UK Sugar Reduction Targets 'Offer Huge Potential Health Boost'

Liam Davenport

April 18, 2019

An agreement between the UK government and food manufacturers to reduce the sugar content of high-sugar foods such as sweets, waffles, pancakes, and breakfast cereals could result in large reductions in diabetes and cardiovascular disease cases but only if it has the intended effect, the results of a modelling study suggest.

In 2016, the UK government published Childhood Obesity: A Plan for Action, which set a target to reduce the sugar content of high-sugar products by 20% by 2020, through working with food manufacturers.

Public Health England has proposed that children's sugar intake could be reduced by reformulating products to contain less sugar, reducing product size, and shifting sales from high- to low-sugar products.

The move complements a so-called 'sugar tax' on sugary soft drinks introduced in 2018, which imposes a graduated levy on beverages depending on their sugar content.

Potential Benefits

An analysis of the potential impact of the tax suggested that it could result in 144,000 fewer individuals with obesity, 19,000 fewer cases of type 2 diabetes per year, and 269,000 fewer decayed, missing, or filled teeth per annum.

Now, Dr Ben Amies-Cull, Centre for Population Approaches to Non-Communicable Disease Prevention, Big Data Institute, University of Oxford, and colleagues have examined the potential benefits of the food sugar reduction programme.

They used data on more than 1500 participants in a national nutrition survey to model the impact on calorie consumption, weight change, and the reduction in disease burden of the 20% target being reached.

It would lead to a reduction in the number of obese 4 to 10-year-olds of 5.5%, alongside a reduction of 2.2% among 11 to 18-year-olds, and a decrease among adults of 5.5%.

This would result in adults, in around 155,000 fewer cases of type 2 diabetes, around 3500 fewer cardiovascular disease cases, and almost 5800 fewer individuals with colorectal cancer, all at a total NHS cost saving of around £286m over 10 years.

Meeting Targets

The research, published online by The BMJ on April 17th, also suggested, however, that the potential benefit of the programme would be wiped out if one of the measures did not deliver the intended calorie reduction.

The team writes: "These findings imply that the sugar reduction programme could be an effective means of reducing obesity related illness and costs, although targets must be met."

Dr Amies-Cull told Medscape News UK that the programme is "only one policy among many, and many are going to be necessary to tackle the obesity crisis".

He said that this sort of "upstream systematic intervention" is a "really useful complement to the more traditional behavioural approach of education around diet and weight loss".

Indeed, Dr Amies-Cull believes that simply introducing a programme such as this alongside the sugar drinks tax and raising awareness around it will help people to appreciate that "sugar is a health concern in its own right".

He does not think, however, that legislation on the sugar content of foods is necessarily the best approach at this stage, but that it could follow if needed.

"I'm not sure that when you legislate broadly that policy could be sophisticated enough not to cause different problems," he said, adding that it could lead to unanticipated and unpredictable effects on consumer behaviour.

Dr Amies-Cull warned, however, that, in the absence of such legalisation, the current voluntary agreement between government and the food industry will need to be monitored closely.

"If priorities change in government or there are bigger distractions, then the benefits may disappear if we're if not careful."

Study Details

To investigate the impact of the government's sugar reduction programme, the researchers conducted a modelling study using data from years 5 and 6 of the UK National Diet and Nutrition Survey, which covers the years 2012 to 2014.

This included 1508 individuals aged 4 to 80 years who lived in England and had completed at least 3 diary days.

The researchers then assumed that the sugar programme would not result in changes in food consumption, aside from the reduction in portion sizes or sugar content of foods, and that there would be no unintended consequences.

These might include individuals swapping from one food to another due to changes in the taste of products or manufacturers altering non-targeted ingredients, such as salt.

They consequently estimated that meeting the sugar reduction targets would lead to a decrease in average energy consumption from sugar among 4 to 10-year-olds of 23.5 kcal/day in girls and 25.7 kcal/day in boys.

This equates to 7.2% and 7.0% fewer calories per day from sugar, respectively, compared with baseline.

Among those aged 11 to 18 years, girls were estimated to consume 22.4 kcal/day less on average from sugar, while boys would consume 28.2 kcal/day, or 6.3% and 6.4% fewer calories per day, respectively.

In adults, the effect was smaller, with women consuming 17.0 kcal/day and men 20.7 kcal/day less from sugar, at an equivalent of 5.0% fewer calories per day versus baseline in both men and women.

