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Earlier this week I received a 3-page, single-spaced letter—plus 4 pages of charts and figures–from Andrew Briscoe III, the President and CEO of the Sugar Association.

I opened it with some trepidation because the last letter I got from the Sugar Association threatened to sue me (to read it, click here and scroll down to the Controversies section).

Whew.  This one merely expresses general concerns about:

the misinformation reported on added sugars consumption and the overstatement of added sugars contribution to increased caloric intakes.  Americans do not consume 25 percent of their calories from added sugars. We write to provide you with accurate data….

I don’t think I ever said that the average American consumes 25% of calories from sugars (although some surely do) but I have complained that the Institute of Medicine’s “safe” level of intake of sugars is 25% of calories.  This is higher than public health recommendations to restrict sugars to 10% of calories or less.  It is meant as an upper limit, but is often interpreted as a license to eat this much.

One quarter of daily calories from sugars is too high for something that provides no additional nutritional value.

The letter concludes:

The Sugar Association is committed to ensuring that all advice consumers receive regarding sugar intake is based on the best available scientific evidence and related data.  The American consumer will be better served by dietary advice that is science-based, practical and accurate, no matter the issue.

Can’t argue with that.  But as with all matters concerning nutrition, the issue is which science you choose to cite and how you interpret it.

Mr. Briscoe uses the term sugars, plural, because sucrose, HFCS, syrups, honey, and other such things are all sugars.

How much do Americans actually consume?  Mr. Briscoe was kind enough to provide USDA tables that address this question.  These describe the availability of sugars in the food supply, not necessarily what people are actually eating.

My interpretation of the tables is that they say:

• Sugars comprise 17% of total calorie availability.
• Adjusted for waste, the availability of sugars is about 27.5 teaspoons per day per capita (meaning everyone:  men, women, and tiny babies).
• Translating this into calories: 27.5 teaspoons x 4 grams per teaspoon x 4 calories per gram = 440 calories per day per capita.
• On a 2000 calorie diet, that’s 22% of total energy intake, although it will be lower for people who take in more calories.

The CDC has just released a summary of intake of added sugars among children and adolescents, in calories per day.

At 4 calories a gram, 400 calories is 100 grams or 3.5 ounces.  Can these calories contribute to weight gain or other health problems?

You bet.

As Mark Bittman put it in his New York Times column this week,

Let me state the obvious: there is no nutritional need for foods with added sugar.

All of this is part of the bigger question: How do we regulate the consumption of dangerous foods? As a nation, we’ve accepted the need to limit the marketing and availability of tobacco and alcohol. The first is dangerous in any quantity, and the second becomes dangerous when overconsumed.

And added sweeteners, experts increasingly argue, have more in common with these substances than with fruit.

No wonder the Sugar Association uses its own interpretation of the science to suggest that current levels of intake are benign and that no level of intake poses a risk.  Mr. Briscoe’s letter says:

No authoritative scientific body that has conducted a major systematic review of the scientific literature has a found a public health need to set an Upper Level (UL) for total or added sugars intake.  Every comprehensive review of the scientific literature concludes that, with the exception of dental caries, no causal link can be established between the intake of sugars and lifestyle diseases, including obesity.

I’m glad he mentioned dental caries.  Karen Sokal, a physician in California, has been tracking the onset of tooth decay among children in Latin America who are now consuming sodas and candy on a daily basis.  She writes:

Mark Bittman’s excellent editorial, “Regulating our Sugar Habit,” (Feb 27) concludes that eating too much sugar has become “the biggest public health challenge facing the developed world.”  Indeed, it poses a big health challenge for the entire world, especially developing countries.

In my 30 years of global health work, I have seen an explosion in the marketing and consumption of non-nutritious foods and beverages followed by a dramatic rise in childhood tooth decay and obesity. Quarterly business reports praise the food and beverage industry’s increased profits based on increased sales in “emerging markets.” The NY Times article on Kellogg’s purchase of Pringles (Feb 12) stated, “The snack business is growing faster and has greater appeal internationally,” which analysts noted “appears somewhat out of sync with the trends toward better-for-you snacking.”

Governmental regulations to ensure the production and marketing of healthful food and beverages must be applied worldwide and protect the health of the world’s most vulnerable populations.

Indeed, they must.  The Sugar Association has much to answer for in its opposition to public health recommendations to eat less sugar.

Nature, the prestigious science magazine from Great Britain, has just published a commentary with a provocative title–The toxic truth about sugar—and an even more provocative subtitle: Added sweeteners pose dangers to health that justify controlling them like alcohol.

The authors, Robert Lustig, Laura Schmidt and Claire Brindis, are researchers at the University of California medical center in San Francisco (UCSF).

