Center for Communications, Health and the Environment
|Spring 2013||Vol. 8, Issue 1|
The Allure and Hazards of Sugary Foods
Sweet It Isn't:
It's sweet. It's ubiquitous. And it is one of the single biggest threats to public health worldwide.
Sugar has been around since ancient times, but its rockstar status is of modern-day making, a result of the confluence of mass production, consumer appetite and corporate profits.
Presently, sugar is a popular, if not important, part of the human diet, found in everything from candy, cookies and cake to pasta sauce, salad dressing and bread. It appears on ingredients lists as its five-letter self, as well as in other forms such as high-fructose corn syrup, evaporated cane juice, dextrose, fructose, maltodextrin, and about 30 other less recognizable monikers, depending on its source and how it was made.
While sugar and its derivatives may make food more palatable
and provide energy, consumption of sugar in any form is the proverbial
double-edged sword on a slippery slope, a "liquid candy" linked to numerous
and reverberating health issues.
Sugar Consumption and Trends
Just four countries will likely account for almost 40 percent of this predicted global "sugar high." India is expected to top the list at 26.5 MMT, up 1 MMT from 2011 and almost double China's forecasted 14.9 MMT, with sugar-producing powerhouse Brazil and the United States rounding out the roster.
While countries track use in tons, the average individual
consumes about 53 pounds (24 kilograms) of sugar each year, the equivalent
of more than 260 food calories per person, per day. Persons in industrialized
nations, where cheap, processed foodstuffs are readily available, ingest
even more: about 72 pounds or 33.1 kilograms. In the United States, total
annual per capita consumption of sugar and natural sweeteners equalled
a hefty 130.5 pounds in 2010, according to the USDA Economic Research
Service's May 2011 "Sugars and Sweeteners Outlook." This consisted of
66 pounds of refined sugar - the highest level since 1999 - and 64.5 pounds
of corn-derived sweeteners, the lowest level since 1986.
Sugar, Health and Chronic Diseases
From 1986 to the early 2000s, for example, American sugar intake rose from 75 to more than 90 pounds per person per year, according to the USDA; meanwhile, in 1980, roughly one in seven Americans was obese, and almost 6 million were diabetic, compared to one in three and 14 million, respectively, by the early 2000s.
While strongly implied, the link between sugar consumption, obesity and obesity-related conditions such as diabetes is not conclusive. Yet it appears to be more than coincidence, as mounting research and scientific evidence support a connection.
As early as 1924, Haven Emerson, director of the institute of public health at Columbia University, reported on diabetes deaths, finding that they had increased as much as 15-fold in New York City since the Civil War years, and as much as fourfold in other U.S. cities between 1900 and 1920. This coincided, he noted, with an almost 50-percent rise in sugar consumption from 1890 to the early 1920s, as well as the birth and growth of the candy and soft-drink industries.
Meanwhile, almost a century later, in 2012, the New England Journal of Medicine (NEJM) reported that, "Compelling evidence supports a positive link between the consumption of sugar-sweetened beverages and the risk of obesity." In fact, a 2009 report by the UCLA Center for Health Policy Research and the California Center for Public Health Advocacy found a 27 percent increase in the likelihood of overweight or obesity for adults in California who drank one or more sugar-sweetened beverages each day regardless of income or ethnicity, while a 2001 observational analysis published in The Lancet found a 60 percent increase in a child's risk for obesity with every additional daily serving of soda.
A study published in the September 21, 2012 NEJM supports such findings, but questions a direct link, pointing out that "children who drink more sugar-sweetened beverages also tend to eat more fast food and to watch more television." This "Double-blind, Randomized Intervention Study in Kids" conducted from November 2009 to July 2011 and completed by 477 schoolchildren aged 4 to 11 years living in an urban area near Amsterdam specifically found that "masked replacement of a sugar-containing beverage with a sugar-free beverage significantly reduced weight gain and body fat gain in healthy children." In fact, children in the sugar-free group gained 35 percent less body fat than those in the sugar group, according to impedance measurements, and 19 percent less when fat mass was calculated from the sum of the thicknesses of four skinfolds.
