Graham MacGregor Professor of Cardiovascular Medicine

Chairman of Action on Sugar

Wolfson Institute of Preventive Medicine, Barts and The London School of Medicine & Dentistry,

Queen Mary University of London, UK

A national campaign for sugar reduction in the UK

Major Underlying Factors Causing Death - Worldwide

GBD 2013 Risk Factors Collaborators. Lancet 2015;385:117 Number of Deaths in thousands

0 2,000 4,000 6,000 8,000 10,000 12,000

Sexual abuse and violenceLow bone mineral density

Occupational risksOther environmental risks

Unsafe water, sanitation, and handwashingUnsafe sex

Child and maternal malnutritionLow GFR

Low physical activityHigh total cholesterolAlcohol and drug use

High fasting plasma glucoseHigh BMI

Air pollutionTobacco smokeHigh systolic BP

Dietary risks

0 2,000 4,000 6,000 8,000 10,000 12,000

Sexual abuse and violenceLow bone mineral density

Occupational risksOther environmental risks

Unsafe water, sanitation, and handwashingUnsafe sex

Child and maternal malnutritionLow GFR

Low physical activityHigh total cholesterolAlcohol and drug use

High fasting plasma glucoseHigh BMI

Air pollutionTobacco smokeHigh systolic BP

Dietary risks

Unhealthy diet High systolic BP

High BMI High plasma glucose

High cholesterol

Processed foods and soft drinks

Fat (saturated) Sugar

Calorie

Dental caries

Cholesterol Blood Pressure Obesity Type 2 Diabetes Cancer

Salt

Heart disease Stroke

Why are we getting so fat?

11 bananas or 18 oranges or half a marathon

A Big Mac, large chips and coca cola

Food/soft drink industry

Calorie-dense Cheap

Profitable

Transient satiation/fullness

Calorie intake ↑

Obesity/type 2 diabetes ↑

“Brilliant” marketing Any time

Everywhere

Eat more

Por$onsizeincreaseover$me

Relentless pressure on consumers

Unhealthy foods/soft drinks are available

•  Any time

•  Everywhere

•  Brilliant marketing + advertising (particularly to children)

•  Very cheap

Who is responsible?

•  Public

•  Government

•  Food industry

Food industry must reduce salt, fat & sugar content of foods

What can we do? • Tax - High salt, sugar, fat foods

•  Subsidise healthy food, e.g. fruit & veg

•  Ban unhealthy food advertising

• Restrict availability

• Reduce portion size

• Reformulation

What is practical?

•  Big food – very powerful

•  Biggest industry & employer

•  Strong ties to & influence on government

•  Some similarities to tobacco (50 yrs)

Sugar- Impact on health

• The only cause of dental decay (caries)

• Major source of hidden calories

•  Leads to obesity & diabetes

Stephan Guyenet http://wholehealthsource.blogspot.co.uk/2012/02/by-2606-us-diet-will-be-100-percent.html

Sugar, Obesity & Diabetes Sugar consumption

(lb/person/yr)

Johnson et al Am J Clin Nutr 2007

Obesity rate for 60-year-old men

Diabetes per 100,000

population

Oneinthreeadultsareobese

Onein30adultsareobese

Oneinnineadultsarediabe$c

Onein50,000

adultsarediabe$c

Relative risk of type 2 diabetes

Soft drink consumption & type 2 diabetes (Cohort study in young and middle-aged women)

Sugar sweetened soft drink consumption

>1 per day

1-4 per month

2-6 per week

<1 per month

Schulze et al. JAMA 2004;292:927

Added Sugar Similar to Salt

•  Pure, white

• Makes inedible food palatable

• Only recently part of human diet

•  Sensitivity of taste receptor depends on intake

• Hidden

Hidden Sugar (tsp)

x11

x9

x7

x6

x4

x6

x5

x4

Fantastic for Public Health

Very little cost

Food industry slowly reduce - No rejection by public

No need to change diet

Hidden Salt in food e.g. processed, fast, takeaway, restaurant food

↓ BP

CASH Strategy for Reducing Salt in UK

Table/Cooking (15%)

Natural (5%)

Food industry (80%)

0.9 g

0.5 g

4.6 g

40% reduction

No reduction

40% reduction

Salt intake Reduction needed

Total 9.5 g

1.4 g

0.5 g

7.6 g

Target 6.0 g

∴ The food industry needs to slowly reduce salt content of all foods by 40% over the next 5 years by setting target for each food category

Source g/day Target intake

g/day

www.actiononsalt.org.uk

Incremental reformulation (UK)

•  Progressive salt reduction targets have been set, i.e. 2005, 2008, 2013 for over 80 categories of food

