On 26^th April, we attended the Ministry of Health’s focus group on sugar-sweetened beverages (SSBs). This event was part of the Ministry’s consultation process to get feedback as well as inform the public and key stakeholders on the progress being made to develop a national SSB policy.

This event was a follow-up to the Ministry’s SSB National Consultation which took place in November 2018 and provided an update on the policy imperatives that were presented last year.

From the focus group we learnt that the updated policy recommendations are:

• A 32% excise only tax on SSBs
• The tax will apply to calorically sweetened beverages including carbonated drinks (sodas), sweetened carbonated water, sugar-sweetened juices, sports drinks, energy drinks, tea and coffee drinks, sweetened milk/milk alternatives, milk powdered blended drinks, powdered drink mixes and drink mix syrups
• Excluded from taxation would be fresh fruit juice (no sugar added), unsweetened milk/milk alternatives, infused water, unsweetened carbonated drinks and non-caloric sweetened drinks
• Alternatives to SSBs will be suggested to the public. These would include: fruit/vegetable infused water, plain water, unsweetened carbonated water, unsweetened herbal (bush) tea and fresh-poured coconut water (unsweetened coconut water)
• The tax revenue will be used to provide: a water infrastructure, water fountains in schools, reusable water bottles in schools, healthier school meals, public health campaigns, National Health Insurance, implementing a marketing ban to children, policy development for safe school zones and to improve agriculture education especially in primary schools

What About Artificially Sweetened Beverages?

One area still to consider, which is an interesting one, is whether to tax artificially sweetened beverages (ASBs).

ASBs are drinks that have been sweetened with non-nutritive sweeteners which include saccharin, acesulfame, aspartame, neotame, sucralose and stevia.

The field of ASBs is a confusing one. It has been hard to answer the simple question of whether they are beneficial or not. Therefore  WHO funded a large global study to answer this question, but this still didn’t answer the question with health officials stating the following:

“The inconclusive results of the review of the evidence suggest that we need to see better, bigger and longer-term studies of non-sugar sweetener use, to find out for sure their benefits and risks. The review suggests that there could be some benefits in terms of preventing weight gain, but the evidence so far is not strong and does not show consistent enough results to be sure.”

Whenever there is doubt, we recommend that the public keeps things simple and uses products where there are clear health benefits and there is no doubt. The best option at the moment is to consume unsweetened beverages.

In the meantime, the Ministry will evaluate whether ASBs should be taxed as part of their SSB policy.

 Why Tax SSBs?

Childhood obesity is a significant challenge here in St Kitts and Nevis. A PAHO report revealed that 33% of secondary school children in the twin-island state were overweight and 14% were obese. More recently, in 2017, a UNICEF report published that 26% of children in St Kitts and Nevis are obese.

SSBs have been linked to weight gain and obesity. Therefore, the taxation of SSBs has been utilised throughout the world as a method of tackling obesity by creating a deterrent which leads to a reduction in the purchase and consumption of SSBs.

Taxation of SSBs has three important aims. The first it to incentivise manufacturers to reformulate or replace their products to create healthier options, the second is to deter the public from purchasing and consuming SSBs by making them unaffordable and the third is to raise funds from the tax revenue that can be used to support initiatives aimed at improving the health of the public.

Next Steps

The Ministry of Health will now take all the feedback from their consultation, focus group and other engagement activities to draft a policy which will be circulated to stakeholders for any final comments before it is sent to Cabinet for approval.

References

1. UNICEF, Situation Analysis of Children in the Federation of St Kitts and Nevis, UNICEF Office for the Eastern Caribbean Area and the Government of St Kitts and Nevis, Christ Church, Barbados, 2017
2. PAHO, Health in the Americas, 2012: St Kitts and Nevis, PAHO, 2012

Childhood obesity is a major health issue in the Caribbean with 1 in 3 children being overweight or obese. Being obese and overweight in childhood is linked to the development of a number of health issues such as diabetes and hypertension, and it also negatively impacts a child’s mental health. These health issues can follow children into adulthood with children affected by obesity, or who are overweight, having an increased risk of becoming overweight or obese adults and developing non-communicable diseases such as cancer and heart disease in later life.

