Hektoen International

A Journal of Medical Humanities

The tempestuous reign of King Sugar: superfood to health hazard

John Turner
Liverpool, United Kingdom


Sugar Loaf and Victorian Sugar Scissors, ‘Nippers’ c.1850.
Islington Education 
Collection, London

“What am I to buy for the sheep-shearing feast? Three pounds of sugar, five pound of currants . . .”
– William Shakespeare, The Winter’s Tale, Act IV Scene iii, 36-49

A scarce, expensive luxury sweetener for two thousand years, “honey powder” and “sugar loaf” became available, affordable, enticingly habituating, and for some, addictive.1 King Sugar has reigned for four centuries as a mover and shaker of turbulent socio-economic change. The seventeenth century surge in sugar cane production sprang from proliferating plantations, thriving in the amenable climate of the British and French West Indies. Advances in European machine technology fueled the burgeoning agricultural phenomenon. Droves of eager merchants jostled for a slice of The Sugar Islands’ new high-risk, high reward trade. Caribbean exports leapfrogged those of Brazil, by 1750 surpassing grain as the most valuable crop in the world.2 But White Gold’s superfood status, ever present on the world’s dining tables, is under threat, implicated as a prime suspect in the gathering twenty-first century obesity epidemic.3

“Plantations are subject to abundance of ill accidents, especially Sugar workes, because they have so many Machines.”
– Sir Thomas Lynch, Governor of Jamaica 1672

Lucrative, labor intensive, and accident-prone, Caribbean plantations utilized windmills, watermills, cattle, and horses to power their new machinery. Slashing cane twenty feet high with machetes, feeding crushers, and ladling boiling sugar resulted in lost limbs and horrific burns. Thomas Tryon, a merchant, slave abolitionist, and vegetarian activist visiting Barbados observed:4

“If a Mill-feeder be catch’d by the finger, his whole body is drawn in, and squees’d to pieces, If a Boyler gets any part into the scalding Sugar, it sticks like Glew, or Birdlime, and ’tis hard to save either Limb or Life.”

The Caribbean climate, so favorable for growing cane, proved less congenial for the health of its new inhabitants. Yellow fever, malaria, typhoid, cholera, and typhus, incapacitated or decimated plantation overseers, workers, and the crews of the merchant ships carrying hogsheads of raw sugar and molasses to European and American ports.5 Colloquial “Kill-devil” fermented from sugar or surplus molasses metamorphosed into the international rum trade, exponentially lifting merchant profits and government revenue duties.6

The Historic St Nicholas Abbey Sugar Plantation, Barbados, West Indies. 

Barbados, uninhabited before the arrival of British settlers in the 1620s, became a model for future sugar plantations with indentured servants and prisoners transported from England providing early manpower.7 A four- to seven-year contract guaranteed food, shelter, clothing, and limited legal rights. Seven thousand Irishmen labored in the plantations, transported from Cromwell’s transient Protectorate after his overthrow of the English monarchy. Eight hundred English West Countrymen were “Barbadosed” as an alternative sentence to hanging, by fearsome Judge Jeffreys at the Bloody Assizes following Monmouth’s 1685 rebellion.8 Barbados acquired the largest white population of any of the English colonies, becoming a springboard for colonization in the Carolinas and elsewhere in the Americas.9 Within twenty years the booming Sugar Revolution transformed the island into a wealth-generating export colony.10 As labor grew scarce and more expensive, Dutch, Portuguese, and English merchants turned to West Africa for an alternative, more brutal source of manpower. By the early nineteenth century 350,000 slaves had been manacled, shipped, and sold.11 King George’s sugar duties provided one of many sparks to ignite the American Revolutionary War. Sacks of Caribbean sugar might have sweetened the Tea Party in Boston Harbor. A 40,000 strong French army, sent to crush the slave rebellion in sugar island St. Domingue [modern Haiti], sustained several thousand deaths from yellow fever, paralyzing military operations. An extraordinary outcome was Napoleon’s $15,000,000 sale of Louisiana to Jefferson’s young American republic, the “biggest real estate deal” the world had yet seen.12

