Attitudes toward sugar

A Study Conducted for: THE SUGAR ASSOCIATION

AND

SUMMARY OF MAJOR FINDINGS

Opinion Leaders

1. Physicians' attitudes toward sugar

- Physicians believe that sugar, in moderation, is a necessary part of the diet of normal, healthy indi-viduals. They feel i t plays a vital role in meeting the energy needs of the growing child.

- Despite these generally favorable attitudes toward sugar in moderation, physicians do express concern about the consumption level of sugar in the United States. They feel that children's and adolescents' intake of sugar and sugar-sweetened products should be restricted. These foods, they feel, are harmful to children's teeth.

- Physicians recommend restricted sugar intake in cases of obesity, maturity-onset diabetes, predisposition to diabetes, coronary heart disease, and elevated triglycerides. Some also recommend restricted sugar intake for hypoglycemia patients.

- Restriction of s11sar intake for the diabetes-prone patient stems from a belief that sustained and

excessive use of sugar accelerates the onset of the disease where the tendency toward the disease exists. The same, they feel, is not true where there is no family history or predisposition to diabetes.

- Physicians see a causative relationship between sugar and coronary disease but deny that such a relationship exists between sugar and skin conditions such as acne.

groups studied. Nine out of ten dentists believe that sugar consumption in the United States is too high.

- The basis for these attitudes toward sugar lies in the fact that dentists regard sugar consumption as the second most important cause of tooth decay.

- The mechanism whereby sugar is perceived to contribute to tooth decay is by contributing to the formation of dental plaque. This, in turn, traps bacteria and permits attack on the teeth.

- Three-quarters of all dentists believe that reduced sugar consumption would prevent most children's cav-ities. About a third believe that similar benefits could accrue to adults if their consumption of sugar was reduced. Fewer than one dentist in ten believes that there would be no benefits to adult dental health from reduced intake of sugar.

3. Attitudes of writers, editors, legislators and other highly visible opinion leaders

- In some respects the attitudes of "visibles" toward sugar is more favorable than that of dentists; in others there is little difference between the two groups.

- "Visibles" are least likely of all the groups studied to acknowledge the need for sugar in a balanced diet. They are as likely as dentists to subscribe to the validity of the "empty calorie" charge leveled against sugar.

- On the other hand, they are less likely than dentists to see a need for restricting intake of sugar and

sugar-sweetened products. Both "visibles" and dentists feel equally strongly that such products are a major cause of tooth decay among children. "Visibles" are inclined to predict less dramatic reduction of cavities among children as a result of reduced sugar consumption than do dentists.

4. Attitudes of medical and dental researchers; dieticians and nutritionists; industry research and development personnel

- This group of "influentials" believes, like physicians, that sugar is necessary for maintenance of a balanced diet, and that i t is difficult to meet a growing child's energy needs without sugar in the diet.

- They do not see a need for normal adults to restrict sugar intake, but do feel that such restrictions should be placed on both children and adolescents.

- Almost equal proportions of these influentials call the "empty calorie" charge leveled against sugar valid as call i t invalid.

- Industry personnel foresee no change in overall future consumption of sugar and sugar-sweetened products. They do, however, predict a decrease in use of pre-sweetened cereals and sugar-pre-sweetened soft drinks, and an increase in the use of sugar substitutes and artificially sweetened foods.

Consumers

- Consumers display markedly ambivalent attitudes toward sugar. Their use of sugar is inconsistent with some of the negative attitudes they express.

- White or table sugar is equated in their minds with brown sugar and corn syrup for "healthfulness", but is thought less healthful than honey (most healthful) and molasses (second most). Although i t is not per-ceived to be harmful to health, neither is i t viewed as particularly healthful. Despite its actual and relative rating vis-a-vis other sweeteners, white sugar is reported used by three-quarters of all

however, they believe firmly that use of sugar, even by normal adults and children, should be restricted.

- Consumers, similarly, regard artificial sweeteners as potential health hazards, and believe that use of these, too, should be restricted, even by normal individuals.

- One of the two major problems consumers associate with sugar is tooth decay. Although consumers are less likely to see dramatic benefits to dental health resulting from decreased sugar consumption, over one-half believe most children's cavities could thus be prevented. Over one-quarter believe this to be true of adult cavities.

- The second major problem consumers associate with sugar is obesity. Sugar is regarded as fattening, though less so than fatty foods. Few consumers are aware of the actual caloric value of sugar. The average esti-mate of the number of calories in a level teaspoon of sugar is 56.1.

Informational Sources and Needs

1. Sources used by opinion leaders

Opinion leaders mention professionally-oriented sources as those used most often -- i.e., professional journals, con-ventions and meetings, and colleagues -- for learning about sugar and health-related issues. The sources used most often tend also to be the ones judged to be most influential.

Relatively few opinion leaders use, or value as influen-tial, either The Sugar Association or the International Sugar Research Foundation. Indeed, commercial advertising is said to be used by at least twice as many, and the

popular press by at least three times as many opinion leaders as say they use either of these former sources. Advertising and the popular press are frequently rated as being at least as credible, if not more credible, than The Sugar Association or the International Sugar Research Foundation.

2. Sources used by consumers

Dentists, physicians, parents and teachers in elementary and high school, in descending order, are most frequently cited by consumers as their sources of learning about sugar and health. About one-third of all consumers cite magazine articles as their informational source, while about one-quarter or slightly more mention books on health and nutri-tion, newspaper articles, TV programs, friends or relatives, and advertising on television.

3. Perceived need for consumer education regarding suqar and health

Opinion leaders were asked to indicate how much need they see for increased consumer education regarding sugar and the seven following health conditions:

- Diabetes - Obesity - Nutrition - Tooth decay - Hypoglycemia - Coronary disease - Skin care

as well as for information about the healthfulness of artificial sweeteners.

Need is seen for information on all the sugar and health topics listed above. This listing is presented in decreas-ing order of perceived consumer need for information.