Childhood obesity is a significant challenge here in St Kitts and Nevis. A PAHO report revealed that 33% of secondary school children in the twin island state were overweight and 14% were obese. More recently, in 2017, a UNICEF report published that 26% of children in St Kitts and Nevis are obese.

Childhood Obesity Solutions

To combat childhood obesity we have to ensure that children adopt a healthy lifestyle and one approach is to explore how we can reduce the consumption of products that are high in sugar, salt and saturated fat. One strategy is to focus on nutrition education and making it easier for to parents identify which foods are high in these components, so they can easily make healthy choices when they purchase groceries.

Front-of-Pack Nutrition Labelling

Front-of-pack nutrition labelling has been introduced in many countries to provide a quick and easy way for consumers to assess the health of the foods they purchase. Currently there are several front-of-pack nutrition labelling systems with the main options being:

Summary indicators. These include the Health Star Rating developed by Food Standards Australia New Zealand which gives foods a 1 to 5-star rating based on their healthfulness and France’s Nutri-score which puts foods into five categories, A to E, based on how healthy they are deemed to be.

The traffic light system. This uses the colour code green, amber and red to communicate whether products have a low, medium or high level of salt, sugar and saturated fat based on daily intake references.

Warning labels. This uses a ‘high-in’ label to inform consumers that foods are high in certain nutrients

Front-of-Pack Nutrition Labelling Consultation in the Caribbean

Caribbean countries are starting to explore the introduction of front-of-pack nutrition labels. The CARICOM Regional Organisation for Standards and Quality held a consultation from 15^th October 2018 to 31^st January 2019 on pre-packaged food labelling which included front-of-pack food labelling. The labelling system being explored is warning labels and we were pleased to have been able to submit a response to their consultation.

Our Views

• We support the introduction of front-of-pack nutrition labels in the Caribbean
• We believe that front-of-pack nutrition labels present a quick, easy and useful way of communicating the healthiness of pre-packaged foods
• We believe that front-of-pack labelling provides information in a way that is easier to understand, with respect to healthiness, than back-of-pack nutrition labelling
• We believe more work is needed to determine which front-of pack  labelling system would be most effective in the Caribbean
• We believe that a full assessment is required to determine if front-of-pack food labels will influence consumer behaviour in the Caribbean and if not, why not
• We feel that if the ‘high-in’ labels are to be used, the colour of the labels should be reconsidered, from black to red. This is important so that we begin to steer dialogue away from black always being seen as a negative, which has a wider societal context with regards to race and ethnicity
• We believe a standard international front-of-pack nutrition label is required to ensure consistency and to prevent confusion

Next Steps

CARICOM Regional Organisation for Standards and Quality will review all the comments it has received from throughout the region and decide on a way forward with respect to nutrition labelling of pre-packaged foods.

We look forward to seeing how the strategy for FOP labelling in the Caribbean develops and are pleased to see this action being taken on this matter.

References

1. UNICEF, Situation Analysis of Children in the Federation of St Kitts and Nevis, UNICEF Office for the Eastern Caribbean Area and the Government of St Kitts and Nevis, Christ Church, Barbados, 2017
2. PAHO, Health in the Americas, 2012: St Kitts and Nevis, PAHO, 2012
3. Kanter, R., Vanderlee, L., & Vandevijvere, S. (2018). Front-of-package nutrition labelling policy: Global progress and future directions. Public Health Nutrition, 21(8), 1399-1408. doi:10.1017/S1368980018000010

On 1^st November, we attended the national consultation on the impact of sugar sweetened beverages (SSBs). This event was organised by the Ministry of Health in collaboration with the Pan American Health Organisation (PAHO) as an early step towards the development of the nation’s strategy for reducing the public’s consumption of SSBs.

The Ministry’s strategy for SSBs forms just a small part of their non-communicable disease (NCD) prevention plan which outlines actions that are needed to create a healthy environment and promote exercise.

Speakers Set the Scene

During the consultation we heard from an excellent panel of speakers which included:

• Mrs Delores Stapleton-Harris, Permanent Secretary, Ministry of Health
• Hon Wendy Phipps, Minister of State with Responsibility for Health, Community Development, Social Services and Gender Affairs
• Dr Godrey Xuereb, PAHO/WHO Representative for Barbados and the Eastern Caribbean
• Dr Keisha Liddie, District Medical Officer
• Dr Lisa Powell, Professor and Director of Health Policy and Administration, School of Public Health, University of Illinois
• Dr Marissa Carty, NCD Coordinator, Ministry of Health

Together the panel outlined the need for the development of a strategy on SSBs, reminding the audience that in St Kitts and Nevis NCDs, such as diabetes, cancer, heart disease and high blood pressure, are a major health challenge with 83% of deaths in the Federation being attributed to these conditions.

