56.A key recommendation of Public Health England’s review is the “introduction of a broad, structured and transparently monitored programme of gradual sugar reduction in everyday food and drink products, combined with reductions in portion size”. The review gives further detail:
We know that most of our food choices are routine or habitual. The sugar content of food remains high despite some work by industry on a small number of foods and we know that ‘healthy’ ranges of products, including those that supply much of our sugar intakes, will only ever have limited appeal …. A structured sugar reformulation programme could lead to a significant reduction in sugar consumption. The evidence showed if the sugar content of soft drinks was reduced by half, the sugar consumption of children under 10 and adults over 19 would decrease by 5g and for those in between, 11g.
57.The PHE report does not give a view on whether this reformulation programme should be voluntary or mandatory. We heard arguments on both sides from our witnesses. In our view a compelling argument was made by the British Retail Consortium, who expressed the need for a level playing field, and for clear leadership from the Department of Health:
If you go down the route of something like reformulation, which we have done in salt, you have to carry everyone with you, first of all to be effective as a policy, so that whichever outlet you go into you are getting the same kind of food or the same kind of reformulation; but also because in some ways some of the voluntary initiatives that many of our members have been engaged in have penalised them against other companies who have decided, because it is a voluntary initiative, not to play their part ….What we said to the Department of Health then was that if there is no proper engagement policy from the Department of Health to drive all companies into it, it will not be an effective policy. Therefore, you may need to look at other methods of driving this through. Depending on the evidence, regulation could possibly be one of the ways to do that.
58.Susan Jebb, Chair of the voluntary Responsibility Deal, made similar comments:
It comes back to being absolutely clear, and being prepared to act, and acting, when the voluntary action does not come up to the mark. That has also been absent. There has not been much stick around. To reflect on the responsibility deal, we have to ask what the incentives are for companies to take part; frankly, there were very few. What are the disincentives for those who stay out of it? Frankly, there were none at all. We have to work that bit through much harder.
59.The salt reformulation programme was given as an example of a successful reformulation programme, the model of which could be adopted for sugar reformulation. Indeed the PHE evidence review includes a case study giving details of the key approaches to working with industry to reformulate foods and reduce salt levels. Witnesses argued that this programme had clear and decisive leadership from a Government regulatory body, the Food Standards Agency, something which it was suggested to us has been missing from the previous Government’s efforts to encourage reformulation through the Responsibility Deal. Professor Simon Capewell of the Faculty of Public Health called it “soft regulation”—centrally led by Ministers and the food regulator with the clear threat of regulation in the case of non-compliance.
60.In its recommendation, Public Health England does not reach a clear conclusion on whether a reformulation programme should be with or without sugar replacements. This was highlighted by Alison Tedstone as a key question, linked to how quickly reformulation should take place:
The thing that really needs thinking about is how quickly reformulation should take place. We know that if you take the salt approach, which is an adaptive model so that as a nation we all gradually adapt our taste buds, that is quite a long-haul thing. If, however, you were to accept that artificial sweeteners are a useful component of this, you can take much bigger steps. You can quite easily take out substantial amounts of sugar using artificial sweeteners.
61.Again, we heard arguments on both sides of this debate. Some witnesses advocated an ‘adaptive’ model, where levels of sugar are reduced and products taste progressively less sweet, rather than being replaced with artificial sweeteners, which reduces sugar, whilst maintaining sweetness. They argued that the human palate adapts very quickly to less sugary tastes, and that as people’s palates adapt to less sweet foods and drinks, they will want them less, reducing overall consumption of sugar. They also suggested not enough is known about the long term health implications of artificial sweeteners to advocate their widespread use as a replacement for sugar.
62.Others, however, argued that the use of artificial sweeteners where possible to replace sugar would enable reformulation to proceed far more swiftly, leading to earlier health gains. According to Public Health England, most sugar reformulation to date has followed this model. This is in contrast to the salt reformulation programme:
The salt case study shows that the gradual changes made to the salt content of food, without replacement with lower-sodium alternatives, have gone largely unnoticed by consumers and have led to an adjustment in the nation’s palate towards a generally lower salt taste in the food that we buy. For example, since the 1980s the salt level in bread has been reduced by over 40%, with around a 10% reduction made in just the last three years, but it continues to be a staple part of our diet.
The food industry response to sugar reduction has, so far, been different—sugar levels in products have been reduced in larger steps, potentially through the aim to make a claim on pack about the change that has been made—and the sweetness has generally been maintained through the addition of no/low calorie sweeteners. Sweeteners can help to reduce the sugar content of foods, and the number of calories present and can also make a food or drink less harmful to teeth. Although sweeteners are safe some consumers remain concerned about their use.
[Our literature review of ‘sweetness’] confirmed that we have an innate desire for sweet foods, which seems to be heightened in childhood relative to later life. While there is evidence of the ability of the palate to adapt to a lower salt taste, the review found only one paper in relation to adaptation of palates to sugar. Personal reports, however, suggest that it is relatively easy to adapt to a less sweet taste, such as giving up sugar in tea or coffee. In addition, while this is not considered within the review, some soft drinks manufacturers have informally reported that consumers do not seem to detect reductions of around 4% in the sugar content of drinks, where these have not been replaced with sweeteners …..
