Kawther M Hashem

Action on sugar—lessons from UK salt reduction programme

Obesity has increased worldwide during the past 30 years in both high-income and low-income countries and in all divisions of society. The estimated numbers of overweight and obese adults worldwide in 2005 were 937 million (922–951 million) and 396 million (388–405 million), respectively. If recent trends continue, it is estimated that there would be 2·16 billion overweight people and 1·12 billion obese individuals by 2030. Overweight and obesity increase health-care costs and threaten the economic growth on which a country’s future prosperity and wellbeing depend. A complex web of multiple factors is implicated in obesity, with more than 100 variables directly or indirectly influencing energy balance, ranging from the accessibility, availability, and promotion of food to physical activity. However, evidence shows that obesity is largely preventable and increased energy intake is an important contributor to the global rise in obesity. Although the changes needed to reverse the obesity epidemic are likely to require many sustained interventions in various domains, one way to tackle overweight and obesity is to reduce calorie intake. Added sugar is a major hidden source of calories and contributes to obesity, type 2 diabetes, and dental caries. Some studies suggest that the role of sugar, particular in sugar-sweetened soft drinks, in obesity might be key because it provides no feeling of satiation. More controversial evidence suggests that sugar might have an effect on the development of fatty liver and metabolic syndrome. Indeed, recent research has shown increased benefits to human health, particularly in preventing dental caries, from reducing added sugar intake from 10% to 5% of total energy intake. This has resulted in WHO releasing new draft guidelines on sugar intake for consultation this month, suggesting that a reduction to below 5% of total energy intake per day would have additional benefits to human health. Sugar added to food and drink has little or no nutritional value and contributes to calorie intake. Consumers may be largely unaware of the amount of added sugar in products—eg, some sugar-sweetened soft drinks have 35 g in a 330 mL can; yoghurts, particularly low-fat yoghurts, can have up to 18 g in a 125 g pot; and some canned soups contain up to 15 g of sugar. Various attempts have been made to try to reduce sugar consumption. New York City tried, but failed, to ban the sale of supersized sugar-sweetened soft drinks. France and, as of 2009, 33 states in the USA have initiated a tax on sugar-sweetened drinks but have so far been largely unsuccessful because of vigorous opposition by the sugar and soft drink industry. In the UK, obesity is a major public health problem: about 25% of adults were obese in 2012 and obesity costs the National Health Service more than £5 billion every year, with an overall cost to society and the economy of almost £16 billion in 2007. If obesity rates were to continue unchecked, it is estimated that 60% of adult men, 50% of adult women, and 25% of children in the UK could be obese by 2050, with a potential cost of just under £50 billion. To combat this rise in obesity, a group of academics behind the UK’s Consensus Action on Salt and Health (CASH) campaign launched Action on Sugar in January, 2014, with the aim of reducing added sugar intake in the UK by following the same model as the successful UK salt reduction strategy. Since 2003–04 the UK has undertaken a voluntary salt reduction programme initiated by CASH in collaboration with the Food Standards Agency and now the Department of Health. Mean estimated salt intake for adults fell from 9·5 g in 2000–01 to 8·1 g in 2011, with a predicted saving of almost 9000 lives a year from strokes and heart attacks. Overall, in the UK there has been about a 30% reduction in the amount of salt added by the food industry. This was done by setting incremental targets for each food group with a specified deadline to be achieved

Gradual reduction of sugar in soft drinks without substitution as a strategy to reduce overweight, obesity, and type 2 diabetes: a modelling study.

