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The Scientific Advisory Committee on Nutrition (SACN) launched its draft report on Carbohydrates and Health for public consultation, recommending people to consume more fibre and less free sugars. Public Health England (PHE) simultaneously released a proposal for reducing the nation’s sugar intake.
Prof Tom Sanders, Head of Diabetes and Nutritional Sciences Division, School of Medicine, King’s College London, said:
“I think there are issues around definitions of ‘free sugar’ and how this will be interpreted by consumers given that foods are only labelled with total sugar. We currently have no way of analysing ‘free sugar’. It also gets very confusing with products like fruit yoghurt where there is a significant contribution of lactose, which while being in the free form, is not classified a ‘free sugars’. Our own research shows that the targets for ‘free sugars’ can easily be met by restricting the intake of sugar sweetened beverages and confectionery and by replacing sugary snacks such as biscuits with fruit and nuts. However, this will not necessarily reduce total sugar intake as the added sugar will be replaced by sugar in fruit.
“Public Health England suggests one way forward may be to get industry to reformulate products. This clearly works for drinks because sugar can be totally or partly replaced by intense sweeteners. Consumers already have had this choice for two decades but it has not stopped the growth in obesity. Artificial sweeteners are only one option and not the answer and despite their safety many consumers are against them. I believe the key message is that we should get our fluid intake mainly from drinking water not fizzy pop or fruit juice.
“Reducing the sugar content of solid foods is more complex because consideration needs to be given to the bulk provided by sugar. Sugar alcohols are a possibility but they have some side effects such as causing laxation and diarrhoea with intakes above about 20g. Reformulation by removing sugar can also inadvertently increase the proportion of fat and calorie content of the product and I can’t see any benefit of replacing sugar with refined starch. Consequently, I am less sanguine about the practicality of reformulation.
“My view is that it would be best to focus on reducing the major contributors of added sugar (soft drinks and confectionery) rather than having across the board reductions as was done for salt. I think taxation based on sugar content would be unpopular and difficult to implement, and I also think warning labels need to be seen in the context of other risks to health which are greater (i.e. alcohol and smoking). However, I might favour legislation prohibiting the sponsorship of sport by high sugar sports drinks because it encourages young people to drink large amounts of sugar. I think banning pick and mix sweetshops in the middle of shopping centres and stopping newsagents offering discounted confectionery when you buy a magazine would be good ideas. Another cultural shift that would be desirable is to get people out of the habit of eating a bucket of popcorn and large fizzy drink when they go to the cinema.”
Prof Naveed Sattar, Professor of Metabolic Medicine, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, said:
“These guidelines are going in the right direction. There is a need to cut refined sugar and at the same time encourage greater intake of fibre to improve the health of the nation and help many people reduce their chances of obesity and its consequences. Excess calorie intake remains the major cause of obesity so there is a need to achieve better dietary habits. For many, the two changes (less sugar, more fibre) can happen in tandem so, for example, an individual could be encouraged to change from a sugar-rich cereal taken with coffee and two sugars to a fibre-rich cereal take with coffee without any added sugar. These are small changes but if sustained and, if need be, extended by adding other small changes, they could have important influences on health. The real question is what we can do to help individuals to make such better dietary choices – this SACN report is helpful but we need the food and drinks industry to step up to the mark or the government to enforce changes via regulation or taxation; something they have as yet shied away from.”
Prof David Boxer, Director, Institute of Food Research, said:
“We welcome this report, as it provides a thorough, systematic review of the current state of knowledge in relation to the biological effects of different carbohydrates on health provides objective and independent evidence on which we can base decisions on how we tackle the problems of obesity and other diet-related conditions.
“The report recommends reducing the consumption of free sugar in the diet to 5% of dietary energy, and an increase in the amount of fibre in the diet. As a nation we are already failing to meet the present guidelines for these, which is a measure of the challenge we all face.
“The food industry has an obvious role to play, by continuing its efforts to minimise the levels of sugars and fats in manufactured foods. Scientific research can help accelerate this, especially where genuine barriers to sugar and fat reduction exist, such as detrimental effects on shelf-life, or where the overall structure or taste of the final product becomes unacceptable to the consumer. The development of healthier products also needs to be done in conjunction with efforts to educate consumers on broader aspects of a balanced diet, and to address other lifestyle factors, such as exercise.”
Dr Elizabeth Saggers, Deputy Director of the Food Safety Centre at the Institute of Food Research, said:
“The evidence that reducing sugar intake improves health is clear from the SACN report, but in reducing sugar content manufacturers need to use caution and have a precise knowledge of the preservative role sugar plays. In some products sugar acts as an important preservative. Sugar ties up the amount of water available within the product in which bacteria can grow. If the water available is increased by removing some of the sugar it is possible organisms may be able to start growing in the product, where previously growth was prevented. This can reduce shelf-life, increase wastage and potentially increase the risks of food poisoning. But these problems can and should be surmountable. For example, product reformulation and its effect on safety and product stability can be predicted using various widely available software tools, and validated by practical microbiological testing.”