Hon Phipps described how NCDs are not only a threat to the health of the nation but are a significant socio-economic issue. Whilst Dr Xuereb provided information on the need for a SSB policy stating that it is just one of many strategies to improve the health of a nation and help countries achieve the sustainable development goal (SDG) on health. He stated that in order to achieve the SDG on health it is important to focus on improving the health of children as currently, in the Caribbean, childhood obesity is very common and is a major factor in children developing NCDs. He explained that what is driving NCDs is the increased consumption of sugar, and the major source of sugar is SSBs – SSBs make up 40% of children’s sugar intake with 70% of children in the Caribbean drinking one or more SSBs per day. He stated that data from Barbados, Mexico and Chile has shown that increasing the cost of SSBs through taxation has reduced the consumption of SSBs and therefore this is an effective strategy in tackling NCDs.

We also heard from Dr Keisha Liddie who presented a very in-depth and comprehensive situational analysis of St Kitts and Nevis. Dr Liddie described the data and trends for NCDs in the Federation showing the increase in the incidence of specific NCDs year on year and their impact on the nation. Finally, Dr Powell explored the economics, practicalities and important considerations when introducing a tax on SSBs and provided a number of recommendations which included:

• Implement a 20% SSB tax
• Include all forms of SSBs in the taxation strategy e.g: soda, energy drinks, sports drinks, fruit drinks, sweetened teas/coffees, sweetened water and beverage powders/syrups). Exclude zero calorie beverages
• Apply the tax to all imported and domestically produced SSBs
• Earmark the tax revenue for public health initiatives with an emphasis on nutrition and physical activity
• Carry out public awareness and education to inform the public about the SSB tax and its objectives
• Ban the sale of SSBs in schools
• Ban the sale of SSBs in hospitals and government buildings
• Regulate the marketing of SSBs in and around schools
• Develop a drinking water infrastructure in schools that provide reusable water bottles to school children
• Provide local agricultural products as snacks in schools
• Promote the implementation of school gardens as a learning tool and to improve access to fruits and vegetables
• Explore appropriate sponsors for youth sports that align with the objectives of improving health
• Provide funding to increase activity spaces

St Kitts and Nevis’ Proposed Approach to SSBs 

Dr Marissa Carty outlined the Ministry’s initial ideas on their approach to reducing the consumption of SSBs and gave the audience the opportunity to provide feedback on all the policy areas. The Ministry’s proposed policy imperatives include:

• A 40% tax on SSBs (update: the proposed tax is now 32%)
• The tax will apply to calorically sweetened beverages including carbonated drinks (sodas), sweetened carbonated water, sugar sweetened juices, sports drinks, energy drinks, tea and coffee drinks, sweetened milk/milk alternatives, milk powdered blended drinks, powdered drink mixes and drink mix syrups
• Sugar would no longer be zero rated when it comes to tax
• Excluded from the tax would be: fresh fruit juice (no sugar added), unsweetened milk/milk alternatives, infused water, unsweetened carbonated drinks and non-caloric sweetened drinks
• Alternatives to SSBs will be suggested to the public. These would include: fruit/vegetable infused water unsweetened water, plain water, unsweetened carbonated water, unsweetened herbal (bush) tea and artificially non-caloric sweetened beverages
• The tax revenue will be used to provide: a water infrastructure, water fountains in schools, reusable water bottles in schools, healthier school meals, public health campaigns, National Health Insurance, implementing a marketing ban to children and policy development for safe school zones.

Our Thoughts

We 100% support the government’s approach to SSBs as there is a need to tackle childhood obesity in St Kitts and Nevis and by reducing SSB consumption this can be achieved.

We believe a 40% (or 32%) tax is sufficiently high enough to deter consumption of all SSBs, anything lower than this could lead to consumers simply replacing expensive SSBs for more affordable SSBs. There was some evidence of this in Barbados where the tax is 10% and this suggested that this level of taxation wasn’t high enough to deter consumers from buying the lower priced SSBs.

