INTRODUCTION prevalence of adult obesity as much as

INTRODUCTION

Currently,
obesity is becoming a global issue in which increase doubled since 1980. It is
estimated that in 2014, more than 1.9 billion adults are overweight and 600
million of them are obese (WHO 2015). In developed countries, obesity has
increased rapidly and contributed to an adverse outcome. Australia, as the
developed country, obesity has been increased about two-fold within 2 decades,
whereas in developing countries such as Brazil and South Africa, also showed a
high number of obesity (15.8% and 16.0%, respectively) (OECD 2014).

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As a
developing country, Indonesia is not only facing undernutrition but also
overweight. Obesity is real and growing threat to Indonesian population.

According to data from the national basic health research in 2007, the
prevalence of adult obesity as much as 10.3%. This figure increased to 15.4%
within 6 years after a similar survey conducted in 2013. This anomaly occured
not only in adults but indicated also in children as well as adolescents
(Litbangkes, 2008; Litbangkes, 2013). 

It is known
that dietary pattern is a direct cause factor of the nutritional problems,
including obesity. High intake of food and lack of physical activity produce
energy imbalances in the body that ultimately result weight gain. Previous
studies clearly showed that a high calorie diet (Lincoln 1972; Hill et al.

2012) and sedentary activity increase the risk of obesity (Arundhana et al.

2013). However, some experts hypothesized that the cause of obesity, specifically,
can be due to excessive of sugar consumption, especially of sugar-sweetened
beverages (SSB) (Lustig 2009). In the last
three decades, Americans have increased weight and thus significantly increase
the prevalence of obesity to became epidemic proportions. The reason
is the level of caloric intake of Americans are very high and largely derived
from sugar-sweetened beverages (Woodward-Lopez et al. 2011; Marrow 2014).

According to
the survey in Australia that fruit juice is the most widely consumed by
children and adolescents (37%), followed by soft drinks (25%) (www.rethinksugarydrink.org.au). Similarly,
in Indonesia, the level of sugary drinks consumption was also quite high,
particularly among children and adolescents. In Makassar,
based on a survey conducted previously showed that 1 of 2 adolescents often
consume SSB. In addition, accessibility to get the SSB is very easy
due to available mostly in retail market (Agyatmi et al., 2012) such Indomaret,
Alfamart, Giant, etc.

 

A study proved
detrimental effects of the SSB consumption. Daily SSB consumption is
significantly related to the risk of obesity in children  and other chronic diseases in the future
(Ludwig et al. 2001, Kumar et al., 2014). Conversely, lowering SSB consumption
is associated with weight loss (Ebbeling et al. 2006). Contributions of SSB to
weight gain through the mechanism of calorie form. The calorie of liquid form
might not fill up the energy like calorie in the solid foods (Marrow, 2014).

This mechanism is not only associated with high-calorie, but there is anomaly
explained  by the experts if the calories
of SSB is not the actual calories (a
calorie is not a calorie, Its a fake). A study demostrated that calories
from drinks differ in terms of its thermodynamics process in generating more
heat than solid food. It makes the calories obtained is equal but the signaling
process to the brain is different. By drinking SSB, people tend to feel not
eaten and still empty so it will have excess calories when they eat (Harcombe
2014). It means that there is an addictive effect on energy intake when
consuming SSB (Mourao et al., 2007; Cassady et al. 2012).

The big
question need to be answered is why people consume SSB increasingly year by
year. SSB became more popular and stated as the favorite drink especially for
young people. The popularity of SSB is very high and not only occurred in
cities but also in rural areas. Sugar-sweetened beverages are the secondary
largest contributor of sugar in the diet of adults and children. Restrictions
on sugary drinks is the one of the best way to fight against obesity trend
which increased year by year. There has been many evidences that lowering the
consumption of SSB minimizes opportunities of health problems development. This
probably could be done through the formulation of appropriate policy goals
(NZBGP 2014). Tax of sugar-sweetened beverages is still considered by many
public health experts and policy-makers as the best strategy for improving the
nutritional status of a national, value for health programs, and lowering
financial burden of treatment and insurance of diseases related to food
(Brownell et al. 2011; Friedman & Brownell 2012).

The regulations
of consumption and the use of sugar in foods is not easy to be made because of
the efforts to reduce the supply and demand of sugar influencing by political
issues. It was real experienced by several countries such as America and Mexico
(PAHO 2015; Donaldson 2015). However, considering disadvantages effects of
sugar (especially fructose), then the government should be concerned on this
issue. In Indonesia, regulation on added sugar in a product has not been set
out clearly. The existing rules are still at the level of food safety
regulation which protects consumers from 
food poisoning due to contamination of biological,
chemical, and other objects that can disturb, harm, and harm to human health (BPOM,
2015).