BACKGROUND Sugar-sweetened beverages are a major source of free sugar intake in both children and adults, and are an important contributor to obesity and obesity-related diseases, including type 2 diabetes. We proposed an incremental and stepwise reduction in free sugars added to sugar-sweetened beverages by 40% over 5 years without the use of artificial sweeteners and assessed the effect of the proposed strategy on energy intake and weight status. METHODS In this modelling study, we used nationally representative data from the National Diet and Nutrition Survey rolling programme (NDNS RP) from 2008-12 and British Soft Drinks Association annual reports to calculate sugar-sweetened beverage consumption (both with and without fruit juices) and its contribution to free sugar and energy intake in the UK population. We then estimated the predicted reduction in energy intake resulting from the proposed strategy at an individual level. We further predicted the reduction in steady-state bodyweight for each adult using a weight loss model. By scaling up the distribution of the predicted bodyweight in the NDNS RP to the UK adult population, we estimated reductions in the number of overweight and obese adults, and the number of adults with type 2 diabetes. FINDINGS A 40% reduction in free sugars added to sugar-sweetened beverages over 5 years would lead to an average reduction in energy intake of 38·4 kcal per day (95% CI 36·3-40·7) by the end of the fifth year. This would lead to an average reduction in steady-state bodyweight of 1·20 kg (1·12-1·28) in adults, resulting in a reduction in the prevalence in adults of overweight by 1·0 percentage point (from 35·5% to 34·5%) and obesity by 2·1 percentage points (from 27·8% to 25·7%). This reduction would lead to a reduction of roughly 0·5 million adults from being overweight and 1 million adults from being obese, which in turn would prevent about 274,000-309,000 incident cases of obesity-related type 2 diabetes over the two decades after the predicted reduction in bodyweight is achieved. If fruit juices were excluded from the category of sugar-sweetened beverages (because of potential challenges for reformulation), the corresponding reductions in energy intake and steady-state bodyweight would be 31·0 kcal per day (95% CI 28·6-33·7) and 0·96 kg (0·88-1·04), respectively. These reductions would result in a 0·7 percentage point (0·3 million) reduction in overweight and a 1·7 percentage point (0·8 million) reduction in obesity, which would in turn prevent about 221,000-250,000 cases of type 2 diabetes over two decades after the predicted reduction in bodyweight is achieved. The predicted effect was greater in adolescents, young adults, and individuals from low-income families (who consume more sugar-sweetened beverages). INTERPRETATION An incremental reduction in free sugars added to sugar-sweetened beverages without the use of artificial sweeteners is predicted to reduce the prevalence of overweight, obesity, and type 2 diabetes. The proposed strategy should be implemented immediately, and could be used in combination with other approaches, such as taxation policies, to produce a more powerful effect. FUNDING None.

How much sugar is hidden in drinks marketed to children? A survey of fruit juices, juice drinks and smoothies

Objective To investigate the amount of sugars in fruit juices, juice drinks and smoothies (FJJDS) marketed to children. Design We surveyed the sugars content (per 100 ml and standardised 200 ml portion) of all FJJDS sold by seven major UK supermarkets (supermarket own and branded products). Only products specifically marketed towards children were included. We excluded sports drinks, iced teas, sugar-sweetened carbonated drinks and cordials as being not specifically marketed towards children. Results We identified 203 fruit juices (n=21), juice drinks (n=158) and smoothies (n=24) marketed to children. Sugars content ranged from 0 to 16 g/100 ml. The mean sugars content was 7.0 g/100 ml, but among the 100% fruit juice category, it was 10.7 g/100 ml. Smoothies (13.0 g/100 ml) contained the highest amounts of sugars and juice drinks (5.6 g/100 ml) contained the lowest amount. 117 of the 203 FJJDS surveyed would receive a Food Standards Agency ‘red’ colour-coded label for sugars per standardised 200 ml serving. Only 63 FJJDS would receive a ‘green’ colour-coded label. 85 products contained at least 19 g of sugars—a childs entire maximum daily amount of sugars. 57 products contained sugar (sucrose), 65 contained non-caloric sweeteners and five contained both. Seven products contained glucose-fructose syrup. Conclusions The sugars content in FJJDS marketed to children in the UK is unacceptably high. Manufacturers must stop adding unnecessary sugars and calories to their FJJDS.

Cross-sectional survey of salt content in cheese: a major contributor to salt intake in the UK

Objective To investigate the salt (sodium chloride) content in cheese sold in UK supermarkets. Study design We carried out a cross-sectional survey in 2012, including 612 cheeses available in UK supermarkets. Methods The salt content (g/100 g) was collected from product packaging and nutrient information panels of cheeses available in the top seven retailers. Results Salt content in cheese was high with a mean (±SD) of 1.7±0.58 g/100 g. There was a large variation in salt content between different types of cheeses and within the same type of cheese. On average, halloumi (2.71±0.34 g/100 g) and imported blue cheese (2.71±0.83 g/100 g) contained the highest amounts of salt and cottage cheese (0.55±0.14 g/100 g) contained the lowest amount of salt. Overall, among the 394 cheeses that had salt reduction targets, 84.5% have already met their respective Department of Health 2012 salt targets. Cheddar and cheddar-style cheese is the most popular/biggest selling cheese in the UK and has the highest number of products in the analysis (N=250). On average, salt level was higher in branded compared with supermarket own brand cheddar and cheddar-style products (1.78±0.13 vs 1.72±0.14 g/100 g, p<0.01). Ninety per cent of supermarket own brand products met the 2012 target for cheddar and cheddar-style cheese compared with 73% of branded products (p=0.001). Conclusions Salt content in cheese in the UK is high. There is a wide variation in the salt content of different types of cheeses and even within the same type of cheese. Despite this, 84.5% of cheeses have already met their respective 2012 targets. These findings demonstrate that much larger reductions in the amount of salt added to cheese could be made and more challenging targets need to be set, so that the UK can continue to lead the world in salt reduction.

