Let us not get out hopes up. Public Health England is in a very difficult position. Faced with unprecedented levels of obesity and diabetes, with a nation that keeps getting fatter and sicker, the agency clearly has to act. The obesity and diabetes epidemics represent a “slow-motion disaster,” as Margaret Chan, director general of the World Health Organisation, phrased it. So inaction is unacceptable.
Yet virtually everything PHE does now is likely to be either too little – unlikely to have any meaningful effect on the prevalence of obesity and diabetes – or too much, in that the industries that may indeed be responsible for the problem are likely to fight it. While the Treasury develops a levy for sugary soft drinks, PHE hopes to induce the producers of sugary foods to reduce the sugar in their products by 20%. If they can reformulate the product, all the better. If not, they should shrink the size of the product itself.
Commendable as PHE’s initiative is, reasons to be pessimistic abound. The programme is based on the idea that sugar does its damage to the body and to children merely through the calories it contains. As such there’s nothing particularly unique – either toxic or addictive – about sugar, as I and others have been arguing. We just consume too much of it.
Guidelines say children should have a maximum of 24-30g of sugar per day – a third of what they’re actually consuming
On the one hand, it’s hard to win a legal battle with an industry when the best you can argue is that we like their products a little too much for our own good. Some rigorous research targeted at answering the question of whether sugar has toxic qualities independent of its calories would help enormously here, even if it took years to complete.
On the other hand is the simple question of how much we can expect a 20% reduction in sugar to help. Will it curb the epidemics? Avert the slow-motion disaster? PHE predicts that this voluntary sugar reduction program will result in 200,000 fewer tonnes of sugar consumed in 2020 than are consumed today, and so 20% fewer overweight children as well. As Ernest Hemingway’s Jake Barnes might have put it in The Sun Also Rises, “isn’t it pretty to think so?”
Even if a 20% reduction in sugar consumption is achieved in three years (and that alone may be unprecedented) it pales in comparison to what health officials imply is necessary to get children eating healthier. UK guidelines now suggest that children should be consuming a maximum of 24-30g of sugar per day – six to seven sugar cubes. Even less for kids under six. According to a recent PHE survey, that’s one-third of what they’re actually consuming (much of which apparently comes in the morning as part of what their parents think of as a healthy breakfast).
So now, assuming industry goes along with this voluntary programme, and assuming that kids don’t respond to smaller portions or sugar-reduced formulations by eating more, both of which are possible, what’s the chance that we’ll see a significant curbing of the epidemics, even if the 20% goal is reached?
Let’s use cigarettes and lung cancer as our pedagogical example, confident, as we are, that cigarettes cause lung cancer. Cigarette consumption in the UK peaked in the mid-1970s when half of all men smoked and over 40% of women. Together they averaged 17 cigarettes a day. Now let’s imagine that we didn’t get those smokers to quit, but we managed to cut their consumption by 20%. Instead of 17 cigarettes a day, they’re averaging 14.
Would we expect to see a decrease in lung cancer prevalence? Would we expect that the lung cancer epidemic would be curbed at all, let alone within a few years of peak consumption? I would wager that even the PHE authorities would acknowledge that such a change would have little effect. Reasons here, too, would abound. Among them that it takes lung cancer risk 20 years to return to baseline after the smoker quits. So these 14-a-day smokers would still be at high risk, albeit perhaps not quite as high.
Indeed, in the US, per capita smoking began to decline in the mid-1960s, immediately after the surgeon general’s landmark Report on Smoking and Health. Lung cancer rates stopped rising only 30 years later. By then, per capita consumption had dropped by almost 50%. More importantly, when it comes to cigarettes, public health authorities don’t target the number of cigarettes smoked, but the number of smokers. Cut that number significantly, as we did, and lung cancer rates fall.
We see an overweight child with a chocolate bar and our tendency is to think that the chocolate bar is the proximate cause. Get rid of that chocolate bar, or shrink it in size, and we have a child who never gets overweight to begin with. But these epidemics of obesity and diabetes have been in the works since the late 19th century, cooking along, quite likely passed down from sugar-eating mothers to their children even in the womb. If so, our kids are getting fatter not just because they’re eating sugar, but because they’re programmed – epigenetically, in the scientific lingo – before they’re even born.
This epidemic has deep roots and may require drastic action to curb. That PHE is acting is admirable. But maybe we should treat this like cigarettes: aim to curb the number of sugar consumers, rather than the amount of sugar they consume. It will still take time to see an effect, but the odds of success will rise.