Tax policy
should be a “filter” for the high-sugar products including the
rationing of sugar-sweetened beverages in Indonesia. Many studies
showed the evaluation of tax of sugary drink to fight the development of
obesity. Recent studies have shown the success of some
countries to prevent the increase in the prevalence of overweight and obesity
through tax sugary drinks. The results
of these studies indicate that the price of the drinks may reduce demand for
SSB (Malik et al., 2006; Ebbeling et al., 2006; Cabrera Escobar et al. 2013). According to
Singh et al (2012), that the policy holder should have effective policies to
reduce consumption of sugar-based drinks which may result the significant
number of deaths (Singh et al. 2015). In 2014,
imposed a tax of 1 cent per 100g SSB in California and marked as the beginning
of the tax policy in the United States (Falbe et al. 2015). The
Indonesian government should also focus on the issue of tax and regulation of
added sugars maximum limit in beverage product.

As one of
the largest cities in Indonesia, Makassar became invasion target of several
minimarket branding. Within five years, the growth of minimarket retail in
Makassar city is very significant approximately more than 10% per year. Minimarket
became the main choice of people to buy food and beverages due to the
accessibility easily, displaying the price, provide comfortable surroundings,
selling various kind of drinks, and served cold. Availability
of minimarket in some places would affect consumption patterns of the people
around the minimarket (Agyatmi et al. 2012). Based on
these problems, this study aimed to provide an overview of sugar content of SSB
which placed in minimarket in Makassar city and analysis of policy that
regulates the SSB products in Indonesia. This study could be providing the
consideration to create policy related to taxing sugar-sweetened beverages in
Indonesia.

 

MATERIALS
AND METHODS

This research was a descriptive study that
aimed to identify the policy-related use of sugar and taxation of SSB product
in Indonesia, and also to provide the nutrient content from sugar-sweetened
beverage products. Literature search related to policy of sugar use and the tax
of sugar sweetened beverages products has been conducted through searching from
google.com by entering the keyword “Act of sugary drinks” obtained 5
documents, “The ministerial regulation+sugar-sweetend beverages” (2
documents), and “Regulation of ministry of trade + sugar-sweetend
beverages” (1 document). After the analysis, there are two documents from
a total 8 documents that were irrelevant because it has been replaced by the
latest regulation such as PERMENEKU number 213 / PMK.011 / 2011 and Act number
8 year 1983. Therefore, it was obtained 6 documents that are considered to
describe the relevant act or regulation by government regarding to the tax of
sugar and the use of sugar in food products in Indonesia.

Data of nutrient content, especially
sugar, collected from beverages sold in the minimarket in Makassar city. A
total of 91 samples of SSB products were successfully selected from one of the
retail brand grown in Makassar (Indomaret). Methods of selecting samples were
systematically by selecting five SSB products randomly per day for 20 days.

Inclusion crieteria of selected beverages are Halal certified by MUI, containing
calories and has a nutritional label, and certified by BPOM. Similar SSB
products which selected, based on name and manufacturing, (different flavors)
will be eliminated as the samples (total 9 products dropped out). Information
of nutritional content obtained from label of the product. Sugar-sweetened
beverages refers to all non-alcoholic beverages with added sugars, such as carbonated,
coffee, juice, milk, sports drinks, supplement drinks, tea, yogurt, and energy
drinks (Rodriguez-Artalejo et al. 2003; Malik et al. 2006; Popkin,
BM., 2010; NZBGP 2014; Falbe et al. 2015). Microsoft Excel
and SPSS were used for data analysis. Data analysis conducted is univariate to
describe nutritional content of products based on category.

 

RESULT
AND DISCUSSION

The
main reason why the government needs to concern about the policy or regulation
related to food and beverage is because of its implications for public health.

Excessive consumption mainly for SSB can lead to obesity disaster and even that
may increase the risk of chronic health problems (Cornelsen and Carriedo,
2015). Through the right policies, potentially decrease the popularity and
demand for SSB. This is evident from the results of a study conducted in Mexico
where the presence of tax policy can lower the purchase SSB by an average of
6%. The highest reduction were in low socioeconomic (Colchero et al., 2016).

Indonesia needs to consider properly the regulation regarding to SSB product
due to its potential threat to consumers through sugar consumption. This study
indicated the high sugar content of each SSB product sold in retail minimarket
in Makassar.