While opinion leaders believe that consumers should know more about artificial sweeteners and health, education on

I. INTRODUCTION. . . . . . . . . . . . . . . . . . . . . . 1

II. SUGAR AND THE NORMAL HEALTHY INDIVIDUAL . . . 7

III. PERCEPTIONS ABOUT THE CALORIE VALUE OF SUGAR 17 IV. SUGAR AND DENTAL HEALTH . . . 23

V. SUGAR AND OBESITY . . . . . . . . . . . . . . . . . . . . . 2 9 VI. DIABETES, HYPOGLYCEMIA AND SUGAR . . . 33

VII. SUGAR AND O'rHER HEALTH PROBLEMS.. . . . . . . . . . . . . 40

VIII. INFORMATION ABOUT SUGAR . . . 44

IX. IMPLICATIONS FOR THE SUGAR INDUSTRY . . . 49

APPENDIX A -- TABULATIONS... . . . . . . . . . . . . . . . . . . . . . 56

APPENDIX B -- DEFINITION OF RESPONDENTS . . . 88

APPENDIX C -- LITERATURE SEARCH: METHODOLOGY 93 APPENDIX D -- QUESTIONNAIRES . . . 96

I. INTRODUCTION

A. Background

This report covers findings of a study conducted for The Sugar Association and the International Sugar Research Foundation to determine attitudes, practices and level of knowledge concerning sugar and health among relevant opinion leaders and among consumers.

The basic premise underlying the lines of inquiry pur-sued in this investigation is that much of human behavior derives from what is perceived to be fact. Significant progress in altering attitudes and behavior can be

achieved only by establishing what these perceptions are and by taking appropriate action to clear up ambiguities and misinformation.

To that end, this study has attempted to identify percep-tions about sugar and health among those who, i t is

believed, are responsible for dissemination of "fact" to the ultimate consumer. At the same time, consumers have been included in the study both to determine the current status of their perceptions and attitudes and to help pinpoint those categories of opinion leaders who appear most influential in shaping consumer behavior.

The ultimate goal of this study, then, is twofold:

To pinpoint areas in which more definitive medical research is required to establish sound information on the relationship between sugar and health

To uncover areas where a meaningful program of com-munications and education is required to alter erroneous perceptions and/or negative attitudes which inhibit sugar consumption.

B. Methodology

The overall study methodology consisted of three distinct, but interdependent phases.

Phase I - Search of the Literature

In order to understand what is being communicated both to professionals and consumers about the role of sugar in the diet, a search of both the professional and popular press literature was undertaken.

This search assured that no relevant area was over-looked in preparing the interviewing instruments used in the data collection phases of the study. Addition-ally, and consistent with the goals of the research, those people who are publishing on sugar and health were identified so that they could be included in the

sample of people to be interviewed. Thus, the search of the literature provided:

An understanding of the kinds of sugar/health problems currently being researched

An understanding of the kind of sugar/health-related information being disseminated

Direction in selecting individuals to be included in the opinion leader sample.

Phase I I ~ Personal Interviews with Opinion Leaders

During the planning stage of this study, i t was deter-mined that i t was essential to interview opinion leaders

in order to assess what they belive about the relation-ship between sugar and health. Three levels of opinion leaders were hypothesized:

Researchers who publish in the professional press and thus influence the health professional

Health professionals -- physicians, dentists, nutri-tionists, etc. -- who deal with and exert a per-sonal influence on the consumer

Writers, speakers, legislators, etc. who are highly visible, and thus potential sources of influence to the consumer.

Based on a priori judgment of both their relative influ-ence on consumers and the size of each sub-population, National Analysts, in conjunction with The Sugar Associa-tion, set quotas for the number of people in each group to be interviewed. National Analysts then devised

appropriate sampling methods for selection of those to be included in the study.

A random selection of physicians and dentists was made in 50 sampling points throughout the United States. Researchers, writers, speakers and legislators were de-rived from lists generated by Phase I. Others included in the opinion leaders' sample were selected on a judg-ment basis. In all, 467 personal interviews were con-ducted in 62 sampling points throughout the United States with opinion leaders, as follows:

Physicians 205 Dentists 70 Medical researchers 55 Visibles* 49 Nutrition specialists 46 All others 42

A more detailed breakdown of opinion leader respon-dents will be found in Appendix B of this report.

*"Visibles" throughout this report refers to food and nutri-tion editors, writers and reporters in the popular press --television, newspapers and magazines.

Phase III - Personal Interviews with Consumers

Personal interviews were conducted with 486 consumers in 57 sampling points representative of the United States.

A detailed breakdown of the demographic characteristics of consumer respondents will be found in Appendix B of this report.

C. Comments on the Organization of This Report

1. Versions of the questionnaire

In order to ask each of the sub-populations (i.e., physicians, dentists, consumers, etc.) only those questions relevant to it, eight separate question-naires were developed for Phases II and III. Copies of these questionnaires will be found in Appendix D.

It will be noted that the same questionniare items appear in several of the versions, but relatively few are common to all eight of them.

2. Statistical data

Findings presented in this report are based on analysis of computer-generated data derived from the survey

questionnaires. In order to present the findings in as nearly narrative and interpretative form as possible, presentation of supporting statistics has been kept to a minimum. Al l supporting summary tables will be found in Appendix A, with reference to table numbers included in the body of the report. As noted earlier, different versions of the questionnaire were used with different categories of respondents. Omission of any type of respondent from these tables is because such respon-dents were not asked the question being reported. Copies of the original computer printout have been submitted separately to The Sugar Association.

3. Definition of terms

In the interest of clarity, i t was deemed desirable somehow to aggregate opinion leader data in a meaning-ful form for convenient presentation. The decision to present all such data in one class, as "the

opinion leaders", was rejected on several counts. First, physicians constitute almost half the opinion leader sample. To the extent that physicians may be homogeneous in attitude, they would tend to mask any divergent opinions held by other sub-populations. Secondly, preliminary examination of the opinion

leader data indicates that dentists do, in fact, have opinions which differ markedly from those of physicians. Thirdly, preliminary examination of consumer data in-dicates that physicians, dentists and popular media are each cited by approximately the same proportions as influential sources of information about sugar and health. Thus, i t would appear that a total which allowed physicians' opinions to dominate the findings could be misleading.

For all these reasons, the determination was made to discuss opinion leader data under four major group labels:

Physicians Dentists Visibles

Other influentials

Where marked differences are noted within a category --for example, if cardiologists have widely divergent opinions from other physicians, or if the opinions of dieticians and industry research and development per-sonnel differ sharply -- such differences are noted and discussed.

