Monday, August 11, 2014

The Not So Sweet Reality of Health Canada's Proposed New Sugar Policy

My American readers may have missed this, but Health Canada, has proposed that on Canada's future nutrition fact panels there'll be guidance surrounding "total" sugar, rather than "added" sugar. Health Canada is advising a 100 gram cap on "total" sugar and so if something you eat has 25g of sugar, that'll be reflected as 25% of your total daily maximal recommendations.

What does that mean? I think Health Minister Rona Ambrose explained it pretty succinctly,
"we're treating sugar as sugar, whether it's from an apple or it's from a yogurt or it's from a cookie."
Why is this a problem?

Try this on for size.

If you had just 2 apples, a banana, a serving of carrots and 2 cups of milk you'll hit this nonsensical total sugar maximum with none of the sugars involved being added by anyone other than mother nature.

Perhaps that's why Marion Nestle was quoted in the Globe and Mail as stating if Health Canada sticks with this plan Canada will become "a laughing stock".

As to how these recommendations could have made it this far, aside from these recommendations appeasing the food industry, perhaps it's because as Minister Ambrose reported,
"The way we approached it - the way I approached it, is from a parent's point of view."
Here's a thought. How about we approach it from the point of view of science and consider the impact of diet on chronic disease which in turn suggests "added" sugar as the type we should limit, and instead of providing Canadians with the wrong message of capping "total" sugars at 100g, provide them with the guidance that "added" sugars be capped at somewhere between 25-50grams?

Please consider sharing this. Perhaps with enough noise this can still change.

[I'd tell you to go to head to the online consultation on the new Nutrition Facts Panel, but having completed it myself, it's clear Health Canada isn't interested in formative feedback. Instead they're wondering what you think of the size of the fonts they've chosen, whether you look at the %DV and if you think being told 5% is a little and 15% is a lot is useful, which of 3 approaches looking at total and not added sugars you like best, whether or not you think uniform serving sizes are helpful, if you like the new layout of the ingredient listings, and finally what you like most, what you like least, and any additional comments you might have....but not more than 500 words please. As far as I'm concerned, the online consultation is just a lip service exercise and far from a formative one.]

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  1. This doesn't surprise me at all about Health Canada. I feel as though Health Canada is more concerned about formalities than the actual scientific evidence. Disappointed yet again.

  2. This is very disappointing. But at least they are proposing that added sugars be declared on labels. At least that will still help people make informed decisions about their sugar choices.

  3. Health Canada is getting it right. Carbs are carbs… it doesn't matter whether they started as corn to make HFCS, or as part of an apple. The body can't tell the difference. And 100g is a good moderate target.

  4. So I could eat just red meat, a head of lettuce and two bags of Skittles every day? I call this the perfect diet.

  5. I am confused. Time and time again you say fruit juice is not healthy (although healthier than coke) because of all the "natural sugars" but now those are okay because added sugars are worse. It is so hard not to get confused by all the dieticians and doctors making rules and complaining about government rules.

  6. I get your point, but now I'm confused. Aren't you contradicting your "grape juice is not good for you even if it has no added sugar" line?

    It's certainly a problem that looking at total sugar makes things like bananas an unhealthy choice, and I'd bet that industry is happy to have something that equates the sugar in fruit with the sugar in a cookie.

    So do you support the WHO approach to controlling "free sugar" instead, that captures the fruit juice problem?

    There needs to be a more consistent approach than only worry about added sugar, and, oh, things that don't have added sugar that are mostly natural sugar.


  7. Nothing in this post suggests that my exceedingly clear and longstanding views on juice have changed. "Free" a much wiser classification that there's not a hope in hell of Health Canada adopting. Moreover, my original post in this sugar policy called out the need to include juices as added sugars.

  8. Do you have any data showing that added sugars (or is it added sugars + juices now?) are worse than naturally occuring sugars?

    You write that's what the science shows, but you don't reference anything. I've seen some (weak) epidemiology linking added sugars to obesity and diabetes, but nothing comparing natural sugars to added sugars.

    Targeting added sugars also leaves the door wide open to "dehydrated grape juice" or "beet puree" some other naturally occuring sugars being used as sweeteners.

    Anyway, I'm not sure my body can tell the difference between HFCS, sucrose, honey or a the sugar in a banana. Sugar is sugar, carbs are carbs, fiber is fiber...

  9. The sugar limit, wherever it is set, should be rated as whether it is above average, average, or below average based on total calories. Eg. if Health Canada is aiming for 20% calories from total sugar (this is what it is proposed to be) and the food has 15-25% calories from sugar, it would be average. Anything above or below would be rated accordingly. This way it fits for everyone.
    And yes, Yoni, the WHO says that juices should be counted as added sugars. So far, HC hasn't opted into that definition. We need to do some letter writing!