To estimate the resulting weight loss in children, the team relied on a meta-analysis of two randomised controlled trials on the effect of sugar consumption on weight gain, while standard calorie conversions were used in adults.

This showed that girls aged 4 to 10 years would lose a mean of 0.26 kg, while boys in that age group would lose 0.28 kg, at a reduction in body mass index (BMI) of 0.17 and 0.18, respectively.

This would reduce the proportion of girls classified as overweight from 26.0% to 22.5%, while the reduction in boys would be from 18.9% to 16.6%.

While the proportion of obese girls in this age group would not change, it would for boys, from 10.9% to 9.7%.

For those aged 11 to 18 years, the mean weight loss from the sugar reduction programme was estimated to be 0.25 kg in girls and 0.31 kg in boys, at a mean reduction in BMI of 0.10 and 0.11, respectively.

This would translate into a reduction of overweight from 19.2% to 18.6% in girls but would remain unchanged in boys. While the proportion of obese girls would stay the same, it would fall among boys from 13.6% to 13.0%.

Adults would see a greater impact on their weight from the sugar reduction programme, at an average weight loss of 1.77 kg, or a fall in BMI of 0.67, in women, and a loss of 1.51 kg, or a reduction in BMI of 0.51, in men.

This would reduce the proportion of overweight women from 32.1% to 30.8%, the proportion of obese women from 17.3% to 15.4%, and that of very obese women from 9.8% to 9.0%.

The proportion of overweight men would fall from 42.3% to 40.8%, while it would decrease from 18.4% to 17.3% for obese men, and from 7.3% to 5.4% for very obese men.

Impacts

Using a chronic disease impact model derived from the 2014 England population aged 18 to 80 years, the team found that these changes would have a greater impact on the health of women than men.

Over 10 years, women would save a total of 27,885 quality adjusted life-years (QUALYs) from the sugar reduction programme, while man would save 23,874 QALYs.

This would translate into 89,571 fewer cases of diabetes over 10 years in women and 64,979 fewer cases among men, albeit at the cost of a slightly increased incidence of lung and gastric cancer due to increased longevity.

There would also be 1920 fewer cases of cardiovascular disease in women and 1591 fewer cases in men over 10 years, as well as 1573 fewer cases of colorectal cancer in women and 4220 fewer cases in men.

The number of cases of cirrhosis would also decrease over 10 years, at 2982 fewer cases in men and 2620 fewer cases in women, while women would also experience 2872 fewer cases of breast cancer.

Taken together, these changes would lead to a saving in the national healthcare budget of £285.8 million over 10 years, of which £161.6 million would be in costs relating to women and £124.2 million relating to men.

This cost saving would increase to £1.56 billion by 30 years and £2.71 billion by 100 years, with the intervention having a greater effect in women over time due to reduced disease burden and healthcare costs.

The team point out, however, that sensitivity analyses revealed that the failure of product reformulation, portion reduction or sales shifts to reduce calorie intake would reduce the impact on disease prevention in proportion to the attenuated reduction in calorie intake.

In an accompanying editorial, Annalijn Conklin, assistant professor, Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver,  Canada, says that the authors are "right to caution" that the benefits will only be seen if both consumers and industry respond "as predicted".

She continued: "Full implementation as predicted would be more likely if the food industry was already working to reformulate, reduce, and shift sales before the UK government published its programme."

Annalijn Conklin warned however that, if any changes in sugar consumption or health outcomes can be attributed to behavioural shifts that predate the current agreement, the "public health collaboration on sugar reduction may be doomed to fail anyway as long as food companies can make profits out of selling unhealthy foods".

Moreover, sugar reduction will need to be sustained long term to provide the projected gains in quality of life and reduced healthcare spending, "which will require vigilant and continuous monitoring by both the UK government and civil society organisations".

Such sustained reductions, Annalijn Conklin suggests, will require a mixture of incentives and sanctions for industry; "otherwise, the aim of a healthier nation will not be realised through less sugar in children's food".

The study was partly supported by the National Institute of Health Research Biomedical Research Centre at Oxford.

Amies-Cull was supported by grants from the National Institute of Health Research and Medical Research Council; Adam D M Briggs was supported by grants from the Commonwealth Fund, National Institute of Health Research, and Wellcome Trust; and Peter Scarborough supported by grants from the British Heart Foundation and National Institute of Health Research.

BMJ 2019;365:l1417 doi: 10.1136/bmj.l1417

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