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A new report by the think tank ISIS Malaysia is raising questions about the effectiveness of Malaysia’s sugar tax. This is after researchers found only modest reductions in reducing sugary drinks consumption. Does that mean the policy isn’t working? Or are we expecting too much from a single intervention? And if that’s so, what do we understand about what actually drives the choices we make about food and drink? On this episode of #ConsiderThis Melisa Idris speaks with Professor Dr Geeta Appannah, Division of Nutrition, Dietetics and Food Science at IMU University and Immediate Past President of the Malaysian Association for the Study of Obesity, and Fahad Ijlal Nizam, Researcher at ISIS Malaysia who authored the research note ‘How to Win the War on Sugar’.
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00:10Hello and good evening, I'm Melissa Idris. Welcome to Consider This.
00:14This is the show where we want you to consider and then consider what you know of the news of
00:18the day.
00:19A new report by the think tank ISIS Malaysia is raising questions about the effectiveness of Malaysia's sugar tax.
00:26This after researchers found only modest reductions in reducing sugary drinks consumption.
00:33So does that mean the policy is not working or are we expecting too much from a single intervention?
00:40And if that's so, what do we really understand about what actually drives the choices we make about food and
00:47drink?
00:48Joining me on the show today to discuss all of this further is Professor Dr. Gita Appena,
00:53who's from the Division of Nutrition, Dietetics and Food Science at IMU University.
00:59She's also the immediate past president of the Malaysian Association for the Study of Obesity.
01:05And we have the author of the research notes, How to Win the War on Sugar, Fahad Ijlal Nizam from
01:15ISIS Malaysia.
01:16Welcome to the show, both of you. Thank you so much for joining me today.
01:20Prof Gita, if I may begin with you.
01:22So I know Malaysia has long recognised the effects of high sugar consumptions, the impact, the high risk of it.
01:30And the government has addressed this through some measures.
01:33But before we get into the effectiveness of those measures,
01:36I wanted to maybe look at the broader picture about Malaysia's dietary behaviour,
01:40particularly around sugar consumption.
01:42How would you describe it?
01:44How would you describe Malaysians' maybe, I guess, nutrition literacy
01:49when it comes to how we make choices around sugar consumption?
01:55Thank you so much, Walisah. That's a very good question.
01:57Based on several studies, local several studies and also expert observations,
02:02what we're saying is that there's a clear mismatch between the knowledge on nutrition literacy
02:08and the application of it.
02:11So there's a clear and critical paradox on this aspect.
02:15And the thing is, Malaysians generally have very good knowledge about the dangers of food high in sugar,
02:23but they don't necessarily apply the knowledge in making healthier choices.
02:28So we know what has a lot of sugar, but we still like, we're not applying that.
02:33So there's a mismatch.
02:35There are several reasons, drivers that are causing this mismatch.
02:39Number one is the misconception of healthier options.
02:45What we are thinking, the sugary drinks served in many eateries,
02:51are not a significant source of sugar intake in our daily life.
02:54Yeah, and take for example, Teh Tarek has got 26 gram of sugar.
02:59And what WHO recommends is 25 gram.
03:02Clearly exceeds the daily limit of what WHO is recommending.
03:0725 grams in a day, and in one cup of Teh Tarek is 26 grams.
03:12Yeah, it's a glass.
03:13That's all you have to drink the whole day.
03:14That's all you drink in a day.
03:15And you exceeded it.
03:17And sirup bandung is 32 gram.
03:20Way too much from what is being recommended.
03:22And people don't drink that in isolation.
03:24People do eat food high in sugar as well.
03:27There you go.
03:28So we exceed the limit way too much.
03:31And there are also misconceptions that some coffees or teas served by several chains
03:37are also not a very significant source of sugar intake.
03:40Okay, tell me more.
03:41And also people, and that's merely because people don't have the skill to estimate what
03:47is the sugar level in those drinks.
03:50Yeah, and that's, that's, that, that is something very worrying.
03:55Yeah.
03:55Although they know the knowledge that sugar is not the healthiest.
03:59And secondly, it's because of what we call people who are taking medication.
