BNF looks at years 7 and 8 of the National Diet and Nutrition Survey (NDNS) Rolling Programme (2014/ /2016)

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1 BNF looks at years 7 and 8 of the National Diet and Nutrition Survey (NDNS) Rolling Programme (2014/ /2016) Contents 1 Introduction NDNS findings on intake compared to nutrient-based recommendations Vitamins and minerals intake Vitamins and minerals status (biochemical indices of nutritional status) NDNS findings on current diets in relation to food-based guidelines Conclusion Introduction The National Diet and Nutrition Survey (NDNS) is designed to assess the dietary habits and nutritional status of the general adult and child population in the UK. The NDNS is conducted continuously as part of a Rolling Programme. Reports are currently available for Years 1&2 ( ), Years 1-3 ( ), Years 1-4 ( ), Years 5&6 ( ) and, most recently, Public Health England has published the combined results from Years 7&8 (2014/ ) 1. This report provides an update on results from Years 5&6 published in In the report, results for food/drink consumption, nutrient intake and nutritional status are presented for six age groups: 1½-3 years; 4 to 10 years; 11 to 18 years; years; years and 75 years and over, split by sex in all except the youngest age group. Certain population groups are excluded from the survey, for example pregnant or breastfeeding women, and older people in residential care. Fieldwork was carried out between , with an overall response rate of 53%. The analyses of food consumption and nutrient intake are based on 2723 individuals (1417 adults and 1306 children; see table below for breakdown by age group). The blood sample analyses are based on 704 adults and 329 children. Age group Number of participants years years years years years years and over

2 The report also looks at dietary intake in relation to government recommendations, and statistically compares current intake (Years 7&8) to past intake (Years 1&2). Dietary intake in the UK - what s new? AOAC fibre and free sugars For the first time, intakes of free sugars and AOAC fibre are presented and compared with the recommendations. Previously, the NDNS measured sugars intake as non-milk extrinsic sugars (NMES) and fibre intake as non-starch polysaccharides (NSP). However, following the 2015 SACN Carbohydrates and Health report 2, government recommendations for free sugars and AOAC fibre were set, and these definitions were used for the analysis. Definition of free sugars The definition of free sugars as described by SACN includes all monosaccharides and disaccharides added to foods by the manufacturer, cook or consumer, plus sugars naturally present in honey, syrups and unsweetened fruit juices. The definition of free sugars used in the NDNS Rolling Programme also includes fruit purees and pastes and vegetables in pureed and juice form. Under this definition, lactose (milk sugar) when naturally present in milk and milk products and sugars contained within the cellular structure of foods (particularly fruits and vegetables) are excluded. New age category The latest report of the NDNS has split the results for food consumption and nutrient intakes for older people over 65 years into two categories (65-74 years and 75 years and over) in order to examine these groups more closely. Overall findings The report does not identify any new nutritional problems in the general population, but suggests that the UK population continues to consume: Too much Too little Free sugars Saturated fat Salt in 2016, estimated salt intake data (based on 24-hour urinary sodium excretion) were published for adults aged years in England for This suggested that average estimated salt intake for adults was 8.0 g/day (9.1 g/day for men and 6.8 g/day for women). Fruit and vegetables Fibre Oily fish Calcium, iodine, iron, potassium and zinc in girls aged years Iron in women aged years and potassium in all adult women 2 es_and_health.pdf

