Fact-checking Action on Sugar

When Labour announced yesterday that they would be aiming their public health rifles at tobacco, alcohol and sugar—rather than the traditional trio of tobacco, alcohol and obesity—it was a major win for Action on Sugar. Despite being barely a year old, this pressure group enjoys blanket media coverage and easy access to politicians.

Last year, their representatives met with Jeremy Hunt to present their 'Childhood Obesity Action Plan'. They would certainly have delivered the same document to Labour health spokespeople like Luciana Berger.

I only got around to reading it yesterday and I wasn't expecting much, but it is conisderably worse than I feared. In fact, it is an absolute disgrace. Time and time again Action on Sugar make hyperbolic and downright false claims that cannot be supported by their own citations, let alone by the wider scientific literature. It is scary to think that there are people in power who take them seriously.

Here are some of the statements they make in this document, along with the references they cite.

Obesity in childhood is strongly linked to the constant availability and consumption of ultra-processed foods and sweetened soft drinks(1). 

Source (1) cited here is Dietary Determinants of Obesity by Susan Jebb. This study doesn't discuss availability at all, nor does it mention 'processed' or 'ultra-processed' foods. For that matter, it only mentions children on two occasions, both of which I quote below.

With regards to 'sweetened soft drinks', it says: 'Cohort studies show either no relationship or a positive association between sugar-rich drinks and weight gain or obesity in adults or children'. Hardly a 'strong link'.

With regards to sugar, it says: 'While some studies show a protective effect of a high proportion of carbohydrate, many others show no association, particularly for studies in children [nb. sugar is a carbohydrate]. The evidence relating to the intake of sugar per se to weight change in inconsistent'. Again, hardly a 'strong link'. Indeed, barely even a hint of a link.

Jebb concludes that the strongest link with obesity is not with sugar at all, but with fat, saying: 'The strongest evidence for an increased risk of obesity relates to diets that are high in dietary fat or low in fibre'. Not quite what Action on Sugar would have you believe, and yet they cite it anyway.

From the outset, then, Action on Sugar totally misrepresent what researchers are saying in their own footnotes. 

These calorie-dense foods have no nutritional value, and are laden not only with sugar, but saturated fat and salt, leading to raised cholesterol and blood pressure, which further increases the risk of cardiovascular disease.

It is unclear which foods they are talking about, but if they contain sugar and fat, they will have some nutritional value because - guess what - carbohydrates and fats are nutrients. You can just about argue that fizzy drinks contain 'empty calories' if you must, but you cannot say that food has no nutritional value just because you don't like the nutrients in it. If it is food, it has nutritional value by definition.

Sugar that is added by the food industry is a major hidden source of calories in many foods and is an unnecessary source of calories that contribute directly to type II diabetes(2) and dental caries(3).

Citation (2) is Dietary Sugars Intake and Cardiovascular Health by Rachel Johnson et al., published in Circulation in 2009. As the titles of the study and journal suggest, it is primarily about cardiovascular disease, not diabetes. In its eleven pages, it mentions diabetes just three times, most relevantly when the authors say that 'fructose consumption has been indirectly implicated in the epidemics of obesity and type 2 diabetes' (my emphasis).

They say indirectly because too much sugar, like too much of any food, can lead to obesity, and obesity is a risk factor for diabetes. This is very different to Action on Sugar's heterodox theory that sugar somehow causes diabetes 'directly' even in people who are not obese. The difference between 'contributing directly' and being 'indirectly implicated' is massive in this context.

Although fluoridation has a small impact, it merely delays the onset of caries, so that in the end all adults develop caries.

Not all adults develop caries [tooth decay] and prevalence of caries has been falling for several decades. As the graph below shows, it is difficult to assess the impact of fluoridation, but fluoridation isn't the main weapon against tooth decay. Toothpaste is.

They continue:

The constant availability, cheapness and overwhelming marketing of ultra-processed foods and soft drinks have changed the food environment in the last 20 years

Per capita sugar consumption has fallen in the last twenty years.

The current policies such as the Responsibility Deal, where the food industry has pledged to reduce calories but can then decide what they do, has not had any effect on calorie intake on a public health scale.

Calorie consumption has fallen in recent years, both for food eaten inside and outside the home. Whether this is due to the Responsibility Deal is another question.

Nevertheless the sweetened soft drink and food industries are starting to acknowledge their role in causing the obesity pandemic worldwide, and also realise that it is entirely their responsibility to reverse it.

Even the more hardened 'public health' campaigners acknowledge that personal responsibility plays at least some part in maintaining a healthy weight, both in eating and exercise habits. Claiming that 'Big Food' and 'Big Soda' are entirely responsible for making people slim - and, by association, have been entirely responsible for making people fat - is absurd.

Removing 100kcal from the diet has been predicted to prevent the development of obesity and type II diabetes(4).

