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Abstract

Objectives:

The average consumption of sugar in the Malaysian population has reached an alarming rate, exceeding the benchmark recommended by experts. This article argues the need of a paradigm shift in the management of sugar consumption in the country through evidence derived from addiction research.

Methods:

“Food addiction” could lead to high levels of sugar consumption. This probable link could accelerate the development of diabetes and obesity in the community. A total of 94 reports and studies that describe the importance of addiction theory–based interventions were found through a search on PubMed, Google Scholar, and Academic Search Complete.

Results:

Research in the field of addiction medicine has revealed the addictive potential of high levels of sugar intake. Preexisting health promotion strategies could benefit from the integration of the concept of sugar addiction. A targeted intervention could yield more positive results in health outcomes within the country.

Conclusion:

Current literature seems to support food environment changes, targeted health policies, and special consultation skills as cost-effective remedies to curb the rise of sugar-related health morbidities.

Keywords

sugar addiction food environment health promotion non communicable diseases dietary habits health policies

Introduction

Worldwide sugar production has experienced a steady increase to cope with the escalating need for domestic human consumption of sugar.¹ The global production of sugar has surpassed the domestic human need for consumption at the start of this decade.¹ Interestingly, countries with the highest level of domestic sugar consumption (India, China, Brazil, the United States, and Russian Federation)¹ seem to have greater rates of diabetes and impaired glucose tolerance.²

The US Food and Drug Administration recommends a daily sugar intake between 6 teaspoons for women and 9 teaspoons for men per day.³ However, the average Malaysian consumes an alarming 19 teaspoons of sugar per day, close to 2 to 3 times above the suggested limit.^4,5 The marked increase in sugar consumption is a contradiction to the prevailing public health initiatives aimed at cutting down morbid sugar intake in the population.

There are many factors that influence the efficacy of programs designed to curb the deleterious effects of sugar consumption behavior. Interventions designed to alter only the aspects of human behavior could pose a major stumbling block in achieving better health outcomes. Research recommends the need for a more cohesive effort in changing the food environment and the nature of human addiction to refined food that includes sugar.^6,7

This article argues that newer dimensions in addiction science could be utilized to control the pressing issue of increased sugar consumption and its associated morbidities (primarily diabetes and obesity) in the Malaysian population. This new approach could help reduce the burden of non communicable diseases namely diabetes mellitus, obesity, and cardiovascular diseases related to increased sugar intake.

Causes of Increased Sugar Consumption From an Addiction Perspective

Food Addiction (“Hyperpalatable” Food Environment, Overeating, and Human Behavior)

The consensus on the term food addiction remains mixed. Certain experts feel that the practicality of the term ‘food addiction’ in humans remains at preliminary phase of scientific research.⁸ Therefore, further experiments are required to determine the usefulness of this concept.⁸ However, when defined under context of consumption behavior (ie, intermittent or repeated intake of food),^9,10 previous studies show that “food addiction” has neurological similarities in both humans and rats.^9,10 Systematic reviews suggest the possibility of the existence of a “food addiction” phenomenon, paving the way for the development of novel strategies to cope with obesity and overeating.^11-13

Over the past few decades, there has been a remarkable transition in the global food environment. A diet based on traditional cultural practices has been replaced by a “hyperpalatable” one, laden with fat, sugar, salt, flavorings, and food additives.⁶ “Hyperpalatable” food upregulates the mesocorticolimbic pathways (similar to drug addiction) through the modification of food cues and the degree of consumption.^11,14 Palatable food enriched in fat and sugar increases hunger and satiety signals.¹⁵ However, the consumption of palatable food also tends to blunt the response to satiety signals and activates the internal reward system.¹⁵ This results in the urge to overeat that is consistent with the pattern of “food addiction” trends witnessed today.

