In this study, we revealed that free sugar consumption in Canada contributes enormously to chronic diseases, to costs for the treatment and management of these CDs, and to costs associated with loss of human capital. The estimated reductions in the disease burden if Canadians were to comply with free sugar consumption recommendations are substantial for all CDs but are particularly pronounced for diabetes. Adhering to the recommendation to limit free sugar consumption to less than 10% of TEI would result in a reduction of approximately 27.0% in the prevalence of diabetes. For the stricter recommendation (<5 % TEI), this reduction would reach as much as 44.8%. The economic burden attributable to free sugar consumption is also substantial for all CDs, with diabetes accounting for the bulk of these costs. For all CDs combined, adhering to the recommendation to limit free sugar consumption to below 10% of TEI and 5% of TEI would have avoided $2.5 billion and $5.0 billion, respectively, in direct and indirect costs in 2019.
This is the first study to reveal the economic burden of free sugar consumption in Canada. In previous work, using the same methodology and the 2015 CCHS-Nutrition data, we estimated the economic burden for not meeting established recommendations for whole grains to be $3.8 billion, for nuts and seeds to be $3.8 billion, for fruits to be $2.5 billion, for vegetables to be $1.7 billion, for processed meat to be $2.2 billion, for milk to be $666 million, for red meat to be $231 million, and for SSBs to be $830 million in 2018 (Loewen et al., 2019). Notably, our estimate of $2.5 billion for the free sugar recommendation that consumption should be below 10% of TEI is of similar magnitude to those foods with a high economic burden (fruits and processed meats). Our estimate of $5.0 billion for the stricter free sugar recommendation exceeds all above-mentioned estimates. In other words, more CDs will be prevented and more costs for treatment and management of CDs will be avoided if Canadians are to comply with this recommendation (free sugar below 5% of TEI) than with any other established dietary recommendation. In Korea, the costs from disease treatment and premature mortality caused by excessive SSBs consumption were estimated to be KRW$ 633 billion in 2015 (approximately $CAN 19.42 per capita per year) (Shim et al., 2019). These costs are much lower than our estimates of the economic burden: approximately $65.44 per capita per year for not consuming below 10% of TEI and $131.87 per capita per year for not consuming below 5% of TEI. However, comparisons with studies from other countries are complicated because of differences in dietary patterns, health care systems, free sugar definitions, and research methodology (Meier et al., 2017; Shim et al., 2019).
Our estimate of the economic burden for not adhering to the recommendation for free sugar consumption below 10% of TEI ($2.5 billion per year) is approximately three times higher than the estimate for not adhering to the recommendations for the SSBs intake ($830 million per year) (Loewen et al., 2019). For the stricter free sugar recommendation, the economic burden estimate ($5.0 billion per year) was about six times higher than that for SSBs. These comparisons suggest a proportionately larger impact of interventions targeting a broader set of products containing free sugar (e.g., confectionery, chocolate, and ice cream) as compared to interventions targeting SSBs and sugary drinks (Cobiac et al., 2017).
Using pricing strategies (food taxes and subsidies) is considered a key policy tool to reduce the chronic disease burden and associated health care costs (WHO Europe, 2015). Jones et al. projected that a 20% tax on SSBs would avoid $7.4 billion in health care costs in Canada between 2016 and 2041 (Jones et al., 2017). Coming on the heels of public health successes from taxation of tobacco cigarettes, taxation of SSBs is considered to be most effective in inducing health-promoting changes in sugar consumption and is recommended by the WHO and Dietitians of Canada to influence the demand for foods high in sugar (WHO Europe, 2015; Dietitians of Canada, 2016). Targeting SSBs has the practical advantages of focusing on a single product or an easy-to-define category of products that are energy-dense and nutrient-poor but with close healthier substitutes (e.g., water), and as such is administratively simple to implement. Where taxation of SSBs is a reality in over 40 countries and cities (Bridge et al., 2020), Canada and many other jurisdictions are currently considering this strategy to curb sugar consumption. However, having the sole focus on SSBs comes with the drawback that only a modest portion of all free sugar in the Canadian diet will be taxed: Liu et al. recently estimated that of all free sugar that Canadians consume, only 17.5% originates from SSBs (Liu et al., 2020). In other words, the targeted health gains arising from taxation will have to come from a movable margin of this 17.5%. Indeed, the WHO recommendation recognizes that SSB taxation should only be applied in settings where SSB consumption is a significant contributor to free sugars intake (i.e., greater than 20 L per person per year) (WHO, 2017).
