HST Blog

​by Judith King (Health Systems Strengthening Copy and Content Editor / PhD candidate: Public Health)

In South Africa ‒ which has the highest prevalence of obesity in Africa ‒ weight-related non-communicable diseases (NCDs) have eclipsed tuberculosis (TB) and HIV as leading causes of morbidity and mortality, and conditions such as diabetes, stroke and heart disease account for three of the top four causes of death nationally.¹ Current rates of obesity in South Africa are 11% among men (with another 20.3% being overweight), and 41% among women (with another 26.6% being overweight).² This is a social and economic risk for the country.

The causal link between sugar consumption and diet-related NCDs

Consumption of the high sugar content in sugar-sweetened beverages (SSBs) ‒ while not the only cause of excess body weight and obesity ‒ is strongly linked to weight gain among adults and children in South Africa.^3,4,5 In a large prospective study conducted in 2019, such consumption was significantly associated with the risk of overall cancer and breast cancer.⁶

Liquid sugar is especially harmful, with data showing that just one sugary drink per day raises an adult's likelihood of being overweight by 27%, and that of a child's by 55%, while increasing anyone's risk of developing type 2 diabetes by 25%.^7,8 The added sugars in these drinks are rapidly absorbed by the body, and pose a significant health risk by raising blood sugar, heightening insulin production, and affecting cholesterol levels and metabolism, which can cause hypertension and inflammation, with a high potential for NCDs such as diabetes, cardiovascular disease, tooth decay, gout, liver disease, and certain cancers.

Describing sugar as a "chronic toxin", Myers, et al.⁹ provide a comprehensive view of the link between sugar consumption and diet-related NCDs, highlighting how this creates a 'poverty spiral' in which "poor health and disability lead to a labour force with diminished capacity" and in turn, slower economic growth.

Yet, as noted by the World Health Organization's Civil Society Working Group on NCDs at the 73rd World Health Assembly in 2020:

"… even in the midst of a public health emergency of international concern, companies that produce harmful products, [including] sugar-sweetened beverages, continue to spread misinformation and deny the link between the harmful effects of their products … to protect their markets."¹⁰

Changing systems for healthier lives

'Changing systems – healthier lives', as the theme for this year's World Obesity Day, signals that to curb the prevailing NCD epidemic, our focus should be trained on where 'behaviour change' begins and ends, and who and what has to change.

This stems from the idea that while individual consumers are exhorted by sugar industry actors to reduce their weight and risk of cardio-metabolic diseases by changing their lifestyle choices, it is also these corporate citizens whose profit-driven stance and aggressive marketing of unhealthy products must change. Moreover, the legal and economic structures enabling corporate profit at the expense of public health should be transformed.

The rationale for the Health Promotion Levy

NCD prevention and control cannot rely solely on public health information and education campaigns, nor on biomedical interventions alone. Obesity is a complex disease brought on and sustained by many factors which are beyond the individual's control.¹¹ South Africa was the first country on the continent to recognise this by introducing the Health Promotion Levy (HPL) in 2018 ‒ an anti-obesity measure designed to reduce consumption of sugar-sweetened beverages (SSBs) by instituting a tax of approximately two cents per gram of sugar per litre, payable by the manufacturer.

Similar to the model used for regulating tobacco and alcohol consumption, sugar taxation is endorsed by the World Health Organization, and has been shown in many countries to be successful in facilitating healthier diets and saving on NCD-related healthcare costs, while generating government revenue.¹² In 2020 – apart from the associated burden on our health system – the cost of these NCDs to the South African economy via health expenditure was R33 billion.¹³

Industry opposition to the HPL

However, prior to its promulgation, sugar industry actors and SSB manufacturers formed an alliance to strongly oppose the HPL, and deployed various tactics to "delay, dilute and delegitimise" this policy.¹⁴ These strategies included questioning the integrity of scientific evidence supporting the tax; disseminating their own funded studies with findings that refute the link between SSB consumption and obesity; and lobbying to influence government policy-makers with claims of the HPL leading to massive job losses and the decimation of South Africa's cane-growing and sugar milling industry.¹⁵ These corporate responses succeeded in weakening the rate of the Levy from the proposed 20% to 10%. 

Data from Statistics South Africa's Quarterly Labour Force Survey do not corroborate the industry's claims that the HPL had resulted in the loss of 16 000 jobs¹⁶, and there is no independently researched and peer-reviewed evidence that the tax has measurably induced the sugar industry's fall in revenue. There are no verifiable data showing that the HPL has generated job losses in the production, distribution and sale of SSBs, nor triggered a decline in SSB producers' profits.

In fact, reliable empirical research findings indicate that the sugar industry's losses and suppressed market demand can be attributed to several operational factors within and around it, such as climate change and COVID-19 affecting production, corruption within some of its companies, cheap sugar imports, and ever-escalating input costs.¹⁷

In 2021, a review of research found that the HPL had led members of urban households – particularly in lower socio-economic settings – to buy almost 30% fewer sugary beverages, thereby almost halving the amount of sugar they consumed from these drinks.¹⁸ The announcement of the HPL also incentivised SSB manufacturers to reformulate their products for lower sugar content (albeit so that they could sustain their profit margins rather than in support of public health goals).

