A spoonful of sugar might help the medicine go down, but is there a greater cost?

A bowl of Nutri-Grain for brekky, tomato relish on your sandwich washed down with a can of coke, and a lazy dinner of baked beans will set you back around 17 teaspoons of sugar a day. And that’s before you add a teaspoon or two to your tea or coffee.

In March 2014 the World Health Organization (WHO) released new draft guidelines on the sugar intake for adults and children. The draft guidelines keep the current recommendation that “free” (refined) sugars should make up less than 10 percent of energy intake per day. But this time the guidelines go further to suggest that a reduction to below 5 percent may have additional health benefits. 5 percent of total energy intake for an “average” adult is around 25 grams (6 teaspoons) of sugar a day.

The guidelines apply to all sugars added to food by the manufacturer, cook or consumer – and to the sugars present in honey, syrups, fruit juices and fruit concentrates. They don’t apply to sugars that naturally occur in milk and fruit.

Our sweet tooth

We’re a nation with a sweet tooth and our consumption far exceeds the WHO recommendations. According to the 2008/09 NZ Adult Nutrition Survey, males eat 120g of total sugars a day and females eat 96g (this includes the sugar from milk products and fruit).

Sucrose (table sugar) was the major contributor, with males eating 55g (14 teaspoons) and females 42g (10.5 teaspoons). Almost one-quarter of the sucrose came from sugar and sweets, followed by non-alcoholic beverages and fruit.

Our kids fare even worse. The 2002 National Children’s Nutrition Survey found that the average daily intake for sucrose for boys was 67g (17 teaspoons) and for girls 61g (15 teaspoons). Over one-quarter of the sucrose came from beverages and one-fifth from sugar and sweets.

What is sugar?

Sauces, chutneys and marinades are often high in sugar.
Sauces, chutneys and marinades are often high in sugar.

When you think of “sugar” you probably think of sucrose (cane sugar). Sucrose (a disaccharide) is by far the most common sugar we eat and it’s made up of glucose and fructose (monosaccharides). You can buy white, brown, raw and caster sugar … but they’re all essentially sucrose.

There are also other types of sugar in the foods we eat. The main sugar in fruit is fructose; in milk it’s lactose; and other sugars include glucose and maltose.

Honey is nearly 80 percent sugar, mainly fructose and galactose.

The types of sugar may be listed separately in the ingredients list, but in the nutrition information panel the total amount will be given under “sugars”. This figure doesn’t differentiate between added sugars or sugars found naturally in foods.

Sugar and your health

There’s convincing evidence that free sugars play a role in tooth decay. Bacteria in the plaque on your teeth use sugars as food. The bacteria then produce acids that can eat into tooth enamel. Sucrose is a particular concern because when it’s metabolised it produces dextrans, which let bacteria stick to the teeth more easily.

Our kids have a big problem with tooth decay. The 2011/12 New Zealand Health Survey, which was released in December 2012, found that 34,000 children aged 1 to 14 years had a tooth removed in the past year because of decay, abscess or infection. Extensive decay (which is largely preventable) was the most common reason for the removal. The same survey found that about 8 percent of adults (270,000) had a tooth removed in the past year.

Then there’s our increasing problem with obesity. The 2011/12 New Zealand Health Survey found that 21 percent of children aged 2 to 14 were overweight and a further 10 percent were obese (up from 8 percent in 2006/07). 28 percent of Kiwi adults are also considered obese – that’s around 1 million people.

But that’s not all

In 2013 the Credit Suisse Research Institute published a report on sugar consumption. On the issue of addiction it concluded that although sugar may not have clear addictive characteristics it does meet the criteria for a potentially addictive substance. The addiction theory has some support here.

Dr Simon Thornley, a public health physician who works in epidemiology and biostatistics at the University of Auckland, told us that although the “addictive” concept isn’t widely recognised by the medical or scientific communities he thinks it exists: “There are many animal studies which support the idea of sugar addiction and I think sugar addiction explains the centrality of sugar in our food supply. Sugar hooks people to a particular food and increases their tolerance for it, making them want to eat more and more.”

When Dr Thornley cut sugar from his own diet he experienced craving, irritability, poor concentration and restlessness (all typical withdrawal symptoms) in the first few days. He’s been contacted by many other people experiencing similar effects from sugar withdrawal.

