Issue 125 sugar and salt update by NH Publishing Ltd

PUBLIC HEALTH

SUGAR AND SALT UPDATE Carrie Ruxton PhD, Freelance Dietitian, Cupar, Scotland

Dr Carrie Ruxton is a freelance dietitian who writes regularly for academic and media publications. A contributor to TV and radio, Carrie works on a wide range of projects relating to product development, claims, PR and research. Her specialist areas are child nutrition, obesity and functional foods.

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

Since dietary guidelines were first published in the UK, there has been a drive to reduce levels of sugar and salt in foods and beverages. Now, a levy will be introduced from April 2018, applying for the first time a direct tax on the sugar content of soft drinks. This article provides an update on recent activities to lower the sugar and salt content of our diet. Until recently, government action has involved direct messaging to consumers, as well as voluntary targets for industry reformulation, mainly directed at salt. Controls on advertising of so-called ‘high fat salt and sugar’ (HFSS) foods to children have also been implemented. In 2015, the Scientific Advisory Committee on Nutrition (SACN)1 set a new target for free sugars of 5% of daily energy; the previous target being 10% energy. Free sugars include all mono- and disaccharides added during processing or cooking, plus those sugars naturally present in honey and fruit juices. Current intakes are far higher than this at around 11% energy in adults and 13-15% energy in children. Maximum recommended salt levels have not changed since 1994 and are 6g per day for adults, with lower amounts advised for children.2 Current intakes in adults are estimated to be around 8g per day,3 but have reduced by 15% in recent years in part due to reformulation. Table 1 presents current recommendations for salt and free sugars. JUSTIFICATION

The 2015 SACN report1 set out the evidence for supporting a sugars reduction, including links between higher intakes of added/free sugars and a greater risk of dental caries in children, as well as higher energy intakes in adults. Consumption of sugar-sweetened soft drinks was associated with dietary energy, body mass index, risk of weight gain and risk 8

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of Type 2 diabetes. SACN estimated that lowering free sugars to 5% energy would reduce daily energy intake by around 100kcal. The main justification for salt reduction is to prevent cardiovascular mortality and morbidity. In 2003, a report by SACN4 highlighted strong associations between high salt intake and high blood pressure, concluding that a reduction in the average salt intake of the population, from 9.5g to 6g daily would lower blood pressure levels and confer significant public health benefits by reducing the risk of cardiovascular disease. HISTORIC ACTION AND PROGRESS

Action to lower sugar consumption has mainly been targeted via dietary advice (e.g. dietary reference values, Eatwell Plate/Guide), a ban on advertising HFSS foods and drinks during children’s TV programming, and a push for manufacturers to adopt front-ofpack (FOP) labelling which displays the macronutrient content in a standardised colour-coded format. Although progress has been slow, there is a trend towards reduced sugar intakes over the past few decades. For example, in the 2000 National Diet and Nutrition Survey (NDNS), the mean percentage energy from non-milk extrinsic sugars was 13.6% in men and 11.9% in women.5 In the most recent NDNS,6 intakes were 12% in men and 11.3% in women. Children’s intakes have also reduced from around 17% in

Table 1: Recommended maximum intakes Free sugars (g/day)

Salt (g/day)