Although encouraging, human habits would likely impede such a reduction on a mass scale. Both sugar consumption and obesity numbers continue to rise across the globe, with a 2012 report by Trust for America's Health finding that, by 2030, America alone could have an adult obesity rate above 44 percent in all 50 states.
This is unwelcome news. Because not only is sugar consumption tied to the onset of obesity and type 2 diabetes, but it is also associated with incidence of heart disease, stroke and certain types of cancer.
In fact, a study published in October 2012 in The American Journal of Clinical Nutrition (AJCN) involving nearly 40,000 men and women in Japan over an 18-year period shows that women who drank sugar-sweetened sodas and juices almost every day had an 83 percent higher risk of ischemic stroke than those who reported drinking the fewest soft drinks.
Meanwhile, a March 2012 Harvard School of Public Health study of 43,000 men aged 40 to 75 followed for more than 22 years found that drinking just one sugar-sweetened soda, juice drink or energy drink a day may increase a man's risk for heart disease by 20 percent. And the risk remained even after other indicators of unhealthy lifestyles such as smoking, lack of exercise and family history of heart disease were considered. Meanwhile, women who drink more than two sugary drinks a day are 40 percent more likely to have a heart attack or die from heart disease, according to data published in 2009 by T.T. Fung, et al, in the AJCN.
A connection between obesity, diabetes and cancer has also been established. First reported in 2004 in large population studies by researchers from the World Health Organization's International Agency for Research on Cancer, the uncontroversial findings indicate that individuals are more likely to contract cancer if they are obese or diabetic than if they are not, and more likely to get cancer if they have metabolic syndrome than if they don't. Part of the issue appears to be that insulin, which is secreted in higher amounts when a person is diabetic or develops insulin resistance, promotes tumor growth, notes Leon Stafford in his November, 12, 2012 online article, "Soda wars: cities seek restrictions, taxes to curb obesity," in The Atlanta Journal-Constitution.
Decidedly less dramatic, but far more prevalent and proven is the link between sugar and dental problems, particularly dental decay in the form of cavities, which, research published in the American Journal of Public Health and elsewhere finds, is the most common chronic childhood disease. In fact, drinking sugary drinks nearly doubles the risk of dental cavities in children, reported W. Sohn, et al, in their 2006 article in the Journal of Dental Research.
Despite much damning evidence against sugar, there may
be at least one bright spot. Chocolate, even in its sweetened form, has
been documented to improve cognitive function, with a 2012 report by Franz
H. Messerli, M.D. in the NEJM suggesting that its consumption
may generate "the abundant fertile ground needed for the sprouting of
Sugar, Satiety and the Human Body
Perhaps most important, however, may be the way the human body processes empty sugar calories.
According to "Is Sugar Toxic?," an April 2011 New York Times article by Gary Taubes, sugar is often lumped together with carbohydrate-rich, nutrient-poor foods like rice, bread and potatoes, but it differs from these carb cousins in a significant and critical way: Sugar and all of its derivatives contain fructose in addition to glucose, with refined sugar (or sucrose) being "a 50-50 mixture of the two."
Humans metabolize fructose primarily via the liver, while glucose is metabolized by every cell in the body. In short, as Taubes explains it, consuming sugar (fructose and glucose) means more work for the liver than ingesting the same number of calories of starch (glucose). And consuming sugar in liquid form (e.g., soda and fruit juices) floods the liver with a fructose-glucose cocktail in a way that eating an apple does not. Research indicates that how quickly the liver must work affects how it metabolizes these monosaccharides.
Backed by a number of biochemists, Dr. Robert Lustig, a specialist on pediatric hormone disorders and expert in childhood obesity at the University of California, San Francisco, argues, according to Taubes, "that sugar has unique characteristics, specifically in the way the human body metabolizes the fructose in it, that may make it singularly harmful, at least if consumed in sufficient quantities."