Other sugar critics go further, saying sugar is toxic. The most vocal of this group is Dr Robert Lustig, a paediatric endocrinologist from the University of California. He claims sugar poses dangers to health that justify controlling it like alcohol. Lustig believes it’s the fructose component of sugar that is the culprit because of the way the body metabolises it. He thinks sugar is responsible for the diseases associated with metabolic syndrome: these include hypertension, high levels of blood triglycerides and increased insulin production, all of which increase the risk of diabetes and heart disease.

But not everyone agrees that fructose is universally the bad guy. Professor Jim Mann, Professor in Human Nutrition and Medicine at the University of Otago, says there’s no evidence that the fructose in fruit is a risk, and the claim that fructose is toxic may be “over the top” based on current knowledge. Much of the fructose research is based on theoretical work and animal studies – and it uses large amounts of fructose so it can’t be related to the usual quantities we eat.

He also isn’t totally convinced that sugar is addictive. He believes the scientific evidence for this claim is very limited compared with the weight of evidence for sugar’s role in other issues such as weight control and dental disease.

So where does all this debate leave the consumer? Professor Mann admits that some of these issues are still emerging but told us the health message based on sugar’s role in dental health and weight control is simple: “Eat as little sugar as possible!"

What the science says

The scientific evidence to support the WHO guidelines is based on two major reviews that focused on the prevention and control of weight gain and dental health.

The first, published in the British Medical Journal (BMJ) in 2013, was undertaken by researchers at the University of Otago. It looked at the evidence between intake of dietary sugars and body weight – and it found that a reduced intake was associated with a small but significant decrease in body weight whereas an increased intake was associated with a similarly significant weight increase, even when participants were encouraged to compensate with an increase or reduction in kilojoules from other foods.

Professor Jim Mann, co-author of the BMJ review, says what’s apparent from the evidence is that foods containing sugar tend to be energy dense and so it’s difficult to replace the kilojoules you’ve cut when you eliminate them. Also, sugar in a liquid form is not as satiating as sugar in food – this means if you drink a sugary drink you don’t compensate by eating less food.

The second review, published in the Journal of Dental Research in 2013, found that there was a positive association between free sugars and tooth decay in both adults and children.

A sugar tax?

A growing number of researchers believe a tax on sugary drinks and other restrictions on their advertising and sales should be part of the solution to our sugar habit. It’s not hard to see why.

Kiwi kids love sugary drinks. More than a quarter of the sugar in our children’s diets comes from such drinks – and 29 percent of children consume more than 4 of these drinks a week. In our product comparison table (see below) 4 sugary drinks had over 10 teaspoons of sugar per serving size!

Link to weight gain

There’s convincing evidence that drinking sugary drinks leads to weight gain in children. Studies have shown that if you shift from a kilojoule-free drink like water to a kilojoule-laden drink such as soft drink, you don't adjust your diet to take account of the extra kilojoules.

According to an Obesity Prevention in Communities study, children who drink 1 can of a sugary drink per day have a 3.3kg higher mean weight than those who don’t. Children who drink 2 cans a day have a 5.3kg higher weight.

A group of researchers and public-health doctors have formed an organisation called FIZZ (“Fighting Sugar in Soft Drinks”). FIZZ believes that the tide of evidence implicating sugary drinks with diseases such as obesity, type-2 diabetes, rotten teeth and gout is so strong that ending the sales of these products is justified. FIZZ’s vision is to achieve a sugary-drink-free New Zealand by 2025.

A tax would benefit New Zealanders

One of FIZZ’s policies is to push for taxes on sugary drinks – a move that FIZZ’s founder Dr Gerhard Sundborn told us would greatly benefit New Zealanders.

A 2014 study published in the New Zealand Medical Journal found that a 20 percent tax on carbonated drinks would prevent 67 deaths from cardiovascular disease, diabetes and diet-related cancers each year. In addition to the health benefits a 20 percent tax could generate up to $40 million in tax revenue if applied to all carbonated drinks. This could be invested in health-promotion initiatives.

The advocacy group also wants to restrict sales and advertising of sugary drinks, implement sugar-free policies in workplaces and schools, and require warning labels on products containing sugar.

