NHD Extra - June 2017

EXTRA

Additional articles for subscribers only

NHDmag.com

June 2017: Issue 125

FAT AND FIT? ACTIVITY EQUIVALENT LABELLING

NHD-EXTRA: PUBLIC HEALTH

ACTIVITY EQUIVALENT LABELLING VERSUS THE SUGAR TAX Emma Berry Student, University of Aberdeen Emma is currently studying MSc Human Nutrition.

She has an interest in Public Health nutrition and health promotion within the community.

Emma hopes to work within the community setting to improve nutritional wellbeing and health.

For full article references please email info@ networkhealth group.co.uk

In January 2016, the Royal Society of Public Health (RSPH) released a position paper proposing Activity Equivalent Labelling on energy dense foods.1 Although the RSPH believed that this would be a more effective way of conveying the energy value of foods to the general public, there has been limited discussion of this as a public intervention.1,2 The most recent government plan for obesity prevention is the sugar tax due to be implemented in April 2018.3 However, there has been controversy over how the proposed sugar tax may disproportionately affect certain groups of the population and, as a result, could have unintended effects on nutrition.4,5 The tax focuses purely on sugar sweetened beverages rather than energy dense food as a whole. In this article I discuss whether relatable nutritional information - in the form of Activity Equivalent Labelling would be more effective as an obesity prevention tool than the tax on sugar sweetened beverages.

INTENDED EFFECTS

The UK government has proposed the tax of sugar sweetened beverages to specifically target childhood obesity levels and force manufacturers to reformulate their products to reduce the sugar levels.3 Although this is a long-term strategy for reducing the effects and cost of obesity, other countries have already seen an

impact from imposing similar taxes.6 The sugar tax is part of a strategy to change the obesogenic environment and promote individuals to make healthier choices, but as it only focuses on soft drinks, the impact on obesity levels will depend on the price of the tax.7 The aim of Activity Equivalent Labelling would be to make nutritional information more relatable to the wider population.1,2 Although the current traffic light system has shown to improve consumer’s understanding of nutrition labelling, it doesn’t necessarily translate into healthier purchases.8 The simple graphical representation put forward by the RSPH assumes no prior knowledge or education in terms of nutrition and is easy to understand when making quick decisions.1,2 An example of how the Activity Equivalent Labelling could look is demonstrated in Figure 1. These labels would be used alongside standard nutritional labelling to aid quick decisions and remind the public of the importance of physical activity.1

Figure 1: An example of Activity Equivalent Labelling. The time of exercises shown is based on an 80kg individual.9

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NHD-EXTRA: PUBLIC HEALTH POTENTIAL ISSUES

There have been many studies looking into the effects of a tax on sugar sweetened beverages.4-7,10 Despite evidence that there could be an improvement in the consumption of soft drinks - and obesity levels - it does depend on the level of tax that is imposed and the actions of the industry in response to this tax.7,10 There is an underlying issue whereby the taxation is choosing to increase the cost of products - at a time when food prices are already rising at a high rate - with no reduction in cost of the healthier options.11 Even if it is only sugary soft drinks which are currently being taxed, it does bring up the larger issue of food security and individuals having the choice of healthy and nutritious food, rather than picking energy dense foods due to their lower cost.11 If individuals choose to drink a sugary drink for lunch, as it’s a cheaper source of energy than a full meal, then is increasing the price of the drink really helping?

Activity Equivalent Labelling is a less controversial obesity prevention tool in terms of influencing food security. However, there are potential negative side effects of using this form of labelling as a method of communicating energy information.

Firstly, the type of activity which can be used in the labels may have intended consequences.

There are many different sports which could be used as an example of the energy equivalents, therefore, picking only one or two examples will ultimately reduce the relatability of these labels.12 If there are different activities used to convey the information, then comparing different products with different activities could become very confusing for individuals. Therefore, to be effective in terms of simple relatable labelling, there must be careful evaluation to see which sports or activities are the most appropriate and how this should be presented.12 The other issue is that the use of Activity Equivalent Labelling could have an unintended negative impact on the relationship between food and exercise for some individuals, putting individuals with disordered eating at an increased risk.13 Consumers may also view the relatability of the activity equivalent given differently depending on the size, shape 50

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or gender of the depicted individual in the infograph.12 Therefore, these labels could have no effect or an increase in energy intake, depending on the individual perceptions of these labels.

ACCEPTABILITY AND REALISTIC EFFECTS?