3 2. NDNS findings on intake compared to nutrient-based recommendations 2.1 Free sugars For the first time, the NDNS presents intakes of free sugars for all paired years (Years 1&2, 3&4, 5&6, 7&8) of the Rolling Programme. In Years 7&8, mean intakes of free sugars were more than double the recommended maximum of 5% total energy in all age groups. Reduction in free sugars intake is a key target in the government s Childhood Obesity: A Plan for Action 3. Many foods and drinks that contain high amounts of free sugars can be high in energy and may have few other nutrients. Having these foods or drinks too often can mean more calories are consumed than needed, which can lead to weight gain and obesity, and obesity is one of the most significant current health concerns in the UK. The amount and frequency of foods and drinks with free sugars we consume can also increase risk of dental decay. Table 1: Free sugars intake (% of total energy) in all age groups for all paired years of the NDNS Rolling Programme Years 1&2 Years 3&4 Years 5&6 Years 7&8 (2008/09 - (2010/11 - (2012/13 - (2014/ /10) 2011/12) 2013/14) 2015/16) Children years Children 4-10 years * ** Children years ** Adults years * Men years * Women years Adults years Men years * Women years Adults 75 years and over Men 75 years and over [11.5] 12.5 Women 75 years and over * *p<0.05 and **p<0.01 [ ] data and bases for a variable with a cell size between are presented in square brackets Mean intakes of free sugars in children (both 4-10 years and years) and adult men aged years were significantly lower in the current survey compared with Years 1&2. In children, the reduction in free sugars intakes is thought in part to be due to a decrease in consumption of sugarssweetened beverages, which is significantly lower in children aged 4-10 years in the current survey compared to Years 1&2 (83 g/day vs. 130 g/day). 3

4 2.2.1 Contribution of foods to free sugars intake Table 2: Percentage contribution to average daily free sugars intake by highest 5 food contributors in current NDNS (Years 7&8) vs contribution in Years 1&2 Years 1&2 Years 7& y Fruit juice Yogurt, fromage frais and other dairy desserts Sugars, including table sugar, preserves and sweet spreads 7 9 Buns, cakes, pastries and fruit pies 6 8 Soft drinks, not low calorie y Fruit juice Soft drinks, not low calorie Buns, cakes, pastries and fruit pies Sugars, including table sugar, preserves and sweet spreads 7 9 Biscuits y Soft drinks, not low calorie Fruit juice Sugars, including table sugar, preserves and sweet spreads 7 10 Chocolate confectionery 8 7 Biscuits y Sugars, including table sugar, preserves and sweet spreads Soft drinks, not low calorie Biscuits 5 7 Beer, lager, cider and perry 8 7 Buns, cakes, pastries and fruit pies y Sugars, including table sugar, preserves and sweet spreads Buns, cakes, pastries and fruit pies Biscuits 6 7 Fruit juice 7 7 Soft drinks, not low calorie y+ Sugars, including table sugar, preserves and sweet spreads Buns, cakes, pastries and fruit pies Biscuits 6 8 Fruit juice 8 6 Puddings 6 5 The government s Childhood Obesity: A Plan for Action tasks industry to cut the amount of sugar in food and drinks, working towards a 20% reduction in the sugar content of products popular with

5 children (such as breakfast cereals, yogurts, biscuits, cakes, confectionery, pastries, puddings, ice cream and sweet spreads). In addition, a new levy on sugar-containing soft drinks (often referred to as the sugar tax ) will be introduced in April Sugars-sweetened soft drinks. SACN recommended that the consumption of sugars-sweetened beverages should be minimised in children and adults. There is evidence in the NDNS report that consumption of sugars-sweetened soft drinks has reduced in children and adolescents. Mean consumption was significantly lower in all age groups except for children aged years and older adults aged 65 years and over in Years 7&8 compared with Years 1&2. The decreased intake perhaps reflects an increased availability of low calorie drinks and increased consumption of water, although in other ages the decrease in daily consumption was not significant. Table 3: Average daily intake of sugars-sweetened beverages (current NDNS Years 7&8 vs. Years 1&2) Soft drinks, not low calorie or sugars-sweetened Mean Consumption g/d beverages Years 1&2 Years 7& y y ** y ** y ** y y and over ** p< Dietary fibre The recommendation for fibre intake for those aged 2 years and over is now defined using the AOAC method of analysis. The latest report of the NDNS Rolling Programme has, for the first time, reported fibre intake using this method for all paired years. Mean intakes of fibre remain well below the recommended amounts in all age groups. Fibre intake in children in particular appears to be falling. The SACN report Carbohydrates and Health suggests that high intake of total dietary fibre is associated with a lower risk of heart disease, stroke, type 2 diabetes and bowel cancer, and confers benefit on digestive health. Government guidelines recommend for adults (over 16 years) that fibre intake should increase to 30 g AOAC fibre a day. For children recommendations are as follows: 2-5 year-olds: need about 15 g of fibre a day 5-11 year-olds: need about 20 g year-olds: need about 25 g

