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OBITUARYPhilip Lawl and thdiscov that DNA damagcan ca s canc .36

LITERATUREHow Cha l sDick ns d w on sci nc , tl ft oom fo wond .32

NEUROSCIENCETh so c of ths lf is in th ains wi ing,not individ al n ons .31

ECOLOGYKomodo d agons andl phants co ld d c fiisk in A st alia .30

Th toxic t th a o t s gaAdd d sw t n s pos dang s to h alth that j stif cont olling th m lik alcohol,

a g Robert H. Lustig , Laura A. Schmidt and Claire D. Brindis .

susceptible to non-communicable diseases;80% of deaths attributable to them occur inthese countries.

Many people think that obesity is theroot cause of these diseases. But 20% of obese people have normal metabolism and

Last September, the United Nationsdeclared that, for the first time inhuman history, chronic non-commu-

nicable diseases such as heart disease, cancerand diabetes pose a greater health burdenworldwide than do infectious diseases,contributing to 35 million deaths annually.

This is not just a problem of the developedworld. Every country that has adopted theWestern diet one dominated by low-cost,highly processed food has witnessed risingrates of obesity and related diseases. Thereare now 30% more people who are obesethan who are undernourished. Economicdevelopment means that the populationsof low- and middle-income countriesare living longer, and therefore are more

will have a normal lifespan. Conversely, upto 40% of normal-weight people manifestthe diseases that constitute the meta-bolic syndrome: diabetes, hypertension,lipid problems, cardio vascular disease,non-alcoholic fatty liver disease, cancer anddementia. Obesity is not the cause; rather,it is a marker for metabolic dysfunction,which is even more prevalent.

The UN announcement targets tobacco,alcohol and diet as the central risk factorsin non-communicable disease. Two of thesethree tobacco and alcohol are regulatedby governments to protect public health,leaving one of the primary culprits behindthis worldwide health crisis unchecked.Of course, regulating food is more

SUmmARY Sug r c nsumpti n is linked t risein n n-c mmunic ble dise se Sug rs effects n t e b dy c n besimil r t t se f lc l Regul ti n c uld include t x, limitings les during sc l urs, nd pl cing

ge limits n purc sing

I l l u S t R a t I o n b y M a R k S M I t h

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complicated food is required, whereastobacco and alcohol are non-essential con-sumables. The key question is: what aspectsof the Western diet should be the focus of intervention?

Denmark first chose, in October 2011,to tax foods high in saturated fat, despitethe fact that most medical professionals no

longer believe that fat is the primary culprit.But now, the country is considering taxingsugar as well a more plausible and defen-sible step. Indeed, rather than focusing on fatand salt the current dietary bogeymen of the US Department of Agriculture (USDA)and the European Food Safety Authority we believe that attention should be turned toadded sugar, defined as any sweetener con-taining the molecule fructose that is addedto food in processing.

Over the past 50 years, consumption of sugar has tripled worldwide. In the UnitedStates, there is fierce controversy over the

pervasive use of one particular added sugar high-fructose corn syrup (HFCS). It is manu-factured from corn syrup (glucose), processedto yield a roughly equal mixture of glucoseand fructose. Most other developed countrieseschew HFCS, relying on naturally occurringsucrose as an added sugar, which also consistsof equal parts glucose and fructose.

Authorities consider sugar as empty cal-ories but there is nothing empty aboutthese calories. A growing body of scientificevidence shows that fructose can triggerprocesses that lead to liver toxicity and ahost of other chronic diseases 1. A little isnot a problem, but a lot kills slowly (seeDeadly effect). If international bodies aretruly concerned about public health, they must consider limiting fructose and itsmain delivery vehicles, the added sugarsHFCS and sucrose which pose dangersto individuals and to society as a whole.

NO ORdINARY COmmOdITYIn 2003, social psychologist Thomas Baborand his colleagues published a landmarkbook called Alcohol: No Ordinary Commod-ity, in which they established four criteria,now largely accepted by the public-healthcommunity, that justify the regulation of alcohol unavoidability (or pervasivenessthroughout society), toxicity, potential forabuse and negative impact on society 2. Sugarmeets the same criteria, and we believe thatit similarly warrants some form of societalintervention.

First, consider unavoidability. Evolu-tionarily, sugar as fruit was available toour ancestors for only a few months a year(at harvest time), or as honey, which wasguarded by bees. But in recent years, sugarhas been added to virtually every processedfood, limiting consumer choice 3. Naturemade sugar hard to get; man made it easy.In many parts of the world, people are

consuming an average of more than 500 cal-ories per day from added sugar alone (seeThe global sugar glut).