04:04Yeah, people living with diabetes, for example, they are prescribed with insulin or oral medication
04:11to manage their diabetes.
04:12But they also think those are licensed for them to consume sugar.
04:18Yeah.
04:19So that's also not so right.
04:21Okay, so there's a, there's a knowledge gap here, or at least a knowledge application gap
04:27that we need to address.
04:29And I want to talk about what that means in terms of the impact of it.
04:34So, so let's say Malaysia has, we have two policy approaches to address sugar consumption
04:41the government has implemented.
04:43So it was the Healthier Choice logo and the sugar sweetened beverage text, right?
04:48Talk to me a little bit about that, Fahad.
04:49If I may begin with you then on this area, explain how these interventions were first implemented
04:56and what your research has found.
04:59Okay, so let's start chronologically, right?
05:032017, the Malaysian government implemented the Healthier Choice logo.
05:08And it essentially is a behavioral nudge, behavioral informational nudge
05:13to help kind of push consumers to healthier choices using a sticker.
05:18Right, I don't have an example right now, but it's basically a little red sticker
05:22or a black sticker with a big tick that says Healthier Choice logo.
05:25I think I've seen it before.
05:26Yeah, it's everywhere.
05:28If you walk into 7-Eleven, that's the one you'll see.
05:31And it basically, it's supposed to help consumers consume Healthier Choice drinks.
05:37And the way that companies are eligible to get it is by reformulating their drinks
05:42to contain less than 5 grams of sugar per 100 milliliter.
05:46So only drinks that has less than that sugary threshold,
05:50then only then you are allowed to put that sticker on or apply for it at least.
05:54So that was the intent, to tell consumers,
05:57hey, we have a healthier choice option, less sugary version of this drink,
06:01consume this one instead.
06:02Now moving on to the sugar, sweetened beverage tax, right?
06:06And it basically is a tax, or it's also known as a soda tax as well.
06:12But the number one misconception about it is that when people say sugar tax, right,
06:16that's the first thing that comes into it.
06:17But we don't actually tax sugar.
06:20We only tax the sugar in the drink.
06:22Okay, so it's only for beverages.
06:26For pre-packaged drinks, right?
06:27So bottled, canned, boxed, all those kind of drinks.
06:30And the going rate, I think as of this year, is 90 cents per liter, right?
06:37So if, let's say, a drink is more than 5 grams of sugar per 100 milliliter,
06:43that's the taxable threshold.
06:45Only then that particular drink will be taxed 90 cents per liter.
06:49So for like a canned drink, which is around 300 milliliters,
06:53that would be about 30 cents per can.
06:56Per can, okay.
06:56And what did your report find about whether these policies are effective?
07:03Okay, yeah.
07:05In the research, we found it actually did induce a big chunk of reformulation.
07:11The SSB tax or both?
07:13Both.
07:14With the logo as well?
07:15Exactly.
07:16So it worked like a carrot and stick where the HCL was the carrot,
07:19the reward for companies to reformulate.
07:21And the tax was a stick where companies didn't want to be taxed.
07:24They would quickly reformulate their drinks to be less than 5 grams of sugar per 100 milliliter.
07:28And now you find that companies are happily disclosing that a majority of their drinks
07:34lay below this taxable threshold.
07:37And now you also, so you have a kind of a landscape of you go into 7-Eleven,
07:42a lot of drinks actually have this Healthier Choice logo.
07:46So you have this situation where it currently has worked,
07:49it's current, it's purposed intention,
07:52which is to reduce the sugar content per drink
07:55to about 5 grams of sugar per 100 milliliter.
08:01So it has worked to a certain extent.
08:03But where you have an issue where now most drinks
08:06are less than 5 grams of sugar per 100 milliliter,
08:09most drinks are now also healthier.
08:13So this is what Dr. Geetha was alluding to
08:15on like a misconception of health and healthier choices.
08:19You have drinks, traditional fast food drinks,
08:22which are carbonated,
08:23I'm not going to name names today.
08:26But you have neon drinks, blue, red drinks,
08:29all with a Healthier Choice logo.
08:31Really?
08:32Right.
08:32And you have this situation where all these drinks are Healthier Choice.