Another drawback of targeting a single product or product group is that it allows consumers to choose alternative sources of free sugar that are not taxed and herewith circumventing the taxation objectives. The findings from this study provide support for broader taxation of a wider range of foods and beverages high in free sugar, which has the potential not only to reduce free sugar consumption at the population level but also to improve the overall quality of the diet (WHO Europe, 2015). Several countries have or had implemented policies with taxation targets beyond SSBs. For example, Finland, Norway, and Hungary had introduced taxation of sweets, chocolate, ice cream, and other sugar-containing foods in addition to SSBs (WHO Europe, 2015). Although administratively complex, a comprehensive set of pricing policies that includes a broad tax on free sugar content (e.g., a given amount per 100g of sugar contained in certain products), and an excise duty on specific products containing sugar (e.g., a given amount per kg/L of the specific product) seems to be needed to reach more consumers and to curb their sugar consumption.
Finally, building on lessons from successful tobacco control, a comprehensive package of complementary policies in addition to taxation is advocated to effectively reduce sugar consumption at the population level (Dietitians of Canada, 2016; WHO, 2017). Taxation of SSBs has been shown to be financially regressive whereby low-income groups bear a larger tax burden (Kao et al., 2020; Men et al., 2021), calling for policies that sugar tax revenues be reinvested in the production, distribution, and marketing of healthful foods to support food security for these low-income groups (Men et al., 2021). Other complementary policies may include regulatory measures (e.g., front-of-package labelling, regulation of health claims, and advertising), legislation limiting or banning use of free sugar across the food supply chain, industry incentives for product reformulation, supportive environments in public institutions (e.g., hospitals, schools, nursing homes) to serve low sugar meals, health education campaigns, and dietetic counselling of people at higher risk (Sassi, 2016; WHO, 2017). Yet, other interventions, including public awareness education initiatives and product labelling policies, have also had SSBs as their only target in Canada (CDA, 2020; Fung et al., 2013).
In the present study, we observed that men contribute much more to the economic burden of excessive free sugar consumption as compared with women, which is consistent with previous reports on the economic burden associated with unhealthy eating (Ekwaru et al., 2016; Krueger et al., 2011; Lieffers et al., 2018; Loewen et al., 2019). Though men consumed more free sugar in absolute terms (grams per day), free sugar consumption as a share of TEI was similar for women and men. The observed sex differences in the economic burden are thus not a result of sex differences in compliance with free sugar recommendations. Instead, they originate from a higher prevalence of chronic diseases, and specifically diagnosed and undiagnosed diabetes, among men relative to women (Leong et al., 2013), and the ensuing higher economic costs attributable to diabetes among men relative to women (American Diabetes Association, 2018). Complementary policies that promote healthy eating and active lifestyles may reduce the prevalence of diabetes and other chronic diseases, and herewith their economic burden and the impact of free sugar on this economic burden. Where these complementary policies specifically target men or are more effective among men than among women, they will reduce the current sex differences in economic burden.
The present study has several strengths. We used the established free sugar definition by the WHO, the 2015 CCHS-Nutrition, Canada’s most comprehensive dietary survey of the past decade, and robust estimates of free sugar consumption (Liu et al., 2020). With respect to the latter, we had considered the free sugar content of each of 5374 foods and beverages recorded in the 2015 CCHS-Nutrition (Liu et al., 2020). We had used both the first and second 24-h recall and had applied the recommended bivariate NCI method so that our estimates are representative for the Canadian population (Liu et al., 2020). We believe our estimates of free sugar consumption are therefore more robust than those obtained through an alternative approach based on the public use microdata file which does not include the second 24-h recall and does not allow the application of the bivariate NCI method, and considered the free sugar content of 177 foods and food groupings (Wang et al., 2020). In the absence of established risk estimates for CDs associated with consumption of free sugar in our diet, we assumed that free sugar in our diet exhibits the same risk as the equivalent amount of free sugar in SSBs. Future research, however, has to reveal the extent to which this assumption is correct. As a limitation to this study, we should mention that dietary intake is obtained through self-report, which is prone to error. Another limitation is that our economic burden estimates represent underestimations. For the direct health care costs, we considered only hospital, physician, and drug costs associated with 16 CDs and not, for example, costs associated with dental caries, mental health, and other diseases. Also, the economic burden following the COVID-19 pandemic will likely increase further since people with CDs (diabetes, hypertension, cardiovascular and cerebrovascular disease, chronic obstructive pulmonary disease, cancer) were 2–4 times more likely to have severe COVID-19 symptoms and complications, thus increasing the health costs for ICU admission and hospital stays (Roncon et al., 2020; Williamson et al., 2020). The public health measures implemented to contain the spread of the virus (i.e., lockdowns) have also increased unhealthy lifestyle behaviours, including free sugar intake (WHO, 2020).