First published 26 Jan 2016. The message for us all to eat less sugar is starting to bite. In 2015, the World Health Organisation (WHO) strongly recommended that both adults and children reduce their daily intake of free sugars to less than 10% of total energy. This is a strengthening of the wording from its 2002 guidelines in which the same limit was recommended but not ‘strongly’ (WHO, 2014).
What’s more, the current international guidelines add a second, ‘conditional’, recommendation to reduce daily sugar intake to less than 5% – approximately 25g or 6 teaspoons of sugar – for ‘additional health benefits’ (WHO, 2015a). It should be noted that these recommendations refer to ‘added sugars’, excluding the ‘intrinsic’ or naturally-occuring sugars such as those in milk and fruit.
It is interesting to look at the response to these recommendations from various nations – in particular the United States (US), South Africa and Australia.
The US ‘Dietary Guidelines for Americans’ is updated every five years. The current guidelines for 2015-2020 (US Department of Health and Human Services, 2015)support WHO’s current recommendation to reduce the daily intake of free sugars to less than 10% of total energy. This is a shift from the earlier US guidelines (US Department of Agriculture, US Department of Health and Human Services, 2010) that recommended ‘limiting’ added sugar. However, the US has not gone as far as WHO’s calls for ‘less than 5%’ of total energy intake as added sugar, despite a proposal by the American Heart Association (AHA). In 2009, the AHA called for an upper limit of approximately 5-6% of energy intake (ie no more than 25g of added sugar for women and 37.5g for men) (Johnson et al, 2009).
The dietary guidelines for South Africans call for the population to ‘Use sugar and foods and drinks high in sugar sparingly’ (2013, my emphasis). This represents a subtle shift in advice since the first guidelines in 2003 and appears (at first) to be purely grammatical. The new phrase ‘high in sugar’ has replaced the earlier reference to ‘food and drink containing sugar’ (my emphasis); and the earlier version also included the phrase ‘and not between meals’ (this has been dropped in the current guidelines). However, if you read beyond the summary ‘message’, a recommendation is made for an upper limit for added sugars of 10% of energy intake and <6% of daily energy intake for those at ‘increased risk of the negative health consequences of sugar’ (Food-Based Dietary Guidelines for South Africa, 2013, p. 103).
The Australian guidelines call for us to ‘Limit intake of foods and drinks containing added sugars such as confectionary, sugar-sweetened soft drinks and cordials, fruit drinks, vitamin waters, energy and sports drinks’ (Australian Government Department of Health, 2013, p. 76, my emphasis). It claims ‘there is insufficient evidence to recommend an exact intake of added sugars suitable for the whole population’ (Australian Dietary Guidelines, 2013, p. 79). This stands in contrast to the call by the Dietitians Association of Australia (DAA) to keep added sugars below 10% of total daily energy intake (DAA, 2014). Although – as in the US – the DAA falls short of endorsing WHO’s recommendation to further halve this amount.
Unsurprisingly, the United States tops the list of the highest sugar-consuming nations in the world with Germany, the Netherlands, Ireland, Australia, Belgium, the UK and others not far behind. The US consumption rate represents more than 5 times WHO’s recommendation of no more than 6 teaspoons of added sugars per day, with almost half those sugars being consumed in beverages other than milk or fruit juice (47%) and a further one-third from snacks and sweets (31%) (US Department of Health and Human Services, 2015).
The estimated approximate daily consumption of added sugar per day by the top 11 sugar-consuming nations (Jevtic, 2015):
- 32 teaspoons per day: United States (126.4g)
- 26 teaspoons per day: Germany (102.9g), Netherlands (102.5g)
- 24 teaspoons per day: Ireland (96.7g), Australia (95.6g), Belgium (95g)
- 23 teaspoons per day: United Kingdom (93.2g), Mexico (92.5g), Finland (91.5g)
- 22 teaspoons per day: Canada (89.1g), Austria (88.1g)
South Africa comes in at a relatively modest 34th, with a daily consumption of 41.5g or more than 10 teaspoons of sugar per day. For a full list of all countries, see Ferdman (2015).