08:36And the MOH actually did a study on the sticker,
08:40the efficacy of the sticker,
08:41and they said that about half the population
08:44knows about the sticker,
08:46and 80% of that half believes in the Healthier Choice.
08:51So they believe that this is a Healthier Choice
08:53and I should consume this.
08:54So we risk, so the Healthier Choice logo,
08:56although as well-intended as it is,
08:59it has somehow transformed into this backfiring behavioral nudge,
09:03where it tells people that, you know,
09:04these neon drinks are kind of healthier,
09:06all still laden with like preservatives,
09:09artificial sweeteners,
09:10but just because the single criteria of sugar,
09:14it causes this kind of misconception of health.
09:16Dr. Gita, what do you think about this?
09:19I mean, both of these policies are partially effective,
09:22but fundamentally limited.
09:24For example, take for example SSB tax.
09:26We know one of the biggest success of SSB tax in Malaysia
09:30is that we have spurred the reformulation among manufacturers.
09:34And I think that's one of the biggest public health win in the recent days.
09:39However, however, yeah, with the problem with SSB is that
09:46it's based on the volume.
09:49So it's smaller cans, pay less tax.
09:53It's not per rate of sugar, but it's per volume.
09:56So there you go.
09:59You know, people can choose smaller,
10:00but many of those sugary drinks.
10:04So it doesn't help.
10:05Okay.
10:05So how do we think about this?
10:07The fact that the policy itself seems to have been effective in some ways,
10:13but then have unintended consequences in other ways.
10:16Yeah.
10:18The policy itself maybe is the design flawed.
10:21Can the policy be improved?
10:23Should it be scrapped?
10:25What do you think, Fahad?
10:25Yeah, no policy is 100%, right?
10:30Every policy, everyone will tell you that there's always room for improvement.
10:33And on the SSB tax itself,
10:36why Malaysia has seen kind of limited impact on consumption of sugar
10:41is because the SSB tax inherently was a Western one-size-fits-all policy, right?
10:47It was a policy implemented, which is helped implemented by the World Bank.
10:51And you have over 130 countries around the world implementing this SSB tax.
10:55But the big difference between us and Western culture
10:59is that our drink menus are just substantially bigger, right?
11:03You could have a whole menu by itself in Malaysia,
11:06just drinks, right?
11:07From teet tare, you have your carbonated drinks.
11:10It's not a problem of the pre-packaged drinks,
11:12but we also have a huge problem of freshly made drinks in eateries.
11:16And the sugars are subsidized.
11:19Okay.
11:20Talk to me more about that because that there's...
11:22So this one-size-fits-all doesn't quite fit in a Malaysian context
11:26because we have other things.
11:29Talk to me about the other things.
11:31Just lay it out for me so I understand.
11:33So what the study says is that one of the study, I think, is for Fahad's...
11:36Also, he has highlighted in his report that
11:39pre-packaged drinks are consumed by five servings per week,
11:44but the freshly made drinks are consumed nine times in a week.
11:51And these freshly made drinks are not from home but in eateries,
11:56local eateries where we all enjoy.
11:58So in terms of practical terms, you're talking about, say,
12:01something that I've bought at E7-Eleven in a bottle
12:03versus me going out for lunch and ordering a drink at my local eatery.
12:10Correct.
12:11Got it.
12:11And that's the biggest issue at the moment.
12:13And sugars are subsidized there.
12:15So they run away from the sugar tax
12:19and makes this even more interesting in this context.
12:22So that's huge contradictions that we're talking about.
12:26On one hand, we are taxing the sugary drinks,
12:29but on the other hand, we are subsidizing the sugar.
12:31So you see the huge contradiction and political policy incoherence over there.
12:38Absolutely.
12:39It is policy incoherence.
12:41So how do we make what was a Western policy approach
12:48fit into a local context?
12:49So you said the SSB tax was implemented, is it in June, in 2019?
12:57So you've had some years to see whether this works or it hasn't worked.
13:01How would it fit into local context?
13:03What would you need to change about that policy?
13:06So one of the main suggestions that the report suggests
13:09is that changing from, number one, just improving the tax as a whole,
13:14as a structure.
