Update 6th March 2014: The World Health Organisation recently suggested reducing each person’s sugar intake per day from 10% of total energy to 5%. Five per cent is equivalent to around 25 grams (6 teaspoons) of sugar per day for an adult of normal Body Mass Index.
This article was first published on April 24, 2013.
We’re getting fatter and sicker. The cluster of diseases labelled “metabolic syndrome” – obesity, type 2 diabetes, high blood pressure, blood fat disorders, cardiovascular diseases and the like – are breaking our health budgets and our hearts.
Obesity, recently calculated by University of Auckland researchers to be an $850 million a year problem, is a trigger for many serious ailments. These include non-alcoholic fatty liver disease (first described in 1980), kidney problems, polycystic ovaries, gallstones, sleep apnoea and depression. We can put a figure on lost productivity and taxes and higher insurance premiums, though it’s harder to assess the huge losses in quality of life for our obese, unhappy citizens. It’s estimated that more than 200,000 of us have been diagnosed with diabetes and 100,000 more are suspected to have the disease. In more bad news, a recent study found 31% of adults have high blood pressure, reversing a previous downward trend. Maori and Pacific people are over-represented in most categories.
In the US, often considered to be a preview of our future, it’s estimated that thanks to metabolic syndrome – which can translate into 15-20 years of life lost – this may be the first generation of Americans who will die earlier than their forebears. Teens with type 2 diabetes, once almost unknown, are a third of new cases. Over 40% of death certificates list obesity as a cause. The total cost to that country’s economy might be US$300 billion a year, and that will snowball. “The majority of obese kids will be diabetic and cardiac cripples by the time they’re 50,” says San Francisco-based obesity expert Dr Robert Lustig.
For Professor Jim Mann at the University of Otago, our extreme situation demands extreme measures. “We are right up there nearly at the top of the world league table for both obesity and type 2 diabetes. It needs to be treated like an epidemic – like scarlet fever or bird flu.”
So why are so many of us, and our kids increasingly, getting so fat? It’s complicated. Blame is shifted around. Obese people attract scorn for eating too much and blobbing in front of the TV, food companies are called evil and greedy for apparently turning a blind eye to what their products can do, and regulators are cast as craven accomplices.
Perhaps, though, we are all in an impossible bind. Few of us now have time to cook from scratch and so resort to cheap, “energy-dense” processed food, particularly in times of stress – that is, most of the time. Food companies, meanwhile, chasing financial targets and battling competitors, turned to adding large amounts of sugar, fat, salt and caffeine to make food taste more and more desirable, and now find these ingredients indispensable. The world needs to feed seven billion people, who are effectively being trained to prefer foods that are full of fat, sugar, salt and caffeine. And there is an increasingly fatal disconnection between 21st-century life and our Stone-Age bodies, which no longer need to chase their food and refuse to give up the easy calories we put into them.
THE PRIME CANDIDATE
Obesity is lots of diseases at once, says Lustig in a new book, Fat Chance: Beating the Odds Against Sugar, Processed Food, Obesity, and Disease, and the whole involves such disciplines as biochemistry, endocrinology, psychology and environmental health. Charges of gluttony and sloth are hurled at the afflicted, says Lustig, despite 55% of Americans now being overweight or obese.
But that cluster of diseases largely has one cause, he claims: sugar.
Everyday sugar, or sucrose, metabolises in the body into glucose and fructose. And it’s fructose, he says, that plays havoc with our insulin levels. The clinic where the paediatric endocrinologist (he specialises in the hormone systems of children) works is “an insulin reduction clinic”.
Everyone says eat less, exercise more, says Lustig. That doesn’t work. He says 75% of obese people have an insulin problem of one sort or another. “Because the higher your insulin, the less you burn, the more you store. That’s insulin’s job.” Also, exercise makes you hungry for carbohydrates and sugary food, because they are readily burnable. “If we get the insulin down, you win. If we don’t, you lose.” Not every one of the often hopelessly obese children he sees responds to low sugar, but the majority do.
Lustig is not the first to finger sugar as a major contributor to obesity and diabetes – it’s 40 years since Professor John Yudkin’s Pure, White and Deadly – but he says dozens of studies now implicate fructose as a major factor in metabolic disease. He painstakingly lays out the biochemical evidence.
