International Sugar Journal

Sugar and Obesity- how did the issue get here and where is it going?

Introduction

“2016 could be the year of the sugar tax, as several large nations consider levies on sweetened food and drinks to battle obesity and fatten government coffers.” [i]

A recent Reuters article neatly sums up the current state of play- governments around the world appear set to tackle obesity by introducing sugar taxes, and other restrictions aimed and reducing consumption.  Countries such as Mexico[ii] and France have taken the lead, and pressure is building on others to follow. The UK has now said it will follow suit in 2018[iii]. As obesity takes over the mantle of Public Health Enemy no 1 from Tobacco and the blame is increasingly laid at the feet of Sugar, advocates proclaim “Sugar-the new Tobacco” and argue for similar methods to be used to counter it.

This article examines how Sugar became the focus of the Obesity control. It looks at the tobacco control story and suggests that many health campaigners are not only determined to use the same methods to control sugar consumption but also to employ some of the tactics developed in that long campaign.

Obesity

Obesity became a matter of concern in developed countries over 30 years ago, particularly the US. In 1998 the first US Federal Guidelines were published. The WHO began a consultation on obesity in 1997 and published its report in 2000. Today it is regarded as having reached epidemic proportions in the US. In the UK, the Health Secretary recently described it as “ a national emergency”[iv]. In an economic study published in 2014, McKinsey concluded that it was causing the same economic harm around the world as smoking and armed conflict.[v]

Once considered a problem only in high-income countries, overweight and obesity are now dramatically on the rise in low- and middle-income countries, particularly in urban settings.

It was recognized that obesity has many causes but is fundamentally a result of weight gain resulting from us eating and drinking more than we need. Why we consume more calories than we expend is explained by a wide range factors, many of which stem from our dietary and physical activity patterns. Accordingly, initial reports stressed the many causes of obesity and the need for a broad based approach to tackling it. The WHO report Obesity: Preventing and Managing the Global Epidemic published in 2000 stated,

“Obesity is a complex and incompletely understood disease…it cannot be prevented or managed solely at the individual level. Communities, governments, the media and the food industry need to work together to modify the environment so that it is less conducive to weight gain. Such partnerships are required to ensure that effective and sustainable changes in diet and everyday levels of physical activity can be achieved throughout the community.”

Fat under fire

The same WHO report identified dietary fat as a potential target, and over time a consensus emerged that focusing on dietary fat was a good approach. In 2007 a large UK review concluded that the ‘strongest evidence for an increased risk of obesity relates to diets that are high in dietary fat or low in fibre’ [vi].

Accordingly, consumers were advised to reduce their intake of fat (particularly saturated fat). Dietary fat also causes atherosclerosis and raises the risk of heart attack, so it made intuitive sense to link it to obesity. As Government campaigns focused on making consumers aware of the danger in fats, so food and drink companies responded by offering low fat products, and these sold very well.

However, in order to maintain taste, as fat was reduced so sugar was added. As result, daily calorie intake was unaffected and obesity levels continued to rise.

Switch to sugar

Subsequently, a new theory[vii] emerged. Rather than consuming too much fat, we were consuming too many carbohydrates, particularly sugar.  Sugars in particular had a capacity to trip a “fat switch” in our bodies, which lead us to convert the sugar to fat and store it, causing weight gain and obesity. Going even further, it was suggested by some scientists[viii] that Type 2 diabetes was increasing independently of obesity as a result of increasing sugar consumption.

In 2009, one of these scientists, Dr Robert Lustig (Professor of Pediatrics in the Division of Endocrinology at University of California and now a high profile anti Sugar campaigner), launched his attack on Sugar with a lecture posted on YouTube . Entitled Sugar – the Bitter Truth,  the video has been seen by over 6 million to date. He argued that sugar (consumed in the quantity seen in countries such as the US) is toxic, that it is addictive, and that it causes obesity and Type 2 Diabetes. Other nutritional scientists lined up in support, but these views are from being universally accepted.