Henry Tate’s refineries in Liverpool (1872) and London Thames (1878) manufactured the recently invented sugar lump, later “Mr. Cube,” more convenient and safer than traditional finger trapping “nippers” used on sugar loaves. Abram Lyle’s London Plaistow Wharf factory produced Golden Syrup, an overnight consumer hit. Tate and Lyle’s merger would dominate the global sugar industry. Cane production continues to have a dismal record of health and safety. The 2008 explosion at the Imperial Sugar refinery in Georgia killed fourteen workers with thirty-eight sustaining blast and burn injuries.13 Three operatives died in 2016 after falling into vats of boiling sugar at a Nicaraguan refinery. Long hours and strenuous work in intense heat and humidity causes heat stress and dehydration. Misuse of insecticides and agrochemicals may contribute to excess deaths from renal failure.14 Machetes wielded by exhausted cane cutters result in slash injuries, some with amputations of hands or arms. Crush injuries from entanglement with unguarded machinery are common.15

The historic specter of enslaved labor continues to haunt the industry. Modern slavery comes in many forms. Tate and Lyle, responding to legislation adopted a new anti-slavery policy in 2017 that committed to eliminating such practices within its supply chain.16 Exploitative child labor in Brazil, the world’s biggest producer of sugar cane, has declined but not disappeared. Giant multinational corporations are implicated indirectly when small farmer “outgrowers” hire children as part of the labor force. Transient seasonal workers burdened by debts and loans are vulnerable, often working with inadequate safety equipment and lax health regulations.

Black Tot Day – Royal Navy annual celebration of the daily rum ration
‘grog’ served from 1655 to 1971.
The National Museum Royal Navy, 
Portsmouth, UK.

The World Health Organization warns of an obesity epidemic of enormous proportions in Western societies headed by the USA and Mexico.17 The UK has the unflattering title of the fattest nation in Western Europe. WHO predicts 74% of UK men will be overweight by 2030 with 10% classified as morbidly obese, carrying stark health implications. The fivefold increase in Type 2 diabetes is associated with rising rates of blindness from retinopathy, renal failure, amputations, and premature cardiac and stroke deaths. Demand for hip and knee joint replacement has more than doubled, while sugar-related childhood tooth decay is at record levels.18 Soaring health costs have propelled sugar, a major source of unnecessary calories, up the international public health policy agenda.

Lifestyle policies are contentious and may conflict with autonomy of personal choice, requiring astute handling and the defusing of accusations of nanny state paternalism.19 Sugar taxes have appeal but encounter consumer resistance, political prevarication, and opposition from powerful commercial interests. Low nutrition high sugar drinks, often caffeine laced for added habituation, are seductively presented as sport drinks and energy boosts. Lucozade, born “Glucozade,” successfully positioned as a “pick me up” health drink and sold in pharmacies, contained a massive 54g of sugar per 300mls until halved in response to the 2017 UK sugar tax.20 Medically endorsed as effective in genuine diabetic hypoglycemia, its “energy beats everything” advertising is less impressive when promoted for non-diabetics as a glucose fix, for fatigue or dizziness subliminally misrepresented as “hypos.” Anti-smoking campaign successes in many Western countries are encouraging but sugar poses different challenges. The French sugar drinks levy of €0.72 per liter in 2012 cut annual soft drink consumption by 3.5 liters per person [European Union Commission 2016]. Further measures banned food outlets from selling reduced price sugar drinks and controversially eliminated traditional free self-service soda fountains from family restaurants. Sugar drink sales in Mexico fell by 5.5% in the first year of a sugar tax and 9.7 % by year two. Hungary, the most obese country in Eastern Europe, imposed levies on sugar drinks, energy drinks, fruit preserves, and other sweetened products in 2011, cutting sugar consumption by the fastest recorded rate of any country.21

A 330ml can of regular cola contains 35g of sugar, double the WHO daily recommendation. Yet Coca-Cola UK insisted, “We don’t believe sugar tax is the right thing . . . the facts don’t suggest sugar tax changes behavior.”22 The British Soft Drinks Association claimed, “No evidence such taxes reduces obesity.” Despite protestations, some manufacturers, alert to the political winds of change, have reduced sugar content ahead of impending legislation.

U.S. government forecasts predict world sugar production will reach 185 million tons in 2017/18 (Reuters). The European Union applied stringent agricultural trade policies to curb sugar cane imports and stimulate European sugar beet farming. Beet production has an infinitely better safety profile than cane.

Sugar Cane Producers

Sugar Beet Producers

                         (Million metric tons, 2016)





European Union [28 countries]






Russian Fed.
























