Kompas has reported its series of investigations showing that the current national consumption of sugar is so excessive that it is considered dangerous. As a result, the number of diabetics has increased, and the cost of treatment has also increased. Data from BPJS Kesehatan, wrote Kompas, shows that over the last five years (2018-2022), the total cost of claims for patients participating in BPJS Kesehatan who are diagnosed with diabetes has continued to increase. In 2018, diabetes patients needed a total cost of IDR 4.9 trillion from BPJS funding, and in 2022 this figure will increase to IDR 6.4 trillion.

Wihout realizing it, excessive sugar consumption, which has become a long-standing habit, poses a hidden danger. Day by day, our society consumes increasingly higher amounts of sugar while simultaneously engaging in less physical activity. This excessive calorie intake, particularly from sugar, combined with a lack of physical exercise, contributes to obesity and various inherited diseases like diabetes, chronic kidney disease, and heart disease.

Data from OurWorld highlights the persistent increase in obesity prevalence among Indonesians, starting from only 0.4 percent in 1975 and escalating to 6.9 percent in 2016. The continuous annual rise in calorie intake has the potential to further elevate the prevalence of obesity. The results of a 2021 survey conducted by BPS reveal that only about 27 percent of Indonesians aged five and above engage in regular exercise. This figure represents a significant drop compared to 2018, which stood at 35.7 percent. Consequently, the number of Indonesians participating in physical activity is declining.

The decreasing age of individuals with diabetes is a concerning trend. Previously, diabetes was predominantly seen as a disease affecting the elderly. However, it now affects a significant number of young people, including those under the age of 40. The fact that diabetics are becoming younger is indeed worrisome. Data from the Basic Health Research reveals a continuous increase in the proportion of diabetics under 40, rising from 5.7% in 2007 to 6.9% in 2013, and further to 10.9% in 2018. Globally, Indonesia is among the top five countries with the highest diabetic population, ranking after China (140 million), India (74 million), Pakistan (32 million), and the United States (32 million), with Indonesia having 19.5 million diabetics.

According to the World Health Organization (WHO), free sugars encompass monosaccharides, disaccharides, and natural sugars found in honey, syrup, and fruit juice. The WHO recommends limiting free sugar intake to a maximum of 10% of total energy intake, and for improved health, suggests further reducing sugar consumption to a maximum of 5% of total energy intake.

Why do we like to consume sugar, often in excessive amounts? It is because foods and beverages containing sugar have a pleasurable taste, appealing to individuals of all ages. We tend to add sugar to our tea and coffee. The Javanese, particularly those from Solo, have a morning tradition of drinking "ginasthel" tea (sweet, hot, and thick tea). Wedangan angkringan without ginasthel tea on the menu would find it difficult to attract customers. Similarly, in Jogja, both wet and dry versions of gudeg, a local tradisional dish, are generously sweetened with coconut sugar, providing a delightful sweetness. Moreover, other local dishes such as rendang, rawon, tongseng, curry, lodeh, semur, and sambal, always incorporate sugar as a seasoning.

Various processed snacks like breads and cakes are also heavily laden with sugar. Snack products from the food industry not only contain sugar but are often loaded with salt and excessive flavor enhancers, making them highly popular among children. Packaged drinks, almost universally, contain substantial amounts of sugar as well. Even our staple food, rice, contains a considerable amount of sugar. Consequently, nearly everything we consume daily, whether homemade or commercially produced, tends to contain excessive levels of sugar. The pleasant sweetness is alluring, despite its potential detriments to our health.

Sugar consumption control

The government's efforts to address the rising obesity rates can be considered inadequate. In 2017, the Ministry of Health introduced the Guidelines for the Movement to Eradicate Obesity (Gerakan Berantas Obesitas/GENTAS), which aimed to raise awareness about proper food composition and physical activity recommendations for the entire population. The government also mandated morning exercise for all healthy government employees in government facilities every Friday or Saturday. While this is a positive step, it falls short of what is truly needed. What is essential is a policy to regulate sugar consumption.

