Multiple studies have shown that people who are overweight or obese are more likely to become dangerously ill with Covid-19.
Accumulation of fat in the abdomen and around the ribs and diaphragm can reduce the ability of the chest to expand, restricting normal breathing. Obesity is also associated with adverse alterations in adipose tissue, commonly known as body fat, which can result in chronic inflammation and impaired immunity. This can also worsen Covid-19. Further, people with obesity tend to have other comorbidities, like diabetes and heart disease, which can also contribute to poorer outcomes if they are infected by the virus.
Indonesia recently marked a sombre milestone in its battle against Covid-19, with official deaths exceeding 136,000, although epidemiologists believe the real figure is likely to be much higher because of a lack of testing. The Economist recently stated that deaths could be up to five times higher than official figures, estimating excess deaths of between 280,000 to 1.1 million.
It has not helped that the prevalence of obesity among Indonesian adults has doubled during the past two decades, leading to a significant increase in the burden of noncommunicable diseases (NCDs), such as cardiovascular diseases, diabetes, and some cancers. Even more worrying, childhood obesity is also on the rise, with 18.8% of primary school-aged children overweight or obese. Obese children are at greater risk of becoming obese adults and developing NCDs earlier in life.
Given obesity is an important determinant of adverse outcomes for Covid-19, there is an urgent need to address this emerging epidemic too.
Indonesia needs a stronger top-down approach
Over the past few years, the Ministry of Health has made some efforts on this front. It has launched a national health promotion program known as the Healthy Living Community Movement (Gerakan Masyarakat Hidup Sehat, Germas), encouraging the public to adopt a healthy lifestyle involving regular physical activity and consumption of fresh fruit and vegetables. It is also funding an important early detection program at community health centres (puskesmas), as part of its Cerdik initiative. Local governments have also worked with communities to encourage individuals and families to adopt a healthy lifestyle.
Local and community-centred actions are essential and the government’s efforts in this regard should be acknowledged. But the commercial drivers of obesity are so influential that much stronger policies are needed – and some tough laws. Just relying on public awareness and education campaigns targeting individual or community behavioural and motivational change will not be enough.
The pandemic represents an opportunity for the government to tackle the problem more seriously and introduce legislation and policies to curb access to unhealthy food and beverages.
Just as the pandemic was beginning to hit, the Ministry of Finance held discussions with the national legislature (DPR) on taxing sugar-sweetened beverages (SSBs) and ultra-processed food. But there has been little progress since. Nor has there been any progress on a range of complementary regulations such as front-of-pack labelling to help consumers identify unhealthy products or regulations that restrict food advertising and marketing to children.
In fact, Indonesia’s lack of laws and regulations on food makes the country a utopia for the unhealthy commodity industry. Even in countries where there are stricter laws, a recent BMJ analysis demonstrated that the advertising and marketing budgets of the industry dwarf those of government health promotion programs.
The industry is also known to use tactics designed to signal virtue, especially through corporate social responsibility and philanthropy initiatives. These strategies aim to present companies in a positive moral light, and build support within communities, while the companies spend billions promoting their harmful products.
For example, Mondelēz International, the maker of popular products like Cadbury chocolates, Oreo, and Ritz, has partnered with schools in Indonesia through its ‘Joy Schools’ program to educate school children about nutrition and exercise. Meanwhile, Nestlé, which produces unhealthy products like KitKat bars and Milo drinks, hosted a football championship involving more than 10,000 primary school children across the country, with support from the Ministry of Youth and Sports Affairs. Similarly, Coca-Cola partnered with the Jakarta Provincial Government to fund the repair of sport facilities around the National Monument.
These tactics can distract attention from these companies’ contributions to obesity and compromise the establishment of a stronger food law and policy regime. The industry is worth US$17,090 million and has benefited from continuous market growth. The average volume of SSBs consumed per person is expected to amount to 39 litres in 2021.
Other countries have taken much stronger actions than Indonesia. The Philippines implemented an excise tax on SSBs in 2019, despite years of food industry lobbying against the proposal. The tax has since helped lower SSB consumption by an average of 8.7%. Other Southeast Asian countries have also used pricing policies to tackle obesity. Taxation of SSBs by sugar content has been in force in Thailand since 2017, Brunei has applied an excise duty on SSBs since 2017, and the Malaysian government introduced a similar measure in 2019.
Outside Southeast Asia, Latin American countries provide some of the best examples in implementing stronger laws and policies to prevent obesity. In 2012, despite ferocious resistance from the food industry, the Chilean senate approved the Law on Food Labelling and Advertising. This introduced comprehensive food regulation, including limits on what foods could be sold in schools, adoption of stark black and white front-of-pack ‘stop sign’ labels to warn consumers about the health dangers of unhealthy food, and bans on the use of cartoon characters on cereal boxes and the sale of sweets and snacks using toys and trinkets to lure young consumers.
Since the law went into effect in 2016, there has been a 25% reduction in the purchase of SSBs and a 9% decrease in the purchase of sugar-sweetened cereals. Many products have also been reformulated with lower levels of sugar and sodium.
African countries have also progressed to imposing sugar taxes to prevent obesity. Last year, Morocco reintroduced an internal consumption tax for SSBs, as did island nations the Seychelles and Mauritius. In 2017, the South African government introduced a SSB levy of 10%, which was followed by reductions in the product formulation and volume of beverage purchases.
Obesity is a serious problem, but it is also a modifiable risk factor. To tackle obesity effectively, the Indonesian government must learn from successful laws and regulations in other countries and put them much higher up their political agenda.
As far back as 1825, philosopher Jean-Anthelme Brillat-Savarin wrote that “the fate of a nation depends on the way that they eat”. Obesity not only costs individual lives, it also imposes costs in terms of excess health care expenditures, lost productivity, and foregone economic growth.
The Covid-19 pandemic should be a wake-up call for Indonesian policymakers to address the commercially related root causes of obesity.