Attitudes to~ard sugar consumption by people with specific health conditions -- i.e., dental health, obesity, diabetes, etc.

Sources of information about sugar and perceived need for additional infornation

Conclusions and implications.

Appendices are devoted to:

Presentation of statistical data Details on sa~ple composition

Methodology used for Phase I -- Search of the Literature

Interviewing naterials

II. SUGAR AND THE NORMAL HEALTHY INDIVIDUAL

Among opinion leaders, dentists have the most blatantly

negative attitudes toward sugar. The "visibles" -- those who write and speak on nutrition and health -- have transmuted

the American preoccupation with slenderness and youthfulness into an attack on sugar consumption; they predict greater potential health dangers from sugar than do physicians. It

is important to note that "visibles" are also less accepting of artificial sweeteners than are other opinion leaders.

Physicians generally belive that sugar, in moderation, is a necessary part of the diet of normal, healthy individuals. They particularly believe sugar plays a vital role in the growing child's diet.

Consumer attitudes toward sugar display a marked ambivalence. Sugar is viewed as a necessary part of the diet, particularly for children. On the other hand, the bad press which sugar has received at the hands of the "visibles" has not gone un-noticed. Coupled with inaccurate knowledge, consumers express doubts as to sugar's healthfulness.

A. Common Nutritional Problems in the United States

In order to avoid biasing responses, all respondents

were told that the study concerned itself with "nutrition and related issues". The first question asked of opinion leaders was what, in their opinion or from their profes-sional experience, they believe currently to be the most common nutritional problems in this country. The question was completely open. It could, and, in fact, did, bring a variety of responses. (Table 1)

The problems named ranged from general statements about obesity, eating patterns, dietary knowledge, and malnu-trition to overly high or low intake of specific dietary components and/or foods.

problem, with all other problems being mentioned by considerably fewer physicians most others by ·fewer than 1 out of 10.

"Visibles" are also more likely to mention obesity than any other problem, although fewer of them (39%) do so. On the other hand, some of the substantial number of "visibles" who mention overeating (35%) may have been implying the problem of obesity.

Dentists are the only opinion leaders who seldom men-tion obesity (10%) and overeating (6%) as common nu-tritional problems. One-quarter of the "other" influ-entials mention obesity. Several other problems are mentioned by at least equal, or larger portions, of

this group.

2. Failure to follow a balanced diet is regarded by more dentists (41%) as a common problem than is any other. This failure to eat "properly" is also the problem cited most often by "other" influentials (32%). It is also regarded as a common failing by a substantial number of "visibles" (32%).

One important difference between dentists and other opinion leaders appears worthy of comment. All other groups mention lack of knowledge about what consti-tutes a proper diet almost as frequently as they de-plore failure to follow such a diet. Only one-third as many dentists, however, who say that people do not eat properly, say that people do not know what a

proper diet is. Do dentists believe that the eating habits of a majority of Americans are dictated by a

kind of perverseness that causes faulty eating habits despite adequate knowledge to the contrary? Do opinion leaders --particularly outside the medical profession feel that they have a special and correct knowledge which has not yet been adopted by the public-at-large? The answers to these questions and their implications become clearer as the data are examined further.

3. High intake of sugar and other carbohydrates are the second and third problems most frequently cited by dentists, with more than one-third (35%) singling out

sugar and more than one-quarter (28%) singling out carbohydrate intake (other than sugar) as constituting common nutritional problems. The large proportions of dentists who attack sugar and carbohydrates is un-equalled among all other opinion leader groups. Even among "visibles" (who, i t will be shown, are only slightly less negative toward sugar than are dentists) the proportion spontaneously citing high sugar intake as a major problem is relatively low (14%).

B. Usage Levels of Sugar and Artificial Sweeteners

Opinion leaders were asked to indicate whether they believe current consumption levels of sugar and of artificial

sweeteners in this country are acceptable, too high or too low. Consumers were asked about daily usage of a number of sweeteners, including white or table sugar and arti-ficial sweeteners. (Tables 2 and 3)

A vast majority of opinion leaders say that the consump-tion level of sugar is too high. Somewhat fewer, but in all cases a majority, find the consumption level of

artificial sweeteners acceptable.

Consumers are more than four times as likely to report daily use of sugar as they are to report daily use of artificial sweeteners. In neither case was an attempt made to obtain estimates of how much of these sweeteners are used daily.

1. Sugar consumption is said to be too high by 9 out of 10 dentists and about the same proportion of "other" influentials. Although a plurality of both physicians and "visibles" say that consumption is too high, 22% of all physicians and 23% of all "visibles" believe that the consumption levels are acceptable. None of the opinion leaders say that consumption of sugar is too low.

2. Artificial sweetener consumption is viewed as accept-able by over half of all opinion leaders, ranging between 51% among dentists and 61% among physicians. The case for artificial sweeteners is, however, not clearcut. Not only does a range of between 26% among dentists and 39% among "visibles" feel that consump-tion of these products is too high, but a number of opinion leaders (ranging from a low of 6% among "visi-bles" to a high of 16% among dentists) are reserving judgment at this time, and several (again, particularly dentists) feel i t is too high.

Within the groups of opinion leaders:

Internists are slightly more likely than other physicians to say that sugar consumption is too high and far less likely to say that the same is true of artificial sweeteners.

Among "other" influentials, dental researchers and industrial personnel are least likely, while dieticians and nutritionists are most likely, to say that consumption of both sugar and artificial sweeteners is too high.

3. Daily use of white or table sugar is reported by 77% of all consumers, as contrasted with 18% who report daily use of artificial sweeteners. While there are no apparent demographic differences of note amonq sugar users, daily use of artificial sweeteners is slightly higher among women (21%) than men (16%).

It should be noted that daily use of one of these sweeteners does not preclude use of the other, so that, among all consumers interviewed:

64% use only sugar daily 18% use neither daily 13% use both daily

c.