    1. But your body doesn't think in "ratios of total calories". Carbs, Protein, and Fat all take separate metabolic pathways, and are nearly independent as to their effects. To lump them together with a magic formula to call it "total caloric intake" is actually to gloss over important details.

      Another way to put this is it *isn't* ok to eat 200g of carb on a 3000 calorie intake if *is* ok to eat 100g of carbs on 1500 calorie diet. The 100g will not likely trigger insulin storage, while the 200g level definitely will, except in extreme workout situations.


    2. Yes-and that's why I don't like %DV. It has inherent flaws. I'd prefer it just said if a food is higher than average in a nutrient, lower than average, or average. As an RD, I never ever use the DV.

  10. This is awesome. Go Health Canada

  11. All sugars are natural and not labelled to allow our organs to process them differently depending on their heritage. Well done Canada for adopting a simple and straightforward approach that is backed up by the relevant science.

    1. HFCS isn't very natural (super-processed). Neither is white sugar (processed). Corn is natural, cane juice is natural.

  12. "If you had just 2 apples, a banana, a serving of carrots and 2 cups of milk you'll hit this nonsensical total sugar maximum with none of the sugars involved being added by anyone other than mother nature."

    So don't have 2 apples, a banana, carrots and milk if it's too much sugar. Have a banana, some berries, carrots, milk and green vegetables instead and be well under the 100g limit. Seriously, 100g is a HUGE amount of sugar and if your normal diet is exceeding it you can probably make some better choices somewhere -- like more protein and fat which are essential and satiating. You can promote a whole foods based diet and a reasonable amount of sugar -- it's not either or.

  13. SunRype 100% fruit juice snack bites?? I think it is important to measure total sugars otherwise these might get by. You talk about intrinsic sugar, but you know they will figure out a way to get around the whole food issue. Their very livelihoods are at stake. Plus no one is going to add a sticker to an apple to say that this has 20% of your total sugar intake for the day. So in effect the total sugars will only be on anything with a label which is what we want.

  14. We get so impassioned about sugar! There's a "spirit of the law" and a "letter of the law" thing here. The letter is never going to be perfect where nutrition is concerned, BUT...

    No, all sugar is NOT created equal. If I'm going to stuff my face with something, real fruit is a much better option than anything I can buy in a package. As is real fruit with FIBER over ANY kind of juice. And that is the message that gets lost when all sugar is combined into one "Total Sugar" number. Exactly what the industry wants.

    To the low-carbers who would love to see the universe validate your lifestyle: Your priorities suck.

  15. It feels like the 'sugar-is-sugar' commenters are really eating up the government's media notes on this. But did you read the linked article or think this through in terms of the actual stated goal, which is healthier decision-making?

    From the Globe article: "'s easy to see why the former may be easier for some producers to swallow. Under the current proposal, the label on a soft drink would say a can contains about 40 per cent of a person's daily sugar intake. If the guideline instead specified 50 grams of added sugar, the figure would be more like 80 per cent of the daily quota because so much of a soft drink's sugar is added."

    An "added sugar" guideline/label, as recommended by most experts and practiced by most countries in the labeling business, allows for a reasonable baseline of sugar consumption through foods that *can actually have a role in good health* -- eg apples, bananas, milk. It says, 'assuming a healthy diet that includes some naturally present sugars, you can have 50 grams of added sugar today; this Coke has 80% of that.'

    Aside from industry appeasement, it makes no sense to position that nutritionally useless Coke alongside *actual foods* in tallying toward a daily maximum. The idea that Ambrose's hypothetical parental decision-maker should treat two bananas as on par with a Coke in a child's lunch is ludicrous. There are other nutritional considerations than counting grams of sugar; guidelines and labels addressing added sugar address this.

    1. Your examples don't work since fruits don't have labels. (Milk does, and now I wonder why, but that's another question.)

      The dilemma is not about sugar-in-bananas vs sugar-in-soda. It's about naturally-occuring-sugars-in-processed-foods vs added-sugars-in-processed-foods.

      You write that most countries use added sugar in labeling. I had no idea. Do you have any reference? Is there any data regarding the effects on health? That could be useful to guide decisions.

    2. That is an interesting interpretation, but sugar labels on apples don't really enter into it.

      You wrote above that "I'm not sure my body can tell the difference between HFCS, sucrose, honey or a the sugar in a banana." Perhaps not, but this invitingly simplistic way of looking at a single nutrient doesn't reflect how we actually eat or use food. Our bodies most certainly can tell the difference between a set of fruits containing 50g of sugar and a 500mL soda containing the same: the former has nutritional value; the latter does not. Tallying both as if they are identical simply isn't logical or relevant to healthy decision-making, which is part of the reason for the WHO's approach (and for the Globe’s sources referring to the Health Canada approach as “an outlier position,” “a laughing stock,” “kooky, ” etc).

