Pearls and Irritations

“A spoonful of sugar helps the medicine go down”, according to Mary Poppins. Many more spoonfuls of sugar currently pervade our lifestyles and unconscious food choices. The recent media focus on sugar has been remarkable, but the media frenzy has sought a single solution, a quick fix, to what is in reality a complex problem: childhood and adult obesity. Rapid increases in obesity rates have occurred since the late 1980s in Australia and in many other countries, and even if starting to plateau, still leaves 63% of adult Australians overweight or obese.

Sugar is pervasive, not only (as we might expect) in fizzy drinks and sport drinks, but also added to a surprisingly wide range of foods. These include tomato or chilli sauces, muesli bars, as well as many “low fat” marketed foods (some yoghurts for example) which are high in added sugar. But is sugar the culprit? or is it just a marker of a trend towards increased processed food, increased consumption of convenience foods, and acculturation of our taste towards increased salt, increased sugar and increased fat ? All of these contribute to the “wicked problem” of weight gain, exacerbated by decreased physical activity at work and play, and through increased car use to get to or from places.

But how does all this relate to sugar? A recent commentary in the Sydney Morning Herald (Peter Martin, April 2) called for soft drink taxes to be introduced [i]. The idea is that we all have to eat something, but some foods contain almost exclusively sugar, and soft drinks and so-called sport drinks contain almost nothing else (what nutritionists call “empty calories” as they lack any of the nutrients, vitamins or fibre that other high sugar foods, such as fruit may offer). High levels of consumption of empty calories from sugar sweetened beverages is a clear and independent contributor to weight gain in many epidemiological studies[ii].

Many arguments are raised against efforts to curb sugar consumption. Firstly beverage manufacturers assure us it is part of a healthy and “balanced” diet. It seems un-balanced if it’s just adding to our total energy intake, and yet corporate marketing portray empty calories as contributors to a glowing lifestyle image and as a metaphor of well-being. One must be cautious of the motivations of the food industry according to Dr Margaret Chan, Director-General of the World Health Organisation. At the 8th Global Cnference of Health Promotion in Helsinki (2013)[iii] she said “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 (of) lobbies, promises of self-regulation, lawsuits, and industry-funded research that confuses the evidence and keeps the public in doubt”. They also contribute to the polarised argument between individual choice to consume unhealthy foods, compared to structural, societal and cultural factors that contribute to us doing so. If we accept that we are mired in advertising and cultural depictions promoting unhealthy foods, in sponsorships of major sporting events and of the Olympics, then our cultural milieu is defined by these products. Governments that choose to address the problem this way are accused of “nanny state interventionism”, but it does require complex counter marketing against unhealthy products, facilitating access to affordable healthy choices, and mandating external industry regulation (as the food industry does not self-regulate well, as demonstrated when self-regulation was tried in restricting advertising of unhealthy foods to young children).

One strategy, suggested by Peter Martin is the introduction of a sugar tax. This will be a differential tax, with the greatest impost on food items with the most sugar, and lesser taxation imposed on foods with less added sugar. This approach has been implemented in Mexico where a 10% tax has resulted in a 12% decline in the consumption of sugar[iv] sweetened beverages. Such taxes have community support and are evidence based[v]. Free-market advocates claim this is unfairly “taxing the poor”, but from a public health perspective targeting those at social disadvantage and targeting children and adolescents are exactly the groups who consume the most sugar sweetened beverages. An even stronger rationale for a sugar tax is that it will generate revenue, just as tobacco taxation has done for several decades. This can fund the substantial government investment required for comprehensive obesity prevention, extending well beyond simply reducing sugar. This could be used to support comprehensive obesity prevention efforts, and are supported by the majority in the community. This is our only chance to build the infrastructure for a healthier community and a healthier food environment in Australia. Thus preventing obesity just won’t happen with any single strategy, and a sugar tax is but one financial mechanism for funding the complex solutions required.

Finally the problem is not only sugar. The Hippocratic maxim of exercise and diet in moderation still holds, and while the media in faddist fashions present us with new single solutions and quick fixes, a prudent approach would be to eat less overall, eat less fat and less sugar, consume mainly fresh produce and mostly plant-based foods. Diets like the Mediterranean diet show such balance, and combined with more active daily lifestyles (and non-smoking) are the only way to make real improvements to population health.

Adrian Bauman, School of Public Health and Charles Perkins Centre, Sydney University

William Bellew is Adjunct Professor, School of Public Health, Sydney University.

[i] http://www.smh.com.au/comment/obesity-its-time-to-tax-soft-drinks-20160330-gnum4b.html

[ii] Malik VS et al. American Journal of Clinical Nutrition. 2013;1;98(4):1084-102

[iii] http://www.who.int/dg/speeches/2013/health_promotion_20130610/en/

[iv] Colchero MA et al British Medical Journal 2016 Jan 6;352:h6704.

[v] Escobar MA et al. BMC Public Health. 2013 Nov 13;13(1):1.

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