Studies of laboratory rats and mice by biochemists such as Michael Pagliassotti have shown that the liver converts fructose, ingested in ample amounts at gross speeds, into fat. This fat, in the form of palmitate, accumulates in the liver, and a condition known as insulin resistance often results. Insulin resistance, whereby cells fail to respond to the natural insulin hormone and are unable to take in glucose, amino acids and fatty acids, has been linked to an increasing array of chronic health issues, including obesity, type 2 diabetes, heart disease, and even cancer.
According to Pagliassotti and reported by Taubes, these
debilitating health changes can occur in as little as a week, if sugar
or fructose comprises 60 or 70 percent of the calories in lab animals'
diets, or over several months, if the animals are fed a 20-percent sugar/fructose
calorie diet, which closely approximates what humans, at least in America,
consume. But here's the clincher: When sugar consumption is halted in
either case, "...the fatty liver promptly goes away, and with it the insulin
resistance." Similar effects have been shown in humans, but generally
only with pure fructose, which is not the equivalent of sugar or high-fructose
The Beef Over Beverages
Sugar-sweetened beverages, including soda, sports drinks, energy drinks, fruit drinks and sweetened coffees and teas, are among the most common and direct forms of empty-calorie intake and global sugar consumption. They account for 46 percent of the added sugar in American diets, according to the USDA's Dietary Guidelines for Americans, 2010, and are the largest single caloric food source in the United States at almost 15 percent of daily caloric intake in several population groups, including adolescents, notes the Center for Science in the Public Interest (CSPI).
In fact, although Beverage Digest reports a decrease in soda consumption in recent years, 48 percent of Americans aged 18 and older drinks a soda every day, reveals a July 2012 Gallup poll. The average 12-ounce can of soda contains about 10 teaspoons of sugar, or 40 grams, and packs around 160 calories.
It may also contain caffeine, a mildly addictive, stimulant drug.
At the same time, on a typical day, about half of the U.S. population aged 2 and older consumes a sugar-sweetened beverage, and 25 percent downs at least 200 calories (more than one 12-ounce cola can's) worth of "liquid candy," reports the Centers for Disease Control and Prevention (CDC) in its National Health and Nutrition Examination Survey (NHANES), 2005-2008, which was released in August 2011. Research reveals that the majority of these sugary drinks are consumed at home.
All told, the average American drinks about 40 gallons of sugar-sweetened beverages annually, notes CSPI. This adds up to as much as 4,250 teaspoons, 17,000 grams or 37 pounds of sugar and 68,000 empty calories every year!
Meanwhile, a typical 10-year-old has to bike vigorously
for 30 minutes to burn the calories in a 12-ounce soda, and a typical
adult has to walk briskly for 46 minutes to burn the calories in a 20-ounce
one. But given modern-day obesity rates, how often do such actions regularly
Added Sugars Compound the Problem
Tens of thousands of commercially available processed foods contain added, or "hidden," sugars. In fact, of the 85,451 unique commercially available foods procurable for purchase between 2005 and 2009, 75 percent, or 64,088, contained added sweeteners, details research by Dr. Barry Popkin, a professor of nutrition at the University of North Carolina School of Public Health.
According to the USDA's Dietary Guidelines for Americans, 2010, "the majority of sugars in typical American diets are sugars added to foods during processing, preparation, or at the table" to "sweeten the flavor of foods and beverages...improve their palatability...preservation...and...provide functional attributes, such as viscosity, texture, body, and browning capacity."
Take the quintessential plain bagel. According to the USDA's Nutrient Database, it contains a total of 5.05 grams of sugar, 4.8, or 95 percent, of which are added. Whole-wheat bread may be a better choice than white, but one slice typically packs 5.57 grams of sugar, 5 grams, or 90 percent, of which are added, the database reveals. And when it comes to cereal, corn flakes may be a lower-sugar option, but a bowl still has around 6 grams of the sweet stuff, all of it added. Meanwhile, granola bars and fruit-flavored yogurts tend to be loaded with added sugar - 20.4 (94 percent) and 11.4 (60 percent) grams, respectively - while a serving of Italian salad dressing delivers almost 9 grams of sugar, 78 percent of it tossed in for the purposes of palate, preservation and plasticity.