Salt and sugars content of breakfast cereals in the UK from 1992 to 2015.

OBJECTIVE To study the salt and sugars content of breakfast cereals sold in the UK between 1992 and 2015. DESIGN Cross-sectional surveys on salt and sugars content collected from the nutrition information panel of breakfast cereals in 1992, 2004, 2006, 2009, 2012 and 2015. SETTING All major UK retailers operating at that moment in time (approximately ten). SUBJECTS The salt and sugars content was collected from product packaging and the nutrition information panels. RESULTS Cereals consistently surveyed across all five years (n22) showed a significant reduction in salt content of 47 % (P<0·001). Sugars content of breakfast cereals (n 15), however, did not show a significant change; 25·65 g/100 g in 1992 and 22·45 g/100 g in 2015 (P=0·170). There was a large variation in salt and sugars content between different categories and within the same type of category. CONCLUSIONS The study shows the progressive reduction in salt content of breakfast cereals in the UK since 2004 as a result of the successful salt reduction programme, particularly the setting of incremental salt targets. Further reductions in salt content need to be made as cereals remain a major contributor to salt intake. Sugars content, however, has been consistently high due to the lack of a sugar reduction strategy. The research demonstrates that the sugars content of breakfast cereals in the UK is of concern, particularly in childrens breakfast cereals, with a typical serving (30 g) containing a third of a 4-6-year-olds maximum daily recommendation (19 g/d) for free sugars intake in the UK. More can and should be done to reformulate, with an urgent need to set incremental sugar reduction targets.

Cross-sectional survey of the amount of free sugars and calories in carbonated sugar-sweetened beverages on sale in the UK.

Objectives To investigate the free sugars and calorie content of carbonated sugar-sweetened beverages (CSSB) available in the main UK supermarkets. Study design We carried out a cross-sectional survey in 2014 of 169 CSSB. Methods The free sugars (sugars g/100 mL) and calorie (kcal/100 mL) were collected from product packaging and nutrient information panels of CSSB available in 9 main UK supermarkets. Results The average free sugars content in CSSB was 30.1±10.7 g/330 mL, and 91% of CSSB would receive a ‘red’ (high) label for sugars per serving. There was a large variation in sugars content between different flavours of CSSB and within the same type of flavour ranging from 3.3 to 52.8 g/330 mL. On average, ginger beer (38.5±9.9 g/330 mL) contained the highest amounts of sugars and ginger ale (22.9±7.7 g/330 mL) contained the lowest. Cola flavour is the most popular flavour in the UK with an average free sugars content of 35.0±1.1 g/330 mL. On average, the supermarket own brand contained lower levels of sugars than branded products (27.9±10.6 vs 31.6±10.6 g/330 mL, p=0.02). The average calorie content in CSSB was 126.1±43.5 kcal/330 mL. Cola flavour had a calorie content of 143.5±5.2 kcal/330 mL. Among the 169 products surveyed, 55% exceeded the maximum daily recommendation for free sugars intake (30 g) per 330 mL. Conclusions Free sugars content of CSSB in the UK is high and is a major contributor to free sugars intake. There is a wide variation in the sugars content of CSSB and even within the same flavour of CSSB. These findings demonstrate that the amount of free sugars added to CSSB can be reduced without technical issues, and there is an urgent need to set incremental free sugars reduction targets. A reduction in sugars content and overall CSSB consumption will be very beneficial in reducing obesity, type 2 diabetes and dental caries.

Cross-sectional surveys of the amount of sugar, energy and caffeine in sugar-sweetened drinks marketed and consumed as energy drinks in the UK between 2015 and 2017: monitoring reformulation progress

Objectives To investigate the sugar, energy and caffeine content of sugar-sweetened drinks marketed and consumed as energy drinks available in the UK. Study design We carried out a cross-sectional survey in 2015 and 2017 of energy drinks available in the main UK retailers. Methods The sugar (sugars g/100 mL), energy (kcal/100 mL), caffeine (mg/100 mL) and serving size were collected from product packaging and nutrition information panels of energy drinks available in the nine main UK grocery retailers, three health and beauty retailers and one convenience store. Results The number of formulations (per 100 mL) and number of products (per serving) have fallen (from 75 to 49 and from 90 to 59) between 2015 and 2017, respectively. Energy drinks surveyed showed a 10% reduction in sugar, from 10.6 to 9.5 g/100 mL (P=0.011) and a 6% reduction in energy content (P=0.005) per 100 mL between 2015 and 2017. The average caffeine content of energy drinks, with a warning label, has remained high at 31.5±0.9 in 2015 and 31.3±1.0 mg/100 mL in 2017. Despite there being reductions, sugar, energy and caffeine content remain at concerning levels in 2017. Conclusions To reduce the harmful impact of energy drinks, further reduction in sugar and a reduction in caffeine by reformulation are urgently needed. Other measures such as ban on the sale of energy drinks to children and smaller product sizes should also be explored, while warning labels should be kept. A reduction in sugar, energy and caffeine content and overall energy drinks consumption could be beneficial in reducing sugar, energy and caffeine intake of consumers of energy drinks.