Under 1 year

Should not be given

Should not be added

1-3 years

No recommendation

4-6 years

7-10 years

11 years and over

19987 to 15% in 2014. Indeed, the NDNS showed a statistically significant reduction in sugars from 14% to 13% in children aged 4-10 years.6 However, further action will be needed to move intakes towards the more challenging 5% energy target set recently. Barriers to sugar reductions include consumer taste preferences and the structural role of sugar in certain products, e.g. biscuits, cakes, breakfast cereals. For salt, government action has been mainly targeted at manufacturers via a series of four voluntary salt reduction targets (from 20062014), which set levels for 80 individual product categories. According to the campaigning group CASH, salt reduction in the UK has been a success, with many food products now 20-40% lower in salt.3 This was confirmed by the Institute of Fiscal Studies which reported a reduction in salt intake of 5.1% between 2005 and 2011.8 Interestingly, the reduction was mainly due to the impact of reformulation, since, during this period, households tended to purchase saltier food products. The out-of-home sector remains an issue, as it was not subject to the voluntary reformulation targets. Salt reformulation appears to have impacted on health as suggested by an analysis of blood pressure and heart disease data from 2003-2011 using the Health Survey for England.9 This revealed significant reductions in mortality from stroke and ischaemic heart disease alongside reductions in blood pressure and salt consumption, although there were also positive changes to smoking prevalence and cholesterol levels. Another strand of government action, targeting both sugar and salt, is the Responsibility Deal which encouraged major players in the industry to make voluntary pledges to lower sugar, salt and calories. However, critics of this policy felt that industry did not go far enough, while the voluntary nature of the policy was

believed to create a non-level playing field. A recent evaluation10 of the Responsibility Deal found only modest progress in the fulfilment of pledges and evidence that the more challenging courses of action, particularly sugar reduction and marketing restrictions, were not being chosen by companies. Progress on FOP labelling has also been patchy as many food businesses have either declined to adopt the traffic light system or have introduced their own colour coding. According to a 2009 evaluation,11 most consumers are aware of the concept of FOP labelling, but find the myriad of different systems confusing, potentially creating a barrier to fuller engagement. NEXT STEPS

Work continues to lower the sugar and salt content of the British diet. Public Health England (PHE) is currently meeting with food business leaders to agree sugar reduction targets over the next three years and to set reasonable maximum portion sizes and calorie caps for food product sectors.12 If successful, this will achieve a 20% reduction in sugar from nine food categories by 2020. The duel focus will support obesity prevention which relates more to daily calories consumed rather than to individual macronutrients. Soft drinks industry levy A soft drinks industry levy (SDIL) will be introduced from April 2018 targeting commercial sweetened beverages and applying, for the first time, a direct tax on the sugar content of soft drinks. The policy is directed at manufacturers rather than consumers or distributors and will charge a levy on drinks with an added sugar content of >5%, with a higher charge applying if drinks contain >8% added sugars. Fruit juices and most milk-based drinks will be exempt.13 The threat of fiscal measures has already resulted in www.NHDmag.com June 2017 - Issue 125

PUBLIC HEALTH

an additional round of reformulations amongst key players. For example, Coca-Cola announced in March this year that Fanta Orange had been reformulated to lower the sugar content from 6.9g to 4.6g per 100ml, which now puts it under the SDIL threshold.14 Turning to salt, PHE this year republished the 2014 salt targets which were due to be implemented by the end of 2017.15 Additional salt targets may be set later in the year, but will be part of PHE’s larger reformulation policy, bringing together sugar, salt and calorie reductions.

CONCLUSION

After several years where progress was minimal, PHE and other bodies, such as Food Standards Scotland, have ramped up activity to encourage food businesses to make meaningful cuts to the sugar, salt and calorie contents of their products. This is expected to impact favourably on consumer health and lower the risk of obesity. The food industry has generally responded favourably to the policies, with a good track record on salt reduction and now has a challenging time ahead to fulfil expectations regarding sugar and calorie reduction.

EXAMPLES OF REFORMULATION • Nestlé announced in March that it would cut the sugar content of its confectionery brands by 10%.16 • 95% of Ferrero products come in portions of less than 150kcal. • In 2015, Cereal Partners launched Less Than 5% Sugar Oat Cheerios with 1.4g of sugar per serving. • In 2015, Quaker launched a Granola range with 30% less sugar and fat than the average product on the market. • Food ingredient manufacturer Macphie reduced the sugar content of its muffin mix by 30% using prebiotic fibre. • Sugar from Coca-Cola drinks products decreased by 18% between 2012 and 2017. • 75% of Pepsi’s estimated retail sales for 2016 were in no-sugar colas. • In 2015, Britvic’s decision to only produce and sell Robinson’s No added Sugar squash removed 6.9 billion calories from the UK soft drinks market. • In 2015, Unilever reformulated the Lipton Ice Tea range using Stevia to reduce sugar levels by 30%.