The Australian Paradox: A Substantial Decline in Sugars Intake over the Same Timeframe that Overweight and Obesity Have Increased

Ecological research from the USA has demonstrated a positive relationship between sugars consumption and prevalence of obesity; however, the relationship in other nations is not well described. The aim of this study was to analyze the trends in obesity and sugar consumption in Australia over the past 30 years and to compare and contrast obesity trends and sugar consumption patterns in Australia with the UK and USA. Data on consumption of sugar in Australia, the UK and USA were obtained from the Food and Agriculture Organization for the years 1980-2003. The prevalence of obesity has increased 3 fold in Australians since 1980. In Australia, the UK and USA, per capita consumption of refined sucrose decreased by 23%, 10% and 20% respectively from 1980 to 2003. When all sources of nutritive sweeteners, including high fructose corn syrups, were considered, per capita consumption decreased in Australia (−16%) and the UK (−5%), but increased in the USA (+23%). In Australia, there was a reduction in sales of nutritively sweetened beverages by 64 million liters from 2002 to 2006 and a reduction in percentage of children consuming sugar-sweetened beverages between 1995 and 2007. The findings confirm an “Australian Paradox”-a substantial decline in refined sugars intake over the same timeframe that obesity has increased. The implication is that efforts to reduce sugar intake may reduce consumption but may not reduce the prevalence of obesity.

The Australian Paradox reported the observation that upward changes in the prevalence of overweight and obesity in Australia run counter to changes in refined sugars intake [1]. Economist, Rory Robertson claims there is no Australian Paradox, just unreasonable treatment of the available data [2]. Unfortunately, there are factual errors in Mr. Robertson's essay and misinterpretation of the distinctions between total sugars vs. refined sugars, sugar availability vs. apparent consumption, sugar-sweetened and diet soft drinks, and other nutrition information. While the terminology, strengths and limitations of various nutrition data are readily understood by individuals trained in nutrition, some confusion may have been avoided if our original paper had referred to refined sugars in its title and described the terminology used.
Our peer-reviewed published analysis argued the case for a decline in refined sugar (sucrose) consumption by Australians over past decades. By several indicators, it has decreased over the same timeframe that the prevalence of overweight and obesity has risen strongly. This paradox challenges the current focus on sources of refined sugar, sucrose or fructose as primary players in the development of overweight and obesity in Australia.
The Australian Paradox relied on three independent lines of evidence: national dietary surveys, apparent consumption data from the United Nations Food and Agricultural Organisation (FAO) and beverage industry data.
National Dietary Surveys provide the most reliable estimates of food intake and therefore total sugars, but they do not tell us exactly what proportion is refined sugar. Total sugars intake includes the naturally-occurring sugars in fruits, vegetables, milk and dairy products as well as "added" sugars. Australian Dietary Guidelines recommend two serves of fruit a day, equivalent to ~20-30 g natural sugar, and 5 serves of vegetables, providing ~20-25 g. A glass of milk contains 12 g natural milk sugar, and 2-3 serves are recommended. A healthy diet could contain 90 g of naturally-occurring sugars.
In the last National Nutrition Survey in 1995 [3], 95% of Australian adults consumed less than 115 g of total sugars per day, a level well within international guidelines of <25% energy [4].
Although there were small increases in total sugars from 1983 to 1995, there were sharper declines in "sugary products" that contribute refined sugar to the diet. Importantly, intake of fruit and vegetables increased [5], implying that the absolute intake of refined sugars had declined. The percentage of energy from total sugars remained either the same or decreased from 1983 to 1995, depending on the age group. Knowledge of food composition is critical to interpretation of the data.
In the 2007 national survey of Australian children [6], total sugars (naturally-occurring and added) amounted to 99, 112, 135 and 145 g per day for children aged 2-3, 4-8, 9-13 and 14-16 years, respectively. On average, they consumed ~16 g/day less sugar from all sources in 2007 compared to 1995 [5,6]. In 1995, they consumed 3.3% of energy as sugar-sweetened beverages; in 2007, the figure across all age groups was only 1.6% [7]. This stands in stark contrast to ~18% of energy from added sugars alone in American adolescents, a level that is a cause of concern.
The Australian Paradox also utilised statistical information provided by the website FAOStat [8]. Compiled by trained professionals and accessed by business and governments for economic analysis and policy setting, FAO data permit the analysis of time trends in apparent consumption of food commodities within and between countries. Australian data on FAOStat are supplied by the Australian Bureau of Statistics using information gathered by the Australian Bureau of Agricultural and Resource Economics (ABARE). This line of evidence indicated that while per capita refined sugars consumption has steadily declined in Australia since 1970 [8,9], the USA displays a marked increase [8].
"Apparent" consumption data are estimates of food intake based on considering a country's production, imports, exports, wastage and non-food uses of particular commodities. It is at best only a crude approximation of actual food intake but every student of nutrition learns its limitations. However, applied over time and across countries, it provides valuable information about trends in consumption. This was the rationale for using it as one line of evidence.
Curiously, Mr. Robertson dismisses the FAOStat data, citing ABARE data instead [10] as "the only timely official information on Australia-wide 'sugar availability'". He equates sugar availability with sugar consumption (real or apparent). He makes adjustments for population increases and concludes that "the trend over the past 22 years has been up and not down". He fails to mention the trend for the previous ~20 years (1969 to 1989) where sugar availability dropped from a peak of nearly 69 kg per person per year to a low of 30 kg per capita ( Figure 1). Therefore, using only ABARE data, we can conclude that overall availability of refined sugar varied widely but shows no significant trend (p = 0.46) during a period when rates of obesity climbed dramatically. Sugar availability, however, is a not the same as consumption. Sugar availability takes no account of food wastage, use in animal food, beer and alcohol fermentation, or in non-food industrial use, and we cannot assume that a steady portion is lost in this way.
Australian Bureau of Statistics Apparent Consumption data are congruent with FAOStat data indicating sugar consumption peaked just after World War 2 (54 kg per person per year) and reached its lowest point in 1998-1999 (38 kg per person per year) [9]. However, rates of overweight/obesity nearly doubled from 37% in the 1980s [11] to 60% in 2000 [12].
Mr. Robertson also fails to note that per capita availability and consumption figures for virtually all food products (poultry, seafood, dairy, cereals, fruit and vegetables), are up in the past 22 years [9]. That is not surprising because the average Australian is now significantly older, taller and heavier than they were 30 years ago [13,14]. More food energy from protein, fat and carbohydrate is required just to maintain weight. If we eat more of everything, then the proportion of energy contributed by refined sugar will not change.  Australians consume less than 70 g of total fructose per day from all sources. Intakes greater than 100 g/day of pure added fructose have been suggested to cause weight gain and adverse effects on metabolism [16,17]. Two recent systematic literature reviews of all available human research on fructose [16,17] make similar conclusions "Fructose does not seem to cause weight gain when it is substituted for other carbohydrates in diets providing similar calories. Free fructose at high doses [>104 g per day, or 25 teaspoons] that provided excess calories modestly increased body weight, an effect that may be due to the extra calories rather than the fructose." [17]. This evidence does not support the claim that "sugar is toxic".
We agree that there is no shortage of refined sugars. We agree that they can be a source of unwanted kilojoules. However, we and many other nutritionists believe refined sugar can be consumed in moderation (up to 10% of energy or ~50 g) as part of a healthy balanced diet. Often overlooked is the fact that refined starches (cornstarch, modified starches, maltodextrins) and foods high in starch such as white flour and white breads, rice, rice crackers, corn chips and crisps, can be a source of unwanted kilojoules, as well as salt and saturated fat, and devoid of essential nutrients unless fortified. There is little logic to dietary recommendations that emphasise restriction of refined sugars but ignore refined starches.