We think it is important that the revenue raised from the SSB tax should fund public health initiatives particularly those that are aimed at childhood obesity and so we applaud the Ministry’s suggestions on the use of the tax revenue. We would also like to see the tax revenue being used to make healthy foods more affordable to ensure that parents and guardians don’t encounter any barriers to adopting healthy eating practices. It is also important for there to be full transparency on the expenditure of the tax revenue so that the public can be confident that the funds have been used to benefit the public’s health.

Next Steps

The Ministry of Health will collate the feedback received from this consultation as well as the consultation conducted in Nevis and continue to engage with key stakeholders to develop their SSB policy. This will then have to be approved by Cabinet.

We look forward to seeing this policy develop and will support the Ministry in any way that we can to see this policy developed, approved and implemented.

Yesterday, we attended the CARICOM Marijuana Commission’s public consultation in Basseterre, St Kitts. This was an interesting, and at times heated, discussion which aimed to inform their report on marijuana use in the Caribbean.

The commission has been tasked with examining the health, social, economic  and legal issues surrounding the use of marijuana and to make recommendations to heads of government on whether the drug classification of marijuana should be changed. They will also make recommendations on, if marijuana is to be re-classified, what legal and administrative conditions should apply.

Yesterday’s consultation was one of many that the Commission has conducted throughout the Caribbean enabling them to reach a wide and diverse audience. In addition,  the Commission itself represents a range of stakeholders including commissioners from the fields of law, social work,  medicine, science, religion, law enforcement and psychology,  and they have youth representation.

Introduction by the Commission

In this public consultation we first heard from Prof Rose Marie Belle-Antoine who gave a brief introduction and provided some background into their work. She explained that the information obtained from the consultation would be combined with the information from other consultations, the St Kitts National Marijuana Commission and their own research on the medical, economic, social and legal implications to provide recommendations for policy changes to heads government in the Caribbean. She also mentioned that there was a need for public education on some of these issues as there are many people who are not informed about marijuana.  She explained the importance of looking at social justice issues (e.g. who gets arrested), gender issues (we hear a lot about the men but what happens to women and what is the impact on families), law enforcement (do they turn a blind eye to some marijuana use), the impact on productivity and addiction issues.

Prof Belle-Antoine also explained that internationally marijuana is classed as a narcotic so if the Caribbean re-classifies marijuana they would need to understand the implications for the Caribbean internationally – would we become a “rouge state.” Here she said we can learn some lessons from Jamaica who have already decriminalised marijuana.

Prof Belle-Antoine also touched on research being conducted in Barbados with prisons to understand if there is any real link between marijuana and crime.  She ended by stating that another important aspect of their work is understanding the  risks of marijuana use and what safeguards can be implemented.

The Public’s View

After Prof Belle-Antoine’s introduction the floor was then opened up to the public for comments and feedback. Overall the audience was in favour of legalising marijuana or decriminalising it. There was a feeling that it shouldn’t be illegal to use a plant  and that an adult should have the right to make an informed decision as to whether they use marijuana or not.  There was an overwhelming feeling that  vast amounts of data on marijuana already exists that give a clear picture of the  benefits and harms showing the benefits do outweigh the harms. Therefore many felt that a decision could already be made on whether we should reclassify marijuana, a report would delay things further. There was frustration about the consultation itself with a few people stating that it felt like “just talk.”

Several members of the public were able to give concrete examples of the use of marijuana for therapeutic purposes – chronic pain, nausea, cancer, liver disease etc. Many mentioned the historic and religious use of marijuana. One participant was able to provide a comparison between alcohol and marijuana showing that alcohol was significantly more harmful than marijuana – alcohol causes 1 million deaths a year and there has been no known death caused from marijuana itself.

The audience raised the huge economic potential in developing a safe marijuana industry in the Caribbean. It  was felt it could help to diversify our economies as many islands are heavily dependent on the tourism industry. It was highlighted how versatile marijuana is with one attendant showing the panel a book made from marijuana.  There was concern that if a marijuana industry is developed, large foreign companies would find a way to exploit our resource and no financial benefit would be reaped by Caribbean islands.

