View from the Nutritional Battlefield

Dangers of Sugar - Robert Lustig

Between February and April, three separate skirmishes in the most recent nutritional battle came fast and furious. One more is coming on May 9. And they are all related — to sugar. The dust has yet to settle, but we must try to make some sense of all this as the fog lifts — both to take stock of our current position, and also to get ready for the next phalanx from the food industry, which will likely start May 9 and run through November in an attempt to co-opt votes on Election Day.

First, Ogden et al. from the CDC[1] released the newest obesity figures for the country, and for different age groups. The results were primarily bad news (in fact the CDC press release was decidedly negative); yet the media were quick to pick up on the one ray of hope found in the study. Among toddlers 2-5 years old, obesity prevalence was reduced from 13.9% to 8.4% in the decade 2003-2012. Interestingly, this reduction was seen only in 2011-2012, rather than a steady decline over the decade.

Ms. Obama, who has a lot invested in Let’s Move, and is under enormous pressure to demonstrate some successes, was quick to praise this study. “I am thrilled at the progress we’ve made over the last few years in obesity rates among our youngest Americans.”

But is it really true? Maybe the reduction is driven by just the toddlers entering the 2 year old bin — we don’t know. What about the other age groups? Maybe some news in that obesity prevalence in the 6-11 year old age group remained constant over this time period. However, that’s where any good news stops. Obesity rates for every other age group (12-80 years) continued its inexorable climb. Furthermore, another study from Skinner et al[2] using the same dataset argue that obesity in all children in all other age groups is rising, and the toddler age group is not declining; they argue that by going back to 1999 instead of 2003 (like Ogden did) wipes out the statistical association, because the 2003 data showed an isolated uptick.

Do these studies really tell us anything? Toddlers are not in control of their environment. Toddlers spend their time in private daycare; not in public schools. There’s no National School Breakfast or Lunch Program for toddlers. Indeed, juice consumption has been shown to predict increasing BMI over time in inner-city Harlem toddlers[3]. The outcry over childhood obesity has become so loud in this last decade since Time Magazine’s “Fat for Life?” cover story that the American Academy of Pediatrics has cut its upper limits for juice consumption, daycares have started to cut back on the Capri Sun, and mothers have reduced the amount of chocolate milk at home. In other words, “control the environment”. Toddlers can’t exercise personal choice or personal responsibility, because their environment is controlled. But in the case of the other age groups, where environment is not controlled, the march of obesity continues unabated.  No surprise. The lesson to be learned from this study is not that toddler obesity is declining, or that Let’s Move is a success. Rather, the nugget of truth is that you can’t control behavior, but you can control the environment, even around sugar. And we have to.

Second, the unveiling of the FDA’s proposed changes to the Nutrition Facts (read: Nutrition Warnings) label.  This marks the first change in nutritional guidance in this country in two decades — and given the volume of science that has been elaborated in that time, clearly long overdue. Ms. Obama was all smiles over this as well. “Our guiding principle here is very simple: that you as a parent and a consumer should be able to walk into your local grocery store, pick up an item off the shelf and be able to tell whether it’s good for your family… So this is a big deal, and it’s going to make a big difference for families all across this country.” True or not true?

Here’s what the new nutrition label does:

1) The serving size will change to reflect what is in the bottle or package, rather than expecting people to do the math on figuring their portion allotment.

2) The FDA dropped their obsession with fat, by removing the line listing “calories from fat”. This is a decided improvement, as the science shows that dietary saturated fat neither makes you obese nor gives you heart disease (unless you have the genetic disease familial hypercholesterolemia, which is 1 in 500 people).

3) The number of calories will appear in larger print, but the focus is still on calories. Is this good or bad?  The New York City menu labeling studies of 2009 showed that knowing the calories didn’t alter people’s caloric intake at fast food restaurants; that “Taste is King”. Furthermore, the calories have always been on the label. What makes FDA think that a bigger font will change behavior in the grocery store?

