Addiction is a chronic illness characterized by compulsive engagement in a particular behavior or set of behaviors, despite adverse consequences, whether these are potential or actual experienced.  Thus persons addicted to nicotine continue to use cigarettes in spite of the long list of potential medical consequences, while the money used to buy the cigarettes literally goes up in smoke. Persons addicted to alcohol typically only give up the habit after they hit ‘rock bottom’, and generally need to be admitted to detoxification programs and enroll in long-term behavior modification programs like Alcoholics Anonymous, AA. Persons addicted to cocaine are not deterred by the cost of supporting their addictions, and ‘beg, borrow or steal’ money to support the habit.

 

Against this background, do we have a ‘sweetened beverage addiction’ here in Barbados, and, if so, can this type of addiction be successfully treated merely by raising the taxes on the drinks? Is a sweetened beverage addiction different from other addictions?

 

People’s behavior generally does not follow ‘logical’ principles. Currently, when faced with a choice between pure water and sweetened beverage, the choice seems overwhelmingly in favor of the sweetened beverage, current consumption patterns seem to suggest. Supermarkets devote entire rows to sweetened beverages, such is their popularity . The ‘Bottle Return’ section outside supermarkets seem to ignore their own signs limiting each customer to 120 bottles, and many people’s weekly supermarket routine include returning last week’s empty bottles first.

 

The soft drink manufacturers clearly state that, whenever they attempt to introduce drinks with less sugar, they are ignored in favor of the drinks with more sugar.

 

At least two local studies in Barbados, the Adolescent Health and Fitness Study (AHFIT, 1997), and the Barbados arm of the Global school-based Student Health Survey (GSHS, 2011), have documented high consumption rates of sweetened beverages in our young people. This is normally the time of life when addictions start. In AHFIT, a study of 468 students attending one of four secondary schools, students consumed an average of over 3 soft-drinks per day during the normal school week. In GSHS, which questioned 1629 Barbadian students from forms 3 and 4, seventy three percent consumed carbonated soft drinks one or more times daily in the last 30 days.

 

Persons addicted to sweetened beverages are not deterred that they may get fat (if he/she is not there already), and may develop one or more of a large variety of weight-related illnesses (if he/she has not been affected already). Because many of these illnesses are ‘silent’, the consequences of the sweetened beverage consumption are often under-estimated. Individual continue to consume sweetened beverages oblivious of the possible health consequences.  This fits the definition of an addiction.

 

One issue here is that few persons, in or out of the medical profession, takes overweight and obesity seriously. In 1980 Dr. Frank Ramsay, then Director of the National Nutrition Unit in Barbados, noted that “measures for the prevention of obesity must be implemented urgently”.  Nothing happened. It was only in late 2012 that the American Medical Association (AMA) formally designated obesity as a disease, and put in place medical and insurance procedures to deal with obesity and its complications (co-morbidities). There are even University courses that deal specifically with Obesity, Obesity 101. We (in the Caribbean) have no similar procedures in place. In the 36 years since Dr. Ramsay’s urgent plea was made Barbados' obesity figures continue to spiral upwards,and obesity related co-morbidities continue to fill our hospitals and our cemeteries, and if we have a national anti-obesity program then it is one of the Ministry of Health’s better kept secrets. Against this background and without the link between obesity and disease being emphasized, would the general population perceive that overweight/obesity should be taken seriously?

 

There seems to be little doubt that sweetened beverages contribute to the consumption of excessive calories that Barbadians do, leading to the ‘large’ obesity figures ( e.g. in the 2015 Health of the Nation study which targeted individuals 25 years and over, 75% of the women and 57% of the men were overweight or obese).  And there is overwhelming evidence that the disease profile in Barbados is dominated by the weight-related illnesses.