13:14So like what Dr. Gita alluded to in the report said as well,
13:17was that the volumetric tax taxes less the smaller drinks, right?
13:22So instead of just looking at volume,
13:25why don't we just tax sugar itself,
13:27making the sugar itself equate to health harm.
13:30So more sugar, more tax, right?
13:32So we suggest that, number one,
13:34to switch from a volumetric tax system
13:36to an absolute sugar tax system.
13:39So that's taxing for every gram of sugar present in that drink, right?
13:44And we did some simulations in the report
13:47and with even a modest of two cents of per sugar,
13:52if you tax that amount,
13:54that would push us up to the World Bank standard
13:57of increasing prices of SSBs by 20% of its current retail price.
14:02Right now, that's about two to three percent
14:05because I think a few guesstimates have been
14:09that companies have absorbed a lot of the tax,
14:12it being very low.
14:13So instead of hurting their customer base by higher prices,
14:16companies have decided to absorb it,
14:18making the price pass-through rate even lower.
14:21So that's number one.
14:22And number two is actually widening our tax code, right?
14:26Some countries have done this already.
14:28Malaysia has yet to do it.
14:30And it's to actually expand towards condensed milk.
14:34Malaysia is a big advocate of condensed milk.
14:36And currently, condensed milk is still tax-free.
14:39Right.
14:40We forgot about condensed milk.
14:43That would actually help into making cakes as well,
14:47other sweet things.
14:48But if you just look at sugar domain,
14:50everything is condensed milk, right?
14:51Milo Ice, OP Bank, everything is condensed milk.
14:54So widening the tax code would help us
14:56in a more local context
14:57where our locals and myself,
15:00you know, guilty,
15:01do love condensed milk.
15:03What do you think, Prof Gita,
15:04do you see that this is possibly a better way
15:08to improve of what we've had before,
15:10improve the way we approach sugar consumption
15:14here in Malaysia?
15:15Yeah, definitely.
15:16It's obviously one of the ways we have to do.
15:18I mean, there are several suggestions to this
15:20because we have to first consider removing the sugar subsidy
15:23because it's huge.
15:25That's number one.
15:25And, you know, expand the scope of tax,
15:28not only the prepackaged drinks,
15:31but we also need to expand the scope
15:33to condensed milk as far as nicely mentioned just now,
15:36I liked it over there,
15:37and other sweeteners that are being used.
15:39And, you know, that's the way to go
15:42because obviously studies are not lying.
15:44I mean, we have data.
15:45We are seeing data showing a lot of sugar consumption
15:49happening in local eateries
15:51compared to the prepackaged drinks.
15:54It's a combination.
15:55It's a combination.
15:56So when you brought up sugar subsidies
15:58and then the possibility of recommending an absolute tax on sugar,
16:03I do wonder how, if I may, how do I phrase this?
16:08How popular such a policy would be,
16:11or how unpopular such a policy would be.
16:14Would, do you think that the public might see this
16:18as a legitimate public health policy
16:22or one that they might consider more punitive on their pocket
16:27at the end of the day?
16:28What do you think?
16:29That's always a hard topic and a question
16:31that I always get from my boss,
16:34from other institutes as well.
16:37And yes, it could be very unpopular in that sense, right?
16:42So the number one goal here
16:44is to actually really push the message
16:46that these policies are health-related policies, right?
16:49An unhealthy population is really expensive.
16:52And Malaysia is not the richest country in the world.
16:54We can't afford an unhealthy population.
16:58A study done in 2021 found that just four NCDs,
17:05diabetes in particular,
17:07has cost economic cost of up to RM27 billion a year.
17:11And it's actually the most expensive NCD in Malaysia, surprisingly.
17:16And if you total up cancer, respiratory diseases,
17:23cardiovascular and diabetes,
17:25that goes up to about RM64 billion in economic losses
17:28for just a single year for four diseases.
17:31That's, to put it to perspective,
17:33that's double the MOH allocated budget for that same year.
17:38So, yes, in the short term,
17:40people might see it as an inflationary impact.
17:44But on the long run,
17:46when public health gets healthier,
17:48it gets better,
17:49you spend less on medical costs,
17:51it becomes a net gain, right?