Conclusion

The evening ended with the commissioners answering some questions on the time-frame for the report and how much influence they would have on governments to implement their recommendations. The Commission explained that they are working as hard as they can to collate all the information and will produce a comprehensive report.  They stated that their report won’t be binding but they hope it would be influential and lead to change, but change does take time.

This was an interesting discussion and we do hope that the report published by the Commission will lead to change in the laws on marijuana and that we can develop a thriving industry that creates wealth for our nations.

Further Information

The CARICOM Marijuana Commission is still keen to hear from the public on this issue and is inviting anybody with an interest in this topic to submit their views to them in writing at marijuana@caricom.org

For more information on the work of the Commission, please visit their website http://caricom.org/marijuana-commission

Let us know what you think about this issue by leaving a comment below.

Last week, the UK’s Chancellor, Philip Hammond, published the UK’s 2017 Spring Budget and there were a few decisions made that will affect the public’s health and wellbeing.  These decisions focus on the following areas:

• Alcohol
• Tobacco
• Soft drinks
• Access to new drugs and treatments
• Health and social care services
• Women’s Health (through the tampon tax fund)

Alcohol

From 13 March 2017, the duty rates on beer, cider, wine and spirits were increased in line with RPI inflation. This was not well-received by the hospitality industry who were hoping for a freeze or cut of the previously announced increases. But the government’s health impact assessment suggests that the increases are likely to lead to a minor decrease in  overall alcohol consumption in the UK. From a public health point of view, this is promising news as excessive alcohol consumption is linked to an increased risk of developing a number of diseases including mouth, throat, breast and live cancers, heart disease, stroke and liver disease so any decrease in alcohol consumption is of benefit to the health of the nation.

Tobacco

From 8^th March 2017, duty rates on all tobacco products increased by 2% above RPI inflation and the government will introduce a Minimum Excise Tax for cigarettes. This will target the cheapest tobacco and raise funds for the government. This policy aims to stop the public, particularly young people, from purchasing cheap cigarettes with data showing that 71% of 16-24 year olds who smoke buy the cheaper brands. By making these products unaffordable it is hoped that it will prevent young people from taking up the habit of smoking or stop those who already smoke. With smoking being strongly linked to lung cancer any strategy that reduces the amount of people who smoke will go some way to reducing lung cancer rates as well as the other diseases linked to smoking such as chronic obstructive pulmonary disease, heart disease, stroke and more.

Soft Drinks Levy

The soft drinks levy was announced in previous budgets and in this budget the Chancellor confirmed the detail of what the levies would be. The rate for  drinks with a total sugar content of 5 grams or more per 100 millilitres will be set at 18 pence per litre and those with 8 grams or more per 100 millilitres will be set at 24 pence per litre. It is expected that this will raise an extra £1Bn and will come into effect from April 2018.

The money raised from the sugar levy will be used to double the funding available to primary schools for PE and sports programmes. The government has estimated the sugar levy will raise £320 million a year for primary schools to support healthier more active lifestyles in children. The funding will not only go towards expanding PE and sports programmes but to also expand breakfast clubs in primary schools ensuring that children have access to a healthy breakfast every week day.

The idea behind the sugar levy is a good one. It’s hoped that the levy will incentivise the soft drinks industry to reduce the amount of sugar in their products, helping the public consume less sugar. The money raised will go towards helping children get more active and healthy and thus tackle our high rates of childhood obesity.  So, from a public health point of view the sugar levy is a win-win.

Access to new drugs and treatments

The Industrial Strategy Challenge Fund (ISCF) will  support collaboration between business and the science community. There will be an initial investment of £270 million in 2017-18 to kick-start the development technologies that have the potential to transform the UK economy.  The first wave of funding will focus on a number of areas, one of which will be improving and accelerating patient access to new drugs and treatments by exploring ways of improving manufacturing technologies.  This is a much-needed area of focus for patients ensuring that they have access to the best treatments, but it is important to ensure that these drugs and treatments are affordable to ensure that all patients benefit.

Health and Social Care Services

An additional £2 billion will be provided to local government over the next three years to support adult social care services. Half of this funding will be made available in the 2017/2018 financial year so that councils across the UK can take immediate action to support local social care providers and relieve the pressure on the NHS locally. This a significant amount of funding and we hope that a clear strategy for social care is developed and implemented so that a real difference is made.