Public health interventions are often met with differing responses from the general public. A review by Diepeveen et al14 demonstrated that the acceptability of government interventions depends on the behaviour targeted, the intrusiveness of the intervention and the characteristics of the respondents. Interventions which were less intrusive had more support, with participants preferring indirect interventions which would alter their behaviour slightly as opposed to more intrusive methods such as taxation. Acceptability also varied between gender, age and whether the participants engaged with the unhealthy behaviour. Intrusive interventions were seen to have more support in women and amongst the older participants.

Individuals engaged with unhealthy behaviour were against a more intrusive intervention.

In terms of a sugar tax, as many individuals consume soft drinks, it is likely to be seen to have a strong opposition from the general public, whereas the Activity Equivalent Labelling would be a less intrusive intervention and would likely receive more support from the general public.

Although the taxation does look to have an impact on the consumption of sugar sweetened beverages and the obesity levels from current evidence, the long-term effect will depend on how much tax is added to the beverages.8 It is possible that after the initial increase in price, there may be a reduction in consumption, but after consumers adapt to the new price that consumption will then increase.14 If industry does choose to absorb some of the tax, then the intended effects of increasing the price for consumers may not be seen. Furthermore, the sugar tax also does not include drinks where syrup or sugar is added at the point of sale;3 therefore, some coffee-based drinks could be higher in sugar than a soft drink but escapes the tax. There is also the common practice of individuals bulk-buying to save money, or shopping elsewhere for soft drinks due to price, which could be increased with taxation.15

Table 1: Summaries of the points made regarding the sugar tax and Activity Equivalent Labelling in this article.

Why?

Sugar Tax • Reduce childhood obesity

What is it?

• •

How could it work?

• • •

When is it happening?

Problems?

•

Expected to be introduced in April 2018

•

Doesn’t tackle the larger problems related to obesity such as poor access to healthy foods May not have a long term impact

•

Tax on sugar sweetened beverages Level of tax depends on amount of sugar in beverage Industry reformulation Increased price to consumers Reduced consumption due to price increase

The Activity Equivalent Labelling may be better received initially from the general public, but the effectiveness of this method of labelling will depend entirely on its implementation and evaluation. This method of labelling has the potential to reach individuals of all education backgrounds and alter the relationship between food and exercise.2 The simpler the method of communicating nutritional information through labelling, the more impact it has on food choice.2,12 Although research has shown that individuals are more likely to engage in physical activity from these labels1 and that individuals are more likely to choose healthier foods.2 These effects will only be possible if the label is seen by consumers and studies have shown that use of nutrition labelling depends on the size of the information, how it is presented and where it is on the product.16 Many of the studies which have looked at Activity Equivalent Labelling have demonstrated examples of the short-term effects on both dietary choice and public perceptions.1,2,12 However, the evidence for the effect of these changes is limited to smaller studies with little real-world context.

More research into the effects of Activity Equivalent Labelling is required, both in terms of the initial impact on food choices and the longterm effects on dietary change.

Activity Equivalent Labelling • Reduce obesity • Improve physical activity levels • Pictures of activities and the time taken to burn off calories in the product • Easier to understand information for the public • More awareness of the importance of physical activity • Reducing calorie intake of the population • No plans to introduce currently • • •

Not enough evidence currently Labels need to be relatable and easily understood Labels need to be visible and easily found to be understood

CONCLUSION

Although the tax on sugar sweetened beverages could have a short-term impact on the consumption of sugary soft drinks and obesity levels, the effects may not be seen long term.

The tax is only focusing on a small selection of products which may impact on obesity levels.

The tax is intended to target one main subgroup of the population, but there may be a larger impact of this tax on the wider population.

Using Activity Equivalent Labelling as a form of conveying relatable information on the energy density of foods could result in a population level change in food choices. It has the potential to influence relationships with food and exercise in a wider range of the population, those who may not currently understand the nutrition advice given.

Overall, this could result in a reduced energy intake and an increase in exercise, impacting the current obesity level. Both methods aim to influence consumer choices to lower calorie options, but neither is a successful solution on its own. Table 1 shows a summary of the points made for both interventions. This highlights that both work as part of a toolkit to help challenge the obesity problem, but should undergo continual monitoring and evaluation to determine if there are any unintended consequences. Further research should be considered to see if Activity Equivalent Labelling is appropriate to include as part of policy to tackle obesity. www.NHDmag.com June - Issue 125

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NHD-EXTRA: BOOK REVIEW

BIG FIT GIRL: EMBRACE THE BODY YOU HAVE Review by Charles Cooke Nutritionist Charlie Cooke focuses on teaching simple nutrition science, boxing fitness and nutritious home-cooking knowledge to the general/ low-income public. He is now pursuing a writing, reviewing and media career while serving in the British Army.

