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0:44

Can I just ask a clarifying question? Is

0:46

the United Kingdom the same thing as England?

0:48

Is that the same thing as

0:49

Britain? Are we about three different things. I

0:51

believe the United Kingdom encompasses

0:54

Northern Ireland, Wales,

0:56

Scotland, and England, but

0:59

I will fact check myself on that.

1:03

That's my producer, Julie 75. And

1:06

she was right about the United Kingdom, by the

1:08

way. You might be wondering why we're

1:10

talking about this at all. And

1:13

the answer has to do with the

1:15

clever natural experiment. We

1:17

know Americans consume a lot of added

1:19

sugar. On average, around fifty

1:22

seven pounds, every year. What

1:24

it's doing to our bodies is a little less

1:26

clear, but a new paper

1:29

gets us closer to solving the mystery.

1:32

It was published in December twenty twenty two

1:34

by the National Bureau of Economic Research

1:37

and is appropriately titled The

1:39

Sweet Life. The Coalition do is

1:42

explore a relationship that's difficult

1:44

to measure, but one that's

1:46

vitally important given how much sugar

1:48

we all consume. I'm

1:50

Bakugena, and this is Freakonomics

1:53

Today on the show, what are the long

1:56

term health effects of eating sugar?

1:59

And back to the United Kingdom, How

2:01

can a food rationing program that

2:03

took place there more than seventy

2:05

years ago? Help us to hear

2:07

it out. So,

2:19

Julie, before we jump into our conversation,

2:21

let me give you some quick background. Here's

2:24

how the the UK food rationing program

2:26

worked during World War two. People

2:28

were issued coupons that entitled

2:31

them to buy specific quantities of

2:33

restricted 75. Things that were processed

2:35

and had lots of sugar, but

2:37

also meat, cheese, butter, bread.

2:40

The government was trying to guarantee

2:43

everyone 75 access to certain

2:45

items, and they were also trying

2:47

to prevent shortages in starvation. Also

2:50

because Britain is an island nation, it

2:52

imported most of its 75, and

2:54

those imports were under siege by the German

2:56

Navy and Air Force throughout the war.

2:59

The rationing program continued for

3:01

a few years after the war ended in

3:04

nineteen forty five as the UK

3:06

was slowly recovering.

3:11

And

3:12

why did this study catch your eye? Because it caught

3:14

my eye too. The basic idea

3:16

was trying to use this national

3:19

policy in the UK to

3:21

figure out what is the causeal effect of

3:23

sugar intake on long term

3:25

health and economic outcomes. There

3:27

are these restrictions that were lifted over time. So

3:30

bread and flour in July of

3:32

nineteen forty eight, and then biscuits,

3:34

jam, canned dried foods,

3:36

nineteen fifty, and then

3:39

bang, September nineteen fifty three,

3:41

sugar and sweets, they went off

3:43

ration. It's a really interesting

3:46

historical twist of fate in The

3:48

rationing provides a nice natural experiment

3:50

to see what happens when people consume

3:53

less sugar than usual for a fixed period.

3:56

And then go back to normal sugar consumption.

3:59

Question is, what kind of health effects do we

4:01

see? I like that kind of stuff in general,

4:03

but you could argue we think we know

4:05

a lot about the impact of sugar on our health

4:07

from decades and decades of studies,

4:10

but What I think most

4:12

people don't appreciate is that the

4:14

level of evidence while it's it's really

4:16

enormous in terms of volume is

4:18

not typically very high quality. What

4:23

do I mean by that? So a lot of the research

4:25

comes from animal models, which

4:28

is useful to understand physiology

4:31

of how sugar affects the body, how

4:33

diseases might result from increased

4:35

exposure to sugar. But it's a

4:38

huge jump to say something about how

4:40

sugar affects the human body by

4:42

just looking at small animals. The

4:44

second thing is there are studies that

4:46

look at randomization of

4:49

humans to different types of

4:51

diets. For example, high or low

4:53

sugar diets or processed sugar

4:55

versus not. But those studies tend to be

4:57

really small, which makes them

4:59

not very generalizable. And

5:01

the follow-up here is typically very

5:04

short. These people are not being followed for

5:07

years or decades. To understand what

5:09

the long term effects are of sugar.