….. This ‘adaptive’ approach would also suit some people’s preferences to avoid no/low calorie sweeteners, but would need to be weighed against the fact that larger step reductions in the sugar content of some products could be achieved sooner with their use.
63.Witnesses also argued that reformulation should not be confined to sugar levels, but should be extended to include fat, which is a major source of calories.
64.We endorse PHE’s recommendation of “a broad, structured and transparently monitored programme of gradual sugar reduction in everyday food and drink products.” There are arguments both for and against the use of artificial sweeteners in a sugar reformulation programme. We recommend that the Government’s sugar reformulation programme should aim to reduce levels of overall sweetness, but such a programme could also include the use of artificial sweeteners where possible, given the potential to achieve reductions in sugar consumption more quickly through their use.
65.We heard that the Food Standards Agency played a leadership role which was instrumental in the success of the salt reformulation programme, but that similar firm and decisive leadership has not yet been provided for sugar reformulation. We recommend that the sugar reformulation programme should be strongly led from the centre of Government and transparently and regularly monitored. A voluntary approach should be adopted with the clear proviso that if the industry does not respond comprehensively and swiftly to voluntary sugar reduction targets then regulatory action will quickly follow. Industry needs a level playing field in order to reformulate products in a way which improves health without advantaging those businesses which fail to act responsibly.
67.We also heard that the portion size of unhealthy foods is an important area for action in reducing calories. Alison Tedstone told us:
I am very worried that we are beginning to see practices that we commonly see in the States coming into the UK; for example, we are now seeing bottomless cups in some restaurants. We are seeing the default offer for portion sizes of sugary drinks in the out-of-home sector becoming bigger and bigger. There has been some success with voluntary systems on that, but very little. Portion size is part of the mix, things like bags of crisps. A single bag of crisps now is substantially larger than 15 years ago, and I do not think many of us leave those few crisps at the bottom of the packet.
68.Susan Jebb added that manufacturers need central guidance on portion size, and pointed to the success that has been achieved in limiting portion size in chocolate bars:
Manufacturers will certainly tell you that most bags of crisps are sold in multipacks […] which are about 25 grams per bag. Yet if you are at the railway station or the newsagents the individual bags you buy are 35 grams, 40 grams and sometimes even 50 grams. If most crisps are being sold in 25-gram bags, why aren’t they all 25-gram bags? There is a whole raft of products where, if we were really clear about what the ask was, we could perhaps start marshalling more support around that. It still has the caveats for voluntary that I expressed before, but we could do more. The fact that, with single bars of confectionery, the three big chocolate manufacturers have all committed to them being fewer than 250 calories shows we can make these stepwise changes.
69.Public Health England give more detail in their review:
Price setting for different portion or pack sizes may be incentivising the purchase of larger volume products as the larger pack size appears to represent substantially better value for money eg soft drinks in quick-service restaurants.
Evidence on trends in portion size in the UK is limited but reviews of the available data suggest that for some product types (such as fast foods and ready meals) there is evidence of increasing portion size over time. A recent Cochrane review and meta-analysis found that increasing portion sizes results in more calories being consumed and estimated that eliminating larger-sized portions from the diet completely could reduce energy intake by up to 16% among UK adults. A cap on portion sizes for relevant foods in both the retail and out of home sectors is, therefore, a clear way of reducing both sugar and calorie intake. There are some good examples of work in this area, such as the reduction in size of some chocolate bars to provide fewer than 250 calories per bar, but further work could be done to reduce these as well as additional work to tackle the ubiquitous large portion sizes that remain.
70.They give further evidence in relation to fruit juices, where Public Health England have issued guidance that children should drink no more than 150ml of fruit juice per day, owing to its high sugar content:
Challenges remain around the adoption of the portion size recommendation for fruit juice. Large cartons generally make it difficult to know the size of a portion without measuring it and small cartons (aimed at the lunchbox market) predominantly contain more than the [recommended] 150ml (generally around 200ml). There is an opportunity for industry to make it easier for parents to give their children just the recommended 150ml portion whether this is by marking portion sizes on the side of cartons or other uses of labelling to highlight this; or by reducing the size of small cartons to correspond with the recommended portion size.
71.We heard that portion sizes for high fat, salt and sugar foods and drinks, including crisps, and sugary drinks in the out-of-home sector, are becoming larger and larger, with (as mentioned above) the introduction of ‘bottomless cups’ in restaurants. We agree with Public Health England that a cap on portion sizes for relevant foods and drinks in both the retail and entertainment sectors is a clear way of reducing both sugar and calorie intake, and we recommend that caps on portion sizes linked to the calorie content of certain foods and drinks should be introduced. As with the reformulation programme, action to introduce portion caps should be should be strongly led from the centre of Government and transparently and regularly monitored. A voluntary approach should be adopted with the clear proviso that if the industry does not respond comprehensively and swiftly then regulatory action will quickly follow, to ensure industry has a level playing field.
60 “New evidence review of measures to reduce sugar consumption”, Public Health England , 22 October 2015
67 Q27, Q19
70 Q8, Q217
71 That is, free refills
Prepared 27 November 2015