In short, added sugars run rife, contributing about 16 percent of the total calories in American diets, according to the CDC and other sources, often through basic, and seemingly innocuous, food items. Yet, the current USDA dietary guidelines recommend keeping calories from added sugar to no more than 5 to 15 percent of total daily calories. And the American Heart Association advocates limiting added sugars to no more than 100 calories a day for most women and 150 calories a day for most men - about six and nine teaspoons, or 24 and 36 grams, respectively. Unfortunately, most Americans get more than 22 teaspoons – or 355 calories and 88 grams – of added sugar daily, far exceeding recommendations.
The major sources of added sugars in the American diet
(as a percent of calories from total added sugars) are soda, energy drinks
and sports drinks (36%), grain-based desserts (13%), sugar-sweetened fruit
drinks (10%), dairy-based desserts (6%) and candy (6%), reveals a 2005-2006
NHANES conducted by the National Cancer Institute.
Counterattack: Sending Sugar a Message
Although particularly outspoken, Lustig isn't alone in this thinking, says Taubes. Growing numbers of experts are beginning to classify sugar and its derivatives as "chronic toxins," substances that are virulent after regular, repeated, long-term use. The only way to know whether this is the case, however, is through in-depth studies and the accumulation of irrefutable data.
In the meantime, experts aren't taking chances, and are working to curb sugar consumption and exposure. One of the most recent actions on this front involves a proposed ban in New York City on the sale of sugar-sweetened beverages in containers larger than 16 ounces by venues regulated by the health department, including restaurants, movie theaters, sports and entertainment arenas, and mobile food vendors. (Vending machines and convenience stores, such as 7-Eleven and its Big Gulps, would be exempt, and the ban would not affect fruit juices, dairy-based drinks like milkshakes, alcoholic beverages or pre-packaged no-calorie diet sodas.)
Aimed to help curb runaway obesity rates, this proposal by New York City's health department and Mayor Michael Bloomberg was scheduled to go into effect in March 2013. In October 2012, however, the soft-drink industry (for which carbonated beverages and sodas account for almost 24 percent of drinks sold in movie theaters and restaurants) joined with several New York restaurant and business groups to file a lawsuit to overturn the restrictions, contending that the New York City Board of Health did not have the authority to ratify the new rules unilaterally. A state Supreme Court judge agreed, and the ban is currently on hold, awaiting appeal.
Nevertheless, the floodgates are open. New York City's Portion Cap Rule is already voluntarily underway in Brooklyn's new 18,000-seat Barclays Center, and other cities, states and municipalities are following suit. In October 2012, for example, members of Washington, D.C.'s City Council said they were considering measures, and previously, in June, the mayor of Cambridge, Mass. proposed restrictions similar to New York's. Also in June 2012, a Los Angeles councilman issued a motion to bar the sale of sugary drinks from public spaces, while in November, voters in Richmond and El Monte, Calif., overwhelmingly rejected (possibly due to the American Beverage Association spending a reported $4 million on signs, campaigns and appeals to oppose them) proposals to raise revenues by taxing sugary drinks and using the proceeds to fight childhood obesity.
Yet, since 2009, according to the Yale Rudd Center for Food Policy and Obesity (as reported in The Atlantic Journal-Constitution), 19 states and eight cities have proposed excise taxes on sugary drinks; 13 cities and counties have banned sugary drink sales on municipal property; and nine countries have levied sales or other taxes on such drinks. A national 2-cent tax on a can of soda in the United States alone would raise $3 billion annually, according to CSPI's Liquid Candy tax calculator (http://cspinet.org/liquidcandy/).