Systematic review of the literature on the effectiveness of product reformulation measures to reduce the sugar content of food and drink on the population's sugar consumption and health: a study protocol

Introduction Obesity, type 2 diabetes and dental caries are all major public health problems in the UK, with significant costs to the healthcare service. We aim to conduct a systematic review to summarise the evidence on the effectiveness of product reformulation measures to reduce the sugar content of food and drink on the populations sugar consumption and health. Methods and analysis Electronic database will be systematically searched using a combination of terms, tailored to optimise sensitivity, specificity, and the syntax and functionality of each database. The databases searched will include the Cochrane Library, EMBASE, MEDLINE (Ovid) and Scopus. The bibliographies of those papers that match inclusion criteria will be searched by hand to identify any further, relevant references, which will be subject to the same screening and selection process. The database search results will be supplemented by hand searches. In addition to the peer-reviewed literature, a number of grey literature searches will be undertaken using the broad search terms ‘sugar’ and ‘food’ or ‘drink’ and ‘reduction’, these searches will include key government and organisation websites as well as general searches in Google. The selection of the studies, data collection and quality appraisal will be performed independently by 2 reviewers. Data will be initially analysed through a narrative synthesis method. If a subset of data we analyse appears comparable, we will investigate the possibility of performing a meta-analysis. Ethics and dissemination Ethics approval will not be required as this is a protocol for a systematic review. The findings will be disseminated widely through conference presentations and published in a peer-reviewed journal. PROSPERO registration number CRD42016034022.

Cross-sectional survey of the amount of sugar and energy in cakes and biscuits on sale in the UK for the evaluation of the sugar-reduction programme

Objectives To investigate the variation in sugar and energy content of cakes and biscuits available in the UK. Design We carried out a cross-sectional survey in 2016 of 381 cakes and 481 biscuits available in nine main UK supermarkets. Methods The sugar and energy content was collected from product packaging and nutrition labelling of cake and biscuit products. Results The average sugar content in cakes and biscuits was 36.6±7.6 and 30.0±9.2 g/100 g, respectively. The mean energy content was 406±37 for cakes and 484±38 kcal/100 g for biscuits. There was a large variation in sugar and energy content between different cake and biscuit categories and within the same category. 97% of cakes and 74% of biscuits would receive a ‘red’ (high) label for sugar. Conclusions This research makes available baseline data of the cakes and biscuits market in the UK for future evaluation of the recently launched sugar-reduction programme. The study showed that reductions in sugar and energy content of cakes and biscuits are possible, since there was a large variation in sugar and energy content between different cake and biscuit categories and within the same category. A reduction in sugar and energy content, and overall cake and biscuit consumption, can help reduce overall sugar and energy intake in the UK and thus reduce the risk of obesity and dental caries.

Sugar and energy content of carbonated sugar-sweetened beverages in Haidian District, Beijing: a cross-sectional study

Objective The consumption of carbonated sugar-sweetened beverages (CSSBs) is associated with a range of health problems, but little is known about the sugar and energy content of CSSBs in China. The study aimed to investigate the sugar and energy content of CSSBs in Beijing, China. Study design We carried out a cross-sectional survey in 15 different supermarkets from July to October 2017 in Haidian District, Beijing. Methods The product packaging and nutrient labels of CSSBs were recorded by a snapshot in time to obtain company name, product name, serving size, and nutrient content, that is, carbohydrate, sugar and energy. For CSSB labels not showing sugar content, we used carbohydrate content as substitute. The sugar and energy content of CSSBs within each type of flavour were compared using Kruskal-Wallis test. The sugar content within the recommended levels was described using frequency. We also compared the sugar and energy content of top 5 CSSBs in terms of sales among three countries (China, UK and USA). Results A total of 93 CSSB products were found. The median sugar content was 9.3 (IQR: 5.7–11.2) g/100 mL, and the energy content was 38 (IQR: 23–46) kcal/100 mL. There were 79 products labelled ‘Red’ (high) per serving based on the criteria set in the UK (>11.25 g/100 mL). We found 62.4% of CSSBs had sugar content per serving that exceeds the daily free sugar intake for adults (25 g) recommended by the WHO. Some of the branded products sold in China had higher sugar content when they were compared with those in Western countries. Conclusions CSSBs in Beijing, China have high sugar and energy content. Reduction in sugar content and serving size of CSSBs and taxation policy on beverages will be beneficial in reducing sugar intake in China.