6 Table 4: AOAC fibre intake (g/day) in all age groups for all paired years of the NDNS Rolling Programme Years 1&2 Years 3&4 Years 5&6 Years 7&8 Years 7&8 % achieving recommended 30 g/d (2008/ /10) (2010/ /12) (2012/ /14) (2014/ /16) Children years Children 4-10 years * 14.0** 10 Children years * 4 Adults years Men years Women years Adults years Men years * 19.5* 9 Women years * Adults 75 years and over Men 75 years and over [17.5] Women 75 years and over *p<0.05 and **p<0.01 [ ] data and bases for a variable with a cell size between are presented in square brackets Table 5: Percentage contribution to average AOAC fibre intake by highest 5 food contributors in current NDNS (Years 7&8) vs contribution in Years 1&2 Years 1&2 Years 7& y Fruit Vegetables (not raw) including vegetable dishes High-fibre breakfast cereals 8 8 White bread 8 8 Wholemeal bread y Fruit Vegetables (not raw) including vegetable dishes White bread 9 9 Pasta, rice, pizza and other miscellaneous cereals 8 8 High-fibre breakfast cereals y Vegetables (not raw) including vegetable dishes Pasta, rice, pizza and other miscellaneous cereals White bread Chips, fried and roast potatoes and potato products Fruit 5 6

7 19-64 y Vegetables (not raw) including vegetable dishes Pasta, rice, pizza and other miscellaneous cereals 8 9 White bread 9 8 Fruit 8 8 Chips, fried and roast potatoes and potato products y Vegetables (not raw) including vegetable dishes Fruit High-fibre breakfast cereals 6 9 Wholemeal bread 7 8 White bread y+ Vegetables (not raw) including vegetable dishes Fruit 10 9 Wholemeal bread 8 9 White bread 8 8 High-fibre breakfast cereals Saturated fat UK health guidelines recommend that, on average, we need to reduce our saturated fat intake. Eating a diet that is high in saturated fat can raise the level of cholesterol in the blood. Having high cholesterol increases the risk of heart disease. Wherever possible we should replace saturated fats with small amounts of monounsaturated and polyunsaturated fats. Population average intake of saturated fat should be no more than 11% of food energy for those aged 5 years and over. SACN is currently reviewing the evidence for saturated fat and health and its report is expected to be published later in Table 6: Average daily intake of saturated fat as % food energy (current NDNS Years 7&8 vs. Years 1&2) % of food energy Years 1&2 Years 7& y * y y y y and over *p<0.05 There has been a significant reduction in the saturated fat intake in older adult men aged years, men aged years and boys aged 4-10 years in Years 7&8 from Years 1&2, but a clear downward trend over time in these age groups was not suggested by the data. There was no reduction in other age groups, and all groups exceed the saturated fat intake recommendations.