Nevertheless, spotlighting sugar got an unexpected boost when Credit Suisse published, in 2013, a report entitled “Sugar at the Crossroads”. This showed the growing medical concern directed toward to sugar. Surveyed in 2013, over 90% of doctors believed sugar caused obesity and Type 2 diabetes.  Well over half said it was addictive, perhaps influenced by Professor Lustig’s well-known views.

No surprise then that medical opinion was keen on reducing sugar consumption and supporting regulation to get there.  The report noted that most of those surveyed lacked nutritional expertise and were simply giving an opinion. Nevertheless, Credit Suisse appeared to support this opinion and went on to endorse the WHO’s view that taxing sugar in food and drink would reduce consumption. Drawing a comparison between taxing alcohol and tobacco to reduce consumption (so called Pigovian taxes), Credit Suisse suggested that a tax on sugary drinks would be effective;

So what would be the effect of introducing a 1% tax per ounce on soft drinks? This would be equivalent to increasing the price of a can by 20%. We see only positive implications if health is the main consideration.“

Since then the pressure to regard Sugar as the root of the obesity problem have intensified. In December 2015 the Royal College of Medicine in England, hosted a Sugar Reduction Summit and summarized the situation;

“Sugar’s role in obesity is increasingly taking centre-stage in the media, with headline grabbing stories not only on its link to obesity but correlations to cancers, cardio-vascular disease, heart disease and diabetes. Scientists and public health professionals have decried the high levels of hidden sugar found in everyday foods from breads to sauces, and drawn parallels between the tobacco and food industries, invoking the rising tide of obesity and questioning whether sugar taxation and additional regulation is an inevitable necessity”.

With this increase in scrutiny, anti-industry rhetoric directed at the wider sugar industry- the food and drink companies providing consumers with high sugar products- has become much more commonplace, including frequent comparisons with tobacco. In one sense, the comparison is natural: if obesity is the new health concern and sugar consumption is key, the parallels are obvious. Also, if tobacco consumption was effectively tackled with regulation it seems natural to apply the same levers to reduce sugar consumption, even if the complex and multi-factoral nature of the obesity problem set it apart from tobacco and smoking. In my opinion, the anti sugar brigade want to go further; they want to impose the same reputation on the industry that tobacco companies now have in health circles. A brief look at the history of tobacco control will explain why.

Tobacco control

Health risk identified

Smoking was identified as a major health risk by the US and UK governments (in particular) in the 1950s, and largely addressed through education campaigns and warnings to consumers. These campaigns were effective but pressure to achieve more built up. At the end of the last millennium the campaign became more confrontational between public health, single issue NGOs (eg ASH -see below) and governments on the one hand, and the tobacco companies on the other.

War declared

The first Action on Smoking and Health, was formed in the US (in 1967) with the UK following suit in 1971. UK ASH declared war on smoking in 1997, followed by the US ASH which started its own war on tobacco in 2000.

By focusing on one issue, smoking, these NGOs were able to present the issues simply. They became effective at attracting media attention and pushing politicians to take action.

Initially the campaigns took the form of proposing extensive regulatory changes eg to reduce smoking incidence and consumption, raise taxes, introduce smoking bans, ban marketing, alter the formulation of the product to reduce tobacco condensate or “tar”, and requiring on-pack warnings. Today, the aim to end smoking is coupled with a fiercely anti industry stance.

Science

Starting in the late ‘50s, a debate ensued between the tobacco companies and health authorities over a number of key issues eg whether smoking caused diseases (particularly lung cancer), whether it was addictive, and if smoking did cause disease was involuntary exposure to second hand smoke a risk. Public health funded vast quantities of research, and presented the results in stark terms. The industry, to avoid being wrong footed, did the same and argued that the answers were not so simple. The industry lost on each count, and many scoffed at its temerity in putting forward alternative views. That they did so is often cited as an example of the tobacco companies’ bad faith. A lesson might be that industry will always struggle to win when it contests health science with health scientists, even if it genuinely believes the issues are more complex than presented.