For instance, the British government implemented regulations to control sugar and carbohydrate levels in processed or fast food. Last October 2022, the British government enforced a ban on the promotion and mass marketing of food products with high sugar, salt, and fat content. Unfortunately, this ban was lifted because foods with controlled levels of these ingredients proved to be much more expensive, costing up to three times as much as regular uncontrolled products.

Due to the delightful taste of sweetness, systematic efforts are required to mitigate the hazards of excessive sugar consumption. There needs to be a comprehensive strategy to reduce sugar intake (including granulated sugar, rock sugar, coconut sugar, etc.) in various dishes and beverages, both homemade and commercially produced. It is undoubtedly challenging to overturn centuries of culinary culture that revolves around sugar. If Jogja's signature dish, gudeg, suddenly loses its sweetness, customers may leave it. Therefore, intense education about the dangers of excessive sugar consumption is necessary. The government can enact regulations through the POM Agency to limit sugar content in the food and beverage industry, similar to regulations imposed on other substances. Additionally, the government has implemented fortification rules (addition of certain substances). For example, in the palm cooking oil industry, the government has mandated vitamin A fortification to prevent deficiencies in children.

Taking inspiration from the aforementioned example, the government can promptly establish regulations that limit sugar levels in the food and beverage industry. BPOM permits, in the form of MD or PIRT, should only be issued if the sugar content does not exceed the specified maximum limit. This approach enables preventive strategies to be implemented through regulations targeting the food and beverage industry.

Furthermore, there is a need to explore alternatives to high-sugar staple foods. Traditionally, school textbooks mentioned that the staple food of the Madurese people was corn, while sago and sweet potatoes were consumed by Papuans. However, nowadays, rice has become the dominant staple food across the country, despite its high sugar content. This shift in dietary diversity has occurred in various regions. In reality, sago and sweet potatoes are healthier options due to their lower sugar content compared to rice. Moreover, sago grows abundantly in the wild in Papua, requiring minimal effort to harvest, while cultivating rice involves higher costs and more complex cultivation processes. The healthier sago has been displaced by sugar-laden rice.

Stevia: A substitute for cane sugar

Furthermore, there is a viable alternative worth exploring: replacing cane sugar with stevia sugar. Stevia, an herbaceous plant similar to basil, has leaves that yield a sweetness level double that of sugarcane, making it suitable for sweetener production. The advantage of stevia sugar is its zero-calorie and gluten-free nature, making it a healthy and safe option for diabetics. Although stevia cultivation for sugar production is currently conducted on a small scale, several industries process it into stevia sugar, which is readily available in the general market and online stores.

Due to the limited scale of production, the cost of cultivating and processing stevia into sugar remains high, resulting in a higher price compared to cane sugar. If the government is genuinely committed to encouraging reduced consumption of unhealthy cane sugar, the development of stevia cultivation is a viable option. As cultivation expands and the processing industry becomes more efficient, the price of stevia sugar will decrease. The government can provide incentives for both cultivation and the processing industry. For example, the stevia sugar processing industry could receive tax incentives, reduced value-added tax (VAT), or subsidies on the selling price. This approach would make stevia sugar more affordable, increase consumption, and promote healthier choices among the population.

A similar subsidy pattern has been successfully implemented for other products. For instance, refrigerators previously used chlorofluorocarbon (CFC) gases, which can deplete the ozone layer. The refrigerator industry later adopted hydrofluorocarbons (HFCs) as a safe alternative that helps preserve the ozone layer. The international community agreed to phase out the use of CFCs and transition to HFCs. However, due to the higher costs involved, the government provided price subsidies for refrigerators using HFCs, enabling people to afford ozone-safe refrigerators. This approach could be applied if the government aims to reduce cane sugar consumption and shift towards stevia sugar.

Special efforts are required to alter the dietary habits of Indonesians who have a preference for high-sugar rice. Reducing the portion of rice and incorporating other low-sugar food options can be a healthier alternative. Consumption of fiber-rich brown or black rice, as well as sago, tubers, and similar foods, can be considered. The challenge lies in developing technology that ensures these non-rice staple foods taste as appealing as rice, can be produced on a large scale, and promoted continuously in a long-term to raise awareness of the people.