Dr Nita Forouhi, MRC Programme Leader and Public Health Physician at the MRC Epidemiology Unit, University of Cambridge, said:
“The SACN report is a welcome mix of maintaining the old and bringing in the new based on latest evidence review, which is both comprehensive and sound, and offers complete transparency in the framework they used for review.
“SACN have painstakingly appraised 225 cohort studies and 403 randomised controlled trials, and we can place a lot of confidence in their conclusions.
“SACN’s bold new recommendations include the guidance to increase population level intake of fibre to 30 g/day for adults and to reduce the free sugars intake to 5% of total calories per day, in line with the WHO recommendations on sugars. SACN clearly distinguish population and individual level recommendations, so while individuals should ensure they don’t exceed 10% of their daily energy intake from free sugars, the aim at the population level is to achieve an average of 5% to help reduce tooth decay and lower the amount of energy consumed. So a typical woman with energy intake of 2,000 kcals is recommended to try to get their free sugar intake to less than 100 kcals/day, equivalent to approximately 5-6 teaspoons of table sugar. This is less than the typical amount in most standard cans of sugar-sweetened drinks and hence why the committee recommends cutting these out of the diet.
“The recommendation that consumption of sugar-sweetened beverages should be minimised by both adults and children is grounded in high quality evidence, including our own from an 8-country study across Europe showing a strong positive link between habitual intake of sugary drinks and the risk of developing diabetes, even after controlling for obesity.
“Hand in hand with the new recommendations, the broadening of the definition of “fibre” intake is particularly welcome. The adoption of the term “free sugars” is also welcome, to make it consistent with the WHO guidance, and to reduce the current confusion in different terminologies that include non-milk extrinsic sugars or added sugars. The past terminology within the UK, and in comparisons made with international recommendations was extremely confusing, even for experts within the field, let alone the general public.
“So what stays the same? SACN decided to maintain status quo on overall total carbohydrate intake at an average of approximately 50% of dietary energy. In my opinion, this is equally bold. It is important to get across the message that the type and quality of carbohydrates matter, and the counsel to consume carbohydrates that are rich in fibre is sensible and evidence-based.
“What about the challenges? Changing a dietary recommendation does not automatically drive the changes in actual intake, which depend both on how people might change their dietary behaviours, and how the foods and drinks available to them help them achieve these goals.
“Shifting population intakes is a difficult task. For instance, current mean intakes of free sugars are over 10% of total energy in all age groups in the UK (over 15% in those aged 11-18 years). People can easily over-consume sugars without realising it, due to added and hidden sugars present in foods and drinks in our ubiquitously sweetened food environment. We have to provide information on healthy replacement foods when people cut down on foods/drinks with free sugars. Shifts in attitudes are equally important. Making drinking water readily available and for free in public places, restaurants and in people’s homes is certainly desirable may seem simple, but will need concerted efforts from individuals, agencies and governments.
“There are many possible solutions. A three-pronged approach involving people, products and places will help. People need more information and health education. Products need to be low in added and hidden sugars and high in fibre. Places that sell food and drinks need to provide access to lower or no free sugars versions, higher fibre versions, and healthier options.
“I would add that sending out easily understood messages to the public is really important. They will respond much more to front-of-pack labels showing the equivalent number of teaspoons of sugar or added sugars in a product. People intuitively ‘get’ the concept of ‘numbers of teaspoons’. This sort of approach is much clearer than labels stating ‘grams of sugar’ or ‘proportion of sugar as allowance of total calories’, since most people struggle to understand how many daily calories they are consuming.
“The action plan from Public Health England for sugar reduction offers some concrete real-world next steps, that agencies will be well advised to adopt, and to ignore them would be at the cost of real damage to public health.”
Prof Suzanne Dickson, Professor of Physiology/Neuroendocrinology, University of Gothenburg, said:
“Implementation of the recommendations of the nutritional guidelines as outlined in the SACN report needs to take into account the fact that people find it very difficult to limit their sugar intake. People can crave sweet food but there is no evidence to suggest it is addictive in the way that drugs or alcohol can be. To develop new strategies to limit sugar intake, we need to better understand the brain mechanisms involved. This is where there are major gaps in knowledge and where progress can be made.”
Dr Toni Steer, Public Health Nutritionist at MRC Human Nutrition Research in Cambridge, who leads HNR’s dietary assessment component of the National Diet and Nutrition Survey, said:
“We know from the latest National Diet and Nutrition Survey results that people in the UK – especially children – consume more than the recommended proportion of free sugars in their diet and all age groups don’t consume enough fibre. These survey results and the SACN report highlight the fact that we need to promote healthy eating to reduce intake of free sugars, fat and salt, while increasing consumption of fibre and fruit and vegetables.”
Ms Catherine Collins, Principal Dietitian at St George’s Hospital NHS Trust, said:
“The populist view of sugar has been to denounce it as an unnecessary food substance in our diet, but as the SACN report so carefully points out, sugar is present in a wide variety of healthful foods – as well as an added ingredient to our daily foods and drinks.
“For many the calorie content of sugar-sweetened drinks as a contributor to their struggle with weight is never considered, yet these incidental calories consumed for thirst contribute significantly to total daily sugar and calorie intake. Sugary drinks alone provide a third of the total sugar intake in the average teenager’s diet.