They argue that although tobacco, alcohol and diet are critically important behavioral risk factors in chronic disease, only two of them—tobacco and alcohol—are regulated by governments to protect public health.

Now, they say, it’s time to regulate sugar.  By sugar, they mean sugars plural: sucrose as well as high fructose corn syrup (HFCS).  Both are about half fructose.

Their rationale?

• Consumption of sugars has tripled over the last 50 years.
• Many people consume as much as 500 calories a day from sugars (average per capita availability in the U.S. is about 400 calories a day)
• High intake of fructose-containing sugars induce metabolic syndrome (high blood pressure, insulin resistance), diabetes, and liver damage.
• Sugars have the potential for abuse.
• Sugars have negative effects on society (mediated via obesity).
• Too much of a good thing can be toxic.

Therefore, they argue, societies should intervene and consider the kinds of policies that have proven effective for control of tobacco and alcohol:

• Taxes
• Distribution controls
• Age limits
• Bans from schools
• Licensing requirements
• Zoning ordinances
• Bans on TV commercials
• Labeling added sugars
• Removal of fructose from GRAS status

In a statement that greatly underestimates the situation, they say:

We recognize that societal interven­tion to reduce the supply and demand for sugar faces an uphill political battle against a powerful sugar lobby, and will require active engagement from all stakeholders.

But, they conclude:

These simple measures — which have all been on the battleground of American politics — are now taken for granted as essential tools for our public health and well-being. It’s time to turn our attention to sugar.

What is one to make of this?  Sugar is a delight, nobody is worried about the fructose in fruit or carrots, and diets can be plenty healthy with a little sugar sprinkled here and there.

The issue is quantity.  Sugars are not a problem, or not nearly as much of a problem, for people who balance calorie intake with expenditure.

Scientists can argue endlessly about whether obesity is a cause or an effect of metabolic dysfunction, but most people would be healthier if they ate less sugar.

The bottom line?  As Corinna Hawkes, the author of numerous reports on worldwide food marketing, wrote me this morning, “there are plenty of reasons for people to consume less sugar without having to worry about whether it’s toxic or not!”

I’ve been saving up items about beverages, mostly having to do with marketing:

Soda companies vs. civic public health campaigns: In strategies reminiscent of those used by tobacco companies, soda companies are filing suit to obtain documents from public agencies all over the country.  Digging them up takes staff time and effort and slows down the real work of these agencies—the point of this approach.

Sonic’s marketing campaign, Limeades for Learning (“when you sip, kids learn”) encourages purchasers of its high-calorie drinks (620 for a medium, 950 for a large) to vote for school projects.

Dr Pepper Snapple’s diet—oops, low-calorie—10-calorie Dr Pepper Ten is aimed at men.  Men, it seems, like low-calorie sodas but squirm at the notion of diet sodas.

Coke covers both bases.  Diet Coke targets women and Coke Zero targets men in an “it’s not for women” campaign.   Is this ad offensive?  It not only excludes half the market, says Food Navigator’s Carolyn Scott-Thomas, but is

patronizing to both men and women in its reinforcement of what I had (perhaps naively) hoped were outdated stereotypes….It deliberately picks at the edges of our comfort zones.  Is it OK to be sexist if it’s done with irony?…Provocation is a blunt instrument.  It may prove effective for sales—perhaps as effective as sexually explicit marketing—but it is still crude and obtuse.”

She asks: “Would this ad be offensive if it involved a bunch of redneck clichés and proclaimed ‘it’s not for blacks’?  You bet it would.”

Coca-Cola has launched a global music effort to connect with teens.  Coke CEO Muhtar Kent says:

Our success in growing our sparkling category today depends on our ability to grow and connect with teens, the generation of tomorrow.

Pepsi, not to be outdone, has invented a social marketing vending machine for the digital age.  Buy a drink and you now have the opportunity to send one as a gift to a friend or a random stranger.

The Committee on Nutrition, American Academy of Pediatrics weighs in on sports and energy drinks.  Its tough report begins with the statement that “Sports and energy drinks are being marketed to children and adolescents for a variety of inappropriate uses.”

Sports drinks…may contain carbohydrates, minerals, electrolytes, and flavoring and are intended to replenish water and electrolytes lost through sweating during exercise.

In contrast…energy drinks also contain substances that act as nonnutritive stimulants, such as caffeine, guarana, taurine, ginseng, l-carnitine, creatine, and/or glucuronolactone, with purported ergogenic or performance-enhancing effects.

The report ends with this unambiguous conclusion:

the use of sports drinks in place of water on the sports field or in the school lunchroom is generally unnecessary. Stimulant containing energy drinks have no place in the diets of children or adolescents.