5:11

And then that third bucket of studies are

5:13

really these associational or observational

5:16

studies where you simply look at people who

5:19

have more sugar intake versus less sugar

5:21

intake, maybe you try to account

5:23

or adjust or control for some other variables

5:26

that are different between those two groups And

5:28

then you attribute any

5:30

differences in outcomes, let's say, rates

5:32

of diabetes to the differences

5:34

in sugar intake. But the people who

5:37

eat a lot of sugar are different

5:39

than the people who don't. So how do you

5:41

know that it's really the sugar intake versus

5:43

other fatty foods that they might eat

5:46

versus exercise versus occupation.

5:48

So it's not the sugar that's causing it

5:50

that's what attracted me to this particular

5:53

study. It was a nice natural experiment to

5:55

get at the effect of one particular

5:58

nutritional element, in this case, sugar

6:00

on health and non health outcomes

6:03

over a long period of time.

6:08

And we should really care about sugar for

6:10

all the reasons that you said

6:12

we know that there are links to

6:15

health problems, but Also, people

6:17

really like sugar, so the ration was 75,

6:20

and sweets and chocolate sales increased

6:22

by more than one hundred and fifty percent

6:24

in one year. There was a very dramatic

6:27

reaction by the people in the

6:29

UK who had not been able

6:31

to access as much of these

6:33

sugary

6:34

snacks as they would have wanted to. As

6:36

soon as they could, they really went for it.

6:39

And

6:39

what's really impressive about this study is they

6:41

also got data from national

6:43

food surveys from the nineteen

6:45

fifties, and they showed this

6:48

large and sharp increase in

6:50

sugar consumption from something like

6:52

below forty grams to more

6:54

than eighty grams of sugar per

6:56

person per day. And then the

6:58

next question is, Alright. How do you

7:01

use that shock to tell us

7:03

something about the long term effects

7:05

of sugar exposure when

7:07

health outcomes? Because just identifying

7:10

it is the first step. Right? So then how

7:12

do you figure out what to look

7:14

for? They basically look to people who

7:16

were born during rationing. And they

7:18

compared them to people who were born just

7:20

after rationing. And then they looked

7:22

at data from the English longitudinal

7:24

survey of aging And

7:26

these are people who are between the ages of fifty

7:29

and sixty five who were born

7:31

in the years around the UK

7:33

rationing. The researchers

7:35

wanted to compare rates of certain diseases

7:38

like diabetes and also

7:40

markers of chronic inflammation in

7:43

those two groups more than fifty years later.

7:45

So they looked at data for each group

7:47

between two thousand eight and two

7:49

thousand eighteen

7:51

those who were exposed to the sugar rationing,

7:53

and those who weren't. And

7:55

papa, why would you wanna look at someone's early

7:58

life exposure? There is some

8:00

evidence that our early

8:02

exposures to different things, environmental

8:05

factors, one of which could be sugar, not

8:07

only affect the way our metabolism might

8:09

develop, but might also affect the way

8:11

that our genes are expressed,

8:14

but it also might just change

8:16

our habits. Suppose you

8:18

see that early exposure to

8:20

something like sugar or television,

8:23

creates this habit forming behavior where

8:25

you want sugar more later in life

8:27

or you're more interested in watching TV later

8:29

in life. Let

8:32

me tell you a little bit about what they found. They

8:35

saw that the prevalence of diabetes was

8:38

about fifty percent higher in

8:40

that group that it was exposed to

8:42

more sugar when they were young.

8:44

And it wasn't just diabetes 75 found elevated

8:46

rates of cholesterol, arthritis,

8:49

and they also looked at measures

8:52

of laboratory markers of chronic inflammation.

8:55

And levels were about thirty three

8:57

percent higher in people who had been

8:59

exposed to more sugar.

9:01

And the other thing that is interesting is they didn't

9:04

find much difference in the total caloric

9:06

intake of these individuals much later

9:09

in life. This is people who had

9:11

similar total calories but more

9:13

of those calories were coming from sugar.

9:15

So it does speak to this broader question which

9:17

is what is the composition of calories that

9:19

we get as opposed to the total number of

9:21

calories that we take.

9:26

And really none of it is terribly

9:29

surprising to this point. So it

9:31

would have I think really blown everyone

9:33

away if they were like, actually, the people who

9:35

suddenly had all this access to sugar were

9:37

healthier. What else did they find

9:39

though? Because I think that the next bid

9:41

is interesting. There's two other

9:44

things that they found, which I think do

9:46

advance the science. The first is

9:48

that they also looked at measures

9:50

of human capital accumulation. We can

9:53

think of that in economics as how much education

9:55

you get in economic well-being.