 

Not everyone who drinks a sweetened beverage will develop an addiction. The path to drug addiction begins with the voluntary act of taking a drug. Over time, a person's ability to choose or decline the drug becomes compromised.  Young people, with less developed minds, are more vulnerable to becoming addicted than older individuals, and there is some evidence that the duration of exposure, e.g. starting at a very young age, increases the likelihood of becoming addicted. Seeking and taking the drug becomes compulsive. This is mostly due to the effects of long-term drug exposure on brain function. Addiction affects parts of the brain involved in reward and motivation, learning and memory, and control over behavior. Thus addiction is a disease that affects both the brain and behavior.

 

Can sweetened drinks addiction be treated?

 

Because addiction is a chronic disease, people can’t simply stop using sweetened beverages for a few days and be cured: this does not happen in any other type of addiction.  Most patients need long-term or repeated care to stop using completely and recover their lives. Perhaps like our current status in dealing with other chronic illnesses, we seem to lack the will and the resources to develop and implement sustainable programs that are likely to have long term success. Attempting to increase the price of the ‘drug’ to reduce consumption has not worked for other addictions: it seems likely that additional measures would be needed if the sweetened beverage tax would eventually lead to reduced consumption of sweetened beverages.

 

Addiction treatment must help the person do the following:

  • stop using drugs
  • maintain a drug-free state
  • prevent relapses

 

This can be approached in public health, as it is unlikely that the thousands of sweetened beverage consumers could be hospitalized for detoxification. A process in which all manufacturers of sweetened beverages are simultaneously  ‘encouraged’ (or legally mandated) to progressively reduce the quantity of sugar in sweetened beverages by 10% per year over a five year period, will gradually reduce the availability of sugar to the general population, including our young people, has been suggested in the U.K. This gradually reduces the availability of the ‘drug’, reducing the available calories that contribute to obesity, while gradually resetting the brain’s reward centre. And over time, there would be reduced availability of the ‘drug’.

 

Since manufacturers would be required to add less sugar to their beverages, their input costs would go down; this certainly helps in maintaining (or even improving) their ‘bottom line’. This is the kind of co-operation that manufacturers like to participate in. {Simply introducing a tax on a particular product has the possible effect of reducing the manufacturer’s bottom line].

 

After years of exposure to these ‘hyper-sweetened’ drinks, many Barbadians are likely to be addicted.  The approach suggested by some  to treating the sweetened beverage situation in Barbados by merely increasing the taxes seems not to take into account the possibility that significant numbers of Barbadians may be addicted to sweetened beverages. Raising the price of the ‘drug’ as a means of controlling addictive behavior has not worked for cigarettes, alcohol, marijuana, cocaine: indeed, in many cases individuals beg, borrow or steal’ to support their addictive behaviors: 'money is no problem'.

 

Taking the taxes from sweetened beverages and using them to subsidize healthy foods thereby lowering the cost of healthy foods, has been suggested as a possible complimentary option. However, in a land where available evidence suggests that locals already consume too many calories, and the hot climate (and global warming) mandates that individuals consume lots of liquids, cultivating a taste for lower calorie beverages is more likely to have long term success.

 

All this is to say that merely increasing the taxes is not likely to stop the epidemic of sweetened beverages. The Minister of Finance noted, one year after he introduced the 10% sweetened beverage tax in 2015, that consumption levels of the beverages had not changed.  He then introduced, on top of the 10% tax, a 2% National Social Responsibility Levy. Others have suggested that the tax was too low in the first place, and calls for taxes ranging from 20-50% on the sweetened beverages have been suggested instead.

 

As the Director of our National Nutrition Unit noted in 1980, we need to do something ‘urgently’ about obesity. No anti-obesity measures were introduced; in the interim the manufacturers saturated the market with sweetened beverages. A few local studies have highlighted the heavy consumption of sweetened beverages by our population, both the youth and adults, and suggest that these drinks are important contributors to our obesity epidemic. There is no evidence that we currently have any urgent or comprehensive response to the sweetened beverage epidemic, and the number of individuals who become addicted to these drinks continues to rise.