Studies seem to support the notion that “food addiction” could be related to biological changes in the brain, similar to what is experienced in drug addiction. In experiments involving rats, overeating sugar promotes changes in both neurochemistry of the brain and behavioral attributes associated with drug abuse.¹⁶ The neural reward circuitries in rats mirror addiction-like behavior when they overate food that are highly palatable.¹⁷ Early human studies indicate that the consumption of highly palatable food lead to the hypofunctioning of the reward circuitry, a process that reinforces the pathological behavior of overeating.¹⁸

Some experts argue that “food addiction” is not entirely physiological in origin. “Food addiction” could occur as an extension of human behavior through inherent biological and hedonic components of material overconsumption or overacquisition.¹⁹ There are 2 compelling forces fuelling the culture of “food addiction”—aggressive marketing of “hyperpalatable” products by the food industry and the dissemination of the mainstream philosophy of unnecessary consumption.¹⁹ Hence, an increase in food consumption through cultural cues reinforces the physiological component of “food addiction.” The paradoxical nature of human physiology seems to confirm this fact—the human body strongly rejects weight loss but reacts favorably to weight gain that is recognized through positive energy balance derived from food consumption.²⁰

Addiction to Sweetness (Influence of “Hyperpalatable” Food on Energy Homeostasis and Brain Neurochemistry)

A recent study in rats has shown that intense sweetness commonly seen in sugar-rich diets tends to override self-control mechanisms in the body by modifying the cocaine reward circuitries in the brain, hence increasing susceptibility to sugar addiction.²¹ Although unproven in humans, this evidence could serve as a starting point for an early reassessment of initiatives designed to curb excess human consumption of sugar.

The complex homeostatic energy balance to control hunger and satiety in humans has several drawbacks that are closely linked to addiction-like behavior. The process of evolution has gradually sensitized the human biological system to favor high-energy-density food (sweet or fatty) over low-energy-density food.²⁰ Research involving animal models have shown that excessive and intermittent exposure to energy dense food such as sugar generates similar effects seen in drug abuse such as bingeing, withdrawal, and craving.^22,23

Several studies have shown that increased sugar intake causes changes in brain neurochemistry similar to that seen in the consumption of addictive drugs.^23,24 Palatable food high in sugar or fat affect dopamine, opioid, and serotogenic receptors in the brain.²⁴ Addictive drugs are known to have the potential to increase extracellular dopamine in the nucleus accumbens of the brain.^25-27 An experiment designed to examine this relationship revealed that the intermittent bingeing of sugar increases the number of dopamine receptors in the brain.²⁸ There was a modification in the opioid system of the brain when withdrawal symptoms occurred either through the administration of opioid antagonists or the deprivation of sugar.²³ The reintroduction of sugar to treat withdrawal symptoms resulted in a relapse that subsequently led to increased consumption of sugar.²⁹

A different pathway that also explains this phenomenon involves carbohydrate craving and antidepressive effects. The hormone serotonin modulates these properties through the active compound called tryptophan.²⁴ The consumption of a high-carbohydrate meal leads to an overabundance of tryptophan because of the transient evacuation of large neutral amino acids (which competes with tryptophan for serotogenic brain receptors in the brain) in the blood by a sudden surge in insulin levels.³⁰

Alarming Health Morbidities in Malaysia Associated With Potential Sugar Addiction

Prevalence of Diabetes Mellitus due to Change in Food Environment

The prevalence of diabetes in Malaysia has witnessed an upward trend. Diabetes mellitus remains the second most common chronic illness in the country.³¹ There has been an 80% increase in the prevalence of diabetics in a span of just a decade.³² This estimate has surpassed the projected prevalence of diabetes for the year 2025.³² The country ranks as the eighth highest sugar importer in the world with a gradual rise in net sugar import seen almost annually.^1,33 Malaysia also imports 99% of its sugar supply (while domestic sugar production only contributes about 1%) to meet the soaring local demand of the commodity.³⁴

