Death by sugar

How the sweet killer is fuelling the biggest health crisis of our time

<p>Sugar Cubes on Blue</p>

Sugar Cubes on Blue


Health Canada has announced a new food label proposal that would, among other changes, group all types of sugar together on a label. The idea is to make the amount of sugar in packaged foods more clear to consumers. The proposal would also set a recommendation of a daily maximum intake of 100 grams of sugar per day, something that did not exist before. Learn more here.

In May, Kate Lunau wrote about the staggering amount of sugar Canadians consume on an annual basis. Here’s her story:

At just 12 years old, Maggie Valentine weighs over 200 lb. “My doctor said I’m a statistic,” says Maggie, who has short, wavy blond hair. “I think it has something to do with my weight.” She’s trying hard to shed pounds, following the same advice we’ve all heard countless times. Maggie jogs and kayaks; she regularly swims laps, and walks her dogs. She also does her best to watch what she eats. Her mom buys her “reduced fat foods” in the supermarket, like Triscuit crackers and certain cereals. Despite their best efforts, though, Maggie’s weight stays the same. “Sometimes, it gets a little bit frustrating,” the preteen says quietly.

Maggie is one of several kids and teens featured in Fed Up, a new documentary from executive producer Laurie David, who was behind the Oscar-winning An Inconvenient Truth. It is a powerful call to arms about obesity—a message we’ve been hearing for years, and apparently have yet to heed. Between 1985 and 2011, the obesity rate among Canadian adults more than tripled; by 2019, overweight and obese adults will outnumber those of normal weight in half of our provinces, predicts a new report in Canadian Medical Association Journal Open. Childhood obesity, too, has risen significantly in the past few decades. Obesity is now seen in babies as young as six months old, and it’s become a global crisis. We all know we’re supposed to eat less and exercise more, but that mantra doesn’t seem to be working. What if the accepted wisdom on obesity—that to lose weight, we simply need to burn off more calories than we consume—is dead wrong?

That’s the case presented in Fed Up, and by a number of doctors and experts. Despite what we’ve heard for years, they say that not all calories are created equal, and that some may be worse for us than others. Beyond that, one of our favourite ingredients might be making us sick. It’s something we’re hard-wired from birth to seek out, and it’s been described as addictive. Yet it seems to be spurring on not only obesity, but—if the emerging science is right—other plagues of modern society like heart disease, diabetes, and perhaps even Alzheimer’s. The culprit, these doctors and scientists say, is sugar.

Infographic: How much sugar do you eat in a year?

How much sugar is in that bowl of cereal—or bottle of vitamin water?

Dr. Robert Lustig, a professor of pediatrics at the University of California at San Francisco, who appears in Fed Up, is the most vocal and visible proponent of this way of thinking: that sugar is, as he puts it, a “toxin.” Even a “poison.” If that’s true, we’re in trouble. We consume it in astounding quantities. According to the latest Statistics Canada figures, Canadians downed 110 grams of sugar a day in 2004, from all sources.

That’s the equivalent of 26 teaspoons, amounting to over 21 per cent of our daily calorie intake, and it’s surely gone up since then. Canadians
eat, on average, 88 lb. of sugar per year; the average nine-year-old boy will consume a whopping 123 lb. of sugar per year, and male teens, 138 lb. A Canadian teen’s primary source of sugar, according to the report, is soft drinks. Americans, meanwhile, have a mean daily intake of about 28 teaspoons; over a year, they’ll consume 96 pounds of sugar, according to a U.S. Department of Agriculture spokesperson.

Even for people with the best of intentions, who refrain from eating ice cream, candy and chocolate bars, sugar is almost impossible to avoid. According to Fed Up, of the 600,000 food items sold in U.S. grocery stores, 80 per cent have added sugar. Sugar and its ilk (including high-fructose corn syrup) are added to nearly everything we consume. Pasta sauce. Bread. Salad dressing. Peanut butter. One tablespoon of ketchup can contain as much as a teaspoon of sugar. “Low fat” products, especially those intended for kids, are often the biggest sugar bombs of all. Sugar-laden processed foods are everywhere: even at the local health food store, it’s truly a matter of buyer beware. Honey, agave syrup, fruit juices, and other sweeteners that often appear in “healthier” options—all are sugars.