Sugar messes with insulin but also leptin, another hormone that also plays a role in metabolism and appetite. Sugar lights up the pleasure centres of our brains, Lustig says, and we eat to feel better because we are more often stressed, so cortisol and dopamine join this doleful party.
He says fast food is built on those four components: fat, sugar, salt and caffeine. “Salt increases the salience of food, but it’s not salt itself that’s addictive. It’s not fat, because the Atkins diet is straight fat, and that causes you to eat less. The ones that are addictive are sugar and caffeine. It just so happens they pair sugar and salt all the time, and sugar and fat all the time. So the salt and the fat increase the salience of the sugar and caffeine.”
The prime candidate in obesity and diabetes is sugar, he says. Fat and protein have barely moved in terms of consumption. What have gone up in recent decades in the US are carbohydrates and fructose, consumption of the latter having doubled in the past 30 years and increased sixfold in the past century.
We have no need of sugar, says Lustig. He and colleagues studied food supply and diabetes across 154 countries between 2000 and 2010. Every additional 150 calories per person per day barely raised diabetes prevalence, says Lustig. “But if those 150 calories were instead from a can of soda, increase in diabetes prevalence rose sevenfold. Sugar is more dangerous than its calories. Sugar is a toxin. Plain and simple.”
Sugar used to be dessert, he says. “It used to be rare, hard to come by. Now it’s all the time. People say to me, Dr Lustig, does that mean I can’t have birthday cake? I say, last time I checked, birthdays were once a year. But the yoghurt you had for breakfast this morning has the same number of grams of sugar as the birthday cake.”
Obesity is an environmental problem, he says. People can lose weight, but most gain it all back. They are victims, he says, “of the mismatch between the environment and their hormone and biochemical systems”.
Mann agrees that our food and social environment seems to be overwhelming our natural eating limits. “That inherent mechanism we have for sensing when we’ve had enough is not sufficiently potent when we’ve got something that tastes as delectable.” Think about how we eat a huge meal then can’t resist a wonderful pudding, he says, then apply that at a population level every day. But he is more cautious than Lustig in labelling sugar as the demon drug for obesity or diabetes.
A study Mann co-authored for the World Health Organisation (WHO), published in the British Medical Journal, on dietary sugars and body weight found that reducing free sugars in the diet has a small but significant effect on body weight. It also appears we gain weight more easily when our diets include lots of sugar foods and drinks, something more common in the young and especially young Polynesians. “The body doesn’t sense that you are having a lot of calories when you are having [sugary] drinks.”
Mann thinks, however, that Lustig has overstated the current evidence. “In 10 years we may be able to say that sugar, and fructose in particular, is the cause of all evil.” For the average consumer in New Zealand today, though, all we can say from the evidence is that excess sugar is “a factor, not the factor”.
Mann, who serves on WHO obesity advisory committees, has other concerns about laying the blame at sugar’s feet. “[Lustig] gives the pro-sugar lobby a lot of ammunition because when we say we want to recommend reduction of sugar – which we do – they come back and use the exaggerated Lustig approach to rubbish what we’re trying to do.”
EAT YOURSELF MORE BLISS
The food industry is, of course, front and centre in all this, according to Michael Moss, a Pulitzer Prize-winning journalist for the New York Times. On the one hand, it provides plentiful, cheap food that’s extremely tasty. On the other hand, our tastes are modified by its products. Do we really need squeezable tubes of yoghurt with three teaspoons of sugar in each 70g tube?
Some salt, sugar and fat is fine. Moss doesn’t view the processed food industry as an evil empire that sets out to make us obese or ill. “And they can justifiably argue that no single one of their products is responsible for the obesity crisis, whether it’s soda or, one of my favourites, potato chips. The problem lies in their collective zeal to do what companies do, which is to make as much money as possible by selling as much product as possible.”
He describes in his new book, Salt Sugar Fat: How the Food Giants Hooked Us, a rare meeting in 1999 of the world’s largest food companies at which an executive from Kraft presented 114 slides. “He lays at their feet responsibility not only for obesity but diabetes and heart disease and high blood pressure and even cancers, and pleads with the companies’ CEOs to do something collectively to turn the corner on behalf of consumers.”
But because of the intense competition, food companies often fail to see the big picture. “You’re just spending every waking hour trying to defeat your competitors and get more space on the shelf.” They employ genius food scientists to improve the “bliss point” and “mouthfeel” of products. Moss says food companies are now using brain scans to study how we react neurologically to certain foods, especially sugar. “They’ve discovered the brain lights up for sugar the same way it does for cocaine.”