The link between sugar and ill health
The evidence is mounting on the link between a diet that’s high in sugar and ill health: primarily obesity, diabetes and cancer. In the US where the most sugar is being consumed, the obesity level is the highest in the world and there are an estimated 29,251,000 people (20-79 years of age) or 10.8% of the population with diabetes (with a further 28.3% of the population estimated to have diabetes that is undiagnosed (International Diabetes Federation, 2015).
In South Africa, the numbers are 2,286,000 people (20-79 years of age) with diabetes, representing 7.6% of the population. And in Australia, there are 1,079,600 people (20-79 years of age) with diabetes, representing 5.1% of the population (for a full list of all countries, see the International Diabetes Federation, 2015). With its huge population and the relatively recent intrusion of the Standard Western Diet, China is leading the world with an estimated 109,649,100 people diagnosed with diabetes.
Evidence of the link between the overconsumption of sugar and ill-health is becoming more and more widely recognised and the anti-sugar message is reaching an ever-increasing audience. Professor Robert Lustig’s wonderful YouTube talk Sugar: The Bitter Truth, for example, has been viewed more than 6 million times. Damon Gameau’s movie That Sugar Film (Gameau, 2015) set new box office records for an Australian documentary. And David Gillespie’s book Sweet Poison took the Australian press by storm (Gillespie, 2008).
And there is the growing number of articles linking the high intake of sugar with the increased prevalence of cancer. See, for example, ‘Sugar identified as a top cause of the surge in cancer’ (Mercola, 2016), ‘High sugar consumption linked to breast cancer’ (Schoffro, 2016), ‘Why sugar is called “The White Death”’ (Bollinger, no date) just to name a few. This last reference is from an excellent website, The Truth about Cancer dedicated to educating people about the prevention of and treatments for cancer.
The relationship between carbohydrate, glucose and insulin
Although some sources directly link our increased sugar consumption to the growing incidence of cancer, according to Gill (2014), it appears to be the relationship between sugar and raised insulin levels that affects the growth of cancer cells. Gill says: ‘much research shows that it is sugar’s relationship to higher insulin levels and related growth factors that may influence cancer cell growth the most, and increase risk of other chronic diseases. Many types of cancer cells have plenty of insulin receptors, making them respond more than normal cells to insulin’s ability to promote growth’ (n.p.). She goes on to say:
All carbohydrates you eat are broken down to simple sugars in the intestine, where they are absorbed into the blood, increasing blood sugar levels. The pancreas releases insulin in response, which travels throughout the blood stream, and performs several important jobs: signalling glucose to enter cells and increasing the storage of calories as fat (Gill, 2014, n.p.).
Her description of what happens when we eat simple carbohydrates will be familiar to anyone who has come off a diet high in sugar or simple carbohydrates:
Eating a lot of simple carbohydrate at once can raise insulin levels quickly. High insulin levels can lead to a rapid fall in blood sugar, in a sort of ‘rebound’ effect. Low blood sugar levels then signal the body that it is low on fuel. This triggers appetite, encouraging you to eat again, to bring blood sugar levels back up again. While levels are ‘bottoming out’, people are hungry, irritable and prone to overeating. This can become a ‘vicious cycle’, with the body’s blood sugar and insulin levels going up and down rapidly. The extra calories you eat can cause weight gain, especially because the excess insulin encourages fat storage (Gill 2014, n.p.).
The link between carbohydrates and high blood glucose levels is yet to be adequately addressed in national or international dietary guidelines, but something that needs to be done.
Australian Government Department of Health (2013). The Australian Dietary Guidelines, available on https://www.eatforhealth.gov.au/guidelines, last accessed 26 Jan 2016.