      I did not write that most countries use added sugar in labeling; to my knowledge most countries don’t require sugar labeling at all. It would be nice for Canada to be a leader and not a straggler on this (as we have been with salt), but this move doesn’t promote much optimism. Meanwhile, here’s a controversial example of a country using a total sugar (percentage) approach, with the expected reaction: It looks as if we will be taking a similar road.

      As for evidence on food labeling and health, this is a pretty large and varied body of literature on this. You might be interested in this recent review, entitled “Legislation, impact and trends in nutrition labeling: A global overview” -


    3. I guess I should have written "I am not sure that my body can tell the difference between HFCS, sucrose, honey or the sugar in a banana contained in processed foods."

      Of course, vitamins, minerals, protein, fiber, etc. have their utility. But we are talking about sugar here (added in processed foods).

      Assuming you are Schwahili, you wrote above "An "added sugar" guideline/label, as recommended by most experts and practiced by most countries in the labeling business..."
      How is that not saying that most countries use added sugar in labeling?

      Salt is a bad example in my book. It still has not been shown that reducing salt intake below current average level is a good idea. Indeed, the last research I saw showed, again, that low salt intake is linked to higher mortality (so is very high salt intake, but the current average is in the best spot).

      I only have access to the abstract of “Legislation, impact and trends in nutrition labeling: A global overview”. It doesn't seem like they track hard end-points. That's what really matters, and that's what I would like to see data about.

    4. Hi Valerie,

      Yes, we are talking about sugar, and we are also talking the reality of sugar consumption: that it comes in the context of many different foods and food products. Proceeding as if individual nutrients exist in a vacuum separate from broader diets (the very foods containing the sugar!) leads to erroneous positions, such as the HC take on sugar as described in the Globe article and Weighty Matters post.

      If a patient comes to me with a dietary intake including 70g of daily sugar consumption in the form of fruit (or other real foods) and 70g in soda, am I going to tell him it doesn't matter which he cuts out, because "sugar is sugar"? Of course not. I'd much rather see a patient, or better yet a population, address the consumption of added and free sugar. Guidelines to this effect are the norm across a number of health agencies, although apparently not Health Canada -- remember that quote: "outlier position."

      On the salt issue, sodium and carbohydrates are both essential nutrients, so it is intuitive (and in fact by definition) that deficient intake will be harmful. I have not read any literature or heard any researcher or practitioner, *ever*, describing the current Canadian average as optimal for sodium consumption. If you have references to support the claim that ~3.5 grams per day of salt is "the best spot" please do share these!

      By hard end-points, do you mean mortality data? Obesity? Incident diabetes? As you know, the chronic nature of the harmful exposure here and the long duration from exposure to "hard" health outcomes mean that we won't have the evidence you want on new labeling approaches for some time -- for or against. We do have evidence that labels can affect dietary decisions, though, and we certainly know that dietary decisions can affect these outcomes. Sitting around demanding incontrovertible evidence amidst ill health and death was the approach of tobacco companies to early signals (and good common sense) on tobacco's carcinogenicity. I'm hoping we won't need decades of research to see useful food labels become commonplace.

  16. Hi Michael,

    I will repeat my point: we are debating the difference between naturally-occuring-sugars-in-processed-foods vs added-sugars-in-processed-foods. As a consumer, I do want "plum puree" or "dehydrated maple syrup" to be counted as a sugar on a food label, same as sucrose.

    If a patient comes to you, the label debate won't touch his fruit intake, as fruits have no labels. Now, would you advise your patient to choose raisins over sweetened dried cranberries because raisins have no added sugars, only natural sugars? That kind of decision is what the labeling will affect.

    For salt, the latest I saw was this one:
    "an estimated sodium intake between 3 g per day and 6 g per day was associated with a lower risk of death and cardiovascular events than was either a higher or lower estimated level of intake."

    It is not exceptional, other sodium studies looking at hard end-points have similar conclusions. However, if researchers look only at blood pressure, they often conclude otherwise (after wild speculations and extrapolations from their blood pressure data, if you ask me). Disclosure: I have hyponatremic-hypertensive syndrome, so I keep an eye on that type of reasearch.

    We do have evidence that labels influence food choices, but we are far from certain that the new choices lead to better outcomes than the old choices. Rushing to implement regulations is dangerous. That's how we got the margarine fiasco (and the low fat diet for diabetics disaster, and the skim milk for children absurdity).

    1. I don't think we're discussing "the difference between naturally-occurring-sugars-in-processed-foods versus added-sugars-in-processed-foods" here. I think Yoni correctly identified that the Total Sugar label implies that apples are in the same category as added sugars, whether the apple has a label or not.