Yet despite these gains, the industry's anti-HPL campaign continues unabated, perpetuating the falsehood that there are no credible studies linking the tax to positive public health outcomes.

The outcome of industry interference in evidence-based health policy

As a result, an increase in the tax announced in February 2022 was postponed to 1 April 2023, and then deferred again in the February 2023 Budget Speech for a further two fiscal years.

In real terms, this signifies a year-on-year reduction in the HPL, which enables greater affordability, and hence greater consumption, of SSBs. This erosion of the Levy's power as a mechanism to address the NCD burden plays directly into the hands of companies that seek only to preserve and increase their profit margins.

On 14 February 2025, the CEO of the South African Sugar Association (SASA) called for "the extension of the two-year sugar tax moratorium to 2030 … in keeping with the lifespan of the Sugarcane Value Chain Master Plan 2030" to enable the industry's diversification and restructuring.¹⁹

Even more concerning is a media report suggesting that – on the grounds of SASA's claim that the HPL has "cost the industry R1.2 billion and threatened the loss of 300 000 jobs" – the 2025 Budget will propose cancelling an increase in the HPL that was due to come into effect on 1 April this year, "to allow the industry time to restructure its response to regional competition".²⁰

How increasing the HPL will support physical and economic health  

As our country faces the urgency of deploying domestic financing options to address recent cuts in international aid for health, an increase in the HPL would be an obvious and easy contribution. In the five years since its inception, the HPL has raised more than R10 billion in revenue.^2,21

Here are some key recommendations for a whole-of-society, evidence-based response and the changes in governance of our food system needed to counteract these corporate assaults on public health promotion:

Ø   To adjust for inflation and ensure that South Africa's sugar taxation fulfils its intended health-promotion aim, National Treasury should increase the percentage of the HPL to 20% per litre, and lower its 4g/100ml sugar content threshold to 2g/100ml without delay.

Ø   Income derived from the HPL should be ring-fenced for financing of robust, properly costed and budgeted NCD responses and chronic disease prevention, rather than having it flow into the National Revenue Fund for ad hoc allocation. From the platform of multisectoral action, prioritised HPL funding could be specifically earmarked for research programmes aimed at improving South Africa's diabetes response, for example.

Ø   Widespread awareness of nutrition and understanding of the forces that shape people's health should be catalysed through public health measures such as clear, accessible front-of-package labelling.

The influence of corporate power on the nation's health should be disarmed by making it legally binding for companies to comply with evidence-based policies to counter the commercial determinants of health. Through regulation, legal reform and advocacy, industry actors should be accountable for recalibrating their business models and corporate governance in support of a sustainably healthy populace and planet.

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The diet-related NCD burden affects all of us, and health as a human right means that we deserve protection from harmful commercial practices.

To change systems for healthier lives:

Ø   Related reading:

Goldstein S, Mahomedy S.  Commercial determinants of health and cancer prevention in South Africa. In: Moeti T, Padarath A, Parkes J, Singh S, Ruff P, editors. South African Health Review 2023 – Strengthening cancer services. Durban: Health Systems Trust; 2024.

URL: https://sahr.hst.org.za/article/120643-commercial-determinants-of-health-and-cancer-prevention-in-south-africa

Ø   The Healthy Living Alliance (HEALA) is running a petition to support a stronger HPL at:

https://awethu.amandla.mobi/petitions/call-on-finance-minister-and-deputies-to-increase-and-expand-sugary-drinks-tax

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References

1.     Chandiwana N, Venter WDF. Obesity is South Africa's new HIV epidemic. S Afr Med J, 2024;114, e1927. URL: https://doi.org/10.7196/SAMJ.2024.v114i4.1927

2.      Hofman KJ, Goldstein S. Diabetes is South Africa's second biggest killer disease: hiking the sugar tax would help. The Conversation, 20 October 2023.

URL: https://theconversation.com/diabetes-is-south-africas-second-biggest-killer-disease-hiking-the-sugar-tax-would-help-216456

3.      Okop KJ, Lambert EV, Alaba O, Levitt NS, Luke A, Dugas L, et al. Sugar-sweetened beverage intake and relative weight gain among South African adults living in resource-poor communities: longitudinal data from the STOP-SA study. Intl J Obes, 2019; 43: 603–614. URL: https://doi.org/10.1038/s41366-018-0216-9  

4.      Tugendhaft A, Manyema A, Veerman LJ, Chola L, Labadarios D, Hofman KJ. Cost of inaction on sugar-sweetened beverage consumption: Implications for obesity in South Africa. Public Health Nutr, 2015; 19:13, 2296‒2304.