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AUTHOR: LOUISE GREEN PUBLISHER: GREYSTONE BOOKS, 2017 ISBN-13: 978-1771642125 PRICE: Paperback £9.83

Plus-size personal trainer Louise Green claims that you can be fat and fit, despite current medical beliefs. In May this year, she appeared on BBC’s This Morning to explain how this is possible. Louise believes that the size of your body does not determine your athletic dreams.

Louise Green, a Canadian overweight personal trainer, is on a mission to support and inspire anyone, but especially overweight women, to do more exercise. Her book is a description of her own experience as a very overweight person facing much challenge and criticism and how she now feels confident and comfortable with her body. Ms Green has a BMI of 35 and claims that she is in ‘perfect health’.

In her recent BBC interview, Louise stated that “last year 34m UK citizens dieted and 99% of them gained the weight back. So, what I’m presenting is a new model: move your body, eat reasonably well and move yourself into a model of success rather than failure.

I just know from 10 years of working with a plus-sized demographic that the UK is spending £2m a year on the diet industry and it’s a model which is failing people. So can we just take the focus off the weight and try to be the healthiest version of yourself?”

I am not one who believes that being ‘plus-sized’ is a rightful vessel for feelings of shame, embarrassment or social isolation; and I don’t want to detract from the great respect that I have for Ms Green in her crusade to promote inclusivity of all women in media and sports. However, I feel that the emotion and the perspectives shared in the pages of her book Big Fit

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Girl - Embrace the Body You Have are too much of Ms Green’s own experiences and opinions, often conflicting with sheer proven fact.

Firstly, there is a persistent and worrying theme of ‘us’ and ‘them’ throughout the text, i.e. that all those (qualified professionals) who don’t support her quest for athleticism while maintaining, in her case, a BMI of 35, are simply controlled by the media and you shouldn’t listen to them. The advice given in this book includes ‘walk out of a doctor’s office if your GP tells you that your BMI is at a high-risk level’. In my view, this is simply a display of unprofessionalism and a lack of respect for experienced and highly qualified doctors.

It is very hard to write this review, as I don’t want to prejudicially portray the idea that those partaking in exercise while holding an above-average or ‘plus-size’ body size are inferior to anyone else within their respective sporting field, but on the other hand, does it not occur to the writer that a lean and muscular physique is often the product of being a high-performing athlete and not the determining factor?

Also, that restrictive dieting doesn’t mean having ‘to be hungry all the time’, but is an effective way to gradually and healthily reduce body fat stores through their use as replacement

Louise Green states that ‘why’ we eat is more important than ‘what’ we eat, that there

is no ‘good’ or ‘bad’ foods, just foods that don’t work for you personally.

energy, to account for the greater demand than is being provided through calorie content of the diet alone.

Louise Green states that ‘why’ we eat is more important than ‘what’ we eat, that there is no ‘good’ or ‘bad’ foods, just foods that don’t work for you personally. She states that she is ‘genetically cursed’ and this can’t be avoided, that she ‘never worries about portion control and eats until satisfied’. She feels that portions should be for meeting ‘energy needs and not calories’, despite the fact that a calorie is a measurement of energy.

The advice given on protein is provided by the United States Department of Agriculture (USDA) and the author does include a list of healthy sources for proteins, fats and carbohydrates, but there is simply insufficient, accurate guidance on how these should be consumed within a healthy

lifestyle. Such information would be useful for health-seeking readers.

There are countless professional athletes who do not possess the perfect physique of a Greek Adonis and I agree that it is a disgrace that our mainstream media don’t do more to support and promote such athletes to the public. But I cannot support the advocacy of maintaining an alarmingly high BMI and still call oneself an ‘athlete’, without performancerelated achievements, most especially when compounded with recommendations in the book that high-risk women should not aim to include weight loss in their health and fitness goals.

It seems that by rejecting the advice of professionals to lose weight, Ms Green has, instead, created her own bubble to counter anyone who doesn’t share her opinion of ‘plussized athleticism’. It is rather worrying that after rejection from all but one publisher, she now has a platform from which to recruit many others to her cause, including that of being a spokesperson for the important and successful ‘This Girl Can’ campaign, run by Sport England.

I wholeheartedly support the increased acceptance of all shapes and sizes of women in sport, in gyms, and in any other quest for health and fitness. However, I do not think it wise to promote the claim of being an athlete while deliberately refusing to take any account of the elevated risk-factors and bodily stresses associated with being obese.

There is no ‘us’ and ‘them’ when it comes to health. We all just want to be healthy, happy and, ultimately, loved - in whatever form that may take. And, though this book may contain great resources for finding plus-sized active wear and a rather snazzy workout playlist, it does not support or respect health and nutrition professional advice, which is based on science and evidence. www.NHDmag.com June - Issue 125

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