CSPI squarely supports taxes as a "tried and true public health measure" with a history of success in limiting both cigarette and alcohol use. And various taxes related to sugar have been instituted to effect in countries such as Hungary, Thailand and France, and U.S. states, including Virginia, West Virginia, Arkansas and Tennessee.
Volume-based excise taxes can encourage smaller portions of sweetened products and reduced intake of sugar and its derivatives. With soft drink consumption, a 10 percent increase in price delivers anywhere from an 8 to 12 percent drop in intake, although to have a significant effect on population health, such taxes need to be at least 20 percent, asserts research published in 2012 in the British Medical Journal. One U.S. study found that a 35 percent tax on sugar-sweetened drinks sold in a canteen led to a 26 percent drop in sales. While real-world results are elusive, the revenue reaped from such taxes has – and should have, according to the Rudd Center – the ability to do good. In Hungary, these tax proceeds go to support healthcare costs; West Virginia uses soda tax revenues to support its medical, dental and nursing schools; and Arkansas, where a soda tax has been in force since 1992, earmarks that revenue – more than $46 million in 2009 – to the state's Medicaid program.
Policy "fixes" do not necessarily result in healthful actions and substitutions, however, caution David R. Just, Ph.D., and Brian Wansink, Ph.D. of Cornell University's Charles H. Dyson School of Applied Economics and Management in an NEJM "Clinical Decisions" piece. Taxing soft drinks in Utica, N.Y., for example, led beer-buying households there to increase their purchases of beer, they note, observing that "a preference for less healthful foods, including sugar-sweetened beverages, strengthens when it appears that a tax is being used to restrict consumption."
Representatives for the multi-billion-dollar soft-drink
industry appear to agree, arguing that people have a right to make their
own consumption decisions, shouldn't be punished for exercising this right,
and know how to limit their sugar intake. Meanwhile, Coca-Cola has introduced
more teas, waters and reduced-sugar drinks over the past five years, and
now offers 800 low- or no-calorie options, according to a global sustainability
report released in November 2012. In addition, the beverage industry,
which decreased the number of sugary drinks put in school vending machines
by 90 percent between 2004 and 2010, has announced plans to launch a "Calories
Count™ Vending Program" this year that will promote lower-calorie products
in all vending machines.
Making A Difference On a Mass Scale
Prohibiting the use of Supplemental Nutrition Assistance Program (SNAP) benefits and other city, county, state and federal funds to purchase sugar-ladened products is another strategy. This could encourage healthier choices, especially if coupled with differential pricing or subsidies for fresh fruits and vegetables for SNAP recipients, incentives to attract quality supermarkets to low-income neighborhoods to increase access to healthy food, and guaranteed, on-demand availability of clean drinking water.
Eliminating or limiting the sale of sugar-ladened drinks and snacks, and the presence of their sponsorships and logos, on government-owned property, in public vending machines and cafeterias, and at government-organized events, meetings and programs could send a strong message and be a means to moderation. So could limiting portion sizes through regulation, which would counter the trend towards super-sizing of unhealthy fare, while still offering consumers control over their consumption choices and amounts.
In its "Guide to Strategies for Reducing the Consumption
of Sugar-Sweetened Beverages," the CDC also proposes including screening
and counseling about sugar intake as part of routine medical care and
training medical care providers to conduct such services as part of a
general program to modify behavior and reduce sugar consumption on a mass
Rethinking Sugar and Its Consumption on the Consumer
In addition, being aware of product positioning and its effects when making food and beverage decisions is important. Because, as experts agree – and controlled studies and market research show – placement matters.
"What and how much people eat are highly influenced by contextual factors," explain Deborah A. Cohen, M.D., M.P.H., and Susan H. Babey, Ph.D. in their October 2012 NEJM article, "Candy at the Cash Register - A Risk Factor for Obesity and Chronic Disease." Most purchasing decisions are made automatically, in less than a second, they note, with choices of sugary and fatty foods taking less time than those of healthful ones; and having just made other decisions or being distracted, stressed and/or tired makes it even harder "to resist palatable foods in convenient locations."
