Dr Aseem Malhotra: Taking action on sugar – applying lessons from the salt reduction programme

The food industry is currently adding growing amounts of sugar to our food. Consumers are largely unaware of this, as the sugar is mostly hidden. Not just in the well-known cola brands (8 teaspoonfuls of sugar in one 330ml can), but also in flavoured water (27.5g per 500ml), vitamin water (15g per 500ml) and sports drinks (20g per 500ml). Confectionary is already known to contain high amounts of sugar, but foods like yogurts (15g per 125g pot), canned soup (20g per 400g can), ketchup (4g per 15ml serving), ready meals (7g per 400g serving) and even bread (1g in 1 slice) are among the everyday foods that also contain large amounts of hidden sugar.

Added sugar is a completely unnecessary part of our calorie intake. It has no nutritional value, and has an adverse effect on obesity, particularly as it provides no feeling of satiation. There is also no doubt that it is a major cause of dental caries and dental disease. More controversial, but important to investigate, is the possibility that it also causes other adverse effects, particularly in contributing to fatty liver and diabetes.

A recent WHO-commissioned systematic review of the literature on the association between sugar consumption and body weight has provided strong evidence of an adverse effect of sugar on body weight in adults, and many  studies also suggest an adverse effect on body weight in children, and in making type 2 diabetes more likely.

Various attempts are currently being made to try and reduce sugar consumption, including New York city’s restriction on the size of fizzy drinks and food and drink taxes. These could all play a role in reducing sugar intake, but none has so far been successful and they have been strongly opposed by the sugar and food industry lobbies.  The new initiative aims to overcome these obstacles by following the path already blazed in reducing our consumption of salt.

Over the last 7-8 years the UK has successfully carried out a voluntary salt reduction programme involving a slow reduction in the very large amounts of salt that are alsoadded to our food, both processed foods and foods eaten outside the home.

Salt content has been reduced across the board – by up to 50% in breakfast cereals, 45% in biscuits, 40% in pastry products, 25% in cakes and pasta sauces and at least 20% in bread, consumers are buying less salt to add to food; the consumption of both added salt  and table salt has been reduced. Average salt intake in the UK measured in random samples of adults has fallen from 9.5g to  8.1g per day, i.e. a drop of 15%, and the lowest known figure of any developed country. According to NICE this will have reduced stroke and heart attack deaths by a minimum of 9,000 per year, with a saving in health care costs of at least £1.5bn a year.  Many other countries, including other developed countries such as Australia, the United States and Canada, and many developing countries, acting with the support of the WHO, are adopting a similar target-based approach to salt reduction.

A similar systematic and unobtrusive reformulation programme gradually reducing the amount of sugar that is added to foods could prove to be an equally effective and practical way of reducing added sugar. The concept of taking action on sugar similar to the salt reduction programme, would be to set ‘targets’: a maximum limit, and a sales-weighted average limit, of the sugar in each food and drink category to be achieved by manufacturers. After two years, and in consultation with the food industry, the limits are reset for th next two years, so that there is a constant gradual reduction in the amount of sugar added.  The great advantage of this programme is that it is done in an unobtrusive way; people will not realise that the amount of sugar they are eating has been reduced; it does not require any change in the foods consumed and it affects the whole population.

As with salt, a reduction of around 40% in the amount of sugar added to food and soft drinks could be achieved over the course of four years, which would reduce calorie intake significantly and help reverse the obesity epidemic, according to the Department of Health.  It would make sense to have a concurrent public health education programme to encourage consumers to choose foods with less sugar, to be more aware of the foods that contain hidden sugar, and also to use less sugar themselves.

There are several parallels between salt and sugar. Firstly, most of the sugar is hidden, as is salt, in processed food and for sugar in soft drinks. Secondly, there are specific taste receptors for sugar, which, with a gradual reduction in sugar intake, become more sensitive, so that the reduced levels of sugar are not noticed if the reduction is done slowly. Thirdly, there are no technical reasons why sugar is added to food. In some products sugar does contribute to the weight of the food and therefore the product would be proportionately reduced by the amount that the sugar weighs.

The success of the salt reduction programme has depended on having a very strong NGO with strong advocacy and strong scientific input, as well as strong support from the Food Standards Agency and now, latterly, with the Department of Health. The new initiative aims to set up a similar strong advocacy group with scientific experts on sugar and health. If it can persuade the Department of Health that this programme is very likely to help considerably with the obesity epidemic, and in particular to stop children becoming obese, while also reducing the incidence of dental disease, and (very likely) the number of people developing type 2 diabetes, it should have a good chance of success.

Dr Aseem Malhotra is a cardiology specialist registrar.

For more information on the campaign see Action on Sugar

Disclaimer: The views expressed in this blog are entirely his own

[Originally posted: 9.01.14 on CHPI.com]