Litigation

In the 1990s, the US tobacco industry was sued extensively in a wide array of claims, ranging from individual suits, class actions, claims by the different states and finally a claim by the Federal Government.  At one point it seemed that the industry might be forced into bankruptcy. The litigation had two significant outcomes, which have influenced global approaches to tobacco control since. First, the industry was forced to agree a settlement with the states, the Master Settlement Agreement[ix]. The industry conceded important restrictions on its marketing freedoms and paid compensation to the states annually. It was also required to disband its previously powerful Tobacco Association. The concept of “regulation through litigation” was born. Secondly, the litigation process disclosed vast quantities of documents, which were made available to the public to inspect, online if they choose. Some of the documents were useful to opponents wishing to paint the industry as morally bankrupt, exploitative and cynical.

Media

The media, and Hollywood, had a field day. Stories were coming out on a daily basis of “iniquitous” practices discovered in previously hidden industry documents. As well as yards of newsprint copy, a highly regarded film starring Al Pacino and Russell Crowe, “The Insider”, heaped further scorn on an industry increasingly being pummeled towards the ropes. Its reputation was near rock bottom.

Freedom to chose undermined

Two notable issues in the litigation were whether the companies deliberately mislead consumers about the addictiveness of cigarettes, and whether they deliberately marketed their products to children. Focusing on the addiction question allowed health advocates to weaken the industry argument that informed adults should be free to chose whether to smoke or not.

Focusing on vulnerable groups, particular children, strengthened this approach. For example, The Robert Wood Foundation a charity (now actively involved in preventing obesity) established The Campaign for Tobacco Free Kids in 1995, to press the point.

Global engagement and action

Perhaps inspired by the furore in the US, the WHO decided to tackle Tobacco related disease head on. Appointed in 1998, Director General Dr. Brundtland, prioritised malaria and tobacco related disease. Within the WHO, The Tobacco Free Initiative was established to drive the development of a global treaty driving tobacco control worldwide. The resulting Framework Convention on Tobacco Control, (the first global treaty addressing a health issue) was adopted in 2003 and has been the main driver of new tobacco regulation at national level since.

Target and isolate the industry

The WHO, perhaps impressed by the effectiveness of the aggressive tactics employed in the US litigation and recognising the tobacco industry’s poor reputation at the time, effectively decided to declare war as well, not just on tobacco related disease but on the industry it identified as responsible. The WHO’s top priorities- eradicating malaria and delivering a world free of tobacco- were compared in a memorable phrase;

“Just as the mosquito is the disease vector for malaria, the tobacco industry is the disease vector for the tobacco epidemic.”

Provisions of the ensuing treaty, the FCTC, not only encouraged signatories to pursue litigation against tobacco companies[x], but also directed them to refuse to have any dealings with the companies doing business in their countries when introducing the legislation that was intended to bring tobacco under control[xi]. In the WHO’s opinion, the tobacco industry had not just behaved badly in the past but it was irredeemably bad and always would be.

This provision, if applied, meant that national regulators attempting to introduce the long list of tobacco control measures in the FCTC, would not have the ability to consult the companies most affected- a handy way of tilting the playing field, and greatly at odds with good regulatory practice.

Summing up, the key lessons from the tobacco wars might be; attack the product and the industry hard, present the issue as corporate profit vs health- a David vs Goliath struggle, develop your own supporting science and discount the industry’s efforts, give the media plenty to work with, overcome freedom of choice with addiction, make the focus protecting the vulnerable, children especially, and above all make it personal. So are these present in the battle to control to obesity? To a large extent, the answer is “Yes”, and most notably in relation to sugar.

The sugar campaign 

Starting with the science, Professor Lustig and others opened up the debate around 2009, identifying sugar as not only a key cause of Obesity and Type 2 diabetes, but also toxic and addictive. Such emotive terms strike a familiar chord with health officials, used to doing battle with tobacco. They argue strongly for intervention and against the argument that individuals should be free to choose what they consume.

This approach also allows campaigners to bring focus. An issue previously regarded as complex, multi-factoral and requiring collaboration between a wide range of stakeholders could be helpfully narrowed down- reduce sugar consumption. Action on Sugar, (an off shoot of another single issue NGO, Consensus on Salt and Health) was established in the UK in 2004 to focus attention on sugar.