17:53So it really is a long-term game.
17:55And it starts from changing our sugar habits from young.
17:59If I can add on what Fahad mentioned just now,
18:02we're not banning sugar at all.
18:04We're trying to correct the market failure over here.
18:09So, I mean, we can take for example what's happening in Singapore.
18:16The Siu Dai by default campaign has been successful.
18:20We did have similar concept in Malaysia.
18:22We have piloted kurang manis.
18:24But what happened is that only people who choose,
18:27who opted in for those kurang manis,
18:30drinks seems to be aware.
18:33But that's one in ten.
18:36The rice, no whatsoever changes.
18:40They still go with by default,
18:43which is high in sugar drinks.
18:45So let's make this as a by default choice
18:49in our environment.
18:52So that's how it works, I suppose.
18:53Can I ask you,
18:54so the title of your report for her was quite interesting to me
18:58because it talked about the war on sugar.
19:01And I want to talk about that phrasing
19:02because I've heard that a lot,
19:03particularly amongst in the healthcare field.
19:07And I can understand the,
19:10they see the repercussions,
19:11medical professionals see the repercussions
19:13of Malaysia's excessive sugar consumption, right?
19:16But when we frame it as,
19:17or when the government frames it as the war on sugar,
19:20is there a danger
19:22that this public messaging becomes quite simplistic?
19:25It boils down to the individual choices that we make
19:31as opposed to,
19:32I don't know,
19:33systemic barriers
19:34or the social determinants of health,
19:38the time constraints,
19:39the convenience that comes with eating out.
19:43As someone in this field,
19:45in nutrition and dietary behaviour,
19:47what do you think, Prof Gita?
19:48Very, very good questions.
19:50I mean,
19:50obviously individual choice happens in an environment
19:54where policy has got a lot to shape.
19:57So that's why we're talking about policy
19:59and therefore changing the entire environment.
20:03So, I mean,
20:04we cannot separate the both of it.
20:07It has to be in together.
20:09Yeah.
20:10So, although it's going to be very punitive
20:14to certain people,
20:15but in long run,
20:16we're going to save so much.
20:18And the cost of health economy
20:22is disproportionately fall in the lower income group
20:26because of this diabetes
20:29and the complications that are happening.
20:31And because they are from the lower income group,
20:33they may not necessarily have the best violence
20:36about the disease
20:38and even about the risk factors
20:39associated with the disease.
20:41So, look at that.
20:43You know,
20:44it's not going to be easy,
20:46but I'm sure this is not impossible.
20:48Right.
20:49What do you think?
20:49You choose the title,
20:51War on Sugar,
20:52in your report.
20:53Do you think that that could be,
20:55is that the right messaging?
20:57Are we treating this
20:58as almost an enemy of public health?
21:04I think the choice of the MOH
21:08to say it is a war on sugar is,
21:10I would say it's actually quite fitting, right?
21:13Because, one,
21:15we do consume a lot of sugar.
21:16Number one in ASEAN.
21:18Oh.
21:18Right.
21:19Three times out of Philippines,
21:20around 57 kilograms of sugar.
21:23That's in adolescence?
21:24That's including,
21:25no, no,
21:26that's kilograms,
21:27including industrial use.
21:28Okay, right, sure.
21:29Around,
21:29adolescents consume over 50 grams of sugar,
21:32more than adults.
21:33Adults.
21:34Interestingly enough.
21:35Oh.
21:35Right?
21:35So, teenage choices
21:38are much more sugary.
21:40Much more sugary,
21:41with lesser pockets.
21:42So, that's another conversation, right?
21:44Okay.
21:44That's another episode.
21:46But in that sense,
21:47the war on sugar,
21:48for me,
21:48is actually quite fitting
21:49because it shouldn't be,
21:51like you said,
21:51it shouldn't be an individual.
21:52It's a whole government approach.
21:55And it's not just MOH, right?
21:57The Ministry of Sukan.
21:58It can go to everything, right?
22:00And it's just like the environment,
22:02the entire environment.
22:04Like, when we say,
22:05is it actually an individual choice?