Source (4) is a reference to the government's Healthy Lives, Health People policy paper (pp. 19-20). It says: 'A group of independent experts, chaired by Professor Ian MacDonald, has considered data on weight gain in England and advised that a reduction in energy intake of 100 calories per person per day on average would correct the energy imbalance at a national level and also lead to a moderate degree of weight loss' (my emphasis).

Once again, Action on Sugar totally misrepresent their source. The policy paper does says not claim that a reduction of 100 calories a day would 'prevent the development of obesity' and it does not even mention diabetes in this context.

It is widely accepted amongst the lay public and media that consuming more calories than we burn is the cause of the obesity epidemic, and thus the solution is to do more exercise. This is not correct. Obesity is due to eating too many calories, particularly food and soft drinks that give no feeling of satiety or fullness.

This is an astonishing repudiation of science. For a start, it directly contradicts what Susan Jebb wrote in the review cited by Action on Sugar earlier. She says explicitly, at the very start of her article, that 'One of the few incontrovertible facts about obesity is that weight is only gained when energy intake exceeds energy needs for a prolonged period... Obesity results not from a high absolute energy intake but from intake which exceeds energy needs, even as a small fraction of energy flux. It is thus the coupling between intake and expenditure that lies at the heart of the problem.'

Here we have Action on Sugar taking not just 'one of the few incontrovertible facts about obesity' but the first law of thermodynamics and turning them on their heads. These people will tell you—or, rather, tell your MP—that black is white. Almost everybody understands that calories out is just as important as calories in, and that exercise—whilst not the only solution to obesity—is certainly one of them. Public Health England, for example, says: 'The link between physical inactivity and obesity is well established.'

The authors of Action on Sugar's policy document do eventually admit that physical activity has some (unnamed) benefits, but can't resist following it with another lie...

Regular physical activity does have beneficial effects but there has been little change if any in our levels of physical activity in the past three decades, whilst levels of obesity has increased (12)(13)(14).

This time we have three studies cited so there must be lots of evidence that activity levels haven't declined in Britain in the past three decades, right?

Wrong. Source (12) is a study of Americans and so has no relevance.

Source (13) is a BMJ editorial discussing a study which found that various interventions have failed to increase the amount of exercise children are taking in the last few years. The editorial notes that the study did not look at sedentary time 'which is emerging as an important risk factor [for obesity] across the life course'.

Source (14) is a study of the energy expenditure of a hunter-gatherer tribe in Tanzania which found energy expenditure to be similar to that of a sample of Americans. As the NHS notes, although the study is of 'anthropological interest', it 'cannot answer the question of which is more important, a calorie-dense diet or lack of physical activity as a cause of obesity'. Naturally, the study says nothing about changes in activity levels in the UK in the last thirty years.

In fact, there is plenty of evidence that day-to-day physical activity has declined in recent decades. Public Health England says that 'People in the UK today are 24% less active than in 1961'. There is also plenty of evidence that physical activity is important in body weight regulation. This really should not have to be explained to an alleged health group.

A child eating a burger and chips, washed down with a sugary drink, followed by a bar of chocolate and crisps, would need to run half a marathon to burn off the calories consumed.

If a child 'burnt off' every calorie he consumed through exercise, he would very soon be dead. Even a completely sedentary human being needs calories to survive. A ten year old boy needs 2000 calories to maintain a normal weight. If he runs half marathons, he will need a good deal more.

...the biggest cause of death and disability in the UK is due to the food we eat, through its very high salt, sugar and fat content, and the lack of fruit and vegetables.

I'm sure the anti-smoking lobby and others would take issue with this claim. Only yesterday we were told that physical inactivity causes more deaths than obesity. Action on Sugar don't (or can't) provide a source for this claim, but I don't think it is too low a blow to point out that their science director, Aseem Malhotra, first came to my attention when he combined every death from heart disease, diabetes and cancer in the world and portrayed the total as being the number of deaths that are due to 'diet-related diseases'. I suspect he may have done something similar here.

I could give more examples, but I hope my point has been made. This lobby group has an extraordinarily cavalier attitude towards evidence. They don't so much twist the facts as make them up as they go.

Considering the folk at Action on Sugar have become the go-to people when the media want a soundbite about the white stuff, journalists really need to start doing some fact-checking. Just because someone has a 'Dr.' in front of their name doesn't mean they will necessarily tell you the truth.

When the scientific director of an organisation that claims to speak with authority about sugar asserts that High Fructose Corn Syrup—a product that is practically non-existent in the EU—is 'added to almost all processed food' in Britain, you should be wary.

When he claims that 'just one sugary drink, typical of a can of Cola, increases the risk of type 2 diabetes by 22%', you should be concerned.

And when this same sugar 'expert' promotes notorious quacks, ignores peer-reviewers, sparks investigations at medical journals with his questionable use of sources and doesn't even know that fruit contains fructose, it might be time to find somebody else to talk to.