Table 1 shows the
macronutrient content of SSB per 100 ml of product. Milk
contained the greatest amount of energy followed by yogurt drinks 70.79 kcal
and 68.50 kcal, respectively). However,
only few studies show the contribution of sugar in the milk to the development
of chronic diseases. An interesting thing is the sports drink has the
lowest energy content per 100 ml (21.00 kcal). Sport drink
that was created in 1965 in the United States is used as a dietary supplement
for athletes in an effort to cope health-related physiological and nutritional
problems. These beverages are designed for athletes or
individuals who requires replenishment of water and carbohydrates and
replacement for electrolytes lost or used during prolonged vigorous physical
activity (HER 2012). These results contrast with the conclusions by
Dragusin and Horswill (2015), that has been involved in sports drinks
contribute to obesity and chronic diseases by providing excess of calories and
sugar (Dragusin & Horswill 2015).

The fiber
content is one of an important components that must be considered in a food
product. As shown by Table 2 that most carbonated
beverages contain lots of sugar and no fiber (11.52 ± 1.62 vs 0.0 ± 0.0). Not much
different from the energy drink where the sugar content reaches 11.16 grams and
also no fiber. The highest-containing sodium is an energy drink (66.88 ±
44.58), while potassium derived from milk beverages group (140.6 ± 45.39). Overall,
the amount of sugar in the product reaches 86,2g/L. SSB taxes policy can be
successful by implement tax per liter production. In Mexico, the imposition of
tax per liter raise product prices about 10% of previous price. It was
successful in reducing the number of SSB purchased only in a half year
(Colchero et al., 2016. The Indonesian government could also implement this
strategy, if it is considered as effective ways.

Table 3 demostrate
the contribution of sugar for total energy of the product. It can be
seen that the sugar in sports drinks contribute highest to the total energy of
the products (93.33%), then the least contribution was from milk (44.98%). Sugar
content per product in average is quite high, especially in carbonated drinks
reached 40.88 g per product. Sugar
content in milk and yogurt are quite low, so that the milk and yogurt could be
stated as the viable products to consume everyday without giving excessive
sugar intake. However, other mechanisms may occur and should be
considered, according to Stolzer 2011, that the protein and fat content in the
milk can increase the secretion of IGF-1 and separately stimulate adipocyte
which gradually increase the weight (Stolzer 2011).

Nowadays, children and adolescents are likely to
choose and consume SSB whenever and anywhere. Based on the
results of a study that the average calories come from sugary drinks as much as
400 kcal / day or equal to 25-30% of the total daily requirement (Mattes &
Campbell 2009). Many studies show that SSB have a weak satiety
properties and compensate restricted diet (failure to adjust the intake at the
next meal occasion) when compared to semi-solids or solids food (Popkin, BM.,
2010; Cassady et al. 2012). The changing pattern of SSB consumption was
significantly occured over the population of the world. At the
beginning, the first consumption of sugary drinks is limited to drink tea or
syrup, but now with the ease of access, the various products can be enjoyed by
all people without limitation. This
experience once perceived by the United States, where there is a shift pattern of SSB consumption
since the 20th century and continues until today. The kind of
beverage that is the most obvious chaning in pattern is milk. In addition,
other SSB also appears increased and became popular, while tea and coffee
tended to be more stable (Popkin, BM., 2010).

Study by Han
and Powell (2013), that children and young blacks tend to prefer the
consumption of fruit drinks (Han & Powell 2013). In this
study, it can be seen that the fruit juice in average contains 25 grams of
sugar or about 2.5 tablespoons (tbsp). In recent
study, the sugar content of carbonated beverages contained highly of sugar up
to 40 grams or 160 kcal. A study
showed the average consumption of carbonated beverages up to 500 kcal per day. The level of
sugar-sweetened beverages consumption may be influenced by socio-economic and
education factors (Bleich et al. 2009). SSB such as carbonated or soda and
fruit juice are sources of calories but few other important nutrients. The
adverse impact from frequent SSB consumption are on negative diet quality,
weight gain, and health condition (Malik et al., 2011; Kumar et al., 2012).

High consumption of SSB may increase the risk of diabetes mellitus (Malik et
al., 2010) which increase the risk of chronic heart diseases event
(Citrakesumasaril et al., 2016). Therefore, reducing
daily SSB consumption and promotes healthy lifestyle might help weight loss and
indirectly reducing CHD and other chronic diseases.