“What would I recommend as a practicing dietitian? First, unless you’re an elite athlete sugary soft drinks really have no place in your diet. They contribute unnecessary calories to daily intake, and for all age groups (but particularly in the young) they contribute to tooth decay – unless of course you already wear dentures.
“Secondly, I’d like to see a complete ban on broadcast advertising of high sugar drinks. With all the major companies producing calorie (and therefore sugar) free options, these should become the only version to be the ‘advertised’ norm – and not the full-sugar versions as currently allowed.
“Third, it’s important to recognise that sugar, confectionary and fruit juice are also major contributors to our overall sugar intake. I always recommend calorie-free sweeteners to those who can’t go ‘cold turkey’ with unsweetened tea, and I’d always recommend buying the smaller bar of chocolate to satisfy that common craving. Studies show that the first bite of chocolate is the one that gives you greatest satisfaction, so no need to run to extra expense and calorie load with that 100g bar. Small is beautiful when it comes to sweet treats.
“With regards fruit juice, I disagree with the pressure groups keen to decry pure juice as being as devilish as a full sugar cola. On paper, of course it is, but fruit juice adds nutrients that a non-fruit eater may lack. I support Change4Life’s good advice to limit juice to a small glass daily – no need to drink the litre of juice or fruit smoothie for benefit.
“Finally, this report is a great resource for those who are interested in the sugar debate, and helps temper some of the ridiculous claims and misunderstanding of sugar currently out there. It will be interesting to see how health professionals and public respond to this work-in-progress.”
Prof Susan Jebb, Professor of Diet and Population Health, University of Oxford, said:
“I welcome this considered and authoritative review on carbohydrates which updates the UK dietary recommendations, particularly for fibre and free sugars. It reinforces the prior data that sugar adds calories to the diet but shows too that there are detrimental effects of sugar on health, independent of body weight. This is particularly the case for sugar-sweetened beverages.
“Amidst the current media focus on sugar, it’s important not to overlook the recommendations in the report on fibre. Increasing fibre intake would have clear public health benefits, helping to control body weight and reducing the risk of chronic disease.
“Dietary recommendations are set on a nutrient basis, but consumers need to put this information in the context of the foods they eat and their overall eating pattern. There is no suggestion that sugary foods should be replaced in the diet by fatty foods. Water should be the drink of choice and we need to eat less confectionery and fewer biscuits and cakes. This will cut calories, fat and sugar and bring holistic health benefits.
“Practitioners in primary care have a privileged and trusted position from which they can engage and communicate with millions of people across the country. We need to ensure that everyone is trained to make brief opportunistic interventions to encourage dietary change and that patients at higher risk are supported to change their diet. We also need more research, embedded in routine primary care, to understand which interventions are most effective in helping people to change their diet.
“As Chair of the Responsibility Deal Food Network I am conscious that this report sets some new priorities for action. We need to consider whether voluntary initiatives, beyond the existing pledge to increase fruit and vegetable intake, can help to increase fibre in the diet, perhaps by encouraging consumers to switch from refined grains to high fibre or wholegrain alternatives. We also need to accelerate action to cut sugar further. We have seen a range of actions by some of the leaders in the various business sectors to cut sugar; including reformulation to cut sugar content, innovation with no/low sugar alternatives and portion control, with a specific focus on sugary drinks. The changes we are seeing in as part of the Responsibility Deal Food Network in England are faster than anywhere else in the world, but there is no room for complacency and progress needs to be accelerated and actions taken across the whole industry.
“But the Responsibility Deal Food Network can only do so much and as a public health researcher I know that the scale of the challenge means we need to consider a much broader range of policies to support and enable consumers to make these fundamental changes in their eating habits. I am encouraged to hear that PHE plan to review the range of options available and the evidence of their effectiveness. This report should be a stimulus for renewed focus in research, policy and healthcare on the importance and urgency of the need to change the nation’s diet.”
SACN report: http://www.sacn.gov.uk/pdfs/draft_sacn_carbohydrates_and_health_report_consultation.pdf
PHE response: https://www.gov.uk/government/publications/sugar-reduction-responding-to-the-challenge
Declared interests
Prof Tom Sanders does not hold any grants or have any consultancies with companies involved in the production or marketing of sugar-sweetened drinks. In reference to previous funding to Tom’s institution: £4.5 million was donated to King’s College London by Tate & Lyle in 2006; this funding finished in 2011. This money was given to the College and was in recognition of the discovery of sucralose by Prof Hough at the Queen Elizabeth College (QEC), which merged with King’s College London. The Tate & Lyle grant paid for the Clinical Research Centre at St Thomas’ that is run by the Guy’s & St Thomas’ Trust, it was not used to fund research on sugar. Tate & Lyle sold their sugar interests to American Sugar so the brand Tate & Lyle still exists but it is no longer linked to the company Tate & Lyle PLC, which gave the money to King’s College London in 2006.
Dr Toni Steer has worked on a project for which MRC HNR received funding from Danone.
Prof Susan Jebb is Independent Chair of the Public health Responsibility Deal Food Network.