Bollinger, T. (no date). ‘Why sugar is called “The White Death”’, article posted on The Truth About Cancer website, http://thetruthaboutcancer.com/sugar-white-death/, last accessed 23 Jan 2016.
Dietitians Assocation of Australia (2014). WHO Guideline: Sugars Intake for Adults and Children, available at http://daa.asn.au/search-results/?search=WHO, last accessed 26 Jan 2016.
Ferdman, A. (2015). ‘Where people around the world eat the most sugar and fat’, The Washington Post, https://www.washingtonpost.com/news/wonk/wp/2015/02/05/where-people-around-the-world-eat-the-most-sugar-and-fat/, last accessed 24 Jan 2016.
Gameau, D. (2015). That Sugar Film, http://thatsugarfilm.com/, last accessed 23 Jan 2016.
Gill, C. (2014). ‘Sugar and cancer’, article on the website Oncology Nutrition, https://www.oncologynutrition.org/erfc/healthy-nutrition-now/sugar-and-cancer/, last accessed 23 Jan 2016.
Gillespie, D. (2008). Sweet Poison, Penguin, Australia.
International Diabetes Federation (2015). ‘IDF Diabetes Atlas – 7th Edition’, http://www.diabetesatlas.org/across-the-globe.html, last accessed 24 Jan 2016.
Jevtic, A. (2015). ’11 Countries that consume the most sugar in the world’, article published on Insider Monkey, http://www.insidermonkey.com/blog/11-countries-that-consume-the-most-sugar-in-the-world-348963/?singlepage=1, last accessed 23 Jan 2016.
Lustig, R. (2009). Sugar: The Bitter Truth, University of California Television, https://www.youtube.com/watch?v=dBnniua6-oM, last accessed 23 Jan 2016.
Mercola, (2016). ‘Sugar identified as a top cause of the surge in cancer’, article published on Mercola.com, http://articles.mercola.com/sites/articles/archive/2016/01/20/sugar-top-cause-cancer-surge.aspx, last accessed 23 Jan 2016.
National Health and Medical Research Council (2013). Australian Dietary Guidelines (2013), available from https://www.nhmrc.gov.au/guidelines-publications/n55, last accessed 23 Jan 2016.
Schoffro, M. (2016). ‘High sugar consumption linked to breast cancer’, article published on EcoWatch, http://ecowatch.com/2016/01/09/sugar-consumption-linked-breast-cancer/, last accessed 23 Jan 2016.
World Health Organization (2014). ‘WHO opens consultation on draft sugars guidelines’, posted on the World Health Organization website, http://www.who.int/mediacentre/news/notes/2014/consultation-sugar-guideline/en/, last accesed 23 Jan 2016.
World Health Organization (2015a). ‘WHO calls on countries to reduce sugars intake among adults and children’, posted on the World Health Organization website, http://www.who.int/mediacentre/news/releases/2015/sugar-guideline/en/, last accessed 24 Jan 2016.
World Health Organization (2015b). ‘Sugars intake for adults and children: guideline’, http://www.who.int/nutrition/publications/guidelines/sugars_intake/en/, last accessed 23 Jan 2016.
National Department of Health (South Africa) (2013). ‘Food-Based Dietary Guidelines for South Africa’, South African Journal of Clinical Nutrition, 26(3)(Supplement), 1-164.
Johnson R.K., Appe, L.J., Brands M., Howard, B.V., Lefevre, M., Lustig, R.H., Sacks, F., Steffen, L.M., Wylie-Rosett, J. (2009). ‘Dietary sugars intake and cardiovascular health: a scientific statement from the American Heart Association’, Circulation, 120(11):1011-1020.
U.S. Department of Health and Human Services and U.S. Department of Agriculture (2015) 2015 – 2020 Dietary Guidelines for Americans, 8th Edition, available at http://health.gov/dietaryguidelines/2015/guidelines/.