Few experts are suggesting removing all these tasty additives. Moss tried saltless cheesy snacks and soups. Result: zero taste. Says Mann: “Have you ever eaten bread without salt in it? It’s disgusting.” Moss suggests that taking too much salt, sugar and fat out will defeat the purpose. “Even worse, what are left are the inexorable consequences of food processing: repulsive tastes that are bitter, metallic and astringent. The industry has boxed itself in.”
The answer is to reduce gradually the amounts of sugar and salt in food, says Mann. Halving it at the population level would be “wonderful”, he says, and probably only marginally noticed.
Former MP Katherine Rich, who heads industry group the Food and Grocery Council, says the industry has already been responding to consumer concerns. “Low- and zero-sugar beverage options now make up around 45% of sales, so the development of these products has taken tens of thousands of tonnes of sugar out of the food supply.” Bread manufacturers have cut the salt content of some leading breads by 15%, resulting in about 150 tonnes of salt being removed from the bread supply each year. Breakfast cereals have had to be reformulated more slowly, she says, but they are also cutting salt levels.
But can such efforts make a difference to our obesity rates? Rich thinks so, particularly healthy eating education efforts at schools, but she says industry and the government can’t control many factors, “such as what people decide to eat or drink in a given day, food availability in the home, how much they exercise and their genetic makeup.”
NANNY STATE’S SPOONFUL OF SUGAR
The Government has rejected calls from public health groups to improve the food environment, saying it is a matter of individual choice. In 2009 Health Minister Tony Ryall removed a national health goal of cutting obesity, saying there were too many nebulous health goals. The school ban on selling unhealthy food was also lifted around the same time.
These were part of Labour’s HEHA (Healthy Eating, Healthy Action) policy. Key population health messages included eating fewer fatty, salty, sugary foods and more veges and fruits, being active for at least 30 minutes a day and fostering environments that supported healthy lifestyles.
Ryall told the Listener the Government continues to invest about $50 million a year in the likes of KiwiSport, Green Prescriptions and the Fruit In Schools programme for low-decile schools. “The National Government is rebalancing the healthy lifestyles approach away from Labour’s nanny-state finger-pointing and encouraging a greater role for physical activity in curbing the obesity problem.”
Ryall also points to a regulation of claims about the health properties of food on labels coming into effect and more restrictions on food ads in children’s TV viewing times. There are no plans to introduce “fat taxes”, he says. “Such a tax would add to the burden of many families in tight economic times.”
Mann is unpersuaded. “We don’t accept it in the case of tobacco smoking, we don’t accept it in the case of cycle helmets. Why does it apply to food, when it’s causing as much ill health as some of these other things are and costing us a fortune?” Education on its own doesn’t work, he says.
Critics have long claimed better food labelling will help better choices. Says Mann: “Who can read those current labels? Nobody. You can buy a bar that looks healthy and it’s got enough sugar calories for a week in it.”
Says Rich: “I still believe that families, communities and education about healthier food choices play a much bigger role than the tiny piece of real estate on a pack. Many people don’t read labels and, of course, many foods are completely unlabelled.”
Labels do list the levels of sugar, fat and sodium, but other ingredients, such as fibre and trans-fats, are not always noted. We need both types of fibre, soluble and insoluble, but not trans-fats. Trans-fats don’t go rancid so mean increased shelf life for products, says Lustig. But they also are “enormously poisonous”, and should be banned. “Your body cannot metabolise them. They just line your arteries and cause bad diseases. Yet they are generally regarded as safe, and the reason is because the [Food and Drug Administration] said, ‘Gee, if we got rid of trans-fats, the only thing we could substitute would be saturated fat, and saturated fat’s bad so we can’t do that.’ Except for one thing: saturated fat is not bad, it’s actually neutral. I’m not going to say it’s good. It would be way better to have saturated fat than trans-fat. The FDA doesn’t believe that, and the food industry doesn’t want that.”
WHOSE KITCHEN RULES?
The worldwide food industry also lobbies against regulation. In December, US magazine Mother Jones ran a lengthy article (see Further reading, page 21), drawing from internal company memos, about how the sugar industry, using what the magazine called “Big Tobacco-style tactics”, in 1976 managed to turn a negative public perception into one of a safe substance for which there are still no recommended daily limits.
