Issue: 2015, Vol 1, No 3, Pages 84–119

Sugar: A taxing problem

David Haslam

David Haslam
GP, Hertfordshire, and Chair of the National Obesity Forum

The sugar tax has arrived in the UK at last, albeit only in Jamie Oliver’s restaurants and a few others, but “the longest journey starts with the smallest step.” My mother used to say, “there’s only 20 calories in a teaspoon of sugar,” whilst she ladled at least two into my milky coffee, and my dentist used to sit at the local pub table munching sugar cubes as if they were dry-roasted peanuts. How things change! In 1674, Thomas Willis treated diabetes by recommending a diet high in sugar, in order to replace the sugar being leaked by the kidneys, thereby inadvertently hastening patients’ deaths. Only in 1797 did clinicians start to realise that a reduction, not an increase, in sugar and starch was required to manage obesity and diabetes.

Low-carbohydrate diets became the obvious default from then on. In 1901, the great physician William Osler recommended (Osler, 1901):

“Avoid taking too much food, and particularly reduce the starches and sugars.”

Raymond Greene, brother of Graham and Hugh Greene, and arguably the most highly renowned endocrinologist of his day, wrote the following under the heading “A diet for obesity” (Greene, 1951):

“Foods to be avoided: bread and anything else made with flour... cereals... potatoes and any other white vegetables... foods containing much sugar... You can eat as much as you like of the following food: meat, fish, birds... green vegetables... eggs... cheese, fruit... except bananas and grapes.”

As one would expect, this advice from such a renowned clinician was spot on target. However, only a few years later, the infamous Ancel Keys upset the apple cart with his lipid hypothesis, which miscategorised foods: cakes and biscuits were labelled high-fat rather than high-carbohydrate, and thus dietary fat was demonised for increasing the number of cardiovascular events. Since then, the Committee on Medical Aspects of Food Policy (COMA) report, dietary guidelines, food pyramids and Eatwell Plates have reflected Keys’ work. A quick glance at the Eatwell Plate reveals an overwhelming carb fest – quite the wrong approach in obesity and diabetes, and reminiscent of Willis’ treatment in the 17th century.

Twenty years later, Professor John Yudkin jeopardised his career and courted ridicule by suggesting in his book Pure, White and Deadly that, actually, carbohydrate – specifically sugar – was the culprit for many of our woes. Only recently, thanks to research and writing by the likes of Gary Taubes, Robert Lustig and John Briffa, has the truth about sugar emerged, and the concept of sugar being bad is gaining momentum, with the public now widely aware that fruit juice, rather than being one of a healthy “five-a-day,” is actually damaging.

It is alarming to consider that the epidemic of obesity is, to a degree, the fault of erroneous advice from our profession, underpinned by the food industry, which grabbed the opportunity and wasted no time launching low-fat products, overflowing with sugar, at premium prices. Indeed, Lustig said of Yudkin (Llewellyn Smith, 2014):

“He knew a lot more data was needed to support his theories, but what’s important about his book is its historical significance. It helps us understand how a concept can be bastardised by dark forces of industry.”

It looks increasingly likely that the “dark forces of industry” will be penalised by a sugar tax, over and above Jamie’s creditable efforts, as voluntary measures such as the Responsibility Deal seem to have had little traction.

However, there are two sides to every argument. Previous efforts at food taxes have failed. Denmark’s fat tax was misdirected, and failed due to cross-border and internet shopping and, ultimately, people deciding to cough up the extra money to buy the food they craved. The tax was quickly rescinded. In the US, following a referendum, only one city – Berkeley, California – approved sugar taxation. However, in Mexico, a current sugar tax seems to sniff of success, not only providing a replicable model for other nations, but also producing evidence for public health statisticians of how a sugar tax would work and what difference it would make, instead of relying on dodgy computer microsimulations.

A pertinent question has always been “what will happen to the money raised by a food tax once it is in Government coffers?” In Mexico, it is being used to provide clean drinking water in schools to improve hydration and reduce the popularity of sugar-sweetened beverages. Jamie Oliver is donating his 10p levy on every sugary drink to a children’s charity.

The Royal College of GPs (2015) is supportive of a sugar tax, and the campaign group Action on Sugar agrees (Macgregor and Hashem, 2014). The Minister for Life Sciences, George Freeman, said, “Companies should know that if you insist on selling those products, we will tax them” (Knapton, 2015). The recent Scientific Advisory Committee on Nutrition report also recommends sugar reduction in the nation’s diet (Public Health England, 2015). Predictably, the Food and Drink Federation don’t see things the same way: “Demonising one nutrient out of a range on the national menu is not a healthy way to proceed” (Food and Drink Federation, 2015). Sugar, a nutrient?!

However, there is a sensible counterargument to a sugar tax, as highlighted in a recent BMJ debate (Sarlio-Lähteenkorva and Winkler, 2015). Professor Jack Winkler, of London Metropolitan University, describes the political and industrial unacceptability of sugar taxes, not to mention the opinion that they won’t work:

“A 10% tax would reduce average personal daily intake by 7.5 mL, less than a sip… a 20% tax would reduce consumption by 4 kcal. Effects of this size will not reverse global obesity.”

Although it would, of course, raise awareness of the dangers of sugar.

The head might say no to a sugar tax, but the heart says yes. The food industry has created a monster in the form of sugar-sweetened beverages, although credit is due for the increased availability of zero-calorie versions of soft drinks. A sugar tax should still be considered, with half an eye on the ground-breaking Mexican example.

Food and Drink Federation (2015) FDF Response to SACN Carbohydrates & Health Report. FDF, London. Available at: (accessed 24.09.15)

Greene R (1951) A diet for obesity. In: The Practice of Endocrinology. Lippincott, Philadelphia, PA, USA

Knapton S (2015) Sugar tax to pay for treating obesity. The Telegraph, London. Available at: (accessed 24.09.15)

Llewellyn Smith J (2014) John Yudkin: the man who tried to warn us about sugar. The Telegraph, London. Available at: (accessed 24.09.15)

Macgregor GA, Hashem KM (2014) Action on sugar – lessons from UK salt reduction programme. Lancet 383: 929–31

Osler W (1901) The Principles and Practice of Medicine. D Appleton & Co., New York, NY, USA

Public Health England (2015) SACN Carbohydrates and Health Report. PHE, London. Available at: (accessed 24.09.15)

Royal College of GPs (2015) RCGP Statement on Jamie Oliver’s “Sugar”. RCGP, London.

Sarlio-Lähteenkorva S, Winkler JT (2015) Could a sugar tax help combat obesity? BMJ 351: h4047