Some academics followed suit. Professor Marion Nestle, Paulette Goddard Professor in the Department of Nutrition, Food Studies, and Public Health at New York University, published her polemic, Soda Politics: Taking on Big Soda (and Winning)[xii], not only singling out sugar but also directing blame for obesity in the US on industry, the soft drinks industry in particular. In presenting the issue as profit driven corporations battling to overcome legitimate public health concerns, Professor Nestle struck a martial tone. War had been declared and The Economist’s review of her book reflected this;

Drinks companies must also reckon with a small army of health advocates, among which Ms Nestle is a major-general.”

Global pressure builds

Although the WHO had been treating obesity as a global epidemic since 2000, it sought to promote collaboration between all stakeholders including industry. However, Dr Margaret Chan,  Director General of the WHO, struck a different note when addressing the 8th Global Conference on Health Promotion in 2013, in Helsinki. She focused on diabetes and went on to describe the challenge of business as opponents of health policies.

“.. it is not just Big Tobacco anymore. Public health must also contend with Big Food, Big Soda, and Big Alcohol. All of these industries fear regulation, and protect themselves by using the same tactics.” 

This language was at odds with the WHO’s official stance towards the food and drinks industry at the time and shocked many.  In contrast to the approach taken towards tobacco, the prevailing view was that health officials needed to work together with industry to develop solutions to the obesity problem.

This approach does not appeal to all. Anna Gilmour (Professor of Public Health, Department for Health, University of Bath and Director, Tobacco Control Research Group, University of Bath), writing in the UK’s Guardian newspaper in 2011 criticized the UK Government for its collaborative arrangement with industry (the Public Health Responsibility Deal) to work on improving public health. Herself a veteran of the tobacco wars, she warned that businesses were inherently untrustworthy, and could not resist using that powerful metaphor from her tobacco days to make the point;

While the government sees food and alcohol companies as partners in health policy, public health increasingly recognises them as vectors of disease[xiii] 

 She continued, 

 “Corporations, whether they sell tobacco, food or alcohol, are legally obliged to maximise shareholder revenue. Their social responsibility is to pursue economic growth rather than health promotion or environmental protection. It is therefore effectively incumbent upon them to oppose any policies that could reduce profitability.” 

Clearly the message is; distrust business and disengage from them, at a minimum, isolate them if possible.

Litigation

Seen in the US as instrumental in forcing the tobacco industry into accepting restrictions, litigation was seriously explored in the US. Beginning in about 2003, cases were filed[xiv], against MacDonalds and other fast food companies in particular. In the event, the cases did not

progress and legislation was introduced in around half the states of the US to prevent such suits. Given that it took over 40 years of trying before any measure of success was registered against tobacco it is too early to say that this weapon has been abandoned for good. “Regulation through litigation” still resonates in the US and given that promoting litigation is actively encouraged by the WHO through the FCTC, it may well arise elsewhere.

Freedom to choose

Recent developments in the UK have brought children further into the spotlight. Jamie Oliver, the celebrity chef and school food campaigner, repeatedly stresses the desire to protect children.

The current UK Health Secretary, Jeremy Hunt[xv], responding to Jamie Oliver, also made the issue personal and involved children in his appeal,

“I have got a one-year-old daughter. On current trends by the time she reaches adulthood a third of the population will be clinically obese,” he said. “One in ten will have Type 2 diabetes. It is a national emergency.” 

Announcing that the UK would introduce a tax on sugary drinks, Chancellor Osborne also invoked the need to protect children, saying it was “doing the right thing by the next generation”.

Nobody denies the importance of addressing Childhood Obesity but describing sugar as toxic, as addictive and a particular risk to children, makes defending the freedom to choose and the freedom of commercial free speech harder. The lessons of tobacco control, it appears, are well learnt. 

Conclusions 

In reality the scientific justification for singling out sugar is far from clear.  Sugar consumption in many developed countries has gone down while obesity and Type 2 diabetes rates have gone up[xvi]. Further, one of Dr. Lustig’s key findings- that disease rates for obesity and Type 2 diabetes have increased as a result of increasing the type of sugar (fructose) found in US soda drinks does not apply in the UK and many other countries, which use sugars made from cane or beet.