Various questioning techniques were used to provide an understanding of how opinion leaders and consumers feel about the healthfulness of sugar. Primary among these was scaling.*

Using scales where the ends read "Harmful to your health" and "Good for your health", consumers were asked to rate a number of natural sweeteners, including white or table sugar, and artificial sweeteners. (Table 3) Opinion leaders and consumers were asked to indicate, using a

scale ranging from "Very unimportant" to "Very important", their attitudes toward restricting use of certain food substances (including sugar and artificial sweeteners) for the sake of good heal th. (Tables 4 and 5) Using another scale whose ends say "Disagree strongly" and

"Agree strongly", respondents were asked to react to a number of additional ideas concerning sugar consumption.

(Table 6)

1. Opinion leaders

Physicians

Physicians have demonstrably more positive atti-tudes toward sugar than do other opinion leaders. They agree rather strongly that sugar is needed

*This is a device which presents a six-point scale with opposite verbal descriptions appearing at each end. Respondents are asked to select the point on the scale which best expresses their opinion about an issue. The scale points selected by all respondents in a given group are summed and divided by the number answering, to represent a mean (or average) score for the group being studied. There are two conventions one may

follow in interpreting these means. One may divide all possible scores into three groups, and assume that a mean of from 1.0 to 3.0 favors the description at the low end of the scale, a mean of from 4.0 to 6.0 favors the description at the high end of the

in a balanced diet (4.3) and that i t is required in meeting the energy requirements of growing children (4.4). They regard saturated fats as a greater threat to good health than they do sugar. It is true that, on balance, physicians exhibit a slight (3.6) tendency to believe that restricted intake of sugar is indicated for maintenance of good health, but when specifically directed to con-sider restriction of sugar intake either by adults without metabolic problems or by normal, healthy children, they reject such prohibition.

On the other hand, i t must be clearly noted that physicians urge moderation in the use of sugar by both adolescents and children. They tend to agree

(3.9) that overall sugar intake by both children and adolescents should be restricted, but i t appears that this restriction is directed most particularly toward "snack" and "non-food" foods1 physicians strongly recommend restriction of children's con-sumption of sugar-sweetened soft drinks (4.5) and pre-sweetened cereals (4.3).

Physicians with different specializations react differently to the role of sugar in the diet. For example, cardiologists and gerontologists are less concerned about sugar and more concerned about saturated fats in the diet than are other physicians. General practitioners are more con-cerned than are other physicians about the use of both sugar and artificial sweeteners.

Before examiuing the attitudes of other opinion

leader groups, i t should be noted that a substantial number of physicians who treat normal adults (21%) claim they recommend restricted use of sugar to such patients even in the absence of metabolic problems. These physicians offer a variety of reasons for doing so, foremost among them being a desire to avoid any future problems of obesity (5% of the total physician sample) .

Dentists

In direct contrast with physicians' attitudes, dentists, as a group, have reservations about the need for sugar in a balanced diet (3.4). It should be noted, however, that this rating represents an averaging between two opposing schools of thought: 23% of all dentists strongly agree that sugar is necessary in the diet, while 21% strongly disagree with this premise.

It is interesting to note that of the ten perio-dontists included in the sample, three are included in the group which strongly denies the necessity of sugar in a balanced diet, with only one periodontist in the group strongly holding the opposing point of view.

Strong opinions about the need or lack of need for sugar in a balanced diet are not confined to either younger or older dentists, the span of years repre-senting length of practice being about the same in each case. However, those who agree that sugar is required in a balanced diet, are more likely to be dentists who have been in practice for longer periods of time.

If dentists appear to be divided as to the need for sugar in a balanced diet, they present a much more unified approach to use of sugar by children and adolescents, rejecting the idea that sugar is needed to meet a child's energy requirements (2.8) and even more strongly agreeing that there should be an o ver-all restriction of sugar intake of both sugar-sweet -ened soft drinks and pre-sweetened cereals.

"Visibles"

The position of "visibles" toward use of sugar tends to be more like that of dentists than that of physi

-Unlike physicians, "visibles" feel that i t is equally important to health to restrict intake of both saturated fats and sugar. They condemn use of sugar by normal adults, and concur with

the restriction of sugar intake by both adolescents (5.0) and children (4.9), although not as over-whelmingly as do dentists. Consistent with this stand, they are only slightly less opposed to soft drinks and pre-sweetened sugars than are dentists.

Although "visibles" do not condone use of artifi-cial sweeteners, they do tend to be somewhat less opposed to their use by both children and normal adults than are physicians. It should be noted that "visibles", like all other opinion leader groups, reject the idea that saccharin represents a potential health hazard. Any reservations which they, or other opinion leaders, express toward use of artificial sweeteners (as opposed to "saccharin") may reflect caution attributable to the cyclamate controversy of a few years ago.

Other influentials

As a group, dieticians, nutritionists, researchers and industry people who constitute the remaining group of opinion leaders included in this study may be characterized as having more positive atti-tudes toward the role of sugar in the diet of healthy individuals than do dentists and "visibles", but more negative ones than do physicians.

2. Consumers

Consumers have been bombarded with a great deal of nutritional and diet information and advice. Their earliest exposure is, of course, in the home, where as children, they are exposed to their parents' ideas of what is "good for you". Many, particularly women, are exposed to home economic teachers during their school years. As adults, the popular press presents

the views of home economists, medical writers, expounders of various diets designed to yield youthfulness, long life, freedom from additives, and so on and on. Addi-tionally, the consumer is aware of the relative taste

appeal of different foods to him-- and this taste appeal is not always perceived as consistent with the desire to maintain or reduce weight, to stay young, to be unadulterated, or to achieve whatever current Utopian goals he may have.

It is not surprising, therefore, that the consumer's evaluation of what is healthful does not coincide

with his behavior, or that his attitudes are frequently ambivalent. Given eight sweeteners and asked to

eval-uate the healthfulness of each, honey is perceived as the most healthful -- far more healthful, in fact, than all others. Honey is, however, reported used daily by

only 15% of all consumers. (Table 3) The sweetener considered second most healthful, molasses, is used

daily by only 10% of all consumers. White or table sugar is tied as third most healthful with both corn syrup and brown sugar, barely make i t onto the "good for your health" side of the scale at a mean rating of

3.8. White or table sugar is, however, the single most

universally used sweetener, daily use being reported

by 77% of all consumers. Included in the list of sweeteners, and reported as being used by a small 6%

of all respondents is raw sugar*. It is impossible

from these data to determine how many, if any, consumers actually do buy and use products reported to be "raw" sugar, nor where such products are purchased. Con-sumer attitudes toward table sugar are clearly ambi-valent and contradictory. Like "visibles", they more strongly support the idea that i t is important to health

to restrict intake when the idea is presented as a

*Raw sugar is reported used daily by 6%, or 30 respondents.