Amid growing alarm about sugar, the World Health Organization (WHO) recently released new draft guidelines on how much of it we should consume. Sugars should make up less than 10 per cent of our total energy intake per day, it states, a number we already exceed. It further adds that cutting this below five per cent—less than half what Canadians currently consume—would have “additional benefits.” (The guidelines refer to almost all sugars in our diet, not including what’s in whole fruits, vegetables, or dairy.) “The evidence [against sugar] is expanding by the day,” the WHO’s Dr. Francesco Branca said of the new recommendations, voicing particular concern about the “hidden” sugars in processed foods.

Woe to the average Canadian, who almost reaches the WHO’s upper 10 per cent limit with just one can of regular pop, and gets within spitting distance of the five per cent lower cutoff after a four-ounce serving of regular Activia yogourt. Still, they wouldn’t know it from checking the nutrition information listed on the product. On the “nutrition facts” panel on Canadian food labels, the grams of sugar in a serving is listed. But what percentage that represents of our daily intake remains a vacant space, as it does in the U.S. Health Canada doesn’t set a recommended limit on sugar consumption (although it says it’s reviewing the WHO’s proposal). A number of experts and groups, like the Childhood Obesity Foundation, are calling on Health Canada to set a daily recommended sugar limit.“It’s so revealing of how the processed-food companies are more powerful than the regulators, supposedly watching them on our behalf,” says Michael Moss, Pulitzer prize-winning author of Salt Sugar Fat: How The Food Giants Hooked Us. “Look at that nutrition fact box—there’s a huge gaping hole next to sugar. They’ll tell you how much is in the product, but not how much is added, and how much is natural. And they won’t tell you how much sugar to eat.”

Industry maintains there’s good reason for this. “Science hasn’t found a specific level of sugar that causes harm,” says Sandra Marsden, president of the Canadian Sugar Institute (CSI), which represents our country’s sugar manufacturers. As part of the WHO’s public consultation, which wrapped up in March and will lead to a final report, the CSI swiftly submitted comments listing perceived problems with the new guidelines, as did other industry groups, including the Canadian Beverage Association (CBA) and Food and Consumer Products of Canada (FCPC). “There is no evidence for a five per cent limit,” adds Maisie Vanriel of FCPC, which represents our food product manufacturers. “Even as a dietician, it would be a toughie for me.”

How much sugar do you eat in a year? Click to view our infographic.

Critics accuse food and drink companies of putting the bottom line ahead of consumer health. The fiercest critics draw a comparison they surely dread. “The industry is responding to obesity exactly how tobacco responded to concerns about lung cancer,” says New York University dietician Marion Nestle, author of Food Politics: How the Food Industry Influences Nutrition and Health. “Attack the science, undermine the critics, [pay for] industry-funded studies.” In a study published in PLOS Medicine in December, researchers looked at 17 papers on sugar-sweetened drinks and their relationship to weight gain and obesity. They concluded that those papers in which authors had a “financial conflict of interest with [the] food industry” were five times more likely to find no association between sugary drinks and obesity.

David Moran of Coca-Cola Canada counters: “Tobacco cannot be consumed in a healthy manner whatsoever. We’re a beverage company. Beverages fit into a healthy lifestyle, but it depends on how active you are, and how many calories you consume.”

There’s a war under way, and consumers are at the heart of it. Heather Reisman, CEO of Indigo Books & Music and an executive producer of Fed Up, is hoping to spark a cross-country movement toward healthier eating, a decision that will impact her company’s bottom line. “We’re eating way more [sugar] than we used to, and it has this really bad effect,” she says. Indigo is removing all sweets from its impulse section (although they will still be sold further back, with teas), which is expected to cost the company $3 million per year. “We know that has a financial impact,” says Reisman. “It’s a small step we can take to show leadership.”

The danger that sugar presents “has nothing to do with the calories,” Lustig says in a YouTube video called “The bitter truth,” which has been viewed over 4.6 million times. “It’s a poison by itself.” Poison or not, we’re programmed to seek it out, and our brains are wired to crave more. It’s a craving that industry understands and anticipates.