The consensus remains that the chief determinant of obesity and Type 2 diabetes in dietary terms, it is the quantity of calories one consumes not which ones. As the WHO Factsheet on Obesity states,

“The fundamental cause of obesity and overweight is an energy imbalance between calories consumed and calories expended”

Diabetes UK, although themselves advocates of regulating to reduce sugar consumption, acknowledge the weakness of the anti sugar science, stating in 2014[xvii]; ‘we want to reduce sugar consumption because having too much can easily lead to weight gain, as is true with foods high in fat. So reducing the amount of sugar in our diets is not all that we need to do to reduce our risk of Type 2 diabetes. The evidence that sugar has a specific further role in causing Type 2 diabetes, other than by increasing our weight, is not clear.’

If public health allows itself and consumers to become single-mindedly focussed on sugar, it risks repeating the risks of the “fat focus” years and losing valuable time in getting closer to workable and effective solutions. It risks misleading consumers again into thinking that they can consume as before so long as it is low sugar, and weakening the important principle that individuals are responsible for themselves and their children.

Nevertheless, it seems likely that regulation to tackle obesity will increase. The 2014 McKinsey study (referred to above) acknowledges that “obesity is a complex, systemic issue with no single or simple solution”. It advocates a broad approach on many fronts. It considers 74 different steps, or interventions, that could be taken and assessed the likely impact of them. McKinsey advocates taking action quickly with as many of these interventions as feasible. Reducing sugar consumption and taxes on food and drink are among these interventions but considered likely to be of limited effect.

With some on the health side of the debate seemingly determined to equate tackling obesity to tackling smoking, and using increasingly confrontational anti industry tactics, there is a real risk that the opportunity to work together will be squandered. The Public Responsibility Deal in the UK has now been abandoned, and it is a concern that leading figures such as Dr. Chan of the WHO use emotive language disparaging the motives and practices of the commercial stakeholders, the food and drink companies.

What the WHO said in 2000 surely remains true today,

“Obesity cannot be prevented or managed solely at the individual level. Communities, governments, the media and the food industry need to work together..”[xviii]

The challenges are, in my opinion; for the food and drinks industry is to lead on the matter wherever it can, for public health to avoid the temptations offered by the single issue advocates keen to draw facile comparisons with tobacco, and for governments to keep cool heads when the temperature rises. Finally, each of these groups should continue to recognize the importance of individuals, responsible for themselves but also has having the freedom to choose.

References

[i] Reuters online- “For sugar tax supporters, 2016 may be the sweet spot” Feb 8 2016

[ii] Tax on sugar added drinks introduced 2014

[iii] Chancellor Osborne announces levy on sugary drinks in UK Budget ,16 March 2016

[iv] BBC interview with Andrew Marr 7 Feb 2016

[v] McKinsey Global Institute, November 2014 Overcoming obesity:
An initial economic analysis

[vi] Jebb, S. (2007) Dietary determinants of obesity. Obesity Reviews 8 (S1): 93-97.

[vii] Johnson, Rachel., et al. “Dietary Sugars Intake and Cardiovascular Health” – Circulation 2009, 120:1011–1020 (2009) August

[viii]  Basu S, Yoffe P, Hills N, Lustig RH (2013): “The Relationship of Sugar to Population-Level Diabetes Prevalence: An econometric Analysis of Repeated Cross-Sectional Data”; PLoS ONe 8(2):

[ix] Master Settlement Agreement, between the US tobacco manufacturers and the AGs of 46 US states, in November 1998. Still in force.

[x] Article 19, FCTC

[xi] Article 5.3 FCTC

[xii] OUP 12 November 2015

[xiii] Emphasis added.

[xiv] see ““From butts to big macs—can the big tobacco litigation and nation-wide settlement with states’ attorneys general serve as a model for attacking the fast food industry? “ Seton Hall Law Review 2004

[xv] BBC Interview with Andrew Marr, 7 Feb 2016

[xvi] Total sugars in the UK diets down 15.4% per capita since 2001, according to UK Government statistics

[xvii]  Quoted in “Sweet Truth,” R. Lyons and C. Snowdon, IEA  2015

[xviii] WHO “Obesity: Preventing and managing the global epidemic  “ 2000