In response, Red Bull says it is not marketing to children.  Instead, it says, the company totally follows the “agreed codes of practice for the marketing and labelling of energy drinks.”

Just for fun I looked up some advertising budgets reported in Advertising Age. For 2010, Coca-Cola spent $267 million just to advertise Coke, Pepsi spent $154 million just to advertise Pepsi and another $113 million for Gatorade, and Dr. Pepper spent a mere $22 million for Snapple.

These expenses are just for those individual products and just for campaigns run through advertising agencies.  Pepsi’s total advertising budget that year was $1.01 billion.

Water, anyone?

I have a commentary in the October 23 issue of New Scientist (UK):

World’s first fat tax: what will it achieve?

Enviably healthy Denmark is leading the way in taxing unhealthy food. Why are they doing it, and will it work

Reports are coming in on the House hearings on the IWG report recommendations.  The IWG, recall from the previous post, is an Interagency Working Group of four federal agencies attempting to set nutrition standards for foods allowed to be marketed to kids.

This first report comes from Broadcasting & Cable:

The first panel of a joint hearing Wednesday on government-proposed food marketing guidelines featured government officials explaining that the principles, announced last April, are only voluntary recommendations to Congress that industry can ignore if they chose, while legislators, primarily Republicans, countering that they represent Big Brother government intruding into meal planning for families and a focus on marketing, without scientific backing, rather than focusing on more physical activity.

Republican lawmakers, it seems, want more science.  That’s always step one in undermining public health proposals: attack the science.  Subsequent steps, you may recall, include attacking critics, focusing on physical activity, and blaming personal responsibility for obesity and its consequences.

According to Healthwatch, Representative Henry Waxman (Dem-Calif)

Compared Republican defenders of unbridled food marketing to children to past champions of the tobacco industry. [He]  drew parallels between Wednesday’s hearing on proposed voluntary marketing restrictions and a 2003 hearing during which some Republicans promoted the safety of smokeless tobacco.

“I just find this an amazing hearing,” Waxman said. “The only thing I can analogize it to is after all the tobacco issues we discussed for many years, Republicans took charge and we never heard anything more about tobacco. Then, suddenly we had a hearing about tobacco.

And the hearing was about how smokeless tobacco should be encouraged as a way for smokers to give up smoking. It was geared to promoting an industry that no doubt supported financially many of the members. I wonder if this hearing is about the same subject.”

What I find most disturbing is the FTC’s backing down on the recommendations which were agreed upon by four federal agencies and voluntary.  CNN reports that David Vladeck, director of the FTC Bureau of Consumer Protection, said:

The coalition of government agencies is “in the midst of making significant revisions” to the original proposal.

Among the changes he suggested are narrowing the age group targeted and focusing on children aged 2 to 11 instead of up to age 17 and allowing marketing of the unhealthier foods at fundraisers and sporting events.

Vladeck also said that his agency would not recommend that companies change packaging or remove brand characters from food products that don’t qualify, as was originally suggested in the guidelines.

“Those elements of packaging, though appealing to children, are also elements of marketing to a broader audience and are inextricably linked to the food’s brand identity,” Vladeck said at the hearing.

This, as I keep pointing out, is about protecting corporate health at the expense of children’s health.

Sad.

In what Bloomberg News terms an “epidemic battle,” food companies are doing everything they can to prevent the United Nations from issuing a statement that says anything about how food marketing promotes obesity and related chronic diseases.

The U.N. General Assembly meets in New York on September 19 and 20 to develop a global response to the obesity-related increase in non-communicable, chronic diseases (cancer, cardiovascular disease, respiratory disease, type 2 diabetes) now experienced by both rich and poor countries throughout the world.

As the Bloomberg account explains,

Company officials join political leaders and health groups to come up with a plan to reverse the rising tide of non- communicable diseases….On the table are proposals to fight obesity, cut tobacco and alcohol use and expand access to lifesaving drugs in an effort to tackle unhealthy diets and lifestyles that drive three of every five deaths worldwide. At stake for the makers of snacks, drinks, cigarettes and drugs is a market with combined sales of more than $2 trillion worldwide last year.

Commenting on the collaboration of food companies in this effort:

“It’s kind of like letting Dracula advise on blood bank security,” said Jorge Alday, associate director of policy with World Lung Foundation, which lobbies for tobacco control.

The lobbying, to understate the matter, is intense.  On one side are food corporations with a heavy financial stake in selling products in developing countries.  Derek Yach, for example, a senior executive of PepsiCo, argues in the British Medical Journal that it’s too simplistic to recommend nutritional changes to reduce chronic disease risk.  [Of course it is, but surely cutting down on fast food, junk food, and sodas ought to be a good first step?]