Resistance from food and beverage industries

Currently, we are surrounded by a multitude of processed food and beverage products that contain excessive ingredients. Sugar, salt, MSG, and preservatives are all used in excess. Snack products targeted at children, for instance, are dominated by intensely sweet, salty, and savory flavors. Through year-round advertising campaigns, our children are introduced to the risks of diabetes and high blood pressure from an early age, which are associated with the food and beverage industry.

The government has actually responded to this issue. In the past, the Ministry of Finance planned to implement an excise tax on sweetened beverages in 2016. The initial proposal, with excise duties ranging from Rp. 1,000 to Rp. 5,000, had the potential to generate additional excise revenue of Rp. 79 billion to Rp. 3.95 trillion.

The implementation of excise duties on sweetened drinks has been carried out in several countries. Hungary, for example, successfully reduced the consumption of sweetened beverages by 26-32% through the Public Health Product Tax (PHPT) policy. In Mexico, the implementation of an excise tax led to a 17% reduction in the consumption of sweetened drinks, particularly among low-income consumers. In Australia, the introduction of an excise tax on sweetened beverages resulted in a decrease of up to 124 grams/day for men and 67 grams/day for women. At first glance, the Ministry of Finance's plan to implement an excise tax on sweetened beverages appears promising and aligns with the objective of reducing excessive sugar consumption. The Minister of Finance stated that this policy is an effort to control diabetes and increase state revenue.

However, increasing excise duties on sweetened food and beverage products will inevitably lead to higher prices. This anticipated price increase of 30-40% has triggered a reaction from the Indonesian Food and Beverage Entrepreneurs Association (Gapmmi). Adhi S Lukman, the chairman of Gapmmi, argued that the proposed increase in excise duties would not be effective and would further burden the industry, potentially reducing state sales and revenue. While excise revenue might increase slightly, it is highly likely that it would be offset by a decrease in corporate income tax (Pph), individual income tax (Pph article 21), and value-added tax. As a result of this ongoing conflict, the Ministry of Finance is currently planning to implement excise duties on sweetened beverage products starting in 2024.

We should reflect on the strategy of gradually increasing excise taxes on cigarettes, which has been implemented in stages. Research indicates that raising cigarette excise taxes can reduce the number of new smokers. Consequently, the government has increased cigarette excise taxes periodically, rather than all at once. Additionally, with the prohibition on retail cigarette sales, it is hoped that novice smokers, such as teenagers and schoolchildren, will be deterred from purchasing increasingly expensive individual cigarettes, as they have  to buy an entire pack.

However, various resistant "innovations" have emerged. One example is the rapid growth of tobacco kiosks that offer loose tobacco, rolling papers, filter tips, and even manual cigarette rolling machines. Making their own cigarettes from retail tobacco has now become a lifestyle for young smokers and the elderly alike. Furthermore, there has been a significant increase in the number of cigarette manufacturers, including small and medium-sized enterprises that offer hundreds of affordable brands, both legal and illegal. These products are highly marketable and are preferred by consumers who are reluctant to purchase higher-priced, well-known cigarette brands.

The effectiveness of the strategy to reduce the number of new smokers by increasing cigarette excise taxes should be carefully evaluated. Similarly, any plans to increase excise duties on sweetened food and drinks should be thoroughly researched and studied to ensure effectiveness while minimizing resistance. While economic growth is undoubtedly important, safeguarding public health is equally crucial. Ideally, these two objectives can be pursued hand in hand.

Djoko Santoso
Professor at Faculty of Medicine, Universitas Airlangga
Chairman of Health Department, Indonesian Council of Ulama, East Java

Translated from:
Gula dan Ancaman Kesehatan Nasional
Djoko Santoso
Kompas, 19 May 2023 
https://www.kompas.id/baca/opini/2023/05/18/gula-dan-ancaman-kesehatan-nasional