing a gradual shift from a young working force to a greying one, prompting health officials in countries like Japan to adopt punitive measures to prevent an epidemiological crisis.

Encouraged by the success of tobacco taxation in reducing smoking, Denmark became the first country in the world to impose a fat tax in 2011, charging 16 kroner (~US$2.88) per kilogram of saturated fat in food sold. However, the tax was scrapped within 15 months, having failed to change the eating habits of Danes who simply went across the border for their unhealthy snacks.

Despite the lack of a successful model, countries such as Malaysia and Taiwan are also considering implementing taxes against products with high sugar content. While the details of the taxation are still not finalized in Malaysia, Taiwan’s Academic Society of Obesity Prevention has suggested a policy that imposes a 0.2 to 0.5 percent tax on food items that exceed the national regulated sugar content.

Rather than tackle obesity at the “input” phase, other countries have adopted eye-raising approaches to address it at the “output” phase. Japan, for instance, passed the “metabo law” in 2008, effectively making it illegal to be obese. Under the bill, companies are required to measure the waistlines of their employees on an annual basis. Employees between the ages of 40 to 74 with waistlines above the stipulated 85 cm for males and 90 cm for females are monitored and required to go for counselling, while their employers face financial penalties.

Comprehensive solutions needed

One might argue that government intervention in necessary to protect the well-being of its citizens, but a 2013 study by researchers at Oxford University published in the British Medical Journal showed that a tax on unhealthy food must raise prices by at least 20 percent to have any impact on obesity. Such a move would undoubtedly be very politically unpopular and governments might find the implementation of these taxes very challenging.

In the case of Japan’s “metabo law”, the effectiveness of such a measure at curbing rates of chronic disease is still not proven. Although the law might make sense in theory, enforcing it is a challenge. Despite attending the annual scheduled check-ups, only a mere 12.3 percent of those whose waistlines exceeded the upper limit followed through with the medical advice.

Taxes aside, there are no quick fix-its to the slow march of non-communicable diseases. Experts believe that strategies to reduce the burden of metabolic diseases need to include education and be sustained over long periods. School-based initiatives, healthy food subsidies, assistance to lower income families, and better food policies are just some of the many improvements that could be made in Asia to re-establish healthy living.

This article was first published in the print version of Asian Scientist Magazine, October 2014.


Photo: Shutterstock.

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Ivan Seah Yu Jun is a medical student at the University of Glasgow Wolfson Medical School in the UK.

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