Briefing. OBESITY and REFORMULATION. Key Points. Key Actions. Definition

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1 OBESITY and REFORMULATION Briefing July 2016 Key Points Reformulation is a change in the balance and content of ingredients in processed food and drink. To promote a healthy diet, reformulation requires reduction in sugar, salt, saturated fat, and calories, and increases in fibre. These changes could be carried out at company or national level Scotland keeps missing its dietary goals for total fat, saturated fat and sugar. Reformulation could powerfully contribute towards a healthier more balanced diet So far, the current voluntary approach in the UK to reformulation has neither improved the diet of the population nor changed obesity levels. Elsewhere, a level playing field involving mandatory approaches has been effective Reducing sugar by 50% in key products would lower sugar intakes from 12% to 9% in adults and from 15% to 10% in children Key Actions A clear, mandatory and supportive framework for reformulation with time-bound targets and sanctions for non-compliance Reformulation requires advanced actions across industry, retail and out-of-home sector Definition Reformulation is a change in the balance of ingredients that, in the context of healthy weight, involves reduction of calories, sugar, fat and salt in food and drinks. The change could be carried out at company or national level. On average, Scots eat almost 3 times more free sugars and 40% more saturated fat than recommended St Vincent Glasgow G2 5RJ info@obesityactionscotland.org

2 Situation in Scotland and the UK Recent UK public health initiatives and campaigns have raised the profile of obesity and the importance of a healthy diet. Considerable focus on dietary sugar and health has also been seen in the media. Reformulation, whether voluntary or regulated, is one of the ways that manufacturers can help consumers lower their sugar intake and contribute to a healthy weight population. The average diet in Scotland is not in line with current Scottish Dietary Goals, with Scots eating too much sugar (14.4% of energy vs recommended less than 5%), total fat (39.4% vs recommended 35%) and saturated fat (15% of energy vs the goal of less than 11%) 1,2. The amount of free sugars in the Scottish diet has not significantly changed since 2001 and is almost three times as high as the current Scottish Dietary Goal 2 and the maximum recommended by the Scientific Advisory Committee on Nutrition (SACN) 1 (both less than 5g/day). The success of the recent voluntary gradual salt reduction programme in the UK could provide a model for other reformulation plans; key components of the plan were investigated and reported 3. One of the crucial components was strong leadership from the Food Standards Agency (FSA). Several countries currently follow the UK s leading or lead in their salt reduction programme. Running since 2003/04, the programme delivered reductions in salt content in many processed foods, resulting in a 15% reduction in 24 hour urinary sodium over 7 years 3. Free Sugars Free sugars comprise all monosaccharides (glucose, fructose) and disaccharides (sucrose) added to foods by the manufacturer, cook or consumer, plus sugars naturally present in honey, syrups and unsweetened fruit juices. Under this definition, lactose (the sugar in milk) when naturally present in milk and milk products and the sugars contained within the cellular structure of foods (particularly fruits and vegetables), are excluded. Current Approach Government s Responsibility Deal (RD) offers a number of pledges that industry can make. Pledge F4 includes calorie reduction: Interviews with businesses, public sector and non-governmental organisations used to evaluate the RD reported that food reformulations such as Pledge F4 Calorie Reduction We will support and enable our customers to eat and drink fewer calories through actions such as product / menu reformulation, reviewing portion sizes, education and information, and actions to shift the marketing mix towards lower calorie options. We will monitor and report on our actions on an annual basis. reductions in alcohol units, salt or calories, were some of the achievements described 4. However, making a pledge often related to work already planned or underway before joining the RD. The RD has also received criticism over the absence of sanctions to drive compliance 5. Professor Susan Jebb, chair of the Responsibility Deal Food Network during the House of Commons Health Committee meeting last October, pointed out that although main manufacturers and retailers responded well to reformulation calls, many independent retailers in the out-of-home sector were crucial in individual communities. Spreading the reformulation agenda across the whole population was therefore extremely difficult 6. The Supporting Healthy Choices (SHC) Framework launched in Scotland in 2014, does not specifically mention reformulation but it does encourage work towards a healthier diet: Commitment 12 We invite all food industry businesses across manufacture, retail and catering to work towards reducing calories, fats, salt and added sugars. To our knowledge there has been no formal evaluation of this framework. Launched in England in 2011, the Coalition