8 3 Vitamins and minerals intake In this section we look at the percentage intake of vitamins and minerals below the Lower Reference Nutrient Intake (LRNI) as reported in the latest NDNS data. Nutrient The LRNI is the amount of a nutrient that is enough for only a small number of people in a group who have low requirements (2.5%). Intakes below the LRNI are considered inadequate for most individuals. The percentage of population with intake of vitamins and minerals below the LRNI is, therefore, an indicator of inadequate intake. Table 7: Proportion of males and females of different age groups in the UK with intakes of micronutrients below the lower reference nutrient intake (LRNI)* Age groups y 4-10 y y 19 to 64 y y 75 y+ All Boys Girls Boys Girls Men Women Men Women Men Women Calcium (food sources only) Folate (incl ** folic acid supplements) Iodine (food sources only) Iron (food sources only) Potassium (food sources only) Zinc (food sources only) *Intakes below the LRNI are inadequate for most individuals. **7% of women aged y (defined by NDNS as 'childbearing age') were reported to have intakes below LRNI As demonstrated by previous NDNS data, there appears to be low intakes of certain vitamins and minerals, in particular amongst adolescent females. For example, around 1 in 5 of year-old girls have inadequate calcium intake at a life stage where calcium is particularly vital because of rapid bone growth. Whilst there is evidence of intakes below the LRNI in a substantial proportion of older children and adults for some minerals, particularly potassium, iron, zinc and iodine, it should be noted that the DRVs for these minerals are based on limited data. Caution should be used when assessing adequacy of intake using the LRNI for these minerals as the health implications of this are unclear.

9 3.1 Vitamin D The SACN report Vitamin D and Health 4 was published around the end of the data collection in Year 8 (2015/2016) of the NDNS, so the impact of the new recommendation for all those over the age of 1 year to consume 10 µg of vitamin D a day will not be seen yet. There is no LRNI set for vitamin D. The table below shows the intake of vitamin D per day (from food sources only and from food sources plus supplements), in micrograms (µg) and as a percentage of recommended intake (10 µg) in all age groups. Table 8: Average daily intake of vitamin D (µg) and % RNI From food sources only From food sources plus supplements Intake % RNI Intake % RNI y y y y y y and over Lower intake from food sources only reflects the fact that only a small number of foods are a source of vitamin D (either naturally occurring or fortified). As it might be difficult to get enough from foods alone, everyone should consider taking a daily supplement containing 10 µg of vitamin D, particularly in the winter months (October to March) when we cannot obtain sufficient vitamin D from sunlight when outdoors. 4 Vitamins and minerals status (biochemical indices of nutritional status) Analysis of participant blood/urine samples provides information of micronutrient status to give an estimate of the proportion of the population at greater risk of deficiency due to depleted body stores or tissue concentrations. 4.1 Iron deficiency anaemia Based on the WHO thresholds of haemoglobin and serum ferritin concentrations used to define iron deficiency and anaemia, the prevalence of iron deficiency anaemia was 9% for girls aged years. 4.2 Iodine Lack of dietary iodine can lead to goitre (enlargement of the thyroid), hypothyroidism and impairment of mental health including retardation in infants and children. Despite indication that 4 nd_health_report.pdf

10 iodine intake may be low in certain groups such as teenage girls and adult women 5,6, analyses of urinary iodine concentrations showed that all age and sex groups met the WHO criteria for adequate iodine intake (median urinary iodine concentration within the range μg/l and fewer than 20% of samples below 50 μg/l). 4.3 Vitamin D Low vitamin D status (as indicated by low plasma 25-hydroxy vitamin D concentrations in blood) was present in all age groups. It will be interesting in future reports to see the impact of the new government supplement recommendations. Table 9: Biochemical Indices of vitamin D status, percentages below established threshold by age and sex % low vitamin D status (concentration below 25nmol/L) 4-10 y All y All 26 Boys 15 Girls y All 17 Men 19 Women y and over All 13 Men 11 Women 15 5 NDNS findings on current diets in relation to food-based guidelines 5.1 Fruit and vegetables The recommendation to eat at least 5 portions per day (equivalent to 400 g) is well recognised. This is based on advice from the World Health Organization, which recommends eating a minimum of 400 g of fruit and vegetables a day to lower the risk of serious health problems, such as heart disease, stroke and some cancers. However, on average, we are currently not meeting the recommendation for 5 A DAY. Intake in adolescents still remains low, with the average number of portions consumed 2.7 per day. Less than 8% of the individuals in this age group in the survey eat 5 or more portions a day. Table 10: Average daily intake of fruit and vegetables (current NDNS Years 7&8 vs. Years 1&2) No. of portions/d (average) % meeting recommendation Years 7&8 Years 1&2 Years 7&8 Years 1& y y years years and over In Years 7&8, the proportion of adults aged 65 years and over meeting 5 A DAY is significantly lower (26%) compared with Years 1&2 (36%). 5 Vanderpump et al. (2011) Iodine status of UK schoolgirls: a cross-sectional survey. The Lancet 377 (9782): Vanderpump (2014) Thyroid and iodine nutritional status: a UK perspective. Clinical Medicine 14(6):s7-s11