Fructose Was Not "Scarce"
From an evolutionary perspective, fruit and therefore fructose, was an important component of intelligent primate diets. Recent data show that mountain gorillas derive over 20-40% energy from fruit for 6 months of the year [18]. The anthropological literature shows that fruits that dried on the vine were available year round. In the 1980s, we analysed hundreds of traditional Aboriginal bushfoods sent to us from all over Australia, including sugarbag (bush honey) and dried bush fruits, such as the bush tomato Solanum centrale containing 80% sugars [19]. Like many animals, our ancestors adored honey (~70% sugars) and made sweet drinks using both honey and floral nectars [20]. Apiculture, the art of raising bees, was widely practiced even by the poor. Indeed at certain times in history, consumption of honey may well rivalled our current consumption of refined sugar [9,20]. Both evolution and anthropology therefore indicate that fructose consumption was a significant source of carbohydrate energy in human diets. Starch is the relative newcomer [21]. Nutritional analysis of a typical low GI menu generates 70 g total sugars/day, of which 35 g would be fructose.

Conclusion
Three different, independent sources of evidence indicate that Australians' intake of refined sugars intake has not increased. By several indicators, it has declined over the same timeframe that the prevalence of overweight and obesity has risen strongly. Australia is not alone in this regard. Over the last 10 years, other countries, including the United States, have also recorded reductions in intake of refined sugars [22,23]. This paradox challenges the view that concentrated sources of sugar, sucrose or fructose are primary players in the genesis of overweight and obesity.