Moss quotes the former CEO of Philip Morris, the tobacco company that used to own Kraft, formerly one of the biggest food companies in the world, suggesting state intervention: “I am no fan of government regulation. But what we’re seeing in the food industry is such a fiercely competitive environment that unless all the companies got together, you are not going to see any one individual company able to step out in front and do it.”
Sugar is a huge investment, and the food industry is supported by others. Says Moss: “The money to be made in marketing processed foods, to kids especially, is one of the things that keeps it going.”
But remember that US$300 billion figure. “The last time I heard numbers like that was in the 90s when the states sued Big Tobacco to recover the costs they were incurring treating people suffering from having smoked,” says Moss.
“Ultimately,” says Lustig, “we have to reduce availability.” That happens in three ways – taxation, restriction of access and government agency action. The evidence is not there for which works best. “For alcohol, which I like, we needed all three.” The same for tobacco. Given history, we will probably need all three for this as well, he says.
Says Rich: “If it’s regulating food ingredients, handing food companies a government-approved recipe or issuing rules about what shoppers can or can’t put into their supermarket trolley, both the food industry and the general public would judge such regulatory interventions as being extreme.”
“Fat taxes” are likewise anathema to industry, but taxes on tobacco are similarly aimed at discouraging use.
For Mann, the answer lies in reinstating what has been abolished. “New Zealand was internationally regarded as having potentially one of most interesting policies in the world, which was HEHA.”
We should at least reintroduce elements such as removing junk food from schools and ban food advertising to kids, he says. Government should also be more encouraging to food manufacturers to change. Nothing will be achieved without changing the environment, says Mann.
The bottom line, says Moss, who has interviewed many company executives, is just that. “I think a lot of these companies do want to do the right thing. They don’t care if they make money selling healthier products; the goal is to make money.”
But it’s hard work. Moss says Jeffrey Dunn, a former president at Coca-Cola in the US, is now attempting to pay his “karmic debt” by selling baby carrots, unsweetened and unfried, using every marketing and packaging technique the food giants had at their disposal. So how is Dunn doing with the carrots? “It’s a hard go,” says Moss. “I think it’s really brilliant. But we’ll need more time to see if it really catches on.”
It’s certainly different from what Dunn told the magazine Fast Company about his Coke days: “We were selling sugar water and fairy dust.”
Being fat and fit is better than being thin and sedentary, says Dr Robert Lustig.
And being thin is no safeguard against metabolic disease or early death. Up to 40% of normal-weight individuals harbour insulin resistance – a sign of chronic metabolic disease – which is likely to shorten their life expectancy. And he says 50% of women and 20% of men could have dangerously high visceral fat – the fat around internal organs.
Waist-to-hip ratio and overall waist circumference are more important figures than body mass index for dangerous visceral fat . Medical tests such as lipid profiles can be helpful. “Looking from the outside, you can’t tell.”
On the other hand, subcutaneous fat – fat just under the skin – may be ugly but it is not dangerous. “In fact, studies that have looked at it say that the more subcutaneous fat you have, the longer you live.”
WHAT CAN YOU DO?
■ Exercise at least 15 minutes a day. It may help you lose weight and will also improve your muscle mass, fitness and strength, metabolism, mood and stress levels.
■ Eat fibre, both soluble and insoluble. It limits insulin response, improves blood sugars, encourages fullness signals, and helps good gut bacteria.
■ In supermarkets, stick to your list, avoid spontaneous decisions, especially at the ends of aisles and by checkouts, and try not to venture beyond the outer aisles where the fresh foods are.
■ If you do enter the middle aisles, be vigilant at eye level – most sugar-loaded products are there.
■ Read labels closely. Remember that 4-5g of sugar or salt equals a teaspoon. Fruit juices may contain as much sugar as soft drinks. Sweetened teas, chocolate milk, wine and ”power drinks” may be no better.
Salt Sugar Fat: How the Food Giants Hooked Us, by Michael Moss (Random House).
Fat Chance: Beating the Odds Against Sugar, Processed Food, Obesity, and Disease, by Robert Lustig (HarperCollins).
Fat, Fate & Disease, by Peter Gluckman and Mark Hanson (OUP).
“Big Sugar’s Sweet Little Lies”, Mother Jones magazine, bit.ly/Sj52SZ