/ 20 December 2013

Sugar-coating a deadly health crisis

New research reaffirms that sugar is one of the biggest obstacles to weight loss - and health in general.
New research reaffirms that sugar is one of the biggest obstacles to weight loss - and health in general.

The amount of sugar being consumed by South Africans could be less than a sweet surprise for the economy.

A study – the first of its kind in the country – has revealed that one in five South Africans is eating too much sugar, and that our collective sweet tooth is likely to cause a few cavities in the country’s coffers.

The study, known as the South African National Health And Nutrition Examination Survey (Sanhanes-1) and compiled by the Human Sciences Research Council, conducted surveys and interviews with more than 25 000 people across 500 different areas in South Africa. The findings showed that 19.7% of South Africans were consuming an excessive amount of sugar. Almost 21% reported a family history of high blood sugar as well.

Our sugar high is part of a global trend. A report called Sugar: Consumption at a Crossroads, compiled by the Credit Suisse Research Institute, says that the global consumption of added sugar has "increased dramatically" over the past few decades.

The average person now consumes 17 teaspoons (70g) of sugar and similar sweeteners a day. In certain countries it’s much, much higher. In the United States the average is 40 teaspoons a day, and in Mexico it’s 35.

In contrast, the World Health Organisation recommends no more than 10 teaspoons of sugar a day. Scientists in the United Kingdom have recently urged people to drop that to five, "if you want to keep your teeth for life".

Global sugar consumption is up 46% since 30 years ago, when it was 48g a day.

In countries such as the US, Credit Suisse estimates, 38% of the average person’s diet is made up of sugar in its various forms. That means more than a third of everything they eat is essentially glucose, fructose or something in between.

But what are the ramifications of our tendency to reach for the sugar bowl?

According to the research, a high sugar intake is associated with the development of chronic conditions such as obesity and diabetes. Although the link has long been accepted, the argument gained new fervour this year after a Stanford-based study found that, for every increase of 150 kilocalories in sugar availability per person per day, there is a 1.1% increased prevalence of diabetes.

The Sanhanes-1 findings reflect this – almost 10% of the 25 000 participants were diagnosed with diabetes. One in five participants (20%) were found to have impaired glucose homeostasis (an imbalance in insulin in the blood).

Obesity in South Africa has increased seriously as well, especially among females. Ten years ago, 27% of the female population was said to be obese. Today, that figure is more than 39%, which is five percentage points higher than the global obesity average. In addition, the study found that 20.2% of South African males and 68.2% of females had a waist circumference that placed them at risk of metabolic complications.

The Credit Suisse report describes this as a "global obesity epidemic". This and related issues such as diabetes are "arguably this century’s primary social health concern", say the authors.

The cost of cake and cookies

Experts estimate that obesity-related concerns are costing healthcare systems around the world more than $600-billion a year. Diabetes type 2 now affects 370-million people worldwide, more than the entire population of the US and more than seven times the South African populace.

The Credit Suisse report cites the International Diabetes Federation’s last estimation of the cost of diabetes, and the results are staggering. It makes up over 10% of all healthcare costs and has a global price tag of $470-billion. "Even more worrisome," says the report, "is that these numbers are growing at a rate of 4% a year, much faster than that for obesity (which is 1% to 2%).

"By 2020, the annual cost to the healthcare system globally will reach $700-billion and the people affected will be close to 500-million."

Health vs economics

On one side is the growing argument that excessive sugar consumption is causing an ever-widening hole in the state coffers through which millions of rands are being spilled. On the other side is the reality that the sugar trade represents one of the biggest – and most important – markets globally.

In South Africa, the sugar industry has an income of R12-billion a year. Sugar cane is the second largest South African field crop by gross value, and sugar production makes up 17.4% of total gross annual field crop production value, according to the South African Sugar Association. South Africa produces about R7.7-billion worth of sugar every year; R2.5-billion of that is exported.

The sugar industry provides almost 80 000 jobs, constituting 11% of all agricultural employment in the country, says the association.

Globally, the annual value of the sugar trade exceeds $24-billion. It is increasing by about 2% every year. And not only are entire economies dependent on sugar production, it is also the lifeblood of the world’s most powerful food manufacturing companies.

"The food companies themselves are hooked on salt, sugar and fat," wrote Michael Moss, a New York Times journalist who spent three years researching his book Salt, Sugar, Fat. "Their relentless drive to achieve the greatest allure for the lowest possible cost has drawn them, inexorably, to these three ingredients time and time again.

"Sugar not only sweetens; it replaces more costly ingredients – like tomatoes in ketchup [tomato sauce] – to add bulk and texture. The industry has boxed itself in."