A majority (18) of those making this claim are women. The geographic distribution of these respondents is: East 3 (1 each: New Jersey, New York, Pennsylvania)

Central 5 (1 each: Illinois, Indiana, Michigan, Minnesota, Wisconsin)

South 17 (Texas 4; Alabama, Georgia, Tennessee 3; Florida,

Oklahom~ 2)

general statement than when restriction is identified with a specific part of the population. Conviction that sugar intake should be restricted declines slightly when the question is specifically tied to normal children and to normal adults. Despite the feeling that sugar intake should be restricted, con-sumers are firmly convinced both that sugar is required for meeting a growing child's energy requirements and for maintaining a balanced diet.

Attitudes toward artificial sweeteners exhibit the same kinds of inconsistencies. For example, while sugar is regarded as healthful but important to re-strict, artificial sweeteners are judged harmful to health. Consumers are uncertain about how important i t is to restrict their use. When asked in a general way (i.e., without reference to any particular popula-tion), they tend to rate i t just below the midpoint

(3.4) as "Not important to health" to restrict, and slightly above the midpoint (at 3.8 each) when the question is specifically related to normal adults.

The attitudes consumers evidence toward artificial sweeteners tend to be far more negative than those of any of the opinion leader groups. The data gener-ated by this study fail to provide any evidence as to why this may be so. One may hypothesize that just as some of the ambivalence displayed toward sugar

reflects a conflict between what people have been told about sugar and their own preference for its taste, some of the negativism displayed toward artificial sweeteners may have its origins in rejection of the taste of these substances.

•

•

III. PERCEPTIONS ABOUT THE CALORIE VALUE OF SUGAR

Medical professionals and nutrition specialists appear to display a marked lack of knowledge about basic carbohydrate and sugar requirements in the diet. Opinion leaders, as a group, support the validity of the "empty calorie" charge leveled against sugar. The claim has relatively strong

support even among medical professionals, with only a slight majority rejecting its validity.

Relatively few consumers are aware of the actual caloric value of sugar. The average estimated number of calories in a level teaspoon exceeds the actual number by more than three times. Sugar is believed to contain more calories than many other sweeteners with actual caloric equivalency.

A. Opinion Leaders

1. Proportion of food requirements from sugar

Physicians, medical researchers, dieticians and nutritionists, all of whom, i t might be presumed, are knowledgeable about the normal adult's food requirements were asked what percent of the normal adult's food requirements should be carbohydrates, and what percent of these carbohydrates should be from sugar.

Apparent lack of this kind of knowledge among these respondents is surprising. The percentage who say they do not know the required percentage from

carbohydrates ranges between from 12% (physicians) to 17% (dieticians and nutritionists). Almost one-quarter of all general practitioners (23%) say they do not know what percentage of the diet should be from carbohydrates.

Estimates of required carbohydrate levels range from less than 25% to more than 60%. Respondents

who say that the normal adult's diet should be between 41% and 50% carbohydrate are relatively small:

18% Physicians

29% Medical Researchers

28% Dieticians and Nutritionists

Of those who give the 41%-50% estimate for carbo-hydrates, the numbers of those saying that 21% to 30% of these carbohydrates should be from sugar are:

4 Physicians

l Medical Researcher l Dietician

(It must be stressed that these are numbers not percentages. In other words, only 6 of the 306 respondents -- 2% -- asked these questions gave answers in an approximately correct range.)

It may be that this seeming lack of knowledge among those professionals whom one would expect to be best informed on diet and nutrition stems, at least partially, from the frame of reference

in which the questions were phrased. Professionals, i t could be argued, are more likely to think

of carbohydrates in terms of grams and sugar in terms of calories.

Although no specific question was asked about why the "empty calorie" claim is believed to be valid or invalid, many respondents did expand on their initial judgment. Since all respondents were not directed to do so, statistical presentation of these gratuitous remarks is not justified. A content analysis of them, however, is appropriate and leads to some conclusions about why this un-scientific catch-phrase has been adopted by such

•

•

,

a large number of people who might have been expected to resist it.

At least four predominant ideas emerge:

- People are more likely to overeat on sweets because they taste good. This only serves to contribute to obesity and health problems attendant an overweight condition.

- Eating (or overeating) sweets satiates the appe-tite and makes i t more likely that other dietary requirements will be underconsumed, or not be consumed at all.

- Acceptance of the claim is a way of condemning the food industry for indiscriminate addition of sugar to processed foods. The goal of this addition, i t is felt, is to improve flavor, and therefore marketing position. The consequence of the

prac-tice is to increase the individual's total

sugar consumption and thus to increase the health problems viewed as associated with other than moderate use of sugar.

- Acceptance of the claim is a way of condemning the sugar industry for what many appear to

regard as excessive lobbying both for sugar and against other sweeteners. Some charge that information disseminated by the industry is inaccurate, not soundly rooted in objective research and promulgated in the interest of the industry without regard for the health of the consumer. The banning of cyclamates, for example, is called premature and unwarranted on the basis of available scientific data, and is charged to have been fostered by the industry as a means of protecting its own interests.

3. Future demand for sugar and sugar-sweetened products

Regardless of the validity or lack of validity of the empty calorie claim and the reasons for its widespread acceptance and repetition, industry personnel believe that sugar's current "bad press" is likely to affect future use of sugar and

artificial sweeteners in the manufacture of foods and beverages. (Table 8) Only about one-third of the food and soft drink research and development people included in the study predict no change in the use of sugar in pre-sweetened cereals

and sugar sweetened soft drinks, while the largest proportion think that use of pre-sweetened

cereals (48%) and sugar-sweetened soft drinks (42%) will decrease in the future. Less drastic change

is foreseen in use of sugar and other sugar -sweetened foods, with almost half (46%) of the industry respondents saying they expect future use of these to remain the same, and the remainder almost equally divided between forecasts of a

decrease (29%) and an increase (25%). Industry personnel overwhelmingly believe that future consumer demand for sweet products will be satisfied by an increase in use of sugar sub-stitutes (79%) and artificially sweetened foods (83%).