3 Voluntary actions aside, some companies have global reformulation targets, i.e. Kellogg s, Unilever, PepsiCo have reformulation targets for sugar, salt and fat 7. The European Journal of Clinical Nutrition recently published an evaluation of the Nestlé Nutritional Profiling System which showed 10% reductions of energy per serving in 6 out of 8 categories of the products investigated without altering portion size. The study also reported reductions in sodium content by 22%, sugar 31% as well as reductions in fat and saturated fat 8. In their recent board meeting paper, Food Standards Scotland suggested that although the current approach resulted in some progress towards salt and sugar reduction, there was still more to be done and actions should be taken to strengthen the approach taken by both RD and SHC by introducing time-bound targets 9. A sugar tax on soft drinks was announced in the March 2016 UK budget. Manufacturers will be levied from 2018 having to pay 18p per litre of soft drinks with 5-8g of sugar per 100ml and 24p per litre of drinks with more than 8g of sugar per 100ml. Fruit juice and milk-based drinks will be exempt. 100ml 5-8g Tax: 18p/litre 100ml Voluntary vs Regulated Approaches >8g Tax: 24p/litre Voluntary approaches have the potential to widen inequalities and may focus on niche instead of on all products 10. Based on an evaluation of the RD, it was suggested that voluntary agreement could be beneficial to public health if the government: increased participation and compliance through incentives and sanctions created greater visibility of voluntary agreements increased scrutiny and monitoring of pledge activities 4 One of the main arguments for a regulated approach is creating a level playing field for business. This was presented by the British Retail Consortium during the House of Commons Health Committee hearings in October Similarly, Professor Susan Jebb argued that we need to be prepared to act when the voluntary approach fails, with incentives for companies that take part and disincentives for those that stay out. A regulated approach, it was also argued, would not affect competitiveness but would support monitoring 10. The need for clear leadership from the government was stressed. Why Address Reformulation? The success of the voluntary gradual salt reduction programme in the UK proves that strongly led, gradual, time-bound, wellcoordinated, promoted and monitored action can deliver intended results. The worldwide rise in consumption of added sugar in the last few decades is in part due to the fact that sugar is a flavour enhancer and preservative, it has a relatively low price, but also due to health concerns around fat 11. Although the amount of sugar in the Scottish diet has not significantly changed since 2001, it is still three times higher than the current dietary goal 2. Food is now cheaper and we have more choice than ever before. This trend influences availability and actual consumption. Public Health England (PHE) in their report Sugar Reduction: The Evidence for Action, claimed that lowering the sugar content of food and drink sold in the UK could be a successful way of reducing the amount of sugar the population consumes. Specifically, reducing sugar by 50% in key products (by reformulation and/or decreased consumption) would lower sugar intakes from 12% to 9% in adults and from 15% to 10% in children 12. The amount of sugar in the Scottish diet is still three times higher than the current dietary goal