Whether the pronounced numbers in diabetic cases in Malaysia are because of an element of sugar addiction in the community remains the subject of debate. The confirmation of the link between excessive sugar or caloric intake and the occurrence of diabetes in Malaysia awaits formal evaluation. In the United States, an ecological assessment between the years 1909 and 1997 claims that the increased consumption of refined carbohydrate and a decrease in the amounts of dietary fiber resulted in a rise in type 2 diabetes cases in the country.³⁵ Another study seems to attenuate this finding by stating that moderate amounts of sugar intake does not play a vital role in inducing the onset of diabetes.³⁶ However, this should not translate to an unlimited amount of sugar consumption.³⁶

The increasing rate of sugar consumption in Malaysia necessitates the need to explore the concept of food or sugar addiction in relation to health policy development. The food environment has made a rapid transition, leaning toward a diet comprising palatable food with high fat and sugar levels. A systematic review found that sugar-sweetened beverages increase the risk of type 2 diabetes.^37,38 There is limited evidence to suggest that total sugars, glucose, or fructose have any direct causational link to the incidence of diabetes.^37,38 However, high-fat and high-sugar diet is a recognized precursor to glucose intolerance and insulin unresponsiveness.³⁹ Once the compensatory measures in the body have failed to reduce plasma glucose levels, the resulting overt hyperglycemia could hasten the onset of diabetes.⁴⁰

Prevalence of Obesity due to Change in Food Environment

Malaysia has the highest prevalence of obesity in Southeast Asia and is ranked at fourth place in the Asian continent.^41,42 One of the predominant factors contributing to this scenario is the availability of food with high palatability (high fat and high sugar content) in the country.^42,43 Parallel to this statement, there has been a notable shift in the food environment toward a more affluent diet (energy-dense and high-fat foods) associated with obesity.⁴⁴

“Hyperpalatable” foods have the potential to cause dependence similar to drug addiction that ultimately leads to obesity.^7,18,45-47 For example, high fructose corn syrup (HFCS) was linked to the development of the obesity epidemic through increased human consumption.⁴⁸ HFCS is a common caloric sweetener found in most processed food such as soft drinks, fruit drinks, most baked goods, cereals, and canned food.⁴⁸ HFCS is known to have addictive properties because of its palatability and its effects on neuroreceptors in the brain.⁴⁹ Consequently, the body develops resistance to leptin, a hormone that prevents weight gain by suppressing the act of overeating.^50,51 Human surveys point toward a conclusive link between consumption sweetened beverages and obesity.^38,52,53

Conversely, obesity in itself could exacerbate a vicious cycle of overeating through altered brain function and neuroanatomy. Brain imaging in humans has revealed that abnormal eating behaviors seen in obesity might bear close resemblance to drug dependence.^10,54,55 Alterations involving the dopamine system in obese subjects led to the excessive use of food through complex disruptions in the neural reward circuitry.¹⁶ The consumption highly palatable food could be at fault as it leads to the activation of regions in the brain that control motivation of food procurement.^56,57

Discussion

There is a lack of consensus on preexisting knowledge on “food addiction” and its implications at a community level. However, in view of the current evidence linked to “food addiction” (primarily to sugar or sweetness) and health morbidities, preemptive health interventions based on addiction theories could serve as a possible strategy in the effective management chronic diseases. The formal recognition of tobacco as an addictive substance is one of the notable examples of such an initiative.⁵⁸ The acceptance of an addiction component to smoking behavior led to a successful implementation of smoking cessation programs.⁵⁸

Strategies for Policy Makers

The reduction of chronic diseases, namely diabetes and obesity, could be effectively achieved if a concerted effort is made to address the prevailing food environment in the country. Environmental factors and policy changes could uplift the standards in eating, physical activity and weight maintenance in the population.^59,60 A feasible option would be the formulation of health policies and health promotion efforts aimed at removing, decreasing or substituting sugar intake (and its related derivatives) in the community.