•  Gradual reduction, 10-20% a year. No rejection by public, i.e. progressive gradual reformulation

•  Continuous media publicity to ensure industry collaborate or regulate targets

https://responsibilitydeal.dh.gov.uk/wp-content/uploads/2012/01/Salt-Targets-for-Responsibility-Deal.pdf

A level playing field - all companies work to the same target

Incremental salt targets (UK) re-set every 2-3 years

Main

Product Category

2010 Targets

(g salt or mg sodium per

100g)

2012 Targets

(g salt or mg sodium per

100g)

2017 Targets

(g salt or mg sodium per

100g)

Bread

1.1g salt or 440mg sodium

(average)

1.0g salt or 400mg sodium

(average)

0.9g salt or 360mg sodium

(average)

1.13g salt or 450mg sodium

(maximum)

Salt Intake, BP and CVD Mortality in England 2003 - 2011

***

***

***

***

7

8

9

10

*

50

100

150

200

250

126

128

130

132

70

72

74

76

Deaths per

100,000 per year

Blood pressure (mmHg)

Salt intake (g/d)

(from 24h UNa)

IHD

Stroke

2003 2006 2008 2011 He et al. BMJ Open 2014; 4:e004549

* P<0.05 *** P<0.001

≈18,000 (9,000 fatal) stroke/heart

attacks prevented/yr

http://guidance.nice.org.uk/PH25

Fantastic for Public Health

Very little cost

Food industry slowly reduce salt, sugar & fat - No rejection by public

No need to change diet

Reformulation of unhealthy food e.g. processed, fast, takeaway, restaurant food

↓ BP, obesity & cholesterol

•  Liquid drinks & foods: easy to reduce

•  Solid foods: ↓portion size or add polyols or insoluble fibre)

•  Incremental targets, i.e. 10% reduction per year (e.g. 50% reduction within 5 yrs)

•  Artificial sweeteners?: Need to ↓sweetness

This will → ↓calorie intake by >100 Kcal/person/d

Incremental sugar targets like salt

•  Fat: the major calorie contributor

•  Easier than sugar (fat 2.5 x calorie/g)

•  Sat fat →↑ LDL cholesterol ∴ focus sat fat, e.g. palm oil

•  Incremental targets, i.e. 4% /yr (20% over 5 yrs)

This will → ↓calorie intake by >100 Kcal/person/d

Incremental fat targets like salt

Obesity plan by AoS for UK 2015

1.   Incremental reduction

3.   20% sugar levy (+reformulation) ─ soft drinks

Sugar (free) 50% ↓ in 5 yrs

Fat (Sat) 20% ↓

2.   Only healthy foods promoted/advertised

↓100 Kcal/person/d

↓100 Kcal/person/d

↓ 50-100 Kcal/person/d

4.   All public sector food must meet strict guidelines

5.   Uniform colour-coded labelling

UK Obesity Plan 2017 Announced by Theresa May

•  Tax on sugar-sweetened drinks (opportunity to reformulate)

•  20% voluntary sugar reformulation by 2020 (PHE) (Targets now set)

•  Will also set targets for reformulation to reduce calorie (fat reduction)

•  No further restrictions on marketing or promotion

Sugar levy 2018 Above 8 g/100 ml (8% sugar) tax 24p /L

5 to 8 g/100 ml (5-8% sugar) tax 18p /L

Less than 5 g/100 ml (<5% sugar) No tax payable

Tesco already reduced its own label drinks below 5 g/100 ml.

Suntory (Lucozade, Ribena) pledged to reduce below 5 g/100 ml.

(Not applied to either pure fruit juice or milk drinks)

Incremental reformulation

Industry must have •  Level playing field • Gradual reduction with incremental targets •  Technical knowledge & support •  Transparent reporting & analysis

Quicker

Media pressure

Politically easy

Smaller reductions

Voluntary

Initially slower

No media pressure

Politically difficult

Bigger reduction

∴ Industry needs mandated or regulated targets for level playing field

Regulation/legislation

UK industry feedback to AoS

Supermarkets & branded companies (Nestle) want mandatory targets e.g. • CEO Sainsbury’s: “We need compulsory and measured targets for the reduction of sugar & fat . Nothing less will work.…..”

•  British Retail Consortium Mandated targets

•  Nestle Regulated targets

Summary

Sugar ↓ >100 Kcal

Fat ↓ >100 Kcal

Other ↓ 50-100 Kcal (↓marketing, tax, etc)

Total >250 Kcal

Reduction in calorie intake per person per day

This will prevent obesity & type 2 diabetes