4 Sugar Replacements and Potential Unintended Consequences Sugar removed from food and drinks may be replaced with no/low-calorie sweeteners to enhance the flavour. Although no/low-calorie sweeteners are safe for use, some concerns about the long term health implications of continued use were expressed during Health Committee hearings last October 6. PHE in their report did not specify whether reformulation should be achieved through the addition of no/low-calorie sweeteners or not. It was suggested that reformulation could be achieved quickly with the addition of no/lowcalorie sweeteners, maintaining sweetness of products, leading to quick health gains, but step-wise adaptive sugar reduction would take time. Gradually changing the nation s palate to adapt to lower levels of sweetness could reduce craving and overall consumption of sugar. A five year model of 40% sugar reduction in soft drinks without adding sweeteners was recently suggested by a group from London 13. The model used British data to propose the changes and predicted that, if achieved, would result in around 0.5 million less adults being overweight and 1 million less adults being obese. Maintained for twenty years, these body weight reductions would prevent about 274,000 to 309,000 cases of obesity-related type 2 diabetes 13. The group suggested implementing the strategy immediately along with other approaches to tackle the obesity crisis. Reducing sugar content in some foods may cause technical issues, for example it may affect the texture of biscuits 12. Moreover, it may result in replacing it with fat and/or salt 10. Policy Position Gradually changing the nation s palate to adapt to lower levels of sweetness could reduce craving and overall consumption of sugar The Scottish Government Commitment 12 of the Supporting Healthy Choices framework invited industry to work towards reducing calories, salt, fats and added sugars which could be achieved by a reduction in portion size of standard products 14. Food Standards Scotland stated the current voluntary approach to reformulation should be revised to include more challenging time-bound targets. Public Health England suggested a broad, structured and monitored programme of gradual sugar reduction in food and drink, accompanied by reductions in portion size, but did not specify whether it should be voluntary or regulated. The Health Select Committee on the Childhood Obesity Strategy supported PHE s stand but recommended reducing levels of overall sweetness with potential use of no/low-calorie sweeteners to achieve quicker reductions in sugar consumption. They recommended a voluntary approach with a clear consequence of a regulatory framework if the industry did not uniformly respond to the voluntary programme. The UK Government has indicated a decision relating to child healthy weight will be reached later this year.

5 REFERENCES 1. Food Standards Scotland. Situation report: The scottish diet: It needs to change Scottish Government. Revised dietary goals for Scotland. Resource/0042/ pdf. Updated Accessed 05/26, He FJ, Brinsden HC, MacGregor GA. Salt reduction in the United Kingdom: A successful experiment in public health. Journal of Human Hypertension. 2014;28(6): Durand MA, Petticrew M, Goulding L, Eastmure E. K, C., Mays N. An evaluation of the public health responsibility deal: Informants experiences and views of the development, implementation and achievements of pledge-based, public-private partnership to improve population health in England. Health Policy. 2015;119: Panjwani C, Caraher M. The public health responsibility deal: Brokering a deal for public health, but on whose terms? Health Policy. 2014;114(2-3): The House of Commons Health Committee. Childhood obesity - brave and bold action. first report of session ;HC Nahal S, Lucas-Leclin V, King J. Globesity - the global fight against obesity Vlassopoulos A, Masset G, Charles VR, et al. A nutrient profiling system for the (re) formulation of a global food and beverage portfolio. European Journal of Nutrition Feb 15 [Epub ahead of print]. 9. Food Standards Scotland. Diet and nutrition: Proposals for setting the direction for the Scottish diet. paper for the board meeting 20 january ;FSS 16/01/ Mwatsama M, Landon J. Options for action to support the reduction of sugar inatkes in the UK. A discussion paper produced by the UK health forum for Public Health England Credit Suisse Research Institute. Sugar consumption at a crossroads Tedstone A, Targett V, Allen R. Sugar reduction: the evidence for action Ma Y, He FJ, Yin Y, Hashem KM, MacGregor GA. Gradual reduction of sugar in soft drinks without substitution as a strategy to reduce overweight, obesity, and type 2 diabetes: A modelling study. Lancet Diabetes and Endocrinology. 2016;4(2): Scottish Government. Supporting healthy choices. A framework for voluntary action. An invitation to the food industry to work in partnership with Government in Scotland Obesity Action Scotland was established mid-2015 to provide clinical leadership and independent advocacy on preventing and reducing overweight and obesity in Scotland. Our main aims: To raise awareness and understanding of what drives obesity and the health problems associated with obesity and overweight with health practitioners, policy makers and the public To evaluate current research and identify strategies to prevent obesity and overweight based on the best available evidence To work with key organisations in Scotland, the rest of the UK and worldwide, to promote healthy weight and wellbeing Overseeing our work is the Steering Group whose membership spans various disciplines involved in preventing and tackling obesity and its consequences: clinicians, public health experts, epidemiologists, nutritionists and dieticians, GPs and weight management experts. There are four members of staff. Royal College of Physicians and Surgeons St Vincent Street Glasgow G2 5RJ Further copies can be downloaded from our website