Health interventions that take into account the addictive aspects of highly palatable food are central to the prevention of food-related diseases.⁶ Many food companies alter the food environment by influencing dietary behavior of the masses. Companies achieve this objective by increasing the availability, affordability, and acceptability of foods that have high sugar content, such as soft drinks.⁶¹ Steps to mitigate these food environment changes are urgently needed since a high glycemic index is a catalyst to the development of major cardiovascular diseases.^60,62 Hence, important venues that supply food in a particular neighborhood (eg, supermarket or convenience store) should place emphasis on availability fruits and vegetables. These are essential in controlling the prevalence of chronic diseases in the community.⁶³

A review of the various studies conducted on food policy interventions predict that subsidization of healthier food such as fruits and vegetables could also make food more accessible (and attractive) to customers. With the implementation of these initiatives, there was an increase the purchase of these wholesome alternatives instead of addictive sugar laden food.⁶⁴

A family-oriented approach also plays an important role. Adolescents seem to consume a healthier diet when parents assume the role of exemplars by eating of healthy food at home⁶⁵. Increasing household availability of fruits or vegetables seems to achieve this effect.⁶⁵ Home food environment that emphasizes unhealthy eating (eg, purchase of fast food meals by parents) is associated with greater availability of soda drinks and salty snacks at home.⁶⁶ The idea of having family meals together needs to be reinforced as it leads to an overall positive home food environment.⁶⁷ Family meals and the act of witnessing parents eat fruits and vegetables have been proven to boost a child’s intake of these important food groups as well.⁶⁸

Globalization has paved the way for an increasing homogeneity and transition in the food environment that is inclined toward nontraditional dietary practices.^61,69 Traditional food practices have been diminishing and are being replaced by energy-dense and sweeter foods that are associated with dietary inadequacy and the emergence of chronic diseases.⁷⁰ Thus, the role of culturally sensitive interventions are crucial. Substituting refined carbohydrates with traditional whole grains found commonly in an Asian diet could be beneficial. This step does not only increase the content of protein in the daily food intake but also helps reduce the incidence of type 2 diabetes.⁷¹

Strategies for Public Health Initiatives

Few studies in Malaysia have assessed the patterns in caloric, micronutrient, and macronutrient intake. These studies were performed at a regional level with limited evaluation criteria.^72,73 The data for dietary intake from food balance sheets demonstrate an annual rise in average human consumption of sweeteners in their daily diet.^44,74 However, this could be misleading and might not correspond to the actual per capita availability of food.⁶³ Trends might also vary due to the different domestic socioeconomic levels in the population.⁷⁵ A nationwide food consumption survey could reveal a more accurate picture.

Officially, there has been only one attempt at quantifying sugar consumption among the Malaysian population.⁷⁶ The Malaysian Adult Nutrition Survey (MANS) in 2003 revealed that there was a daily high consumption of sugar and sweetened condensed milk intake among both rural and urban populations.^76,77 To uncover an underlying “food addiction” tendency toward a particular group of food items, future endeavors should focus on establishing trends in the national food consumption survey (especially sugar). Data from MANS 2003 and future national food consumption survey should be compared with international food composition tables to help identify the exact type of sugar and fat intake in the society. This could increase the accuracy in designing health education programs to help reduce the prevalence of chronic diseases as seen in certain countries.⁷⁷

Strategies for Clinicians

Excessive intake of “hyperpalatable” food with high sugar content alters the reward system in the brain by triggering a compulsive overeating response.⁴⁷ However, there is no reason to completely withdraw sugar from a patient’s diet. Dietary recommendations should often be individualized. Clinicians need to be aware that the advice on moderate amounts of sugar intake is acceptable and is likely to increase dietary compliance without any deleterious effects in a diabetic patient.^36,78

Primary prevention techniques to screen patients with high predilection to “food addiction” need to be adopted. Sound psychometric scales have been employed to assess eating patterns that are similar to “food addiction.”⁷⁹ These screening tools could guide early detection of high-risk groups with addiction-like eating patterns, which in turn could facilitate an early intervention process.