22:07Do kids,
22:09can kids have choices
22:10to have healthier choices
22:11in their schools
22:13if they're surrounded by vending machines,
22:15air balang,
22:17all those carbonated drinks
22:18in the schools,
22:19and water is the only substitute
22:22to those sugary drinks?
22:24So, I believe the war on sugar
22:25is a strong American sugar drink.
22:26And one of the main reasons
22:28why I chose that title
22:29is because of the subsidy,
22:32the paradoxical subsidy, right?
22:34If we are implementing,
22:35if we are declaring a war on sugar,
22:38then this kind of subsidy
22:40is, in that sense,
22:42shooting ourselves in the foot.
22:43Yep.
22:43So, we need to align our policies,
22:45make it more coherent
22:46so that we go one direction
22:48and for healthier Malaysia.
22:50Okay.
22:51We've got a couple minutes left
22:52and I want to give both of you
22:53some time to maybe give a message
22:56to the audience
22:56or to policymakers
22:57who may be listening tonight.
23:00What, Prof Gita,
23:01what would you like audience members
23:04to, I guess,
23:05bear in mind
23:06when we make those choices
23:08and when we,
23:10what's available to us
23:11in the current ecosystem,
23:12what would you like,
23:13what message would you like
23:14to leave us with?
23:15Well, okay,
23:16that's a very interesting question
23:17because we don't have a very,
23:20I mean,
23:20we don't have a very precise answer
23:22for that,
23:23but we have to remember
23:24that Malaysia,
23:25the current point,
23:26is number one in Asia
23:28for diabetes prevalence.
23:29Number two in us,
23:31in ASEAN,
23:32for obesity.
23:33And these two diseases
23:34comes with a lot of complications.
23:37It's very expensive
23:38for the country to manage
23:39and if we don't do anything
23:41about it now,
23:42it's going to be very difficult
23:43for Ministry of Health
23:44to manage it
23:45because as Fahad mentioned,
23:46this is double of the budget
23:47that's being given
23:48to Ministry of Health
23:49to manage this
23:50and you imagine
23:51children nowadays
23:52are drinking more than adults
23:54and they are going to be
23:55our future generation
23:56if they,
23:56and they're going to have
23:58diseases
23:58and a very much younger age
24:00and we're going to manage them
24:01for the rest of their life
24:02and all these economic aspects
24:05are calculated
24:06from health care expenditure,
24:09calculated from loss
24:10in productivity
24:11and also loss
24:13in premature death
24:14and we don't want that
24:15to happen to our children
24:16in near soon,
24:18in the near future.
24:19So, think about it.
24:21Fahad,
24:22the message for the audience
24:23you'd like to leave
24:23after working so hard
24:25on this report,
24:26what would you like
24:27the takeaway message
24:29to be from the work
24:29that you've done?
24:31I hope that
24:32the work that I've done
24:33has kind of
24:36rekindled
24:36or reignited
24:37the conversation
24:37on the health harms
24:39of sugar.
24:40one of the reasons
24:41I brought up on this project
24:44was because
24:44it was so quiet.
24:46It was, you know,
24:47sugar is quite unhealthy
24:49for you
24:50and at the rate
24:51that we're going
24:51it can only get worse.
24:53Where we are right now
24:54it's already unhealthy
24:55and where we are right now
24:56our pockets are
24:57going dry
24:58from spending too much
24:59on health harm
25:01and health effects
25:02and expenditure.
25:04So, my message
25:04to the audience
25:05is
25:06although it tastes
25:07really good
25:08try limit yourself
25:09to one sugary drink
25:10a day
25:11and remain yourself
25:12a water.
25:12That's what I'm trying
25:13to do at least.
25:14Well, I will try
25:14to do the same
25:15I think after
25:16hearing your
25:16and reading your report.
25:18Thank you both
25:18for being on the show.
25:19I appreciate your time.
25:20Thank you for having us.
25:21That's all the time
25:21we have here on this episode
25:22of Consider This.
25:23I'm Melissa Idris
25:24signing off for the evening.
25:25Thank you so much
25:26for watching
25:26and good night.
25:42We'll see you next time.
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