         DOI: 10.1017/S1368980015003006

5.      Vartanian LR, Schwartz MB, Brownell KD. Effects of soft drink consumption on nutrition and health: a systematic review and meta-analysis. Am J Public Health. 2007; 97:4, 667‒675. DOI: 10.2105/AJPH.2005.083782

6.      Chazelas E, Srour B, Desmetz E, Kesse-Guyot E, Julia C, Deschamps V, et al.  Sugary drink consumption and risk of cancer: results from NutriNet-Santé prospective cohort. BMJ, 2019; 366.  DOI: https://doi.org/10.1136/bmj.l2408

7.      University of the Witwatersrand. Facts about SSBs and obesity in South Africa.

         URL: https://www.wits.ac.za/news/latest-news/research-news/2016/2016-04/ssb-tax-home/sugar-facts/  

8.      Morenga LT, Mallard S, Mann J. Dietary sugars and body weight: Systematic review and meta-analyses of randomised controlled trials and cohort studies. BMJ, 2013; 346:e7492. DOI: 10.1136/bmj.e7492

9.      Myers A, Fig D, Tugendhaft A, Mandle K, Myers J, Hofman KJ. Sugar and health in South Africa: Potential challenges to leveraging policy change. Glob Public Health, 2017; 12:1, 98‒115. DOI: http://dx.doi.org/10.1080/17441692.2015.1071419

10.    World Health Organization Civil Society Working Group on NCDs. Statement on Item 3. 73rd World Health Assembly (WHA73) COVID-19 Response: Reducing risk of COVID-19, cancer and other NCDs, 18 May 2020.

         URL: https://ncdalliance.org/resources/73rd-who-world-health-assembly-statement-on-item-3-covid-19-response-reducing-risk-of-covid-19-cancer-other-ncds

11.    Ryan D, Candeias V, Fruergaard Jorgensen L. We need to change the narrative around obesity – here's why. World Economic Forum, 17 May 2018.

URL: https://www.weforum.org/stories/2018/05/we-need-to-change-the-narrative-around-obesity-heres-why/

12.    Lee, K, Freudenberg N. Public Health Roles in Addressing Commercial Determinants of Health. Annual Review of Public Health, 2022; 43, 375‒395.

URL: https://doi.org/10.1146/annurev-publhealth-052220-020447

13.    Boachie MK, Thsehla E, Immurana M, Kohli-Lynch C, Hofman KJ. Estimating the healthcare cost of overweight and obesity in South Africa. Global Health Action, 2022; 15:1. URL: https://doi.org/10.1080/16549716.2022.2045092

14.    López González L. 'Delay, dilute, delegitimise': How the food industry shapes what you eat — and what you weigh. Daily Maverick, 15 October 2021.

URL: https://www.dailymaverick.co.za/article/2021-10-15-delay-dilute-delegitimise-how-the-food-industry-shapes-what-you-eat-and-what-you-weigh/

15.    Du M, Tugendhaft A, Erzse A, Hofman KJ.  Sugar-sweetened beverage taxes:  Industry response and tactics. Yale J Biol Med, 2018; 91:2, 185‒190.

16.    Dare C, Boachie MK, Goldstein S, Thsehla E. The association between the Health Promotion Levy and employment in South Africa: an interrupted time series analysis. BMC Nutr, 2025; 11:1, 28. DOI: 10.1186/s40795-025-01012-6

17.    Mbalati N. Scrapping of the sugar tax will not save the sugar industry from its own woes. Business Report, 17 October 2024.

URL: https://www.iol.co.za/business-report/economy/scrapping-of-the-sugar-tax-will-not-save-the-sugar-industry-from-its-own-woes-3c805d9d-e24b-478b-adbd-62e71afe38fc

18.    Hofman KJ, Stacey N, Swart EC, Popkin BM, Ng, SW. South Africa's Health Promotion Levy: Excise tax findings and equity potential. Obesity Reviews, 2021; 22;9, e13301. URL: https://doi.org/10.1111/obr.13301

19.       Pillay Y. Sugar industry unveils diversification plan amid crippling sugar tax crisis.

Business Report, 17 February 2025.

URL: https://www.iol.co.za/business-report/economy/sa-sugar-industry-unveils-bold-diversification-plans-amid-crippling-sugar-tax-crisis-8708eecf-b190-4390-880c-931c76f5f92c

20.       Magubane K. Enoch Godongwana's postponed budget cancels sugar tax hikes. TimesLIVE, 20 February 2025.

URL: https://www.businesslive.co.za/bd/national/2025-02-20-enoch-godongwanas-postponed-budget-cancels-sugar-tax-hikes/

21.       National Treasury. National Assembly, Parliament of the Republic of South Africa. Question for written reply: Question Number 1300 [NW1493E] and Reply.

URL: https://www.treasury.gov.za/publications/other/MinAnsw/2021/PQ%201300%20-%20Wilson%20-%20NW1493E.pdf

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