A pharmacist's perspective on health and metabolic disease
Apart from being best-selling authors, clinicians and public health researchers, what else do Aseem Malholtra, Grant Schofield and Robert Lustig have in common? They have teamed up to take on “Big Sugar”.
In their paper published today in the Journal of Insulin Resistance (edited by Jason Fung), they liken the task of reducing diet-related diseases including obesity and type 2 diabetes, to being very similar to the groups that took on “Big Tobacco” when smoking was linked to lung cancers.
Despite the studies showing that tobacco was linked to lung cancer from the 1950s, it took more than forty years for this to be accepted by the tobacco companies.
New Zealand actually started public health campaigns in the 1948 to educate the public that smoking was linked to cancer, then in the in the 1970s, the warning notices came out on directly on the tobacco packets.
But these public health warnings were insufficient to counter the glamorisation of tobacco products. Movie stars were often photographed with a cigarette in their hands and there were many strategic placements in movies – consider the scene “You’re the one that I want” in the movie “Grease”, when Danny meets a made-over Sandy. Many sporting and other events were sponsored by tobacco companies. I can remember Benson and Hedges sponsoring cricket in New Zealand, but they also sponsored motor racing, golf, horse racing, cultural events such as fashion design competitions. All activities linked with glamour, spectacle, opportunity, wealth and reward. Hard act to counter with cold, boring facts about health and lung cancer.
No surprise then that consumption of tobacco products kept increasing throughout this time, and that people started smoking at a younger age.
We’ve turned things around and now it is much less common to see people smoking, and we have drastically reduced the numbers of people dying from smoking related disordered. But the big numbers in people quitting smoking did not come through a “personal choice to improve health”. It came through other measures:
The New Zealand government started greater legislation to reduce harm from smoking and this meant restricting advertising and reducing the “glamour quotient”.
Although preventing TV and radio advertising of tobacco products started in the 60s. In the 1990s things got more serious. A new law prevented the selling of tobacco products to those under the age of 16 years (increased to 18 in 1998), placed bans on smoking in public transport, and in certain workplaces, cafes, restaurants, and stopped the tobacco companies sponsoring events and much more heavily regulated the advertising of tobacco products. No advertising was allowed to glamourize tobacco products, which stopped celebrity endorsements.
In 2004, legislation got even tougher, all workplaces, including hospitals, prisons, hospitality venues, and areas around early childhood centres (among other places) had to become 100% smokefree. Other regulations around advertising and retail displays were strengthened.
Looking at the graph (below) about trends in smoking prevalence in NZ from 1983. Although the prevalence of smokers has been slowly decreasing since before the late 1980s, there has been a noticeable drop about 1990 (that admittedly quickly plateaued) and again in 2004 that has been much more sustained.
This suggests that changing the environment, putting up taxes (they happened about the same time as well as the legislation changes) and making it difficult to smoke were bigger incentives to help people quit, or to prevent them from starting in the first place were far more effective.
I know this because in my pharmacy practice, we noticed every change to the taxes and especially when the laws changed. Smoking cessation aids, such as nicotine patches and gum were fully subsidised on special prescriptions (approximately $5/product per month) and almost any healthcare worker (except pharmacists, but that is a different grumble) could be certified to prescribed them.
Many people would be grumbling about having to quit smoking because a) they could not afford it; b) it was too difficult to smoke at work, at the pub, out with friends, then finally we started getting some peer pressure encouraging people to quit. Have to admit I loved it when the parent would admit that their children had browbeaten them into quitting.
With very few exceptions, people were not quitting cigarettes for the good of their own health; even most pregnant women quit for the sake of their baby – not themselves.
So how can we expect people to give up sugar, a substance just as, if not more, addicting than cigarettes, without legislative support and environmental changes.
This is why I applaud this paper by Aseem, Grant and Robert. Their eight point plan (below) is modeled on steps taken to curb use of tobacco products – which has been very successful in reducing harm associated with tobacco products.
They predict that if all these steps were taken, then we would see a decrease in people being diagnosed with type 2 diabetes within 3 years.
It took forty years from the evidence emerging that tobacco was linked to cancer to legislation to prevent it. Even now, it is estimated that one in five premature deaths in New Zealand are due to smoking.
I’m sure there were plenty of nay-sayers at the time, (like we have now about sugar taxes), saying that cigarette smoking was personal choice, and that people should be listening to the educational material provided, and that increased taxes only penalised the poor who could least afford them. Who can deny that these legislative changes did what they were intended to do and decreased the prevalence of tobacco use. Apart from the tobacco companies, would anyone want us to go back to where we were with tobacco control in the 1980s?
We are in the same situation now with products containing added sugars (refined or otherwise). How many people will die prematurely from diet related diseases that could be prevented by changing the sugar-laden environment?
How long do we have to wait for a government brave enough to enact these recommendations?
The proposed eight-point plan
Education for the public should emphasise that there is no biological need or nutritional value of added sugar. Industry should be forced to label added and free sugars on food products in teaspoons rather than grams, which will make it easier to understand.
There should be a complete ban of companies associated with sugary products from sponsoring sporting events. We encourage celebrities in the entertainment industry and sporting role models (as Indian cricketer Virat Kohli and American basketballer Stephan Curry have already done) to publicly dissociate themselves from sugary product endorsement.
We call for a ban on loss leading in supermarkets, and running end-of-aisle loss leading on sugary and junk foods and drinks.
Sugary drinks taxes should extend to sugary foods as well.
We call for a complete ban of all sugary drink advertising (including fruit juice) on TV and internet demand services.
We recommend the discontinuing all governmental food subsidies, especially commodity crops such as sugar, which contribute to health detriments. These subsidies distort the market, and increase the costs of non-subsidised crops, making them unaffordable for many. No industry should be provided a subsidy for hurting people.
Policy should prevent all dietetic organisations from accepting money or endorsing companies that market processed foods. If they do, they cannot be allowed to claim their dietary advice is independent.
We recommend splitting healthy eating and physical activity as separate and independent public health goals. We strongly recommend avoiding sedentary lifestyles through promotion of physical activity to prevent chronic disease for all ages and sizes, because “you can’t outrun a bad diet”. However, physical (in)activity is often conflated as an alternative solution to obesity on a simple energy in and out equation. The evidence for this approach is weak. This approach necessarily ignores the metabolic complexity and unnecessarily pitches two independently healthy behaviours against each other on just one poor health outcome (obesity). The issue of relieving the burden of nutrition-related disease needs to improve diet, not physical activity.
Malhotra, A., Schofield, G., & Lustig, R. H. (2018). The science against sugar, alone, is insufficient in tackling the obesity and type 2 diabetes crises – We must also overcome opposition from vested interests [science against sugar; obesity; type 2 diabetes]. 2018, 3(1). doi:10.4102/jir.v3i1.39
Tobacco control. Retrieved from https://www.health.govt.nz/our-work/preventative-health-wellness/tobacco-control on 11 May 2018
Background Information: New Zealand’s Tobacco Control Programme Retrieved from: https://www.health.govt.nz/system/files/documents/pages/appendix-8-april-background-info-tobacco-control-programme.pdf on 11 May 2018