Brief intervention methods using motivational interviewing techniques have proven to be successful in managing addiction behavior seen in alcohol dependence and smoking.^80,81 By using a new model that employs motivational interviewing techniques, suitable candidates could be screened for sugar addiction tendencies. Studies using brief intervention model in daily consultations as a preemptive approach to palliate “food addiction” have not been explored to this date. Research into this field could unlock an economically valid and convenient technique to prevent sugar addiction at the primary care setting.⁸²

Behavioral therapies effective in the treatment of drug addiction could also be beneficial in the treatment of food related addictions namely compulsive overeating and obesity.^47,83 Cognitive behavioral therapy has been extensively used to achieve abstinence and prevent relapses in patients with substance abuse disorders.⁸⁴ One drawback that needs to be anticipated is the relapse into drug-seeking behavior secondary to the priming effects of the causative drugs.⁷³ Only absolute abstinence prevents the occurrence of these effects.⁸⁵ Initiatives such as the “12-Step Program” encourage absolute abstinence to stay clear from priming effects of the food stimulates overeating.⁸⁶ On the other hand, absolute abstinence to food is difficult to achieve as food is essential to overall human well-being. Nevertheless, this remains a viable option since selective avoidance of food that are high in carbohydrate or fat content could be exercised to help avoid the effects of priming seen after such exposure.⁸³

Conclusion

More human and community-level studies are required to shed more light on a concrete link between “food addiction” and health morbidities. Spreading awareness on the possibility of sugar addiction could hold the key in generating novel interventions that might help curb the escalating global epidemic of obesity and diabetes. Health policies could integrate this concept in formulating cost-effective and practical preventative strategies. The following suggestions might serve as a relevant starting point:

Community health education is key. The general public needs to be educated on the possible addictive properties of sugar and other “hyperpalatable” food products. The conventional practices and health promotion tactics need to be revised to include a greater focus on the addictive aspects of sugar in order to achieve this particular aim.

Steps need to be taken to improve healthy eating and physical activity environments by restricting access to “hyperpalatable” food. A robust food procurement program at the state or national level could be an avenue worth exploring in order to curb unhealthy dietary consumption at schools, colleges/universities, nursing homes, correctional facilities, hospitals, and day care centers.⁸⁷

Alongside tobacco, “hyperpalatable” food such as sugar should be identified as a potential health danger.⁶ Governments in certain countries have put into practice policies to tax sweetened beverages (eg, soda tax) or products with high fat content (eg, fat tax) as part of their effort to combat it the negative externalities of the potentially addictive macronutrients such as childhood obesity.^88-90

Footnotes

Acknowledgements

The author would like to thank Professor Dr Teng Cheong Lieng of the International Medical University Malaysia for providing helpful inputs on how to approach the topic discussed in the article.

Declaration of Conflicting Interests

The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author received no financial support for the research, authorship, and/or publication of this article.

Author Biography

Yogarabindranath Swarna Nantha is a Senior Medical Officer at the Seremban Primary Care Health Clinic, under the Ministry of Health Malaysia. His academic and research interests have been in the area of health management and infectious diseases (namely tuberculosis). Currently he works at the outpatient department of the institution and occasionally teaches undergraduate medical students from the International Medical University.

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Addiction to Sugar and Its Link to Health Morbidity

Abstract

Objectives:

Methods:

Results:

Conclusion:

Keywords

Introduction

Causes of Increased Sugar Consumption From an Addiction Perspective

Food Addiction (“Hyperpalatable” Food Environment, Overeating, and Human Behavior)

Addiction to Sweetness (Influence of “Hyperpalatable” Food on Energy Homeostasis and Brain Neurochemistry)

Alarming Health Morbidities in Malaysia Associated With Potential Sugar Addiction

Prevalence of Diabetes Mellitus due to Change in Food Environment

Prevalence of Obesity due to Change in Food Environment

Discussion

Strategies for Policy Makers

Strategies for Public Health Initiatives

Strategies for Clinicians

Conclusion

Footnotes

Acknowledgements

Declaration of Conflicting Interests

Funding

Author Biography

References