Sugar Is the New Tobacco, so Let's Treat It That Way

Aseem Malhotra, MBChB, MRCP - October 31, 2016

I was recently asked to speak at the UK parliamentary "Sugar Summit." This event was convened by Rend Platings, a mother so disturbed by England's chief medical officer's revelation that, as a result of obesity, today's generation of parents may be the first to outlive their children, that she launched a campaign, Sugarwise, to help consumers identify foods with added sugar.^[1]

Keith Vaz, chairman of the All-Party Parliamentary Group for Diabetes, chaired the event, whose audience was made up of a number of representatives from such high-profile UK retailers as Tesco, Caffè Nero, and the Jamie Oliver Group, as well as such influential stakeholders as the UK Department of Health, Public Health England, the British Soft Drinks Association, and the Food and Drink Federation.^[2]

I began by welcoming the UK government announcement of an introduction of a 20% tax on sugar-sweetened beverages in 2017. I similarly welcome the recent statement calls by the World Health Organization (WHO) to tax sugary drinks by at least 20% in order to curb the global epidemics of obesity and type 2 diabetes. We mustn't forget that the substantial decline in tobacco consumption in the past three decades, which was the single most important factor driving a decrease in cardiovascular mortality during that period, only happened after legislative measures that targeted the affordability, availability, and acceptability of smoking.^[3]

Health Effects

Oxford researchers have estimated that a 15% reduction in sugar consumption through such a tax would prevent 180,000 people in the UK from becoming obese within a year and a larger number from becoming overweight.^[4] But the scientific evidence reveals that the positive health benefits for the whole population of such a tax goes beyond a mere reduction in calories:

• An econometric analysis of 175 countries (considered the highest quality of study with the exception of randomized controlled trials) revealed that for every additional 150 sugar calories available for consumption, there was an 11-fold increase in the prevalence of type 2 diabetes in the population. This is compared with 150 calories from another source such as fat or protein and independent of body mass index (BMI) and physical activity levels.^[5]
• The prevalence of type 2 diabetes in the US population between 1988 and 2012 increased by 25% in both obese and normal-weight populations,^[6] which goes to show that type 2 diabetes is not a condition related purely to obesity.
• A high-quality prospective cohort study revealed a trebling in cardiovascular mortality among US adults who consumed more than 25% of calories from added sugar versus those who consumed less than 10%, with consistent findings across physical activity levels and BMI.^[7]
• The positive health effects of reducing sugar intake appear to be quite rapid. In a study of 43 Latino and African American children with metabolic syndrome, keeping total calories and calories from carbohydrate identical, a reduction from a mean of 28% of calories from added sugar to 10% significantly reduced triglycerides, LDL cholesterol, blood pressure, and fasting insulin within just 10 days.^[8]

 How Much Sugar Is Safe?

So, how much sugar do we need? For the purpose of health, the optimum consumption is zero. Added sugar has no biological requirement and is, therefore, not by any definition a "nutrient." It is the fructose component (sucrose is 50% glucose and 50% fructose) that fulfils four criteria that justify its regulation: toxicity, unavoidability, the potential for abuse, and its negative impact on society.^[9]

How much sugar is safe? The consumption of just small amounts of free sugar, which includes all added sugar and sugar present in fruit juice, syrups and honey, on a daily basis, has a deleterious impact on the most common noncommunicable disease globally: tooth decay. Treatment of dental disease is responsible for 5%-10% of health expenditures in industrialized countries, and in the UK, tooth decay is the number-one cause of chronic pain and hospital admission in young children.^[10,11]

As pointed out by researchers from the London School of Hygiene & Tropical Medicine, there is a powerful argument that the WHO should recommend a maximum limit of sugar consumption to make up no more than 3% of daily calories (about three teaspoons).^[12] The average UK and US citizen, however, consumes at least four to seven times that amount.^[13,14] This is perhaps not surprising when one acknowledges that it has been almost impossible for the consumer to avoid sugar, as it is so prevalent in the food environment and much of it is hidden. In the United States, almost half of all sugar consumption comes from foods one wouldn't normally associate as having added sugar, such as ketchup, salad dressings, and bread. A third of sugar consumption comes from sugary drinks, and a sixth from foods that people normally perceive as junk, such as chocolates, cookies, and ice cream.^[14]

In the United States, there isn't any reference dietary intake for sugar on food labels. In Europe, the labelling exists but doesn't differentiate between children and adults. One can of regular cola contains nine teaspoons of added sugar, which is triple the 2009 upper limit intake suggested by the US Department of Agriculture for an 8-year-old child. The UK Guideline Daily Amount label describes these nine teaspoons of sugar as 39% of the guideline daily amount. On the basis of this false reassurance, it would be understandable for parents to believe that it is safe for their child to drink two and a half cans per day.^[15]

The food industry often argues that the public should have a "personal responsibility" when choosing what foods to eat, which deflects blame from their own culpability in the obesity epidemic to the consumer. The truth is that the public lacks knowledge because of confusing food labels, and the public lacks choice because sugar is added to approximately 80% of processed foods.

