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After a recent family trip to get our Christmas tree, my teenagers insisted on coffee shop festive hot chocolates, which were so loaded with extra garnishes they seemed more like desserts.
I’m not alone in my concerns about the amount of sugar my kids are getting in their drinks. The Health Secretary Wes Streeting has announced plans to expand the sugar tax, so in future it would include milk-based sugary drinks. The current version applies just to fizzy drinks and squashes.
In response to the first version of the tax, which arrived in 2018, manufacturers replaced at least some of the sugar in their drinks with artificial sweeteners, rather than putting up prices.
As it is likely that expanding the tax will lead to even more sweeteners in drinks, it seems a good time to look at the pros and cons of sugar versus sweeteners.
Case against sugar
The original drinks tax was brought in because of growing concern that sugar is one of the key contributors to the obesity crisis, after decades of health bodies focusing more on fat.
Government advice on how much sugar we should be consuming was lowered in 2015. It changed to saying “free sugars” (most dietary sugars apart from those within whole fruits and vegetables) should provide no more than 5 per cent of our daily calories.
That’s about 30 grams of sugar for typical adults – quickly busted by a single can of cola, which has 35g.
Many non-diet drink have sweeteners in them (Photo: Catherine Falls Commercial/Getty)The sugar in fizzy drinks is seen as particularly unhealthy because it comes with no other nutrients. It is sometimes called “empty calories”.
Certainly, many studies have shown that the more fizzy drinks people have, the more likely they are to be overweight. And soft drinks also cause tooth decay.
The current sugar tax applies to pre-packaged drinks with added sugar. If they have more than 5 grams per 100 millilitres, manufacturers have to pay a levy to the exchequer, a cost usually passed on to customers.
The new version – set to arrive in two years – would apply to pre-packaged dairy-based drinks like milkshakes, yogurt drinks and iced coffees, as well as sweetened dairy alternatives like oat milk.
The expanded scheme will also lower the sugar threshold at which the tax kicks in for all drinks, milk-based or not, from 5g to 4.5g.
Case against sweeteners
Artificial sweeteners were, until recently, seen as one of the modern food industry’s most useful inventions. They are a group of chemical compounds that give a sweet taste with zero or near-zero calories.
There have long been claims that some of the sweeteners have side effects, but these were dismissed by most scientists. For instance, aspartame, found in many diet drinks, has been claimed to cause cancer. But that stems from studies where animals were exposed to large amounts. Cancer Research UK says aspartame is safe in the quantities most people would consume.
Two other sweeteners, stevia and sucralose, have also been linked to liver damage, but again, this was mainly based on animal research.
On top of those controversies, there has also been a more recent backlash against sweeteners more broadly.
Campaigners against ultra-processed food (UPF), like Dr Chris van Tulleken, say they disrupt metabolism, because their sweet taste means the body prepares for an influx of sugar but doesn’t get it. This could potentially stimulate appetite or disturb the hormones that regulate blood sugar.
Some animal studies have suggested they may change the balance of our gut bacteria – although again, the implications for people are unclear.
Which is worse, sugar or sweeteners?
On the face of it, food and drink with sweeteners can be used to replace sugar in the diet – which you would think has to be good for weight control.
But when the strategy is put to the test, the research evidence is unclear. Large population studies find that people who consume more sweeteners tend to be heavier and have more heart attacks and diabetes, although such research can be biased because people may choose diet drinks precisely because they are overweight.
But even randomised trials – the best kind of medical evidence – give pause for thought. Short-term trials do suggest swapping full-sugar fizzy drinks for diet versions leads to a little weight loss. But longer-term trials do not find any weight change, according to a review of the evidence by the World Health Organisation (WHO) two years ago.
After this analysis, the WHO reversed its stance on sweeteners, recommending against their use for weight control.
The UK Government’s Scientific Advisory Committee on Nutrition (SACN) also reviewed the evidence and said, earlier this year, that we should be more cautious, especially as intake of sweeteners is rising.
SACN said “younger children” (without defining their age) should have no sweeteners and everyone else should try to minimise consumption.
This means, bizarrely, that Streeting’s new health plan is likely to have an effect – of boosting sweetener consumption – that is the opposite of the latest recommendations from his science advisors.
Will the sugar tax work?
Putting aside the health concerns over sweeteners, it is also unclear whether the sugar tax would actually work in tackling obesity.
Streeting said last week that the two moves will prevent 15,000 cases of obesity. “The levy has already shown that when industry cuts sugar levels, children’s health improves. So, we’re going further,” he said.
When I asked Streeting’s spokesperson, they declined to comment on where his figures came from. To my knowledge, there has only been one study of how the sugar tax might have affected child obesity.
It looked at two age groups in both boys and girls, where obesity rates had been gradually rising year by year until 2016, when the tax was announced and drinks started being reformulated.
In one group (10 to 11-year-old girls), that upward trend seemed to flatten out after 2016. This culminated in an 8 per cent difference between the actual obesity level in 2019 and what the obesity level would have been if the line on the graph had continued rising.
The authors said the tax was responsible. But in the other three groups, there was no change – so this study does not seem convincing evidence to me.
And any possible fall was quickly dwarfed by a 22 per cent jump in child obesity in all groups that happened the next year. “I don’t think it’s made one iota of difference to obesity in kids,” said Professor Tom Sanders, a nutrition scientist at King’s College London.
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As for the claim that the expanded tax will prevent 15,000 cases of obesity, I understand this is based on an impact assessment, where the calculations were that it would prevent 14,000 adults from becoming obese and 1,000 children. So this is hardly a swingeing blow against child obesity, despite Streeting’s claims.
I dug further into that assessment. It was based on modelling studies – not the most concrete kind of evidence – that suggested the expanded sugar tax would cut energy intake by 0.3 calories per person per day, on average. That’s an underwhelming 0.015 per cent of our average daily calorie intake.
That value of 0.3 calories was then plugged into equations to calculate how it would affect the population’s weight in the long term. And that’s what led to Sreeting claiming his policy would lead to 15,000 fewer obesity cases after some (unspecified) length of time.
But that assumes someone having 0.3 calories fewer from drinks each day would not compensate for it in other ways – perhaps by sitting down for a few more seconds daily or even having one extra biscuit per year.
To me, it seems a very theoretical – even implausible – claim, and not one that should be used to guide important public health policies that shape our food environment.
Where does that leave us?
For those, like me, who are wondering whether to choose diet drinks or regular versions this Christmas, the contrast between Government policy and the recommendations from their science advisors can be puzzling.
Perhaps we should follow the advice of Dr David Unwin, a GP in Southport, who is a diabetes expert for the Royal College of General Practitioners. Dr Unwin applauded the sugar tax, as he sees sugar as the most damaging component of modern diets.
On the other hand, he said that while sweeteners can be useful for helping people reduce their sugar intake, the best long-term approach is to train yourself out of a sweet tooth. “The ultimate goal is to cut both sugars and sweeteners down as much as you can.”
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