On the other side are public health advocates concerned about conflicts of interest in the World Health Organization.  So is the United Nations’ special rapporteur for  the right to food, Olivier De Schutter.  Mr. De Schutter writes that the “chance to crack down on bad diets must not be missed.”

On the basis of several investigative visits to developing countries,  De Schutter calls for “the adoption of a host of initiatives, such as taxing unhealthy products and regulating harmful food marketing practices…Voluntary guidelines are not enough. World leaders must not bow to industry pressure.”

If we are serious about tackling the rise of cancer and heart disease, we need to make ambitious, binding commitments to tackle one of the root causes – the food that we eat.

The World Health Organization’s (WHO) 2004 Global Strategy on Diet, Physical Activity and Health must be translated into concrete action: it is unacceptable that when lives are at stake, we go no further than soft, promotional measures that ultimately rely on consumer choice, without addressing the supply side of the food chain.

It is crucial for world leaders to counter food industry efforts to sell unbalanced processed products and ready-to-serve meals too rich in trans fats and saturated fats, salt and sugars. Food advertising is proven to have a strong impact on children, and must be strictly regulated in order to avoid the development of bad eating habits early in life.

A comprehensive strategy on combating bad diets should also address the farm policies which make some types of food more available than others…Currently, agricultural policies encourage the production of grains, rich in carbohydrates but relatively poor in micronutrients, at the expense of the production of fruits and vegetables.

We need to question how subsidies are targeted and improve access to markets for the most nutritious foods.…The public health consequences are dramatic, and they affect disproportionately those with the lowest incomes.

In 2004, the U.N. caved in to pressures from food companies and weakened its guidelines and recommendations.  The health situation is worse now and affects people in developing as well as industrialized countries.  Let’s hope the General Assembly puts health above politics this time.

At the end of 2005, the Institute of Medicine (IOM) produced an unusually hard-hitting  report on food marketing to children.  The report complained about lack of cooperation from food companies in providing data.  Even so, the report concluded that “marketing works.” It is highly effective at getting kids to demand and eat junk foods.

The report gave the food industry two years to cease and desist.  If it didn’t, federal regulation should be considered.

Well, five years have come and gone and some of the people involved in the IOM report have just published a progress assessment in the American Journal of Preventive Medicine:  Despite lack of evidence in their review of the literature for real progress, the investigators’ assessment is anything but hard-hitting:

Food and beverage companies made moderate progress; however, limited progress was made by other industry subsectors. Industry stakeholders used integrated marketing communications (IMC) to promote primarily unhealthy products, which threaten children’s and adolescents’ health and miss opportunities to promote a healthy eating environment.

Miss opportunties?  That’s one way to put it.  Here are the conclusions:

Diverse industry stakeholders have several untapped opportunities to advance progress by promoting IMC to support a healthful diet; substantially strengthening self-regulatory programs; supporting truthful and non-misleading product labeling and health claims; engaging in partnerships; and funding independent evaluations of collective efforts.

The paper acknowledges:

the tensions among private- and public-sector stakeholders to promote a healthful diet to children and adolescents…conveying consistent and appealing messages; ensuring transparency by sharing relevant marketing data; obtaining company-wide commitments…balancing freemarket system goals with protecting young people’s health; and committing to monitor and evaluate all efforts.

Oh those pesky freemarket system goals.  Food companies cannot stop marketing junk foods to kids because the foods are profitable and their job as publicly traded companies is to grow profits every quarter.

That’s why federal regulation is essential, a point not mentioned by these investigators or in the accompanying editorial.  Instead, the editorial calls for counter-advertising:

The experience with tobacco is instructive. The most rapid period of decline in the use of cigarettes occurred not after television advertising was banned but in the period before the ban when counter ads were mandated as a proportion to the product ads.

I remember that period well.  The counter-advertisements were so effective that kids insisted that their parents stop smoking.

But those ads were mandated.  That’s still government.  Food companies cannot and will not stop marketing to kids on their own.

Note to physicians: you can 1 CME credit by reading this paper.

My San Francisco Chronicle column on food advocacy includes a severely edited list of organizations working on food issues, particularly school food and the farm bill.   I thought the entire list might be useful.

Note that information about how to contact government officials appears at the end.

I consider this list preliminary.  Please use the Comments to add to it.  And pass it along, use, and enjoy!

How to contact federal and state government officials

The White House: http://www.whitehouse.gov/contact

Members of Congress http://www.congress.org/congressorg/directory/congdir.tt

• Communicate with members: http://www.congress.org/communicate
• Meet with members: http://www.congress.org/visiting
• Meet with staff: http://www.congress.org/congressional_staff

State officials: http://www.congress.org/legislative_protocol

Local media: http://www.congress.org/congressorg/dbq/media/