B. Consumers

1. Calories in a level teaspoon of sugar

To test the level of knowledge about its actual caloric value, consumers were asked how many calories they believe there are in a level tea-spoon of sugar. As was anticipated, relatively few (4%) correctly say 18 calories.(Table 9) Women are more likely (6%) than men (2%) to

give the correct response. Overall, the average number of calories assigned a level teaspoon of sugar is 56.1, with women's average of 52.1 being just slightly lower than the 60.8 estimated by men.

Undoubtedly because sugar consumption has been so frequently and so closely linked with obesity, more than one-third of all consumers (39%)

attribute to sugar more than four times (72 or more) the number of calories i t actually contains;

more than half (56%) estimate that a teaspoon of sugar contains in excess of 37 calories.

I t is understood that the estimated average number of calories in a teaspoon of sugar has decreased slightly since the last time this question was included in a consumer study reported to The Sugar Association. In the intervening time

the Association's "18 calories in a level teaspoon" advertising campaign appeared in the popular

press. The data from the current study were carefully reviewed for any evidence that this decrease could be attributed to that campaign. There is little evidence, however, to confirm that hypothesis. Three age groups were

established -- under 34 years, 35 to 54 years, and over 54 years. If that campaign appeared 8 to 10 years ago, those in the youngest age group, would, presumably, have been least likely to be aware of or to have had their answers

influenced by i t . In point of fact, however, there is little difference by age groups of average estimated number of calories, no

difference in the percentages giving a correct response, and in fact, less likelihood for those in the oldest age group to offer any response to the question.

Average estimated calories Say "18 calories"

Say "Don't know"

Age 18-34 35-54 55 or more 56.2 4% 3% 57.6 4% 3% 53.8 4% 14%

2. Ranking of caloric value of eight sweeteners

Reference was made earlier to consumers having been asked about the healthfulness and daily use

of eight sweeteners. They were also asked to rank the caloric value of these sweeteners from highest to lowest. On the average, white or table sugar was ranked as having more calories than any of the other seven sweeteners, about one-quarter (27%) ranking i t above all others. On the other hand, consumers tend to see little difference between the relative caloric value of white sugar, raw sugar, honey, molasses and brown sugar, all of which achieve an average ranking of between 3.6 and 3.8. Consumers generally rank corn syrup as somewhat below these five in caloric value, dextrose even lower, and artificial sweeteners at the bottom of the list, being ranked eighth by 7 0 % of all consumers. (Table 10)

As further evidence of the low level of knowledge about calories among some consumers, i t should be noted that 7% rank sugar in eighth place --i.e., having the fewest calories of all eight sweeteners. Minimal sex and age differences are to be observed among these 7%. Strangely, those who have at least completed high school or

have attended college are more likely to rank sugar in eighth place (9%) than are those who did not complete high school (1%).

•

•

IV. SUGAR AND DENTAL HEALTH

The rationale behind the extremely negative attitudes dentists have toward sugar is their firm conviction that sugar and

sugar-sweetened foods are a leading cause of tooth decay. Other opinion leaders concur in this judgment. A majority of opinion leaders and consumers believe that reduced sugar

consumption would dramatically improve children's dental health. Smaller, but substantial, proportions perceive similar benefits for adults.

A. Dental Professionals' Recommendations Regarding Sugar

Dentists and dental researchers were asked about the types of patients for whom they recommend dietary restrictions.

(Table 11) For each type of patient for whom such

restrictions are said to be recommended, these respondents were asked about the kinds of restrictions imposed. (Table 12) Their attention was particularly directed to any restrictions they may place on sugar. (Table 13)

1. Frequency of recommending dietary restrictions

A large majority (80%) of dentists recommend dietary restrictions for at least some of their patients, with between two-thirds and three-quarters saying

they do so for all children, adolescents and cavity-prone adults. About 4 out of 10 dentists also

recommend restrictions for adult patients with normal dental problems. Dental researchers are even more likely than dentists to recommend dietary restrictions for virtually every kind of dental patient. Whether this reflects special knowledge as a result of research or whether i t reflects a recommendation in wr1ting (not face-to-face to a patient who may or may not follow the advice given, nor to a patient whose "good will" is important lest he seek another dentist) is outside the purview of this study .

2. Kinds of restrictions imposed

Dentists' dietary restrictions to all patients, whether they be children, adolescents or adults, are directed primarily at sugar and sugar-sweetened foods, with

about half the dentists saying they recommend restricted sugar usage by children and adolescents, and a third

saying they recommend its restriction by adults. The

prohibition against both sugar and sugar-sweetened foods is even more likely in cases of cavity-prone

children (56%) and adults (46%) than for patients with

normal dental problems. Whether or not they actually

recommend i t to their patients, 63% of all dentists

say that pre-teenagers should eliminate most, if not

all, sugar from their diets. Dental researchers appear a little more lenient, with only 39% saying all or

most sugar should be eliminated. The majority of

dental researchers (55%) would, i t appears, be

satis-fied with a less drastic reduction in sugar intake,

saying only that "some sugar" should be eliminated.

Although reports of dietary restrictions which dentists

seek to impose on their patients are entirely

consis-tent with their expressed attitudes toward sugar, one wonders whether such reported restrictions are not

more often expressions of dentists' attitudes toward

sugar than accurate accounts of their behavior. No mention was made by any of the dentists about

recom-mending restriction of artificial sweeteners, when

given an open-end opportunity to do so. However, when probed about whether or not they recommend restriction

of artificial sweeteners, one-quarter of all dentists

claim to do so. It might successfully be argued that failure of some dentists spontaneously to mention this earlier in the interview was due to oversight; failure

of any to do so suggests that, in part at least,

reported recommendations to patients to reduce sugar

consumption may be somewhat overstated.

3. Attitudes of opinion leaders outside the dental

profession

The attitudes of dieticians and nutritionists toward

sugar consumption by pre-teenagers approximates that of dental researchers. "Visibles" are more likely than

others to believe that pre-teenagers should maintain a balanced diet (22%), perhaps out of firmer belief that sugar is required to meet a growing child's energy needs. Even so, however, a substantial number (43%) say that some sugar should be eliminated from the pre-teenager's diet, while only slightly fewer (35%) opt for elimination of most, if not all, sugar.