11 For younger children, portion sizes are smaller and therefore 400 g is inapplicable. The NDNS though does report mean consumption of fruit and vegetable (g/d) for children. Table 11: Average (range 2.5 th 97.5 th centile) daily intake of fruit and vegetables (g) in children ages 1.5 to 10 years (current NDNS Years 7&8 vs. Years 1&2) Years 7&8 Years 1& y 170 (26-402) 178 (16 386) 4-10 y 193 (27-418) 199 (23 433) Despite evidence of widespread awareness of the 5 A DAY message, there has been a lack of change over time. It is important that we promote fruit and vegetable consumption and understand the barriers to change so that we may facilitate increased intake in all ages. 5.2 Oily fish Oily fish (e.g. salmon, mackerel, sardines, trout) are high in long-chain omega-3 fatty acids, which may help to prevent heart disease, and are a good source of vitamin D. Government recommendations, based on advice from the UK s Scientific Advisory Committee on Nutrition (SACN) 7, are that the general population should consume at least 1 portion of oily fish per week (140 g cooked weight). Mean daily intake of oily fish is shown in the table below. There was no evidence of any change in consumption over time, with average intake still falling well below the recommendation. Table 12: Average daily intake of oily fish (current NDNS Years 7&8 vs. Years 1&2) Mean daily consumption oily fish g/d Years 7&8 Years 1& y y y y y y and over 10 9 Essential long-chain omega-3 fatty acids and vitamin D are important to include in the diet for health yet consumption of oily fish is particularly uncommon in children, and although higher in adults is still very much below recommendations. Current school food recommendations state that oily fish must be provided once or more every three weeks. 7 Fish_Consumption.pdf

12 5.3 Red and processed meat UK recommendations are for high consumers of red and processed meats (those consuming more than 90 g cooked weight per day) to reduce their intake to not exceed 70 g per day. This is because evidence suggests a diet high in red and processed meat can increase risk of developing bowel cancer. Table 13: Average daily intake of red and processed meat (current NDNS Years 7&8 vs. Years 1&2) Mean Consumption g/d Years 7&8 Years 1& y y 38* y y 62* y y and over *p< 0.01 The World Cancer Research Fund (WCRF) recommends eating no more than 500 g a week or red meat, and eating little if any processed meat, in order to reduce the risk of bowel cancer. There has been a significant reduction in mean red and processed meat intake in children aged 4-10 years, adults aged years and women aged 65 years and over. Mean consumption in men (aged years and years) continues to exceed 70 g. 6. Conclusion Overall, findings suggest that, on average, our intakes of free sugars and saturated fat are above recommendations, and we are not eating enough fruit, vegetables, oily fish and fibre. Now that the Rolling Programme measures free sugars and AOAC fibre intakes, it will be interesting to monitor these going forward to see whether any progress is being made through efforts from industry and government to help the population achieve the dietary recommendations for these, and other, nutrients. In light of concern around the intake of some micronutrients, such as vitamin D, iodine and folate, in particular age groups, data from the NDNS Rolling Programme will continue to be useful as a way of monitoring the UK population s intake and status of these micronutrients, and may be useful when setting new recommendations in government policy in the future.