The government will also provide an additional £100 million to the NHS in England in 2017-18  to improve waiting times and manage the increasing demands on A&E departments. There was mention in the budget of “increase the provision of on-site GP facilities” in A&E and we feel with the increasing pressures that GPs are under coupled with the shortage of GPs, moving them into an A&E setting may not be the best approach to tackling the challenges in A&E.

The government will continue its work supporting Sustainability and Transformational Plans in the NHS and will invest £325 million over the next three years to support local proposals that aim to improve patient care in a sustainable way.

Support Women’s Health and Wellbeing Through the Tampon Tax

Tampons are considered a luxury item and therefore have to be taxed, but following a campaign to cut the tampon tax the government decided, in a previous budget, that every year £15M raised from the tampon tax will be given to women’s charities. In this current budget the Chancellor has agreed to continue this.

The tampon tax has made a significant difference to women’s health with charities like Ovarian Cancer Action,  Jo’s Cervical Cancer Trust,  The Eve Appeal and Breast Cancer Care benefiting from the funding. We hope that this funding will continue and that charities focusing on health issues that are of particular concern to black women will apply.

Our Conclusion

The government has introduced some policies and allocated funding to  areas that will make a difference to the health of UK’s public. We do believe that opportunities were missed to really support disease prevention by going further with measures to reduce obesity and there was only an indirect focus on physical activity through the use of the funding for the sugar tax.

For the black community to benefit from this budget we encourage black charities working on women’s issues to explore the tampon tax funding and put in an application when the next funding round opens. We also encourage the black community to engage with their local councils and get involved in any consultations regarding the use of the money allocated to them for social care services.

Last week, George Osborne, the UK’s Chancellor, announced his latest budget.  The budget has some impact on the public’s health and in this budget the major public health announcement was the levy on soft drinks (the sugar tax).

George Osborne stated that soft drinks companies will pay a levy on drinks with added sugar. This will apply to drinks with a total sugar content above 5 grams per 100 ml. A higher rate will be applied to drinks with more than 8 grams per 100 ml.  The levy won’t be applied to milk-based drinks or fruit juices.  The levy will come into effect from April 2018.

The money raised from the sugar levy will be used to double the funding available to primary schools for PE and sports programmes. The government has estimated the sugar levy will raise £320 million a year for primary schools to support healthier more active lifestyles in children. The funding will not only go towards expanding PE and sports programmes but to also expand breakfast clubs in primary schools ensuring that children have access to a healthy breakfast every week day.

The idea behind the sugar levy is a good one. It’s hoped that the levy will incentivise the soft drinks industry to reduce the amount of sugar in their products, helping the public consume less sugar. The money raised will go towards helping children get more active and healthy and thus tackle our high rates of childhood obesity.  So, from a public health point of view the sugar levy is a win-win.

In addition to the sugar levy, the budget tackled the following health-related issues:

1.  Improving access to child prosthetics –  £1.5 million will be invested in child prosthetics so children with limb deficiency have access to sports prosthetics. The government will also create a fund to support research into the creation of new innovative prosthetic products for the NHS
2. Smoking – the government will continue to increase tobacco duties by more than inflation each year to discourage smokers and would-be smokers from purchasing tobacco products
3. Support for those with mental health conditions and young disabled people – the government will  offer new peer and specialist support to help address the disability employment gap and will publish a White Paper on the role that the health, care and welfare sectors can play in supporting disabled people and those with health conditions to get into and stay in work.

There was much controversy with regards to financial support for disabled people.  The Personal  Independence Payment (PIP) is supposed to replace the Disability Living Allowance. In his initial budget George Osborne planned to introduce much stricter criteria for who is eligible for the PIP, this would save £1.3bn by 2020, but would affect 640,000 disabled people who would lose their benefits or get less money. In the past week disability rights campaigners spoke out about these cuts and Iain Duncan Smith, the Works and Pensions Secretary, resigned stating that the cuts were  “deeply unfair”. This led to George Osborne admitting that the disability cuts had been a mistake and would be withdrawn. This is good news for those with a disability who need these benefits to improve their wellbeing and we’re happy to see that these have been withdrawn.

The Lake Foundation is happy to see the various measures that have been put into place to improve the public’e health and wellbeing and are very happy to see the sugar levy included in this latest budget and look forward to seeing how this will be implemented.

You can read the full budget here