B. Perceived Importance of Selected Factors as Causes of Tooth Decay

Respondents were presented with a list of factors which may contribute to tooth decay and asked to rank them from most to least important. Opinion leaders were given eight

such factors to consider. Consumers were presented with a list of five factors. Common to both lists were sugar and sugar-sweetened products, bacterial action, heredity, and lack of fluoridation• (Table 14)

1. Opinion Leaders

- Dentists

Dentists rate poor oral hygiene -- presumably a combination of infrequent and/or inadequate professional and home care -- as the single most important cause of tooth decay. Sugar and sugar-sweetened products rank second, while bacterial action is third.

Inadequate diet, heredity, and lack of fluorida-tion are ranked as fourth through sixth, with infrequent prophylaxis and fruits in seventh and eighth places,respectively.

When dentists were asked what additional factors contribute to tooth decay, most say that this list includes all significant causes. The only

addi-- Other opinion leaders

All other opinion leaders concur with dentists about the three main causes of tooth decay, although they do not always rank them in pre-cisely the same order. Physicians do list poor oral hygiene, sugar and sugar-sweetened products, and bacterial action as first, second, and third respectively, as do "other" influentials. This latter group, however, equates inadequate diet as equally an important cause as bacterial action.

In view of the fact that "visibles" are only slightly less negative than dentists in their attitudes toward sugar, i t comes as something of a surprise to find that this group lists sugar

and sugar-sweetened products as third in importance in tooth decay, rating bacterial action as most important and poor oral hygiene as second.

2. Consumers

Consumers regard poor brushing as the most important cause of tooth decay. Since this is a non-technical equivalent for the poor oral hygiene to which dentists were asked to respond, one can safely conclude that dentists have successfully gotten that particular message across to their patients.

Whether or not dentists do recommend restriction of sugar intake as frequently as they claim to, they appear to have been equally successful in convincing the public of the role of sugar in tooth decay, for consumers, like dentists, rank i t as second. Finally, consumers, like dentists, relegate the role of bacteria to third place as a causative factor in tooth decay.

C. Sugar and Dental Health

Since there was reason to anticipate that sugar would be

associated with dental problems, specific items were included in various of the field questionnaires to provide a better

understanding of the perceived role of sugar in dental problems. (Table 15)

One of the statements with which most opinion leader groups were asked to agree or disagree is "Sugar consumption is

a major cause of tooth decay". All groups strongly subscribe to the statement, as is evident from the immediately

pre-ceding discussion, and requires no further comment.

1. Dental professionals' perceptions about the role of sugar in dental problems

Dentists say that sugar consumption contributes to the formation of plaque. Thus, one begins to understand the mechanism by which they believe that sugar con-tributes to tooth decay. Since dentists can only suggest, but not enforce frequent and thorough pro-fessional and home care of teeth (poor dental hygiene is the most important cause of tooth decay), since sugar consumption contributes to the formation of plaque (sugar and sugar-sweetened products are the second most important cause of decay), since plaque traps bacteria (the third most important cause of decay) and bacteria attack the tooth structure with resultant cavities, dentists are strongly motivated to recommend restriction or elimination of sugar from the diet. This is particularly true for children, who are more cavity-prone than adults and who, additionally, cannot be counted on to cleanse the mouth and teeth thoroughly enough or frequently enough to overcome potential trouble.

In addition to formation of plaque, dentists believe, though not as strongly, that by urging restriction of sugar intake they are also reducing the potential for periodontal problems. This, again, may be related to formation of plaque and tartar as a result of

eating food or drinking beverages containing sugar.

Interestingly, dental researchers are more convinced than dentists about the role of sugar in formation of plaque, and slightly less certain of its role in

2. Perceived benefits of reduced sugar consumption

Three-quarters of all dentists (74%) believe that

reduced sugar consumption would prevent most children's cavities, while about half that many (34%) believe i t would prevent most, if not all, adult cavities. No

dentists, i t should be noticed, make the claim that sugar is the sole cause of tooth decay, and none sees sugar reduction as a means of preventing all cavities in children. (Table 16)

"Visibles" and other influentials perceive some bene-fits to the dental health of both children and adults from reduced sugar consumption. Fewer visibles (58%) believe that most children's cavities could thus be prevented. Among "other" influentials, 4% suggest that such reduction could eliminate all children's cavities. "Visibles II

and "other" influentials tend to concur with dentists that, while reduced sugar

consumption could prevent some adult cavities, results among adults would not be as dramatic as among children.

Consumer attitudes toward sugar and children's cavi-ties are, at the same time, more and less optimistic than those of "visibles". A few (6%) believe that reduced consumption could prevent all children's cavities, while the majority (53%) believe i t could prevent most of them. Similarly, while a small number

(3%) think that reduced sugar consumption could prevent all adult cavities, the majority see only minor bene-fits, if any, to adult dental health as a result of such reduction.

V. SUGAR AND OBESITY

Opinion leaders and consumers agree that reduction of total caloric intake is extremely important in achieving weight loss. Reduced sugar intake is universally seen as a necessary part of this total caloric reduction. There are, however, differences of opinion among various categories of respondents about the relative importance of sugar reduction vi~-a-vis reduction of other food components.

Consumers regard sugar as fattening, in and of itself. They see its caloric value as higher than meat protein, but lower than that of fats.

A. Sugar as a "Fattening" Food

Consumers firmly believe that sugar is a fattening food (4.8). They regard i t as containing more calories than an equal weight of meat protein, but fewer calories than an equal weight of fats. On that basis, they conclude that although sugar is a fattening food, i t is less fattening than fats.

Opinion leaders concur that sugar is no more fattening than fats, with no real differences existing in reactions of consumers, physicians, "visibles" and "other" influentials in reactions to the statement, "Sugar is no more 'fattening' than fa ts" . (Table 1 7)

Opinion leaders and consumers both feel that i t is impor-tant for obese individuals, whether adults or pre-teenagers, to restrict their use of sugar. They differ, however, in their feelings about use of artificial sweeteners by such individuals. Although opinion leaders attach little impor-tance to restriction of these subsimpor-tances by the obese,

consumers feel i t is only a little less important for those with a weight problem to limit their use of artificial

•

B.

