Obesity – facing a taxing problem

A report from the Irish Heart Foundation (IHF) and Social Justice Ireland (SJI) has sent out warning signals on our obesity epidemic and proposes practical solutions and targets.

The old saying is that the only certainties in life are death and taxes. The IHF and SJI, in their report, have added a healthcare certainty – that raising taxes (on unhealthy foods) can help prevent death (from chronic disease).

The two organisations have come up with practical targets aimed at tackling the growing epidemic of obesity in Ireland.

The report¹ from the Irish Heart Foundation and Social Justice Ireland has pointed out that apart from the human and disease cost of obesity, the cost of managing obesity and conditions related to it could more than quadruple over the next 15 years unless a greater level of action is taken on the problem.

Costs of obesity in Ireland

The report estimates that obesity could cost a total of €1,175 a year for every man, woman and child in Ireland (€5.4 billion in total) if present trends continue and no policy interventions are made.

The report in many ways echoes concerns being expressed by health professionals, policy analysts and governments worldwide that unless effective action is taken on chronic diseases in the years to come, the provision of healthcare services will eventually become unaffordable.

Proposed action

The two organisations have proposed that the government adopt a target to reduce body mass index (BMI) in the population by 5% by 2020.

Their report says such a reduction in overall BMI would significantly reduce the incidence of chronic disease, in particular cardiovascular disease and type 2 diabetes.

It says this reduction would improve the health of the population and guarantee significant long-term savings to the Exchequer in Ireland. A 5% reduction in BMI by 2020 is estimated to generate savings of €394 million by 2020.

As an immediate target, the two organisations have proposed that the government introduce a sugar-sweetened drinks (SSD) tax in the next budget in October. This was proposed by previous health minister James Reilly, but has yet to be implemented.

The IHF and SJI say some of the revenue from this new tax could be used to develop effective obesity prevention programmes and initiatives to eradicate food poverty. 

They point to the clear relationship shown between poor diet and disease, with Ireland experiencing high levels of both.

Food poverty

The report points out that prevalence of obesity in Ireland has increased significantly in the past two decades. Between 1990 and 2011, obesity rose from 8% to 26% in men and from 13% to 21% in women. Currently, 24% of adults are obese, and there has been a two- to four-fold increase in obesity in Irish children aged eight to 12 years since 1990.

In 2013, one-in-eight of the population was estimated to be experiencing food poverty. Food poverty is defined as having missed a meal in the previous fortnight due to lack of money, inability to afford a meal with a meat or a vegetarian equivalent every second day, or inability to afford a roast or vegetarian equivalent once a week.

The IHF and SJI point out that the Growing up in Ireland study showed that social inequalities increased the risk of overweight and obesity from an early age. At nine years of age, children from disadvantaged areas are much more likely to be obese.

There is a significant likelihood that some obese children will have multiple risk factors for cardiovascular diseases, type 2 diabetes and other comorbidities before or during early adulthood. 

Childhood obesity has been recognised as a vital child protection issue and a challenge to the right of children to the highest standard of health, by the government’s special rapporteur on children.

While the report acknowledges that evidence has recently been produced by the Childhood Obesity Surveillance Initiative and in a recent systematic review of studies of some stabilisation in childhood obesity rates, it still remains an urgent issue to be addressed.

On adult obesity, the report points out that the National Adult Nutrition Survey has shown that based on cut-off points for waist circumference and waist-to-hip ratio, 23% of Irish men and 27% of women have an increased risk of CVD and 31% of men and 37% of women were shown to be at a high risk for CVD risk factors.

The TILDA study indicated that central obesity has been shown to be a key factor in CVD and diabetes in people over 50.

Health inequality basically means that people who are poorer are sicker are more likely to die than people who are better off, the report says. Mortality from CVD is a major element of health inequality in Ireland.

As the social gradient in health means that obesity is more prevalent in disadvantaged communities, we are likely to see an increase in socio-economic inequalities in deaths from CVD.

The report says people often tend to blame poor lifestyle behaviours for ill health, sometimes leading to a ‘blame culture’ against those who are obese.

Yet individuals cannot be held solely responsible for lifestyle factors which lead to their ill health. Lifestyle factors such as poor diet are influenced by social, economic, cultural and political factors.

“Unequal experience of the social determinants of health across the population impacts on the distribution of poor health, including obesity. To tackle the health inequality in obesity and CVD,  the government should address the accumulation of disadvantage across people’s lives in the conditions in which they live, work and age,” the report states.

It says food poverty may lead to diet-related diseases, including obesity. The connection between diet and health may explain why people with a chronic illness in 2010 were more likely to experience food poverty than those without such an illness.

Social stress, such as unemployment and cost of food, are barriers to healthy eating among people in lower socio-economic groups.

