The sugar reduction environment

Professor Julian G. Mercer

Rowett Institute

June 2014

‘Eating too much sugar is bad for us. ….the steps PHE will take to help families and individuals to reduce their sugar intake and …. initiatives to further reduce sugar consumption. ….meet the Department of Health’s request … to provide … draft recommendations in spring 2015 to inform the government’s thinking on sugar in the diet. We will do this work in the light of the Scientific Advisory Committee on Nutrition’s report on carbohydrates, …published in draft form ….’

Importance of sugar reduction What is PHE doing? – Change 4Life; other activities Next steps – “sugar swaps”; new Change 4Life campaign; 5-a-day refresh Further approaches – supporting people to make healthier, lower sugar choices;

making the available choices healthier, and reducing their sugar content

Possible initiatives: advertising of foods to children, fiscal measures that relate to sugar-sweetened drinks, the role of the food industry, food procurement across the public sector, and education and training; supporting the Department of Health in its work with the food and drink industry (Public Health Responsibility Deal).

2015

Recommendations

• WHO recommends a reduced intake of free sugars

throughout the life-course (strong recommendation).

• In both adults and children, WHO recommends reducing

the intake of free sugars to less than 10% of total energy

intake (strong recommendation).

• WHO suggests a further reduction of the intake of free

sugars to below 5% of total energy intake (conditional

recommendation).

Free sugars include monosaccharides and disaccharides added to foods and beverages by the manufacturer, cook or consumer, and sugars naturally present in honey, syrups, fruit juices and fruit juice concentrates. Not sugars present as lactose when naturally present in milk and milk products, or sugars contained within the cellular structure of foods.

The evidence base

Meta-analysis of RCTs in adults suggests an association between reduction of free sugars intake and reduced body weight. Increased intake of free sugars was associated with an increase in body weight. RCTs in children (recommendations to reduce sugar-sweetened foods and beverages [SSBs]) were characterized by low compliance, with no overall change in body weight. Meta-analysis of prospective cohort studies found that children with the highest intakes of SSBs had a greater likelihood of being overweight or obese. A positive association was found between the level of free sugars intake and dental caries in children - higher rates of dental caries when the level of free sugars intake is more than 10% of total energy intake. Lower levels of caries in national population studies when per capita sugars intake was less than 10 kg/person/year (approx. 5% of total energy intake).

July 2015

The evidence base:

Total carbohydrate intake appears to be neither detrimental nor beneficial to cardio-metabolic health, colo-rectal health and oral health.

The hypothesis that diets higher in total carbohydrate cause weight gain is not supported by the RCT evidence

Higher consumption of sugars and sugars-containing foods and beverages is associated with a greater risk of dental caries.

Greater consumption of SSBs is associated with increased risk of type 2 diabetes mellitus.

Increasing or decreasing the % of total dietary energy as sugars when consuming an ad libitum diet in adults leads to a corresponding increase or decrease in energy intake.

RCTs conducted in children and adolescents indicate that consumption of SSBs, as compared with non-calorically sweetened beverages, results in greater weight gain and increases in body mass index.

The dietary recommendations are proposed in the context of an energy intake which is appropriate to maintain a healthy weight.

The dietary reference value for total carbohydrate should be maintained at an average population intake of c. 50% of total dietary energy.

The definition for ‘free sugars’ should be adopted in the UK. Average population intake of free sugars should not exceed 5% of total dietary energy from 2 years. Free sugars should be replaced by starches, sugars contained within the cellular structure of foods

and by lactose naturally present in milk or milk products for people of healthy BMI. In those who are overweight, the reduction of free sugars could be part of a strategy to decrease

energy intake. The consumption of SSBs should be minimised in children and adults. The dietary reference value for adults for dietary fibre (all carbohydrates that are neither digested

nor absorbed in the small intestine) should be 30g/day – increased from the previous value of about 23-24 g/day.

SACN recommendations

Dietary Goals for Scotland - changing recommendations on intakes of sugar and fibre

July 2015

Evidence suggests that there is inadequate compensation for energy delivered as sugars.

The new recommendation for sugars is designed to minimise risks associated with high free sugars intakes: (i) improving management of energy intake to reduce the risk of obesity, and (ii) improving dental health.

100kcal (418kJ)/person/day reduction in energy intake of the population would address energy imbalance and lead to a moderate degree of weight loss in the majority of individuals (Calorie Reduction Expert Group, 2011).

The new dietary recommendation for sugars, with intake reduced by c. 5% of total dietary energy would achieve an energy intake reduction across the population of approx. 100kcal per day

This is one approach to lowering the energy intake of the population. SACN also acknowledges that there is nothing specific about the effect of

sugars when energy intake is held constant, apart from where dental caries is concerned.