It’s what Professor Demetre Labadarios, executive director of population health, health systems and innovation at the Human Sciences Research Council, calls the food industry’s "lethal drive" for market share.

Increased public campaigns around the ills of sugar and efforts, such as New York mayor Michael Bloomberg’s attempt earlier this year to ban sugary drinks from restaurants, have put food processing companies under the ethical spotlight.

In a November interview with James Quincey, the president of Coca-Cola Europe, BBC presenter Jeremy Paxman asked the multinational executive if he thought consumers were aware that they consume 44 standard sachets of sugar in one large (movie-issue type) paper cup of Coca-Cola.

"Uh … maybe they don’t," replied Quincey. "That's why we are very focused on getting the information out there. We want to make sure that people have the information available to them, so that they can make the choices, and if they don’t want the big one, then fine," he said. "We are not trying to hide the information," he added.

In Mexico, a sales tax on sugary beverages was introduced last month. And the authors of the Sanhanes-1 report have vocally recommended that the country introduce tobacco-type warning labels on foods that "are known to be associated with increasing the risk of disease".

"Such foods should display appropriate warning labels so that the public’s awareness of potential or real harm is increased," said Labadarios. This would help to "level the field".

When asked whether the department of health plans to enforce warning labels on sugary and other foods, its director general, Precious Matsoso, said that there are "multiple strategies we need to consider". The department recently brokered a broadscale "strategic plan for the prevention and control of noncommunicable diseases" over the medium term. The plan outlines targets for bringing down the prevalence of various related diseases over a defined period.

"One aspect of intervention is regulation," said Matsoso. "But most important is mobilisation – of civil society, churches, schools and business." But according to Moss, competition for space on the grocery shelf will stop any real reform from taking place in the food processing industry.

Food manufacturers know that "our bodies are hard-wired for sweets", said Moss.

"Sugar not only makes the taste of food and drink irresistible. The industry has learned that it can also be used to pull off a string of manufacturing miracles, from doughnuts that fry up bigger to bread that won't go stale."


The twin bullets of obesity and diabetes

South African diabetes and obesity figures are two manifestations of an alarming trend: a growing prevalence of noncommunicable diseases (NCD) in the country and the world.

The authors of the Sanhanes-1 report flagged the rapid development of NCDs as an "emerging epidemic". It is one of biggest challenges faced by the South African health administration, they said, and ranks along with HIV and Aids, and tuberculosis.

"South Africa is part of the world scenario," said Professor Demetre Labadarios, executive director of population health, health systems and innovation at the Human Sciences Research Council (HSRC), which compiled the research.

"The projection is that by 2030 NCDs are projected to account for anywhere from two-thirds to three-quarters of the burden of disease in middle-income countries."

A 2011 discussion paper produced by the World Bank’s Human Development Network titled Chronic Emergency: Why NCDs Matter outlines the difficulties South Africa faces as an emerging economy battling the spread of both communicable and noncommunicable diseases simultaneously.

It’s a "double burden of disease," said the paper.

"Further, compared to their higher-income counterparts, many developing countries will face elevated NCD levels at earlier stages of economic development and with a much compressed timeline to address the challenge."

The economic cost of noncommunicable diseases

According to Demetre Labadarios, a failure to manage the widening disease burden could have a giant impact on the economy. "If we do not manage NCDs effectively in South Africa, the threat to the economy will be enormous and potentially destructive or disabling," he said.

No studies relating to the direct economic impact on South Africa appear to have been carried out, but estimations from other developing economies outlined in a discussion paper produced by the World Bank’s Human Development Network give a sense of the cost.

  • China: Reducing cardiovascular mortality by 1% a year between 2010 and 2040 could generate an economic value equivalent to 68% of China’s real gross domestic product (GDP) in 2010; more than $10.7-trillion, according to a 2011 World Bank report.
  • Egypt: NCDs could be leading to an overall production loss of 12% of Egypt’s GDP, according to one 2011 study.
  • Brazil: The World Bank estimates that the cost of NCDs between 2005 and 2009 could equal 10% of Brazil’s 2003 GDP.
  •  India: Eliminating NCDs could, in theory, have increased India’s 2004 GDP by between 4% and 10%, cites the discussion paper.

The paper highlights the extent of the economic cost of the diseases. "The overall economic and social cost of NCDs vastly exceeds their direct medical costs," it said.

"NCDs affect economies, health systems, and households and individuals through a range of drivers such as reduced labour productivity, higher medical treatment costs, and lost savings.

"These drivers aggregate into significant socioeconomic impacts, including in the areas of: country productivity and competitiveness; fiscal pressures; health outcomes; and poverty, inequity and opportunity loss." – Source: Population Health, Health Systems and Innovation, HSRC