Forty years ago, a similar fear gripped consumers in Canada and the U.S., but back then, the enemy was dietary fat. With heart disease rampant, groups like the American Medical Association and the American Heart Association called for a reduction in fats. Food companies rolled out new lines of health-conscious, “low fat” products. (A low-fat label, it turns out, persuades us to eat as much as 50 per cent more, according to Cornell University’s food and brand lab.)

The problem was, these new foods tasted “like cardboard,” Lustig says. To make their offerings more appealing, manufacturers added sugar, or high-fructose corn syrup (“glucose-fructose” on Canadian food labels), which made its appearance on North American store shelves in the 1970s. Not only is high-fructose corn syrup much sweeter than refined sugar, it’s also way cheaper, and soon it was in all sorts of foods that shoppers might not expect, from pretzels to deli meat to processed cheese.

It’s human nature to seek out a sugar rush. High-calorie food stimulates the same parts of our brain as drugs and alcohol, brain-scan studies have shown. “Sugar, fat and salt are the basic drivers for survival,” says Dr. David Jenkins of the University of Toronto, who holds the Canada Research Chair in nutrition and metabolism. For most of our history, “we’ve struggled like mad to get sugar,” and now, within just a few decades, we’ve become buried in it. Before food processing, when we got sugar mainly from fruits and vegetables, we consumed about 30 grams per day of it, according to Lustig’s estimates. By 1977, Americans consumed more than 70 grams per day, and by 1994, it was 110 grams.

With food scientists focused on how to make their products tastier, cheaper and more convenient, resisting the lure of processed food became all but impossible. “It starts with the bench chemists,” says Moss, who’s spent years investigating the inner workings of the food industry. “Through trial and error, they determine the perfect amount of sugar, salt and fat.” Moss describes his encounters with Howard Moskowitz, the mastermind behind bestselling Cherry Vanilla Dr. Pepper and other blockbusters. “He coined the term ‘bliss point,’ ” Moss says, “that perfect amount of sugar that’ll send us over the moon, and will send products flying off the shelves.”

But sugar isn’t just incorporated into food and drink as a taste enhancer. “It provides so much more,” Moss continues. “It’s the preservative that allows [foods] to sit in the warehouse for months. Or the cheap substitution for other ingredients, like fresh herbs and spices, or fully ripened tomatoes.”

Soon enough, people were consuming sugar—whether they knew it or not—at breakfast, lunch and dinner. Food manufacturers “added sugar to things that didn’t used to be sweet,” Moss continues. “Flavoured yogourt can have as much sugar as ice cream,” making plain yogourt taste unforgivably bland by comparison. “It teaches us to expect sweetness all the time,” he says.

All sugar, even high-fructose corn syrup (now vilified as “unnatural”), is processed by the body in pretty much the same way. “Physiologically, sugar is sugar,” Nestle says. Refined sugar consists of glucose and fructose molecules bonded together. Sugar’s fructose component is metabolized mainly by the liver, which is what Lustig and others believe makes it uniquely dangerous. When it hits in a rapid dose, say a soft drink or a Twinkie, it’s quickly converted to fat in that organ. Doctors don’t worry about fruits and veggies, because they’re full of fibre and digest more slowly, giving the body a chance to use up stored energy. And fibre leaves us feeling full, unlike a handful of candy. (The jury’s still out on artificial sweeteners, but studies have linked them to weight gain, suggesting they prime the brain to seek out high-calorie sweets later.)

Infographic: How much sugar is in that bowl of cereal—or bottle of vitamin water? Click to view.

Of course, as a source of calories, eating lots of sugar leads to extra pounds. But it’s more complicated than that. While sugar isn’t the direct cause of diabetes, for example, it seems to spark a cascade of effects that wreak havoc in the body. Dariush Mozaffarian, a cardiologist and epidemiologist at the Harvard School of Public Health, explains: “Fat in your liver is linked to insulin resistance,” when the body no longer makes good use of that critical hormone, which helps cells throughout the body absorb glucose and use it for energy. Glucose then builds up in the bloodstream, raising the risk of Type 2 diabetes. Type 2 diabetes is now common, most alarmingly among kids—which was all but unheard of less than three decades ago. By the year 2050, according to Fed Up, one in three Americans will have diabetes.

