Sugar, the bitter truth

Robert Lustig is a paediatric endocrinologist and childhood obesity expert at the University of California. He is one of the most vocal of the anti-sugar campaigners. Lustig is uncompromising in his condemnation of sugar as the cause of the obesity epidemic having serious impact on both children and adults.

He also asserts that governments around the world, under pressure from powerful food producers, have kept this fact hidden. But this is changing gradually, as even the World Health Organisation (WHO) has tinkered with one of its age-long recommendations.

Owing to the obvious effect excessive sugar consumption is having on populations around the world, a WHO guideline, which was released last month, recommended that adults and children reduce daily intake of free sugars to less than 10 percent of their total energy intake.

But this is not the first time the WHO is recommending that quantity. It first did so in 1989, based on the findings of its study group. By 2002, a joint WHO/FAO Expert Consultation sustained the recommendation. However, what is new in the current recommendation is that the organisation added a covert, which states that “a further reduction of free sugar consumption to 5 percent or roughly 25 grams (6 teaspoons) per day would provide additional health benefits.”

What the WHO refers to as free sugar are monosaccharides (such as glucose, fructose) and disaccharides (such as sucrose or table sugar) added to foods and drinks by manufacturers, cooks or consumers. Sugar is also present in honey, syrups, fruit juices and fruit juice concentrates.

To clarify the change in position of the organisation, Francesco Branca, director of WHO’s Department of Nutrition for Health and Development, says “we have solid evidence that keeping intake of free sugars to less than 10 percent of total energy intake reduces the risk of overweight, obesity and tooth decay. Making policy changes to support this will be key if countries are to live up to their commitments to reducing the burden of noncommunicable diseases.”

In Nigeria, sugar consumption soared in the last two decades. National consumption rose from 771,890 tons in 2000 to 1.2 million tons in 2012. Within this period, per capita consumption undulated between 11.2kg and 6.6kg. Understandably, the population has grown consistently at 2.6 percent for most of the period, but the product offering, coated in sugar, has grown even faster.

“Traditionally, we used to give our children more of akara, fruits and homemade foods as snacks, but the changing dynamic of manufacturing exposes more children to sugary drinks of all types: biscuits, cakes, chocolates and other foods laden with sugar these days,” says Dr. Olabode Ijarogbe, president, Dental Association of Nigeria and consultant dentist at the University of Lagos Teaching Hospital, Akoka.

There is no guarantee that the situation will not get worse. According to the United States Development of Agriculture (USDA), Nigeria’s sugar market has a potential of 1.7 million tons. High demand has led to massive investment in local production; as of year-end 2014, four key players pledged to invest $2.6 billion in sugar processing as only 10,843 tons are produced locally. But increased consumption has come with its high toll on health.

WHO’s new recommendations are based on analysis of the latest scientific evidence. This evidence shows, first, that adults who consume less sugar have relatively lower body weight compared with their peers. Secondly, it is believed that increasing the amount of sugars in the diet is associated with a weight increase. In addition, research shows that children with the highest intakes of sugar-sweetened drinks are more likely to be overweight or obese.

The recommendation is further supported by evidence showing higher rates of dental caries (commonly referred to as tooth decay) when the intake of free sugars is above 10 percent of total energy intake compared with an intake of free sugars below 10 percent of total energy intake.

Based on the quality of supporting evidence, these recommendations are ranked by WHO as “strong.” This means they can be adopted as policy in most situations, says the WHO. But the effect of high sugar is already evident in Nigeria.

According to Ijarogbe, “the effect of excessive consumption of sugar on the teeth of children and adults are similar. Sugar and other fermentable carbohydrates, after being hydrolysed by salivary amylase, provide substrate for the actions of oral bacteria, which in turn lower plaque and salivary pH. The resultant action is the beginning of tooth demineralisation.

“Sugar, especially those from starchy foods and carbonated drinks, plays a role in the kind of tooth decay which is becoming more frequent in Nigeria.”

In the United States, Riva Touger-Decker and Cor van Loveren, both scientists, published a research paper in the American Journal of Clinical Nutrition that stated that “a dynamic relation exists between sugars and oral health exists.”

On whether low sugar variants of carbonated drinks are less of a problem, Ijarogbe says the research in that direction is still forthcoming. But beyond teeth, excessive intake of sugar has broader implications on the human body.

A study conducted by Drs. Jean Welsh and William Dietz, published by the American Dietary Society, linked excessive intake of sugar-sweetened soft drinks with weight gain, and incidence of diabetes.

Using a sample of 91,249 women surveyed in an eight-year period, they discovered that total calorie intake increased an average of 358kcal per day for women whose sugar-sweetened soft drink consumption increased from less than one bottle per week to more than one bottle per day.

Average weight gain for this group, adjusting for dietary and lifestyle confounders, was 4.69kg. For those whose consumption decreased from one bottle per day to less than one bottle per week, average total calorie intake decreased by 319kcal/day, and average weight gain was 1.34kg.

Iyawe Osadiaye Hanson, a member of the Nutritional Society of Nigeria, suggests that sweetened food should be consumed in moderation, “parents should imbibe the attitude of giving their children fruits and milk instead of sweet drinks. Apples, bananas, oranges, pomegranates, grapefruit, tangerines, avocado, tomatoes, and vegetables are very good and should replace sweetened drinks.”

Consuming sugar-sweetened beverages, such as soft drinks, fruit drinks, iced tea, and sports drinks, may increase your chances of developing Type 2 diabetes. Being overweight, physically inactive and eating the wrong foods all contribute to our risk of developing Type 2 diabetes. Drinking just one can of (non-diet) soda per day can raise our risk of developing Type 2 diabetes by 22 percent, researchers from Imperial College London reported in the journal Diabetologia. The scientists believe that the impact of sugary soft drinks on diabetes risk may be a direct one, rather than simply an influence on body weight.

The prevalence of diabetes mellitus is on the increase globally, with a more rapid increase in developing countries, including Nigeria. It is estimated that currently, 366 million people are living with diabetes and this will rise to 552 million by 2030, globally. Nigeria has about 4-6 million people living with diabetes with variations in rural-urban prevalence. Diabetes is a common cause of sudden death, amputations, kidney failure, heart attacks, stroke and blindness in Nigeria.

The WHO says “countries can translate its recommendation into food-based dietary guidelines that consider locally available food and customs. Additionally, some countries are implementing other public health interventions to reduce free sugars intake.

These include nutrition labelling of food products, restricting marketing to children of food and non-alcoholic drinks that are high in free sugars, fiscal policies targeting foods and beverages high in free sugars, and dialogue with food manufacturers to reduce free sugars in processed foods.”

The Americans have been at the forefront of doing this. While Nigeria does not have a policy document that recommends food, it is now left for the citizens to make their choices. But it is also imperative for governments within the country to set minimum standards for food labeling, as the citizens should also make effort to better understand the content of food labels.