9:58

What they found there was that, on average,

10:00

the cohorts who were exposed

10:03

to this period of greater sugar. They

10:05

were less likely to complete postsecondary

10:07

education by about twenty

10:10

percent. They did not find

10:12

any effect on the probability of being

10:14

employed, but that exposure to

10:16

sugar was associated with the reduced

10:18

likelihood of work in a skilled profession

10:21

and having above median wealth

10:24

by the time you were let's say fifty to sixty

10:26

five. If you believe these results has

10:28

been causal, The argument would be

10:30

that it's related to the health behaviors

10:32

that develop the health outcomes that

10:35

then develop and the effects of health

10:37

on education and wealth.

10:41

Does this tell us anything new? Or

10:43

do think kind of adds to an existing

10:46

literature. I think it probably adds

10:48

to an existing literature because we know

10:50

from other studies how health

10:52

affects education and employment

10:56

and wealth. I think what was elegant here was

10:58

that they focus again on a very simple

11:00

thing, which is sugar. And just in terms

11:02

of how people crave

11:05

sugar compared to other

11:07

nutrients, so sugar tends

11:09

to be slightly more addictive.

11:12

There's actually states that look at how they

11:14

had addictive properties of sugar compared to something

11:16

like cocaine. Right? And Anybody who's

11:19

got a sweet tooth would appreciate that. The

11:20

reaction of my children when I take away dessert

11:23

is evidence enough for me.

11:25

We talked about the creative way this

11:27

study's co authors, Paul Gertler

11:29

and today a Gratcher, figured

11:31

out the long term effects of early

11:34

life sugar consumption. But

11:36

how else could you try to answer that question?

11:39

Or similar ones about nutrition?

11:41

And what other signals could

11:43

you look for in this unique natural

11:46

experiment that's coming up

11:48

after the break?

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15:00

Think about how else you could use this

15:02

data, what else you would do with it. I've

15:04

got some more ideas if you humor

15:06

me. There's usually more than

15:08

one way to answer a research question and

15:10

also more than one answer. A

15:12

lot of my time is spent trying to figure

15:14

out the best approach. Because

15:17

it's possible that even with some really

15:19

cool data, you could miss the mark

15:21

entirely. So what else

15:23

could we do with the information from the

15:25

UK 75 rationing program. I

15:30

think they answered the big question here. I mean, they

15:32

could look at other health outcomes besides

15:35

ones related to chronic disease.

15:37

For example, rates of ADHD might

15:40

be different in Cohort who

15:42

are exposed to sugar rich diets

15:45

because of how sugar affects

15:47

the way that we think and behave. Maybe

15:49

you would see higher rates of ADHD in adulthood

15:52

among people who are exposed to these

15:54

sugar rich diets when they are kids.

15:57

It makes me think of whether or not you could use

15:59

the exact same framework that they looked at

16:01

to measure spillover 75. So

16:03

for example, do these

16:05

preferences that young kids develop

16:08

affect older siblings who weren't

16:10

affected by the rationing. They generate

16:12

these preferences for sugar, does any

16:14

of that spillover into the older

16:17

siblings because 75 example, now there's just more

16:19

sugary food in the house.

16:22

If that happens, then we're actually understating

16:24

the negative effect of sugar by looking

16:27

at the estimates from their study. The

16:29

other thing is, is there something inter

16:31

generational going on here? Are

16:33

those adults who are exposed to

16:36

high sugar diets who now

16:38

in their fifties and sixties intake

16:40

more sugar, what happens to their

16:42

kids? So you could totally imagine

16:45

that UK policy in nineteen

16:47

fifty three might have long term

16:49

effects, but there's at least three other

16:51

ways that you could look at very similar sorts

16:54

of issues in more modern

16:56

day. A

16:58

lot of schools have vending machines but

17:00

some schools don't. So you could imagine

17:02

looking at variation across schools

17:05

and access to vending machines. Or

17:07

even taking photographs of the vending machines to

17:10

figure out what is the nutritional content of

17:12

the things in those machines to look

17:14

at how well that correlates with child

17:16

health outcomes. And you could look at

17:18

schools that introduce policies to

17:20

allow vending machines versus schools that

17:23

in the same period of time in the same area do

17:25

not. You could look at kids that

17:27

are exposed to taxes

17:30

on sugary beverages versus not and then

17:32

look at the long term effects of that

17:34

exposure to attacks

17:36

which reduces your likelihood of using

17:38

a sugary beverage perhaps The

17:40

last idea I had is imagine

17:43

you had data on families in

17:45

which one child was newly diagnosed

17:48

with a type one diabetes.

