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Sugar consumption by Americans and obesity are both too high – are they connected?

We thank Dr. White for pointing out that the rise of sugar consumption in the American and possibly European diets may have slowed (1), but it has continued to rise in other parts of the world and even if it increased no more, it would be at levels we view as unacceptably high for long-term health. However, Dr. White and we both ignored the rising use of fruit juice concentrates, which is likely higher in fructose compared with sucrose. Fruit juice concentrate, which is now found in 10% of all foods and beverages, is not included as a sugar by United States Department of Agriculture in any measurement and represents a major component of the growth of added sugar in recent years in our food supply (2). Monteiro highlights the large differential increase in lowand middle-income countries vs. High-income countries in these sales (3). The increased use of fruit juice concentrate as a sweetener and the increase in juice consumption likely both contribute to an overall imbalance in the consumption of fructose relative to glucose compared with that found in sugar. There are also data that the rise of body mass index has slowed, but we know of no one who would be complacent with more than 30% of our population being obese and this slowdown is found only in a few high-income countries and contrasts sharply with very rapid rise in obesity in much of the world (4). Similarly for soft drink intake, it may have ‘levelled’ off or most likely slightly declined, but the level is, in our view, far too high, particularly for the 40–60% of Americans who consume 133–600 kcals per day of added sugar, predominantly from beverages (5); also, juice consumption is increasing in some segments of the population. In a recent review called ‘Sugar Consumption at a Crossroads’ prepared by Keating and Natella (6) of Credit Suisse for their industrial clients, they do not try to varnish the truth about the current ‘unease’ over sugar and fructose consumption. They estimate that added sugars account for 17% of calories, and if all sources of sugar are included, it represents 38% of calories. This number of calories from different sugars crowds out of the diet, even in those who ‘overeat’ and become obese, important foods and the micronutrients they contain. In an editorial by Goran (7) accompanying our article in International Journal of Pediatric Obesity, he notes that two papers did not find a relation of beverage intake and obesity and that two others did. However, we know of no studies that show that drinking sugar-sweetened beverages reduces weight, and Keating and Natella (6) point out that there are NO studies showing that sugar intake is good for you. The recent World Health Organization review (8) of the effect of added sugar in both beverages and food adds to the very large literature on this topic and the recent random controlled trials in children, which found significant weight effects in this age group from increased added sugar from beverages (9,10). The current epidemic of obesity comes from transferring the carbon produced in plant and animal foods to human fat cells slowly over a period of 40 years. The unhealthy consequences of this transfer take time to manifest themselves, but to us it is now clear that the various added sugars in beverages is one incontrovertible component of this excess supply of carboncontaining calories. The mildly addictive caffeine in these beverages may well represent one of the drivers to increase soft drink intake, and the associated fructose may well be one of the causes of the nonalcoholic fatty liver disease that was unknown 40 years ago but has become a very expensive health problem. As Basu et al. (11) note in a survey of 75 countries, a 1% rise in soft drink consumption was associated with an additional 48 overweight adults per 100 adults (adjusted B; 95% confidence interval [CI] 3.1, 6.5), 2.3 obese adults per 100 (95% CI 1.1, 3.5) and 0.3 adults with diabetes per 100 adults (95% CI 0.1, 0.8). These findings remained robust in lowand middle-income countries. The time is at hand for spokesmen for the sweetener industry to stop trying to convince people that the various sugars in soft drinks does not contribute to the epidemic of obesity, and work collectively to help solve the problem before the time bomb of obesity and diabetes bankrupts the healthcare system (12).