Cohen and Babey recommend treating "the prominent placement of foods associated with chronic diseases" as a risk factor, and they suggest harnessing market research to test new approaches to risk-reduction, such as "limiting the types of foods that can be displayed in prominent end-of-aisle locations and restricting foods associated with chronic diseases to locations that require a deliberate search to find."
Meanwhile, corporations are harnessing their own market research. Nearly $1 billion a year is devoted solely to promoting sugar-sweetened beverages, with much of this advertising seen by children. At the same time, the packaging of sugar-ladened drinks and foods is designed for individual, immediate and continued consumption, with portion sizes ballooning in recent decades. Placement of these palatable items within easy reach and at key points promotes impulse purchases, while volume-based discounting encourages "super-sizing," argues Thomas Farley, M.D., M.P.H. of the New York City Department of Health and Mental Hygiene in a NEJM 2012 "Clinical Decisions" piece.
CSPI recommends encouraging retailers to remove sweets and sugared drinks from check-out lane displays. Strengthening ordinances to restrict the amount and type of signage on stores and buildings, implementing social marketing campaigns and regulating the packaging of sugar-loaded items to make it less snazzy and appealing (à la what some countries are doing with cigarette packs) could also help minimize exposure to product pushes and temper the influence of advertising and marketing messages in consumption decisions.
"The use of simple behavioral nudges, such as making soft drinks less visible and less convenient, can have a big effect on consumption...," agree Just and Wansink. They note that behavioral approaches have been successful in increasing fruit and vegetable consumption among children by making these products more visible and attractive by associating them with exciting names like "x-ray-vision carrots" or a well-known fictional character such as Batman. Unlike Farley and others who advocate for government directives, however, Just and Wansink believe "voluntary approaches are much more likely than regulations to create long-term behavioral habits."
Be that as it may, CSPI is lobbying the U.S. Food and
Drug Administration to require labels on non-diet soft drinks stating
that frequent consumption of these drinks promotes obesity, diabetes,
tooth decay, osteoporosis and other health problems. Meanwhile, in July
2012, the secretary of the U.S. Department of Health and Human Services
received a letter signed by more than 100 organizations and individuals
asking her to direct the surgeon general to prepare a report on the health
impacts of sugary drinks and issue a call to action to spur national efforts,
both governmental and voluntary, to reduce their consumption.
Focusing on the Future
While the home may be Ground Zero for sugar consumption, exposure to sweetened food and beverages is sometimes introduced, and very often fueled and reinforced, at school and through local communities.
There are some straightforward and obvious actions administrators and institutions servicing youth can take to counter such influences and contain sugar consumption. Subsidizing fresh fruits and vegetables in schools and establishing farm-to-school programs and/or school and community gardens can promote healthier foods and encourage "buy-in" and pride in their consumption. And eliminating the provision or sale of sweetened food and beverages in childcare and after-school programs, and banning or limiting the sale of such items on school property, including in cafeterias and vending machines, has the potential to significantly reduce kids' intake.
CSPI also recommends changing local zoning laws to limit
the number/density of sweetened food and beverage retailers near schools
and playgrounds. Additionally, it suggests establishing minimum nutrition
standards for children's meals that include toy-giveaways and other incentives,
and eliminating the sale and marketing of sweetened food and drinks at
venues frequented by children, such as zoos, museums and parks.
The Bottom Line
Such a push is imperative, however, and its objectives ultimately achievable.
A supportive food environment is the key, asserts Farley. One that is mindful of the superpower status of sugar and responsibly checks its ability to appeal through availability, placement, promotion, packaging and pricing. An environment that takes into account current scientific data. And one that approaches policy decisions in an integrated, as opposed to an isolated, manner.
|Copyright © 2013 Center for Communications,
Health and the Environment (CECHE)
Dr. Sushma Palmer, Program Director
Valeska Stupak, Writer, Editor & Design Consultant
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