In October 2011, Denmark chose to tax foods high in saturated fat, despite the fact that most medical professionals no longer believe that fat is the primary culprit. But now, the country is considering taxing sugar as well — a more plausible and defensible step. Indeed, rather than focusing on fat and 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 to 'added sugar', defined as any sweetener containing the molecule fructose that is added to food in processing.

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No ordinary commodity
In 2003, social psychologist Thomas Babor and his colleagues published a landmark book called Alcohol: No Ordinary Commodity, in which they established four criteria, now largely accepted by the public-health community, that justify the regulation of alcohol — unavoidability (or pervasiveness throughout society), toxicity, potential for abuse and negative impact on society2. Sugar meets the same criteria, and we believe that it similarly warrants some form of societal intervention.

First, consider unavoidability. Evolutionarily, sugar was available to our ancestors as fruit for only a few months a year (at harvest time), or as honey, which was guarded by bees. But in recent years, sugar has been added to nearly all processed foods, limiting consumer choice3. Nature made sugar hard to get; man made it easy. In many parts of the world, people are consuming an average of more than 500 calories per day from added sugar alone (see 'The global sugar glut').

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Now, let's consider toxicity. A growing body of epidemiological and mechanistic evidence argues that excessive sugar consumption affects human health beyond simply adding calories4. Importantly, sugar induces all of the diseases associated with metabolic syndrome1, 5. This includes: hypertension (fructose increases uric acid, which raises blood pressure); high triglycerides and insulin resistance through synthesis of fat in the liver; diabetes from increased liver glucose production combined with insulin resistance; and the ageing process, caused by damage to lipids, proteins and DNA through non-enzymatic binding of fructose to these molecules. It can also be argued that fructose exerts toxic effects on the liver that are similar to those of alcohol1. This is no surprise, because alcohol is derived from the fermentation of sugar. Some early studies have also linked sugar consumption to human cancer and cognitive decline.

Sugar also has clear potential for abuse. Like tobacco and alcohol, it acts on the brain to encourage subsequent intake. There are now numerous studies examining the dependence-producing properties of sugar in humans6. Specifically, sugar dampens the suppression of the hormone ghrelin, which signals hunger to the brain. It also interferes with the normal transport and signalling of the hormone leptin, which helps to produce the feeling of satiety. And it reduces dopamine signalling in the brain's reward centre, thereby decreasing the pleasure derived from food and compelling the individual to consume more1, 6.

Finally, consider the negative effects of sugar on society. Passive smoking and drink-driving fatalities provided strong arguments for tobacco and alcohol control, respectively. The long-term economic, health-care and human costs of metabolic syndrome place sugar overconsumption in the same category7. The United States spends $65 billion in lost productivity and $150 billion on health-care resources annually for morbidities associated with metabolic syndrome. Seventy-five per cent of all US health-care dollars are now spent on treating these diseases and their resultant disabilities. Because about 25% of military applicants are now rejected for obesity-related reasons, the past three US surgeons general and the chairman of the US Joint Chiefs of Staff have declared obesity a “threat to national security”.

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Consequently, we propose adding taxes to processed foods that contain any form of added sugars. This would include sweetened fizzy drinks (soda), other sugar-sweetened beverages (for example, juice, sports drinks and chocolate milk) and sugared cereal. Already, Canada and some European countries impose small additional taxes on some sweetened foods. The United States is currently considering a penny-per-ounce soda tax (about 34 cents per litre), which would raise the price of a can by 10–12 cents. Currently, a US citizen consumes an average of 216 litres of soda per year, of which 58% contains sugar. Taxing at a penny an ounce could provide annual revenue in excess of $45 per capita (roughly $14 billion per year); however, this would be unlikely to reduce total consumption. Statistical modelling suggests that the price would have to double to significantly reduce soda consumption — so a $1 can should cost $2 (ref. 10).

Other successful tobacco- and alcohol-control strategies limit availability, such as reducing the hours that retailers are open, controlling the location and density of retail markets and limiting who can legally purchase the products2, 9. A reasonable parallel for sugar would tighten licensing requirements on vending machines and snack bars that sell sugary products in schools and workplaces. Many schools have removed unhealthy fizzy drinks and candy from vending machines, but often replaced them with juice and sports drinks, which also contain added sugar.

Another option would be to limit sales during school operation, or to designate an age limit (such as 17) for the purchase of drinks with added sugar, particularly soda.

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Ultimately, food producers and distributors must reduce the amount of sugar added to foods. But sugar is cheap, sugar tastes good and sugar sells, so companies have little incentive to change. Although one institution alone can't turn this juggernaut around, the US Food and Drug Administration could “set the table” for change8. To start, it should consider removing fructose from the Generally Regarded as Safe (GRAS) list, which allows food manufacturers to add unlimited amounts to any food.