Metabolic syndrome affects 20 per cent of Canadians. It’s a cluster of risk factors, from having a big waistline and fat packed around the abdomen, to high blood pressure, both of which raise the risk of cardiovascular disease—and again, Type 2 diabetes. In February, a study published in JAMA Internal Medicine found that consuming added sugar was associated with increased risk of death from cardiovascular disease. (Although the Heart and Stroke Foundation of Canada takes a position on several issues around nutrition, from sodium to trans fats, it has yet to make a recommendation about sugar intake. It’s working on one.)

Even the rising Alzheimer’s epidemic could be linked, at least in part, to our modern diets. Suzanne de la Monte, professor of neurosurgery at Brown University, suggests that Alzheimer’s might be a form of insulin resistance in the brain—a “Type 3 diabetes,” as she calls it. Insulin, she explains, is “the master hormone” throughout the body, including in the brain, where it plays a crucial role in plasticity, and stimulates brain cells to take up and metabolize glucose for energy. While Alzheimer’s does have a genetic component, “you can’t really explain this soaring increase in Alzheimer’s disease on the basis of genes alone,” de la Monte says. “It has to be the environment, because we’ve changed the environment and what we eat so drastically.”

Still, there’s roiling debate among scientists about whether the fructose in sugar really is the devil that Lustig and others make it out to be. Dr. John Sievenpiper, a scientist at St. Michael’s Hospital’s Li Ka Shing Knowledge Institute in Toronto, has published a series of papers concluding that excess calories from fructose aren’t any worse from other sources. He believes science doesn’t justify recommending a daily limit for sugar consumption: “I don’t care if it’s five grams or 100 grams,” says Sievenpiper. “If it’s providing excess calories, it’s a problem.”

Others fire back that sugar can be a danger, but add that refined starches are just as bad, and of course we consume those in huge quantities, too. Unlike sugars, these are only made up of glucose, which isn’t metabolized like fructose in the liver. Yet if it comes in a rush, from a piece of white bread, for example, it’s converted to fat in the liver, too, says Mozaffarian. He was lead author on a 2011 study in the New England Journal of Medicine, finding that some foods are more likely to pack on pounds—and undermining the notion that all calories contribute equally to weight gain. In his paper, the foods most associated with extra weight were potato chips, sugary drinks, and the old staple of many dinner tables: potatoes. Fibre-rich foods like fruits, veggies and nuts had the opposite effect. “Eating a piece of white bread is no different than Skittles,” Mozaffarian says. “It’s basically sugar.”

Investigative health and science journalist Gary Taubes, author of Why We Get Fat: And What To Do About It, thinks that when it comes to obesity and other conditions, “sugar is probably the primary problem,” pointing to traditional Asian cultures, where white rice is a staple, and which had low rates of obesity and diabetes until recently. He’s co-founder of the Nutrition Science Initiative, a non-profit funding two upcoming studies that will track overweight and obese people, while tinkering with their diets (in the second study, virtually all carbs will be replaced with fat). These studies, Taubes says, are intended to test what he calls “the central dogma of obesity, that a calorie is a calorie.”

It’s a message we hear from the food and drink industry over and over again: that a calorie is a calorie is a calorie, and that the true cause of obesity is a failure to burn them off. “Sugar is like any source of calories,” says Marsden, of the Canadian Sugar Institute. To lower the risk of obesity, she says, “you need to focus on total calories and activity.” “It’s always been very important to the sugar industry that a calorie is a calorie,” says Taubes. “As long as people think we get fat [just because] we eat too much, industry can say, eat in moderation, and exercise more,” but don’t abandon a beloved product.

The worry is that much of the debate around sugar plays right into industry’s hands. Like a game of Whac-A-Mole, as soon as one ingredient—whether it’s gluten, peanuts, trans fats, or something else—is pegged as particularly harmful, companies rush out a line of products with a reduced amount of that “problem” ingredient, but these new products aren’t necessarily healthier. “Industry loves it when we concentrate our concern on one thing, whether it’s sugar, fat or salt, because they can adjust,” Moss says. “They can lower the amount of sugar, and boost fat and salt, and put it on shelves next to the regular version. It will increase sales,” he says, “not diminish them.”

When it comes to the food industry, a consumer can feel a bit like David before Goliath. Designing the perfect products to reel us in, scientists consider everything from the ideal noise level for the crunch of a chip, to something called “vanishing caloric density,” that feeling when a food hits the tongue (think ice cream or Cheetos) and all but disappears, leaving an insatiable craving for more. Laden with sugar, fat and salt, these products are palatable, convenient and cheap.