17:50

It's plausible to think that

17:52

if a family has a child that's diagnosed

17:55

with type one diabetes, that

17:57

they would then have less sugary

17:59

foods in the household. Right?

18:02

Let's say, these are families with three kids.

18:04

The middle kid has diabetes. The

18:06

oldest kid is exposed to a sugar rich

18:09

environment, then the middle

18:11

kid is diagnosed with diabetes, the

18:13

youngest kid then grows up in an environment

18:15

where there are perhaps less sugary

18:18

foods in the house. The prediction

18:20

would be that there would be a gradient

18:23

in sugar related health outcomes between

18:25

the first child and the third

18:27

child in families where

18:29

there is a middle child with type one diabetes,

18:32

and you would see no such gradient in

18:34

families in which the middle child does

18:37

not have type one diabetes. I

18:42

literally just came up with that. You're gonna give me, like, some credit

18:45

for that or no? No. I get no. I I give you credit.

18:47

Of

18:47

course. Okay. Thank you. Something 75.

18:49

But it makes me think that you can use that

18:51

with any food sensitivity

18:53

or allergy.

18:54

Oh, yes. Yes. Yes. Yes. Yes. So

18:56

child has a gluten intolerance. How

18:59

does that affect the diet that everyone else in

19:01

the house or the other sibling or let's say

19:03

there's a nut

19:04

allergy? I think you should do some

19:06

kind of study involving these

19:09

approaches.

19:12

So what about the study called

19:14

the Suite life that kicked off this conversation.

19:17

Let's say you're somebody who works in the

19:19

nutrition field and you're

19:21

looking at this study. What are

19:24

you going to think to yourself as far

19:26

as making guidelines or

19:28

how people should be forming

19:31

their

19:31

diets. I think the specific information

19:33

of this study may not move the needle

19:36

in terms of our cumulative knowledge

19:38

in an understanding about the impact of

19:40

sugar. But to me, that's

19:42

totally fine. To be honest, the

19:44

field of nutritional epidemiology It's

19:47

almost like a nutritional wasteland. You

19:49

can't really infer anything from these studies

19:52

because they aren't causal at all.

19:54

But they're always in the news and journals

19:57

love to publish them. What I really

19:59

loved about this study was that

20:01

it introduces this way of economic

20:03

thinking of using natural experiments

20:06

to study the effect of a nutritional behavior

20:09

on outcomes. And it allows

20:11

us to study the effect not just in the short

20:13

term, but also longer term.

20:15

So that's where I see the value of this particular

20:18

paper. And

20:20

I'll just add this. You may have heard

20:22

about another recent paper that linked

20:25

the popular sugar substitute erythritol,

20:27

to increase risk of cardiovascular events,

20:30

like heart attack and stroke. I

20:33

know I did because it was all over

20:35

the news. That research took a

20:37

lot of different approaches, including analyzing

20:39

animal data and clotting

20:41

in blood samples. It also

20:44

looked at rates of cardiovascular problems

20:46

in actual human beings. And

20:48

while they did account for a handful of

20:50

factors, that predict cardiovascular risk,

20:54

the research didn't ultimately fully

20:56

account for the fact that people who consume

20:59

products with sugar substitutes are

21:02

different from people who don't. Their

21:04

diets, exercise habits, incomes,

21:07

and a lot of other factors likely

21:09

vary. If you fail to consider

21:11

those factors, you may get an unreliable

21:13

answer about whether sugar substitutes

21:16

are helpful or 75. Because

21:19

when the right methods are applied, these

21:21

types of relationships can easily

21:24

reverse. Anyway, that's

21:26

it for today's show. I want to thank my

21:28

producer, Julie 75, for joining

21:30

me. And thanks to you, of course,

21:32

for listening. Does this new research

21:34

make you wanna change your sugar consumption?

21:38

How closely do you follow nutrition

21:40

studies in the news? Send

21:42

us an email at bafu at 75 dot

21:44

com. That's BAPU

21:46

at freakonomix dot com. Coming

21:49

up next week on the show, nobody

21:51

wants to be in the hospital. If

21:54

you find yourself there though, could

21:56

the slightest change a sunier room

21:58

perhaps or a softer pillow,

22:01

make you feel better, find out

22:03

what the research says and how

22:05

we might reframe the way we think

22:07

about these amenities. That's next

22:09

week on FreakonomicsMD.

22:12

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