Based on
previous studies, the high SSBs consumption contribute to poor eating habits
and lead to weight gain and obesity. This probably increases the development of
chronic diseases such as diabetes mellitus, dental caries, hypertension, heart
disease, and stroke in the future (Friedman & Brownell 2012). There should
be a comprehensive prevention to adress the high intake of SSB consumption
especially in young population. The
government plays pivotal roles for these problem, as shown by some developing
countries such Mexico to fight against sugar-sweetened drinks (Donaldson,
2015), the Indonesian government needs to focus on this issue through provide
effective policies and programs. Table 4 presents the policies that
exist in Indonesia which regulates sugar needs and its use in processed and
ready-to-eat products. According Pekhrun (2016), there are several options
that could be done for lowering the level of consumption of sugary drinks such
tax enforcement, displaying of warning labels, healthy food assistance
programs, or healthy breakfast program for children (Pekruhn 2016).

The
literature searching have not found the policy of sugar-sweetened beverage
taxation. Although in Finance Ministry Regulation number 132 year 2015 is set
on import duties for beverages containing added sugar, but this only applies to
imported beverages. Even then there is no limit on how many additions of sugar
are allowed and how maximum-contained sugar is recommended. In Health Ministry
Regulation number 41 year 2014, it has set the sugar needs of individuals a day
no exceed 50 grams. In fact, the content of the sugar alone in carbonated
beverages per serving has reached 33.6 grams or 67.2% of the daily requirement.

It means that only 32.8% of sugar remaining that could be obtained from other
foods. Di Prancis, minuman manis dan tinggi energi cukup mendapatkan perhatian,
pemerintah setempat memberlakukan pajak sebesar ?1 per/L. The benefits gained
enormous, public health revenue as well as money revenues approximately ?268
Million (Cornelsen and Carreido, 2015).

The results
of a systematic review as evidence that the consumption SSB was consistently
linked with increased energy intake (Malik et al. 2006). In the Government
Regulation number 69 year 1999 regarding labeling and advertising of food, it
does not require displaying the sugar content of a product per serving, while
in the Health Minister Regulation number 30 year 2013 obligate to display the
content information of sugar, salt and fat and information of health messages of
processed and fast food. There are two conflicting rules that can lead to the
government becomes less assertive on this issue. Indonesian Government
Regulation number 69 year 1999 needs to be revised due to the information about
the sugar content is very important to be known by the public.

If the
specific rules on the sugar tax can be issued by policy makers, it is not
possible the illnesses associated with the consumption of sugar can be
prevented. This is in line with a study in which after implementation
of tax policy on sugary drinks then daily consumption of sugar-sweetened
beverages were decreased (from 0.56 to 0.47 servings per day). Similarly,
health costs of diabetes and heart also achieved, a decrease approximately $
17.1 billion within 10 years. Prices of
food products influence consumption patterns, including the sweet drinks.

Demand of SSB product would be decreasing if the price is raised such through
increasing product taxes. Rising price about 10% will result declining about 8
to 12.6% of product consumption (Friedman & Brownell, 2012; Wang et al.

2012). On the other hand, in case if producers still produce SSB products
despite with the high taxes, the fixed state benefits obtained through tax
revenues and could be allocated in the health sector. As performed by the
United States in 2008, which the Congressional Budget Office suggest that the
beverage tax 3 cents per 12-ounce drink alone could produce 50 billion USD in
10 years to help other health financing (Wang et al. 2012).

Although
the rationale of high consumption of SSB is still unknown, but the other
factors could be an explanation. Difference in food environment and marketing
strategy of beverage may affect the increasing the accessibility of SSB.

Expansion of advertising space for SSB possibly elevating the SSB consumption
(Kumar et al., 2012). For instance in Makassar, growing of retail minimarket
extremely fast. These condition encourage the decision maker to establish
revision of District Regulation number 15 year 2009 about Restriction of Modern
Retail Minimarket (Makassar Government, 2009). However, the progress is still
unclear after 3 years. The possibility of SSB consumption is also high because
of the absences of policy that restrict the opening of retail minimarket which
mostly sell SSB. Until 2013, the number of Retail Minimarket in Makassar were
151 unit.

 

CONCLUSIONS

Sugar-sweetened
beverages have a relatively high sugar content in each product, where
carbonated beverages had the largest sugar content. The government
should take comprehensive action to prevent an increase of sugar consumption
especially through sugar-sweetened beverages consumption. According to the
experts and previous studies, there are three possible ways such as 1) issuing
a policy to increase tax of sugary drinks or raising the price of SSB product; 2) reducing
the advertising of SSB in mass media mainly on television, and/or 3)
establishing a policy of SSB-free area or vending machine in public spaces. Further
research is needed to investigate the velocity of SSB affects the incidence of
non-communicable diseases. It should also the advocacy
efforts to encourage the government to establish sugar-sweetened beverage
taxation and restrictions of the sugar use in the beverage product in Indonesia.