The companies’ genius extends from the lab to the shelves of our local grocery store. Take the cereal aisle. In a new study that looked at 65 cereals in 10 different U.S. supermarkets, researchers from Cornell found that those intended for kids are placed half as high on shelves: about 58 cm, compared to 122 for adults. What’s truly unnerving, though, is their second finding—that the colourful mascots on those boxes gaze downward, on average, at a 9.6-degree angle, so their eyes essentially follow kids. (Characters on adult cereal, meanwhile, mostly stare straight ahead, locking eyes with us.)

Marketing to children has been, and remains, one of the most controversial practices of the food industry. In the U.S., it’s extremely hard to limit, says Kelly Brownell of Duke University’s Sanford School of Public Policy. “The first amendment protects speech, and one form is commercial speech,” he explains. Since 1980, Quebec has banned all marketing to kids under 13, and the province “is ahead in that regard,” says obesity expert Yoni Freedhoff, medical director of the Bariatric Medical Institute in Ottawa, and author of The Diet Fix: Why Diets Fail and How to Make Yours Work.

But even without Cap’n Crunch peering down from the cereal aisle, processed food, for kids, is nearly impossible to avoid. Fed Up explores its encroachment into U.S. schools where, because of cutbacks and industry pressure, fast food lunches are the norm. (In the documentary, Duke University’s Brownell compares schools to “a 7-Eleven with books.”) School lunches “are horrendous here, too,” says Freedhoff, an adviser on Fed Up, who decries “the use of junk food in fundraising, and to reward, pacify and entertain kids. It’s so normal now,” he continues, “that when we speak up against it, people get mad.”

Efforts to reduce sugar consumption can lead to friction with big companies. In 2012, Coca-Cola sent letters to Ottawa city councillors over a public health campaign urging people to cut back on sugar-sweetened drinks. Stephanie Baxter of the Canadian Beverage Association explains: “No one single food or beverage is responsible for weight gain and obesity. By targeting one category, you’re creating a false sense [of security] for consumers.” Following a meeting between public health officials, Coke representatives and the CBA, the Ottawa campaign, which emphasizes nutrition and activities like walking, continues. “At the time, there was some misinterpretation we were targeting particular companies or products, which was unfortunate,” says Sherry Nigro of Ottawa Public Health.

Brownell is buoyed by a renewed push to remove junk food from U.S. schools—one that began at the local level, with individual districts. Ontario, too, introduced its new school food and beverage policy in 2011, which includes beefed-up nutrition standards.

Although New York’s famous “soda ban,” which would have limited the size of sugary drinks, is stalled before the courts, the ideas of taxes and bans are no longer so far-fetched. In November, for example, voters in San Francisco will decide whether to support a tax on sugar-sweetened beverages.

Last year, for the first time, Coca-Cola addressed obesity in a global television campaign. Its ad highlights the company’s more than “70 low- and no-calorie choices,” smaller portion sizes, and the move to post calorie content on the front of the can or bottle. (This initiative was launched by the Canadian beverage industry in 2011.) In schools, Coke offers healthier choices like water, juice and diet drinks, it notes. The ad concludes with a familiar message. “All calories count,” the female narrator says over images of kids and teens dancing, jogging and playing hockey. “No matter where they come from, including Coca-Cola and everything else with calories. If you eat and drink more calories than you burn off, you’ll gain weight.”

Observers like Freedhoff insist we can’t expect the food and drink industry to solve the obesity crisis. Companies are out to make a profit—and will keep selling us products we’re willing to buy. “These aren’t social service organizations,” he says. Change has to come, Freedhoff maintains, from “empowering the individual to understand the marketplace, whether it’s calorie counts on menu boards, banning certain claims on the front of packages,” or issuing clear guidelines on how much sugar we should have in a day.

Following its public consultation, the WHO is now finalizing its updated guidelines on sugar. Earlier this year, Health Canada launched a public consultation of its own: one aimed at improving our country’s nutrition labels. Many will be watching to see what is said about sugar. For now, though, that space on every nutrition label in the country remains troublingly blank.