But is this vision achievable? “We think it is,” says Dr Sundborn. “Already there are initiatives in place overseas. Tokelau has banned sugary drinks (although there’s an issue with enforcement). France, Hungary and Ireland all have taxes and in the United States 33 states have either enacted taxes on sugary drinks or put into place legislation stating soft drinks aren’t exempt from state taxes like basic foodstuffs are. Mexico is the latest country to pass a tax on sugary drinks”

In California, a bill was recently introduced that if passed will require sugar-sweetened drinks to carry a warning label about obesity, diabetes and tooth decay.

Researchers at the University of Auckland are establishing the New Zealand Beverage Guidance Panel to provide guidance on the risks and benefits of various drinks. Like FIZZ, one of their draft policy recommendations is to introduce a 20 percent tax on sugary drinks.

Our view

  • The government should look at introducing a sugar tax and other incentives to reduce the over-consumption of sugary drinks in this country – particularly by children. The scientific evidence is now strong enough to support such measures.
  • You don’t need to cut out sugar completely. But it makes sense to limit your intake of sugary foods and drinks that don’t provide much in the way of nutritional value and can lead to excess kilojoules.
  • Frequent snacking on sugary foods can result in dental decay. Regular teeth cleaning with fluoride toothpaste, flossing and regular check-ups are all essential to healthy teeth no matter how much sugar you eat.
  • Always read the nutrition information panel – even when you’re deciding between similar products of the same brand. And check the ingredients list for sugar and its many aliases.

Sugar in food

There are 2 types of sugar: intrinsic sugars found inside fruit and vegetables (mainly fructose) and milk (lactose); and added free sugars (mainly sucrose, which is glucose plus fructose). It's the free sugars that've been added to food by manufacturers you need to reduce. Free sugars are often in foods we need to cut back on and don’t provide other nutrients like those found in fruit, vegetables or dairy products.

So it's not just as simple as cutting back on the sugar you add to your tea and coffee. You also need to be careful of the sugar you can't see in processed foods.

Free sugars such as sucrose, glucose and corn syrup may be listed separately in the ingredients list. But if you look at the nutrition information panel, the total will be given under "sugars".

Tip: You can work out the number of teaspoons in foods by dividing the grams of sugar on the label by 4 (there are four grams of sugar in a standard level teaspoon).

Sugary drinks
It’s no surprise that some drinks are full of sugar. But you might be surprised at how big a sugar hit you’re getting. A can of coke has more than 9 teaspoons of sugar and if you buy super-sized drinks such as e2 Orange you’ll be chugging back more than 18 teaspoons. Fruit juice and fruit drinks are also sugar offenders, with around 6 teaspoons in a 250ml glass. You also need to check the labels in the water aisle: Pumped Mandarin looks like water but it’s still packed full of 4 teaspoons of the white stuff.

Breakfast cereals
Our 2013 survey of kids' cereals found that 18 products were more than 30 percent sugar. A 30g serving of Nutri-Grain has 2.4 teaspoons of sugar and most chocolate varieties 2.9 teaspoons.

Sauces and chutneys
Kiwis love tomato sauce and some people eat it with everything! But most brands are more than 20 percent sugar – that’s about 1 teaspoon of sugar in each tablespoon of sauce. You also need to check the nutrition information on products with the same name but different packaging. Wattie’s Tomato Sauce in a can has 20.1 percent sugar; but in a squeeze bottle it’s 32.4 percent. BBQ sauce and sweet chilli sauce give you an even bigger sugar hit. Most brands of chutney are more than 20 percent sugar, which is around 1 teaspoon or more per tablespoon.

Sugar even sneaks in to your favourite takeaway burger. The BK Whopper and Salad burgers have more than 3 teaspoons of sugar.

Quick and easy
There’s nearly 4 teaspoons in half a can of Wattie’s Baked Beans – and some of the heat-and-eat meals we looked at had 3 or more teaspoons per serve.

A quiet tipple
Good news for red wine drinkers – a glass of dry red wine is essentially sugar-free. A glass of sparkling white wine will give you nearly 1 teaspoon of sugar … and if you like a daily tipple of port or sweet sherry you’ll be getting more than 1½ teaspoons in a small glass. Remember that all alcoholic drinks also contribute empty kilojoules from their alcohol content, so they can still lead to unwanted weight gain.

Report by Belinda Castles.

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