Big Tobacco, Big Sugar

The fact that it took 50 years before the first links between smoking and lung cancer were published in the British Medical Journal and before effective regulation was introduced is testament to how Big Tobacco was able to defend its practices. Key to the strategy was denial, planting doubt, confusing the public, buying the loyalty of scientists, and giving ammunition to political allies.^[16]

The similarities between Big Tobacco and the sugar industry are disturbing. As a recent publication in JAMA Internal Medicine showed, the sugar industry paid three influential Harvard scientists to downplay sugar's role in heart disease and to shift the blame to fat.^[17] Last year, the New York Times exposed that the Coca-Cola Company paid millions of dollars to fund research that downplayed the role of sugary drinks in obesity and push lack of exercise as the main factor.^[18] And, according to one former UK shadow health minister, the incorrect advocacy of a low-fat, high-carbohydrate, and high-sugar diet by "morally corrupt scientists and politicians who allowed themselves to be manipulated by food suppliers" is to blame for global obesity.^[19]

The recent calls by the WHO to tax sugary drinks are very welcome news for health campaigners. The public health messaging, however, has to be more clear. There is nothing wrong with the occasional treat, but sugar has no place as part of a "healthy balanced diet." Similar to smoking, any further regulatory measures to reduce sugar consumption, such as banning of sugary drink advertising and dissociating sugary drinks with sporting events, will have a further impact on improving population health within a short time. The science is more than sufficient; the case against sugar is overwhelming. Sugar is the new tobacco, so let's start treating it that way.

References

1. Sugarwise http://sugarwise.org Accessed October 26, 2016.
2. Sugarwise. Mother convenes summit in parliament on sugar. Press release. October 12, 2016. http://www.mynewsdesk.com/uk/level/pressreleases/mother-convenes-summit-in-parliament-on-sugar-1601325Accessed October 26, 2016.
3. Royal College of Physicians. Fifty years since Smoking and health: Progress, lessons and priorities for a smoke-free UK. Report of conference proceedings. London: RCP; 2012. https://www.rcplondon.ac.uk/sites/default/files/fifty-years-smoking-health.pdf Accessed October 26, 2016.
4. Briggs ADM, Mytton OT, Kehlbacher A, et al. Overall and income specific effect on prevalence of overweight and obesity of 20% sugar sweetened drink tax in UK: econometric and comparative risk assessment modelling study. BMJ. 2013;347:f6189.
5. Basu S, Yoffe P, Hills N, et al. The relationship of sugar to population-level diabetes prevalence: an econometric analysis of repeated cross-sectional data. PLoS One. 2013;8:e57873.
6. Menke A, Casagrande S, Geiss L, Cowie CC. Prevalence of and trends in diabetes among adults in the United States, 1988–2012. JAMA. 2015;314:1052-1062. Abstract
7. Yang Q, Zhang Z, Gregg EW, Flanders WD, Merritt R, Hu FB. Added sugar intake and cardiovascular diseases mortality among US adults. JAMA Intern Med. 2014;174:516-524. doi:10.1001/jamainternmed.2013.13563.
8. Lustig RH, Mulligan K, Noworolski S, et al. Isocaloric fructose restriction and metabolic improvement in children with obesity and metabolic syndrome. Obesity (Silver Spring). 2016;24:453-460. Epub Oct 27.
9. Lustig RH, Schmidt LA, Brindis CD. The toxic truth about sugar. Nature. 2012;487:27-29. Abstract
10. Prynne M. Tooth decay is the biggest cause of primary school children being hosptialised. The Telegraph. July 13, 2014. http://www.telegraph.co.uk/news/health/news/10964323/Tooth-decay-is-the-biggest-cause-of-primary-school-children-being-hospitalised.html Accessed October 27, 2016.
11. Interview with Professor Aubrey Sheiham. The Sugar Podcast. August 11, 2014. http://www.sugarpodcast.org.uk/Accessed October 27, 2016.
12. Sheiham A,James PT. A reappraisal of the quantitative relationship between sugar intake and dental caries: the need for new criteria for developing goals for sugar intake. BMC Public Health. 2014,14:863.
13. Public Health England and the Food Standards Agency. National Diet and Nutrition Survey Results from Years 5 and 6 (combined) of the Rolling Programme (2012/2013 – 2013/2014). https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/551352/NDNS_Y5_6_UK_Main_Text.pdf Accessed October 27, 2016.
14. Johnson RK, Appel LJ, Brands M, et al. Dietary sugars intake and cardiovascular health: a scientific statement from the American Heart Association. Circulation. 2009;120:1011-1020. Abstract
15. Aseem M. The dietary advice on added sugar needs emergency surgery. BMJ. 2013;346:f3199.
16. Brownell KD, Warner KE. The perils of ignoring history: big tobacco played dirty and millions died. How similar is big food? Milbank Q. 2009;87:259-294. doi:10.1111/j.1468-0009.2009.
17. Kearns CE, Schmidt LA, Glantz SA. Sugar industry and coronary heart disease research. a historical analysis of internal industry documents. JAMA Intern Med. Epub September 12, 2016. doi:10.1001/jamainternmed.2016.5394.
18. O'Connor A. How the sugar industry shifted blame to fat. The New York Times. September 12, 2016. http://www.nytimes.com/2016/09/13/well/eat/how-the-sugar-industry-shifted-blame-to-fat.html Accessed October 27, 2016.
19. McColl I. There is one cure for obesity and one only: eat less. It's that or the fatness epidemic will kill more than Spanish flu. The Telegraph. October 11, 2016. http://www.telegraph.co.uk/news/2016/10/11/there-is-one-cure-for-obesity-and-one-only-eat-less-its-that-or/ Accessed October 27, 2016.