•

•

The attitudes consumers express against use of artificial sweeteners by the obese is particularly surprising when one realizes that consumers are even more strongly opposed to use of these substances by those who are overweight than they are to their use by normal individuals, (Table 5) One possible explanation for this finding is that consumers

believe artificial sweeteners are harmful to health. (Table 3) Since normal individuals are less likely to use artificial sweeteners, their total consumption of these substances is likely to be relatively small. Overweight individuals, on the other hand, are more likely to consume artificial

sweeteners in lieu of sugar and/or in foods prepared with these sweeteners. Thus, the total consumption, with con-comitant threat to health, is greater among the overweight. Therefore, the need for the obese to limit their use of artificial sweeteners is more imperative than for normal individuals.

Relative Importance of Specific Actions to Weight Loss

Respondents were asked to indicate the importance or lack of importance of specific actions to weight loss, including reduced total caloric intake, reduced intake of specific kinds of foods, and increased daily exercise. All opinion leaders and consumers of whom the question was asked agree that reduction of total caloric intake is of paramount importance. Beyond that, however, different groups of

opinion leaders attach varying degrees of importance to the suggested al terna t i vea. (Table 19)

1. Opinion leaders

Physicians believe that i t is equally important to reduce intake of sugar, fatty foods and starches in achieving total caloric reduction. Although they believe that increased daily exercise is indicated, they view this as less important than restricted

caloric intake. Reduction of salt intake is considered relatively unimportant in weight reduction, undoubtedly in recognition that this serves merely to reduce re-tained fluid without affecting stored body fat. There

•

•

2.

are no notable differences among types of physicians

in their attitudes toward this issue.

"Visibles" believe increased daily exercise is almost

as important as decreased caloric intake in a weight

reduction program. Although, on balance, most believe

that reduced salt intake is unimportant to weight loss,

"visibles", as a group, are slightly more likely than

physicians to believe that salt intake should be

restricted by those attempting to lose weight.

"Visibles'', like physicians, agree that sugar, fatty

foods, and starches should all be restricted by those

who are dieting. However, they are most inclined to

urge reduction of sugar, and least inclined to urge

reduction of starches.

"Other" influentials concur with physicians that, while

both are important, reduced caloric intake is more

important to weight loss than increased daily exercise.

They believe equally strongly that sugar and fatty foods

should be restricted and regard reduced starch intake

as being of slightly less importance to successful

weight loss. More "other" influentials believe that

reduced salt intake should be part of a weight loss

regimen than do other opinion leaders.

Consumers

To consumers nothing is unimportant in attempting to lose weight. Consumers attach equal importance to

reducing total caloric intake and increasing daily

exercise. While differences in the importance assigned

to reduced intake of each of the three foodstuffs are

minimal, the highest degree of importance is assigned

to reducing intake of fatty foods and the lowest to

reducing intake of sugar. This is entirely consistent

with their opinion that sugar contains fewer calories

Possibly because reduced salt intake and concomitant reduction of retained body fluid results in readily apparent weight loss, consumers attach a relatively high degree of importance to reducing salt intake to achieve this goal. Anyone who has attempted to shed poundage is aware of the psychological l i f t one achieves during dieting when each "weigh-in" indicates even a slight loss, and conversely the feeling of defeat when active self-denial fails to produce anticipated bene-fits. Since reward serves to strengthen any kind of behavior, and since salt reduction tends to produce the desired results, i t is not surprising that consumers attach the importance they do to salt reduction in a diet program.

VI. DIABETES, HYPOGLYCEMIA AND SUGAR

Use of sugar by maturity-onset diabetics and the

diabetes-prone is restricted by most physicians. Rationale for imposing this restriction on pre-diabetics derives from the feeling that sustained and excessive use of sugar can accelerate onset of the disease in such individuals. Similar bad effects are not anticipated where no such predisposition exists.

Level of awareness of hypoglycemia is high among opinion leaders, most of whom regard i t as a relatively uncommon dis-order. Physicians are inclined not to regard the condition as serious. Other opinion leaders, particularly "visibles", take the opposite viewpoint.

Consumers think hypoglycemia is caused by excessive sugar consumption, an opinion not shared by "visibles" or "other" influentials.

A. Treatment of and Attitudes toward Diabetes

1. Physicians

Three-quarters of all physicians say that they treat diabetics. The proportion of physicians who treat this condition varies by type of practice, with

internists (90%) and general practitioners (88%) being most likely to treat, cardiologists and gerontologists

(71%) less likely, and other physicians (46%) least likely to do so. Among treaters, largest diabetic patient loads are reported by internists, and smallest by general practitioners.

Three-quarters of the physicians who treat diabetes do not adhere to a strict control or a loose control regimen, preferring to vary their approach in accor-dance with the severity of the problem and the

Physicians were asked about the kind of reduction in

carbohydrates they recommend for various kinds of

diabetic patients, and what restrictions they place

on use of sugar. (Table 20) Although a small proportion (13%) of physicians say they allow maturity-onset diabetics of normal weight who are

on insulin to maintain a normal diet, the remainder are about equally divided between preference for a

slight or a marked reduction in carbohydrate intake. Internists are least likely to permit normal diet

for such patients, wit h about half of these physicians

preferring slight (over marked) carbohydrate reduction.

Permission for a diabetic to maintain a normal diet

varies little in terms of the kind of treatment being

used to control the condition, with 13% saying they

do so for patients on oral hypoglycemics and for patients on neither insulin nor orals.

About one-third of all physicians allow patients with a family history of diabetes or a predisposition to

the disease to maintain a normal diet. The majority

(55%) recommend a slight reduction of carbohydrates for such patients.

Restrictions on use of sugar, either at table or in food, are recommended for all diabetics, regardless

of treatment,by better than 8 out of 10 physicians.

General practitioners, internists, cardiologists and

gerontologists are all equally likely to impose to

these restrictions on sugar use on diabetics. Similarly,

about two-thirds of all physicians (68%) say they

impose restrictions on sugar usage on their diabetes-prone patients.

2. Medical researchers

Half of all the medical researchers included in this

study have participated in research related to diabetes.

Those who have participated in such research were