The Irish Heart Foundation and Social Justice Ireland point out that healthy food is more expensive than less healthy food, which is more processed and higher in sugar, fats and salt. People living in food poverty tend to spend a higher proportion of their income on food, yet due to the high cost of healthy food find it difficult to adhere to healthy eating guidelines. The effects of the recession shifted the balance further in terms of people purchasing less healthy foods.

Another factor the report mentions is that people suffering from food poverty may also have difficulty accessing affordable healthy foods in shops in their neighbourhood.

Families with children in Ireland are three times as likely as those without children to be affected by food poverty.

The report points out that research on imposing a ‘fat tax’ in Ireland proposed that such a tax accompanied by a subsidy on healthy foods such as fruit and vegetables would have a neutral or negligible poverty impact and could address the problem of food poverty and obesity simultaneously by making a healthy diet more affordable.

Lack of action

The report points out that while some initiatives have been taken, and a new government obesity policy has been promised, the government has never developed a national food policy, or a specific food poverty policy. Overall, action and results have been limited.

The report stresses that obesity is a major contributor to chronic diseases, and there is now real concern that high obesity rates will contribute to higher mortality from heart disease and stroke in the future.

Overweight, obesity and excess abdominal fat are related to the main risk factors for coronary heart disease (CHD), including hypertension and high cholesterol, and overweight and obesity are independent risk factors for congestive heart failure, with obesity also a risk factor for ischaemic stroke.

The IHF and SJI also point out that by 2020 the number of adults in Ireland with chronic diseases will increase by around 40%, with, for example, an increase of around 50% in the incidence of CHD between 2007 and 2020 predicted. 

They point out that over the past three decades Ireland has seen a rapid decline in mortality from CVD and CHD, mainly due to improvements in risk factor control. 

However, risk factor incidence has worsened since 2000 and recent research has shown a ‘flattening’ in death rates, possibly due to the risk factor increase. This has led to concerns that the recent drop in mortality rates could be reversed.

Challenges

The report highlights the significant challenges ahead in terms of combating obesity. It shows that Ireland, among 27 EU countries, is projected to have the highest percentage of population who are obese, at just under 45%, in 2030.

Without any policy intervention it is predicted that there will be an additional 717,950 overweight or obese adults in 2030 compared to 2010. 

“If this projected trend becomes reality, it will result in a significant increase in the number of people with chronic diseases and a knock-on impact in direct healthcare costs,” the report says. These would include GP visits, drug and inpatient costs.

Current direct healthcare costs of overweight/obesity in Ireland are €400 million per annum, with an additional €728 million in indirect costs. 

If present trends continue and no policy interventions are implemented, the cost of obesity will rise from €4.3 billion in 2020 to €5.4 billion in 2030. The bulk of these healthcare costs relate to managing CHD and stroke.

Including indirect costs such as reduced productivity, absenteeism, etc, the total cost to the State of obesity by 2030 will be just over €15 billion.

“These costs represent a huge social and economic burden to the state,”  the report warns.

Savings

The report estimates that reducing BMI in a population can substantially reduce the health burden of obesity, while in turn reducing the costs of CVD and other chronic diseases.

It is projected that a 1% reduction in BMI could lead to €104 million in direct healthcare cost savings by 2020 and €143 million in these savings by 2030.

A 5% reduction would lead to e94 million and €495 million in savings respectively by 2020 and 2030. The report says a 5% cut in BMI would significantly reduce the incidence of chronic disease, in particular CVD and diabetes, and would reduce the number of CHD and stroke cases by nearly 36,000 by 2030.

The report says these savings in healthcare costs would have a major impact on population health and health costs, in addition to generating long-term social and economic benefits. 

These savings should be directed into improving the health service and other public services, “which in turn will improve economic performance and quality of life,” according to the report. The IHF and SJI proposals include:

• That government adopt a target to reduce the population’s BMI by 5% by 2020 to significantly improve the population’s health and guarantee significant Exchequer savings

• A ‘whole of government’ approach should be adopted to reach this target

• The government should introduce a sugar-sweetened drinks tax in the 2016 budget and ringfence the revenue generated to address food poverty, promote health policies and reduce obesity

• A sugar tax could be combined with a subsidy to reduce the cost of fruit and vegetables

• Research should be undertaken to fully understand the direct and indirect costs of obesity in an Irish context, and also in a lifecycle context, including an examination of the health and poverty implications of obesity in children

• Junk food should be removed from schools

• Limit the number of fast-food outlets built near schools

• Improve nutritional ‘traffic light’ labelling on food products

• Restrict junk food advertising aimed at children

• Ensure that children get 60 minutes of physical activity a day.

References

1. 1. Reducing obesity and future health costs – a proposal for health-related taxes. Irish Heart Foundation and Social Justice Ireland. Available on www.irishheart.ie and www.socialjustice.ie