Now, lets consider toxicity. A growingbody of epidemiological and mechanisticevidence argues that excessive sugar con-sumption affects human health beyondsimply adding calories 4. Importantly, sugar

induces all of the diseases associated withmetabolic syndrome 1,5. This includes: hyper-tension (fructose increases uric acid, whichraises blood pressure); high triglyceridesand insulin resistance through synthesis of fat in the liver; diabetes from increased liver

glucose productioncombined with insu-lin resistance; andthe ageing process,caused by damage tolipids, proteins andDNA through non-enzymatic bind ing

of fructose to thesemolecules. It can alsobe argued that fructose exerts toxic effects onthe liver similar to those of alcohol 1. This isno surprise, because alcohol is derived fromthe fermentation of sugar. Some early stud-ies have also linked sugar consumption tohuman cancer and cognitive decline.

Sugar also has a clear potential for abuse.Like tobacco and alcohol, it acts on thebrain to encourage subsequent intake.There are now numerous studies examin-ing the dependence-producing propertiesof sugar in humans 6. Specifically, sugardampens the suppression of the hormoneghrelin, which signals hunger to the brain.It also interferes with the normal transportand signalling of the hormone leptin, whichhelps to produce the feeling of satiety. Andit reduces dopamine signalling in the brainsreward centre, thereby decreasing the pleas-ure derived from food and compelling

the individual to consume more 1,6.Finally, consider the negative effects

of sugar on society. Passive smoking anddrink-driving fatalities provided strongarguments for tobacco and alcohol con-trol, respectively. The long-term economic,health-care and human costs of metabolicsyndrome place sugar overconsumption in

the same category 7

. The United States spends$65 billion in lost productivity and $150 bil-lion on health-care resources annually forco-morbidities associated with metabolicsyndrome. Seventy-five per cent of all UShealth-care dollars are now spent on treat-ing these diseases and resultant disabilities.Because 75% of military applicants are nowrejected for obesity-related reasons, the pastthree US surgeons general and the chairmanof the US Joint Chiefs of Staff have declaredobesity a threat to national security.

HOw TO INTERvENE

How can we reduce sugar consumption?After all, sugar is natural. Sugar is a nutri-ent. Sugar is pleasure. So is alcohol, but inboth cases, too much of a good thing is toxic.It may be helpful to look to the many genera-tions of international experience with alcoholand tobacco to find models that work 8,9. Sofar, evidence shows that individually focusedapproaches, such as school-based interven-tions that teach children about diet and exer-cise, demonstrate little efficacy. Conversely,for both alcohol and tobacco, there is robustevidence that gentle supply side controlstrategies which stop far short of all-out pro-hibition taxation, distribution controls,age limits lower both consumption of theproduct and accompanying health harms.Successful interventions all share a commonend-point: curbing availability 2,8,9.

Taxing alcohol and tobacco products inthe form of special excise duties, value addedtaxes and sales taxes are the most popular

dEAdLY EffECTExcessive c nsumpti n f fruct se c n c use m ny f t e s me e lt pr blems s lc l.

Chronic ethanol exposure Chronic fructose exposure

hem t l gic dis rders

Electr lyte bn rm lities

hypertensi n hypertensi n (uric cid)

C rdi c dil t ti n

C rdi my p t y My c rdi l inf rcti n (dyslipidemi , insulinresist nce)

Dyslipidemi Dyslipidemi (de n v lip genesis)

P ncre titis P ncre titis ( ypertriglyceridemi )

obesity (insulin resist nce) obesity (insulin resist nce)

M lnutriti n M lnutriti n ( besity)

hep tic dysfuncti n ( lc lic ste t ep titis) hep tic dysfuncti n (n n- lc lic ste t ep titis)

Fet l lc l syndr me

addicti n h bitu ti n, if n t ddicti n

S urce: ref. 1

Sugar is cheap, sugar tastes good,and sugar sells,so companies have little incentive to

change.

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and effective ways to reduce smoking and

drinking, and in turn, substance abuse andrelated harms 2. Consequently, we proposeadding taxes to processed foods that containany form of added sugars, such as HFCS andsucrose. This would include sweetened fizzy drinks (soda) and other sugar-sweetenedbeverages (for example, juice, sports drinksand chocolate milk), and also sugared cereal.Already, Canada and some European coun-tries impose small additional taxes on somesweetened foods. The United States is cur-rently considering a penny-per-ounce sodatax (about 34 cents per litre), which wouldraise the price of a can of soda by 1012cents. Currently, each US citizen consumesan average of 216 litres of soda per year, of which 58% contains sugar; taxing at a penny an ounce could provide annual revenues inexcess of $45 per capita (roughly $14 billionper year); however, this would be unlikely to reduce total consumption. Statisticalmodelling suggests that the price wouldhave to double to significantly reduce sodaconsumption so a $1 can of soda shouldcost $2 (ref. 10).