The 5% of total dietary energy intake from free sugars recommendation applies to all age groups from 2 years upwards. Current average intakes are at least twice the new 5% recommendation, and three times the 5% value in 11 to 18-year olds.

The new UK sugars recommendation will be challenging to achieve and is stricter than that recommended in the USA and by the World Health Organisation.

Dietary modelling with everyday foods shows that a diet that provides 5% or less of free sugars, the new target for fibre of 30g/day (in itself a challenging target given current intake levels), and also meets other dietary reference values for nutrients, is possible.

However, it will inevitably result in a dietary pattern that is dissimilar to the diets consumed by many in the UK currently.

The British Nutrition Foundation has developed some example menu plans to illustrate how the new free sugars and fibre recommendations can be met.

The type of diet that emerges is not representative of the average diet eaten in the UK. It would require a substantial change in dietary habits for most people and considerable support and practical advice from multiple stakeholders.

Innovative food solutions from manufactures and retailers may also be needed to help consumers achieve the recommendations.

Is 5% achievable?

October 2015

‘SACN’s recommendations have already been accepted by government. They are now being integrated into official UK advice…’

PHE suggests a programme which will address the following levers: 1. number and type of price promotions in all retail outlets 2. marketing and advertising of high sugar food and drink products 3. provision of a clearer definition for high sugar foods 4. a programme of gradual sugar reduction in everyday food and drink products, combined with reductions in portion size 5. a price increase of a minimum of 10-20% on high sugar products through the use of a tax or levy such as on full sugar soft drinks6. addressing buying standards for food and catering services across the public sector to ensure provision and sale of healthier food and drinks 7. provide accredited training in diet and health for those who influence food choices in the catering, fitness and leisure sectors and within local authorities 8. continue to raise awareness of concerns around sugar levels in the diet

August 2016

Not a tax on all sugar – targets producers and importers of sugary soft drinks - a lever to incentivise industry to move faster and act now.

Producers to pay charge on drinks with more than 5g sugar per 100ml, and higher for more than 8g per 100ml.

This is “added sugar”, meaning that fruit juices and milk drinks will not be involved.

Soft drinks will be targeted as they are a major source of sugar for children and teenagers - one can may contain 35g, more than the recommended daily maximum.

Implementation expected from April 2018. No plans for similar levies on other products, but

hopes that this will act as a catalyst for action on other products.

10.6 6.9 6.6 6.8 5.7 4.6 2.4g/100ml

0 0 0 g sucrose/100ml

Sugar in soft drinks – vs 5g and 8g thresholds

August 2016

Strategies related to the food and drink industry: Introducing a soft drinks industry levy Taking out 20% of sugar in products: • ‘All sectors of the food and drinks industry will be challenged to reduce overall

sugar across a range of products that contribute to children’s sugar intakes by at least 20% by 2020, including a 5% reduction in year one’.

• This can be achieved through reduction of sugar levels in products, reducing portion size or shifting purchasing towards lower sugar alternatives.’

• The 4-year, category-specific targets will be published in March 2017.• PHE will provide an assessment of progress at 18 and 36 months (Sep 2018

and Mar 2020). Government will then assess whether sufficient progress is being made or whether alternative levers need to be used to reduce sugar and calories in food and drink consumed by children.

• ‘If there has not been sufficient progress by 2020 we will use other levers to achieve the same aims’.

Supporting innovation to help businesses to make their products healthier

November 2016

December 2016

18 pages in the 2017 Finance Bill.

March 2017

sets out guidelines for the food industry on how to achieve the 20% sugar reduction across the top nine categories of food that provide the majority of sugar in the diets of children up to 18 years

provides average and maximum calorie or portion size guidelines for products provides the baselines against which progress will be monitored is focusing predominantly on reducing the levels of total sugars - total sugars

are declared on the nutrition panel and this is the data that will be used to track progress towards the 20% reduction target

‘For the purposes of this programme, from here onwards ‘free’ sugars will be referred to as added sugars.’

‘This is the first time that such an extensive, structured programme for sugar reduction has been set out in the UK and possibly worldwide.’… ‘there is broad international interest in this programme.’

‘businesses that embrace sugar reduction through innovation for the UK market may reap the benefits by leading the way internationally in product development.’

Fiscal measures – do they work?

• Many countries – including Norway, France, Finland, Hungary and Mexico – have introduced taxes in various forms on soft drinks.

• Evidence suggests that increasing prices of high sugar foods and non-alcoholic drinks, potentially through taxation, may reduce purchases of these products proportionate to the level of the price increase imposed.

• Reviews of the evidence suggest that a tax of 10% to 20% would be necessary to have a significant impact on purchases, consumption and ultimately population health.

• With specific reference to SSBs, reviewers have concluded that reductions in purchasing are proportionate to increases in price.

• A levy aimed at producers and importers, not consumers, has been tried in Hungary, where companies did act to remove unhealthy ingredients.

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