Egypt, Arab Rep.














Source: International Sugar Organization Yearbook (2016)

King Sugar’s gloriously inglorious reign is encountering turbulence. Western obesity has become endemic and rocketing health costs are stimulating anti-sugar measures, drawing on behavioral economics to nudge, shape, and re-educate consumer behavior.23 Global sugar consumption is at record levels but taxes—actual, pending, or threatened—are beginning to bite as the rising power of a vociferous health lobby collides with commercial mammon.



  1. Oldie Redon, Francoise Sabban, Silvano Serventi, The Medieval Kitchen: Recipes from France and Italy (Chicago: University of Chicago Press, 1998), 1-9.
  2. Niall Ferguson, “Sugar Rush” in Empire: How Britain made the Modern World (London and New York, Allen Lane), 12-14.
  3. OECD (2010), “Introduction: Obesity and the Economics of Prevention”, in Obesity and the Economics of Prevention: Fit not Fat, OECD Publishing, Paris, https://doi.org/10.1787/97892640865.
  4. Thomas Tryon, (1634-1703), cited in Tristram Stuart, The Bloodless Revolution (London and New York: Harper Collins 2007). 48.
  5. P.K Crimmin, The Sick and Hurt Board: Health of Seaman 1700-1806; Journal of Maritime Research, 1999, 10.1080/21533369.
  6. Rum Heritage, www.stnicholasabbeyrum.com.
  7. Aubrey Gwynn, “Indentured Servants and Negro Slaves in Barbados (1642-1650),” Studies: An Irish   Quarterly Review 19, no. 74 (1930): 279-94. http://www.jstor.org/stable/30094620.
  8. Linda Colley, ‘Looking beyond the Atlantic’ in Captives; Britain, Empire and the World, 1600-1850 (New York and Toronto, Anchor, 2004) p.143.
  9. Richard Dunn, Sugar and Slaves: the Rise of the Planter Class in the English West Indies 1624-1713 (Chapel Hill: University of N. Carolina Press, 2000).
  10. David Eltis, “New Estimates of Exports from Barbados and Jamaica”, 1665-1701, The William and Mary Quarterly Vol. 52, No. 4 (Oct., 1995), pp. 631-648.
  11. The Trade Triangle, International Slavery Museum Liverpool (2018)
  12. Gordon Wood, “The Jeffersonian West” in Empire of Liberty: the Early Republic, (Oxford: Oxford University Press, 2009), 298
  13. U.S. Chemical Hazard and Safety Investigation Board Report 2008.05-1GA (2009)
  14. Julia Wijkstrom et al., “Clinical Findings and Progression Rate in Mesoamerican Nephropathy.” American Journal of Kidney Diseases, Vol. 69, Issue 5, 626 – 636.
  15. International Program for Hazardous Child Labour in Agriculture / Sugar Cane;www.ilo.org/childlabour.
  16. The Modern Slavery Act 2015; www.legislation.gov.uk/ukpga/2015/30/contents/enacted
  17. WHO National Comparisons on Obesity report, (2015)
  18. www.ukgovernment/child-oral-health, 2017.
  19. Richard Thaler and Cass Sunstein, “Libertarian Paternalism” The American Economic Review, Vol. 93, No. 2, (2003).
  20. Sarah Alicea and Ruth Poole, “Life after Lucozade,” Practical Diabetes vol. 35.2, March/April 2018
  21. Review of total & added sugar intakes and dietary sources in Europe, Nutrition Jl., Jan 21,2017
  22. https://www.theguardian.com › Business › Coca-Cola; 17 Mar 2016
  23. Nudge, nudge! How the sugar tax will help British diets; Financial Times, 18 March 2016



JOHN TURNER, MBBS, MA, FRCP trained and held posts at St. Mary’s Hospital Paddington [Imperial College London], St. Vincent’s University Hospital in Dublin, Ireland, the Radcliffe Infirmary Oxford, and Nuffield Department of Medicine University of Oxford. He holds a Master’s in History from the University of Chester UK and is currently a member of the Voices of Medicine Team at the Royal College of Physicians, London. He practiced as a Consultant Physician at Aintree University Hospital in Liverpool from 1977-2017 and is Honorary Lecturer in the School of Medicine University of Liverpool.


Summer 2018  |  Sections  |  Food

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