Other successful tobacco- and alcohol-control strategies limit availability, such asreducing the hours that retailers are open,controlling the location and density of retailmarkets and limiting who can legally pur-chase the products 2,9. A reasonable parallelfor sugar would tighten licensing require-ments on vending machines and snack barsthat sell sugary products in schools andworkplaces. Many schools have removedsoda and candy from vending machines, butoften replaced them with juice and sportsdrinks, which also contain added sugar.States could apply zoning ordinances tocontrol the number of fast-food outlets andconvenience stores in low-income commu-nities, and especially around schools, whileproviding incentives for the establishment of grocery stores and farmers markets.

Another option would be to limit sales

during school operation, or to designatean age limit (such as 17) for the purchase of drinks with added sugar, particularly soda.Indeed, parents in South Philadelphia, Penn-sylvania, recently took this upon themselvesby lining up outside convenience stores andblocking children from entering them afterschool. Why couldnt a public-health direc-tive do the same?

THE pOSSIBLE dREAmGovernment-imposed regulations onthe marketing of alcohol to young peoplehave been quite effective, but there is no suchapproach to sugar-laden products. Even so,the city of San Francisco, California, recently instituted a ban on including toys withunhealthy meals such as some types of fastfood. A limit or, ideally, ban on televi-sion commercials for products with addedsugars could further protect childrens health.

Reduced fructose consumption couldalso be fostered through changes in sub-sidization. Promotion of healthy foods inUS low-income programmes, such as theSpecial Supplemental Nutrition Programfor Women, Infants and Children and theSupplemental Nutrition Assistance Pro-gram (also known as the food-stampsprogramme) is an obvious place to start.Unfortunately, the petition by New York City to remove soft drinks from the food-stampprogramme was denied by the USDA.

Ultimately, food producers and dis-tributors must reduce the amount of sugaradded to foods. But sugar is cheap, sugartastes good, and sugar sells, so companieshave little incentive to change. Althoughone institution alone cant turn this jug-gernaut around, the US Food and DrugAdministration could set the table forchange8. To start, it should consider remov-ing fructose from the Generally Regardedas Safe (GRAS) list, which allows food

manufacturers to add unlimited amounts toany food. Opponents will argue that othernutrients on the GRAS list, such as iron and vitamins A and D, can also be toxic whenover-consumed. However, unlike sugar,these substances have no abuse potential.Removal from the GRAS list would send apowerful signal to the European Food Safety

Authority and the rest of the world.Regulating sugar will not be easy particularly in the emerging markets of developing countries where soft drinksare often cheaper than potable water ormilk. We recognize that societal interven-tion to reduce the supply and demand forsugar faces an uphill political battle againsta powerful sugar lobby, and will requireactive engagement from all stakeholders.Still, the food industry knows that it hasa problem even vigorous lobbying by fast-food companies couldnt defeat thetoy ban in San Francisco. With enough

clamour for change, tectonic shifts inpolicy become possible. Take, for instance,bans on smoking in public places and theuse of designated drivers, not to mentionairbags in cars and condom dispensers inpublic bathrooms. These simple measures which have all been on the battlegroundof American politics are now taken forgranted as essential tools for our publichealth and wellbeing. Its time to turn ourattention to sugar.

Robert H. Lustig is in the Department of Pediatrics and the Center for Obesity Assessment, Study and Treatment at theUniversity of California, San Francisco,California 94143, USA.Laura A. Schmidt and Claire D. Brindis are at the Clinical and Translational Science Institute and the Philip R. Lee Institute for Health PolicyStudies, University of California, SanFrancisco, California 94118, USA.e-mail: rlustig@peds.ucsf.edu

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Countries: Case Studies (eds Pi s r p-a derse ,P. & C e g, F.) n . 9-5 (2007); v i e p://g . re.c m/prjs 4

4. J i Who/Fao Exper C s i .Diet,Nutrition and the Prevention of Chronic Diseases Who tec ic Rep r Series 916 (Who; 2003).

5. t ppy, l., l, k. a., tr , C, & P q , n. Nutrition 26, 10441049 (2010).

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p://g . re.c m/w4 59. R m, R., Sc mid , l. a., Re m, J. & M e P. Br.

Med. J. 337, 2364 (2008).10. S rm, R., P we l. M., C riq i, J. F. & C p ,

F. J. Health Aff. 29, 10521058 (2010).

THE GLOBAL SUGAR GLUTGlobal sugar supply (in the form of sugar and sugar crops, excluding fruit

and wine) expressed as calories per person per day, for the year 2007.

>600

Calories perperson per day

500600400500300400200300100200