A report published by Public Health England called Sugar Reduction. The Evidence for Action says we are eating too much sugar and it is bad for our health.[1] Rising sugar consumption is fuelling increasing rates of obesity, heart disease, stroke, diabetes, tooth decay, and some cancers[2] [3]; and treating obesity costs the NHS £5.1bn (€7bn; $7.7bn) every year.[1]

The most striking advice from the report is that our recommended intake of free sugars should be just 5% of our daily calories, which is half the amount previously recommended by the World Health Organization.[1] [4] This equates to about 25 g (six level teaspoons) a day for the average adult, less than the amount of sugar in a Snickers bar. As well as reducing the sugar content in foods and drinks, the report also recommends changes to the way sugary foods are advertised and discounted. The report says, “By meeting these recommendations within 10 years we would not only improve an individual’s quality of life but could save the NHS around £500m every year.”[1]

To meet this objective drastic changes are needed. Currently, the average Briton consumes nearly three times the recommended 25 g of free sugars each day, and nearly two thirds of the UK population are defined as either overweight or obese.[3]

Why are we consuming too much sugar?

Hidden sugar

Added sugar in foods is a recent phenomenon and is a result of sugar becoming cheaper to produce. Added sugar in food and drink comes in several forms including fruit concentrate, maltose, dextrose, and syrup. Manufacturers use it not just for flavour but to maintain freshness, texture, and consistency in food products. These types of sugars can be found in sweet things like chocolate but also in many products from sauces to cereals. A contributing factor to the increase in added sugar in foods was in response to the popularity of low fat diets in the 1970s, which saw fat replaced by sugar. Added sugar is now widespread, with 80% of supermarket products containing added sugar.[1] A film which shows the extent of the problem is That Sugar Film, where the presenter consumes 20 teaspoons of added sugar from a typical breakfast of cereal, yoghurt, and fruit juice.[5]

Advertising

Advertising has also had a profound influence on our increased consumption of sugary foods, with high sugar products more likely to be promoted than other foods. Coca-Cola alone spent $3.3bn on advertising globally in 2013.[6]

The report by Public Health England estimates that promotional offers account for around 40% of all expenditure on food and drinks consumed at home, and one study showed that end of aisle displays alone contributed to a 50% increase in sales of fizzy drinks during the course of one year.

Product sizes have also increased over the years. In 2013, the British Heart Foundation compared the product sizes of 245 food items sold now with those sold in 1993, and it found a substantial increase in size. For example, a stated portion of peanuts is now 80% larger than before, and a family pack of crisps has doubled in size.[7]

In children, the situation is particularly worrying. Almost half of eight year olds in England have decay in their teeth,[1] and a huge 19% of 10 to 11 year olds are already in the obese category (body mass index >30). Advertising campaigns often target children, and many unhealthy foods are sold using children’s television characters—for example, Tesco’s Mr Men yoghurts, Dora the Explorer cake mixes, and Bob the Builder crisps. It is difficult to expend the amount of energy obtained from these readily available high sugar foods—a child would have to ride a tricycle for an hour and a half just to burn off the calories after consuming one average sized chocolate bar.

How can we reduce over consumption?

Affordability

The Public Health England report calculates that around 6% of total sugar purchased could be avoided if promotions on high sugar products did not occur.[1] The report says that pricing that incentivises purchasing larger portions or multipacks should be discouraged, as well as impulse buys at the end of aisles or at till points.

Foods containing high levels of sugar are among the cheapest, and these are purchased and consumed more often by people in lower socioeconomic groups.[1] This is likely to contribute to the substantial correlation between high body mass index and low socioeconomic status, with children living in the most deprived communities being nearly twice as likely to be obese or overweight as those in less deprived groups.

The introduction of a sugar tax has been debated at length and is a highly politicised subject in the United Kingdom. An investigation published in The BMJ showed how key public health experts are involved with the sugar industry and related companies responsible for many of the products blamed for the obesity crisis through research grants, consultancy fees, and other forms of funding.[8]

Elsewhere in the world there have been positive steps in the way of putting a tax on sugar. Taxes have been introduced in, Finland, France, Hungary, Mexico, and Norway, resulting in as much as a 10% decrease in the sales of taxed beverages.[9]

Availability

To tackle the obesity epidemic in children, several countries have taken action to reduce the availability of sugar at schools. France has a public health law which has banned vending machines in schools since 2005, and in Australia they separate foods and drinks into three categories—green, amber, and red—on the basis of their energy, saturated fat, sugar, sodium, and fibre content. Both of these campaigns have had a positive effect on reducing sugar consumption in children.[9]

Jennifer Rosborough, campaign manager and nutritionist at Action on Sugar, says, “A gradual reduction in the amount of sugar in food and drink is the most effective policy in reducing sugar intake as shown by the very successful salt reduction programme.” Salt levels in bread have been reduced by 40% since the 1980s but it continues to be a staple part of our diet. If the same gradual reduction in sugar content was applied a typical food shop would automatically bring in a lower quantity of sugar. Jennifer Rosborough says that along with the initiatives proposed in the Public Health England report, “we urgently need an independent nutrition agency to implement this very important policy” of sugar reduction.

Awareness

Recognising which products are high in sugar could be made clearer. The traffic light nutrition labelling is currently still voluntary in the United Kingdom and many products label sugar in its different forms—for example, dextrose or modified starch—which can be confusing to consumers.

A successful attempt to improve this can be seen in the Los Angeles Sugar Pack campaign, where they represented sugar content with “packs” instead of grams. This labelling was easier to visualise and resulted in 60% of respondents reporting they were likely to reduce their daily intake of sugary drinks.[1]

What next?

European Union agricultural reform is under way, which will lower the commodity price and liberalise production of sugar by 2017.[3] Without price controls there is a risk of sugar becoming incorporated even more into food products.

The report by Public Health England comes at a critical time and has set an ambitious but necessary target to take action on the rising levels of obesity, tooth decay, heart disease, and diabetes. If we keep on going as we are now, this will not only have a detrimental effect on people’s quality of life but will continue to add financial pressures on the NHS to treat people who have health conditions as a result of poor diet.

In the past we have achieved reductions in our consumption of fats and salt, so the question is: Will sugar be next? In late 2015, the House of Commons Health Committee backed a 20% tax on full sugar soft drinks as one of the measures to tackle childhood obesity, as well as a crackdown on advertising these products to children. In a report they said there was “compelling evidence” that a tax would reduce overconsumption of these sugary products.[10] The government has resisted the introduction of a sugar tax up until now and will publish its child obesity strategy in 2016.

Rachael Marsh, foundation year 2 doctor<sup>1

1</sup>Darent Valley Hospital, Dartford and Gravesham NHS Trust

Correspondence to:

Competing interests: None declared.

Provenance and peer review: Commissioned; not externally peer reviewed.

Cite this as: Student BMJ 2015;23:h6587