4) The Percent Daily Values (%DV) will be on the left, rather than the right. And finally, hold for the drum roll,

5) The inclusion of the added sugar by the manufacturer will be listed on the label. This matters, and if it holds up, will be big news. Added sugar has been shown to cause weight gain, heart disease, and diabetes. Added sugar is the factor that the food industry uses to get you to buy more. But how can you tell if it’s too much? Added sugar is expressed in grams, not teaspoons, so most people still won’t know how much is too much (by the way 1 teaspoon = 4.2 grams). And we still don’t have a Dietary Reference Intake for sugar.  The %DV on the label is still missing.  Yet the American Heart Association says added sugar should be about 8%[4], and the World Health Organization just announced that it supports limiting added sugar to 5% of total calories. Clearly, the FDA is caught in a schizophrenic situation. On the one hand, they want the public to know how much sugar they are consuming. On the other, Congress doesn’t want you to know, and they tell the FDA what to do.

Third, cities and states are starting to take matters into their own hands. The California state senate health committee just approved SB1000, the “Sugar Sweetened Beverages Safety Warning Act”.  Just like the cigarette black box, each can of soda will say: “Drinking beverages with added sugars contributes to obesity, diabetes, and tooth decay.” Now it goes to the full senate, and then to the public. Meanwhile, the City of San Francisco will be debating a 2 cents-per-ounce soda tax, to be placed on the ballot for November. Economic models have determined that a 20% tax can reduce consumption by 16%; and the SF bill will deliver any money raised back to the communities that collected them in the form of obesity treatment, parks and rec, schools, and the Dept. of Public Health.  Almost immediately, the “Astroturf” grass-roots (funded by the American Beverage Association) “Coalition for an Affordable City” sprung up, and is robo-calling and door-knocking to defeat the measure, just like what happened in Richmond, Telluride, and other “uppity” communities.

And yet to come, on May 9 watch for the nationwide release of the Katie Couric-Laurie David documentary, “Fed Up”, which blows the lid off the 35-year disinformation campaign by the food industry to increase their profits, aided and abetted by the U.S. Congress.

Today is the calm before the storm. The food industry is already firing up its lobbyists, and they are taking to the airwaves and the internet. The salvos in these individual battles will be deafening, but hopefully not destructive. We’ve been duped for decades, and we’re likely to be duped again, unless the science wins out, the populace stands firm, City Halls and State Houses and Congress demand change, and the White House listens to the people, instead of the industry.

 

ROBERT LUSTIGRobert H. Lustig, M.D., M.S.L. is Professor of Pediatrics at the University of California, San Francisco. He is the author of “Fat Chance: beating the odds against sugar, processed food, obesity, and disease”, “Sugar Has 56 Names: a shoppers guide”, and the “Fat Chance Cookbook”. He is the President of the Institute for Responsible Nutrition www.responsiblefoods.org, a non-profit devoted to improving the global food supply.




[1] Prevalence of childhood and adult obesity in the United States, 2011-2012. Ogden CL, Carroll MD, Kit BK, Flegal KM. JAMA. 2014 Feb 26;311(8):806-14. 
[2] Prevalence and Trends in Obesity and Severe Obesity Among Children in the United States, 1999-2012.Skinner AC, Skelton JA. JAMA Pediatr. 2014 Apr 7. doi: 10.1001/jamapediatrics.2014.21. [Epub ahead of print]
[3] Fruit juice intake predicts increased adiposity gain in children from low-income families: weight status-by-environment interaction. Faith MS1Dennison BAEdmunds LSStratton HH. Pediatrics. 2006 Nov;118(5):2066-75. 
[4] Circulation. 2009 Sep 15;120(11):1011-20. doi: 10.1161/CIRCULATIONAHA.109.192627. Epub 2009 Aug 24.

Dietary sugars intake and cardiovascular health: a scientific statement from the American Heart Association.

Johnson RKAppel LJBrands MHoward BVLefevre MLustig RHSacks FSteffen LMWylie-Rosett JAmerican Heart Association Nutrition Committee of the Council on Nutrition, Physical Activity, and Metabolism and the Council on Epidemiology and Prevention

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