With obesity and diabetes rates soaring, the world is faced with a problem exacerbated by the normalising of junk food. The dangers of added sugar must be realised to cause change, Aseem Malhotra tells Shreshtha Trivedi

Sugar lumps

Dame Sally Davies says a sugar tax may need to be introduced to curb soaring obesity rates

Dame Sally Davies says a sugar tax may need to be introduced to curb soaring obesity rates

The chief medical officer for England Dame Sally Davies recently said a sugar tax may need to be introduced to curb soaring obesity rates.

And within hours of her announcement, the World Health Organization recommended that people should halve their consumption of sugar – to keep it below 10 per cent of daily calorie intake, with an ideal target of five per cent.

One man who thinks these are steps in the right direction is Aseem Malhotra, an interventional cardiologist at Croydon University Hospital and scientific director of Action on Sugar.

Media ‘blitzkrieg’ against sugar

Sugar, or more precisely added sugar, has been under intense scrutiny in the last couple of months, with several campaign groups and charities launching a “media blitzkrieg” about its harmful effects, blaming sugar for the obesity diabetes public health disaster.

Action on Sugar and others have been at the forefront of active campaigns against “big sugar”.

‘Sugar isn’t central to food, it’s central to food industry profits’

Their aim is to make the food industry reduce added sugar in their food products by 40 per cent within four years and put in place stricter legislation similar to the ones imposed on the tobacco industry.

The Global Burden of Disease report, published by The Lancet, says poor diet is more to blame for disease than physical inactivity, alcohol and smoking combined. Unlike fat or proteins, sugar has no nutritional value and has been found to be “mildly addictive”.

Dr Malhotra refutes Andrew Lansley’s claim that “sugar is central to food”. “It is not central to food, it is central to the food industry’s profits,” the cardiologist says. “It is fine to eat it as a treat, but it is not a part of normal, balanced diet.”

There have been several studies stating that the impact of sugar on the body is independent of calories.

One study – conducted jointly by Stanford University and California University in Berkeley and San Francisco last year – concluded that for every excess 150 calories of sugar a person consumes – say from a can of soft drink versus 150 calories from olive oil – there is an 11-fold increase in the prevalence of type 2 diabetes. This is independent of physical activity or exercise.

Obesity alarm bell

The idea that all calories are not the same is not new. However, the startling increase in the rates of obesity around the world has rung alarm bells among experts, campaigners, public health officials, doctors and the media.

In the National Obesity Forum’s latest report, the body admits it underestimated its previous projection that 50 per cent of the population in the UK will be obese by 2050.

Already over a quarter of all adults (26 per cent) in England are obese and a further 41 per cent of men and 33 per cent of women are classed as overweight. There are also now 3.2 million people with diabetes in the UK – mostly type 2 – which is fuelled by obesity and poor diet.

The comparison between added sugar and tobacco has been in the spotlight recently, with various experts differing in their views over the impact and effects. Some even deem the comparison far fetched.  

‘Taxation has definitely reduced tobacco consumption and we want to do the same with sugar’

But the tobacco example is a good one to emulate, Dr Malhotra says. Tobacco consumption has significantly dropped in the last 20 years and can be attributed to the “three As”: targeting availability, affordability and acceptability.

“In terms of availability, the ban on smoking in public places has made it less accessible than before,” he explains. “Acceptability comes with that. Affordability relates to taxes and tobacco is now taxed.”

It took people time to understand how harmful smoking was. This fact may have been realised earlier if the tobacco industry had not played dirty through their lobbying efforts, Dr Malhotra says.

From its beginnings, the industry promoted smoking as good for people’s health and it used celebrity and sports endorsements.

He believes a similar model should be followed for added sugar, adding that he has seen patients who have stopped smoking because they cannot afford it any more. “Taxation has definitely reduced tobacco consumption and we want the same to happen with sugar,” Dr Malhotra says.

Normalising junk food

The argument used to oppose a sugar tax is that its consumption should be about taking personal responsibility and that a tax will signal a move toward a “nanny state”, encroaching on what some believe to be individual rights. Dr Malhotra is quick to dismiss both notions. 

The term “nanny state” is used by people who – for various reasons, including propaganda – do not want the legislation.

“I am all for exercising personal responsibility but to do that you have to have knowledge and you have got to have real choice,” he says.

“If you haven’t got choice, you can’t exercise personal responsibility. People think their food choices are deliberate, but more often than not it is automatic.”

The work environment, schools, health centres and even hospitals are overrun with sugary foods, often with no alternative healthy food choices.

‘People think their food choices are deliberate, but more often than not it’s automatic’

“There are also similarities between how sugar and tobacco have been marketed,” Dr Malhotra says. “The only difference is that tobacco was avoidable. Sugar is almost unavoidable, and it targets even young kids.

“People who say this will turn us into a nanny state don’t realise that chronic disease management is the biggest impact on the economics of healthcare. We have normalised junk food. It’s a public health scandal.”

Nonetheless, food taxes have yielded mixed results. Denmark imposed a “fat tax” that saw foods containing more than 2.3 per cent saturated fat were subject to a surcharge. Eventually it had to be abolished because it resulted in inflated food prices and cross-border shopping.

While banning something does not necessarily help, diet does needs to be at the centre of health policy, according to Dr Malhotra. The government has a duty to protect its citizens from the excesses and manipulations of the food industry. There is a lack of appreciation among medical professionals for public health.

“This is a population-wide problem and the NHS needs to tackle it by population-wide interventions, not through individual behaviours,” he says.

An obesity report – which Dr Malhotra co-authored – for the Academy of Medical Royal Colleges gave a 10 point plan to reverse the obesity problem. It included compulsory nutritional standards in hospitals, such as banning the sale of junk food, banning junk food advertising for children on the internet and putting a tax on sugar. Most of these pointers revolved around the food environment.

Industry scapegoat

What people have done wrong, he says, is fail to see how their diets have been dominated by processed food. Even people with a normal body mass index will be affected by diet related diseases. We are all vulnerable to poor diet, irrespective of our weight and exercise habits.

The advice to “eat less and move more is meaningless, even though well intentioned”. “People can’t eat less and it is not that easy to move more,” Dr Malhotra says. “It’s about changing the type of food people are eating. The impact of physical activity has been exaggerated. Obesity is mostly about calorie consumption.”

There is also another perception that people are lazier than they used to be 10-15 years ago. Evidence tells us that in the last 30 years since obesity rocketed, physical activity has remained unchanged, according to the cardiologist. In fact, activity has increased slightly and it is “the type of calories we are consuming that has changed”.

‘This is a global problem and no country has tackled it perfectly but Britain can lead the way’

“The food industry has very cleverly used physical activity, associating it with how people can get away with [eating] junk food,” he says.

He questions the decision makers who allowed the Olympics to be sponsored by fast food outlets and suppliers such as McDonald’s, Coca-Cola, Cadbury’s and Heineken. “[It] sends out the wrong message by not only increasing the acceptability of junk foods, but also successfully linking them with physical exercise,” Dr Malhotra says. 

He has met with health secretary Jeremy Hunt and prime minister David Cameron in the hope that active campaigning around the harmful effects of hidden sugar will make everyone realise what he says is obvious. This is a global problem and no country has tackled it perfectly. “Britain can lead the world on this,” he says

Aseem Malhotra is an interventional cardiologist at Croydon University Hospital and scientific director of Action on Sugar