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Obesity- Tipping Back the Scales of the Nation 19th April, 2017
- 1. Charlotte Evans Lecturer in Nutritional Epidemiology, Leeds University
- 2. Curbing the Nation’s Sweet Tooth Dr Charlotte Evans c.e.l.evans@leeds.ac.uk Lecturer in nutritional epidemiology & public health nutrition Nutritional Epidemiology Group, School of Food Science and Nutrition, University of Leeds Obesity: Tipping back the Scales of the Nation, Manchester, 19th April, 2017 2
- 3. History of sugar consumption 50kg per year/person is equivalent to approx. 130g per day or 500kcal per day
- 4. Sources of sugars 27 25 20 11 0 20 40 60 80 100 120 Other Savoury food Dairy Alcohol Biscuits& cake Softdrinks Sweets Definitions • Free sugars • Non-milk extrinsic sugars • Added sugars
- 5. Risk factors for Cardiovascular disease Associated with higher risk of CVD High blood sugar/type 2 diabetes mellitus High Tryaclglycerol (TAG) Obesity High blood pressure
- 6. Objectives: 6 1. To review the evidence that free sugars promote weight gain 2. To discuss the most effective ways of reducing consumption of free sugars in the UK
- 8. Systematic review of trials Effect of increasing free sugars on measures of body fatness in adults. Te Morenga L et al. BMJ 2013;346:bmj.e7492 ©2013 by British Medical Journal Publishing Group
- 9. Diets higher in sugars increase energy intake 9 Overall (I-squared = 0.2%, p = 0.422) Brynes AE, et al., 2003 ID Saris WH, et al., 2000 Drummond S, et al., 2003 Raben A, et al., 2002 Drummond S & Kirk T, 1998 Reid M, et al., 2007 Study Poppitt SD, et al., 2002 1274.52 (888.76, 1660.27) 880.00 (-314.62, 2074.62) difference in means (95% CI) 1100.00 (387.70, 1812.30) 1000.00 (-403.12, 2403.12) 2796.00 (1442.83, 4149.17) 845.00 (-635.95, 2325.95) 1315.07 (673.75, 1956.39) Weighted 1470.00 (-1300.89, 4240.89) 1274.52 (888.76, 1660.27) 880.00 (-314.62, 2074.62) difference in means (95% CI) 1100.00 (387.70, 1812.30) 1000.00 (-403.12, 2403.12) 2796.00 (1442.83, 4149.17) 845.00 (-635.95, 2325.95) 1315.07 (673.75, 1956.39) Weighted 1470.00 (-1300.89, 4240.89) Higher EI with low sugar Higher EI with high sugar 0-2000 -1000 0 1000 2000 3000 4000 5000 Difference in Energy Intake (KJ/day) between groups: low sugar diet vs high sugar diet See supporting documents from the SACN carbohydrates and health report: https://www.gov.uk/government/publications/sacn-carbohydrates-and-health-report
- 10. Sugar sweetened beverages (SSB)
- 11. Weighted mean differences (95% CI) in weight change (kg) between the intervention and control regimens from randomized controlled trials in adults. Malik V S et al. Am J Clin Nutr 2013;98:1084-1102 ©2013 by American Society for Nutrition
- 12. Sugar Sweetened Beverage (SSB) consumption and risk of type 2 diabetes, Reference - Association between sugar-sweetened and artificially sweetened soft drinks and type 2 diabetes: systematic review and dose–response meta-analysis of prospective studies, Greenwood et al. (2014) British Journal of Nutrition
- 13. Recommendations around the world German Nutrition Society, Germany: High consumption of sugar-sweetened beverages increases the risk of obesity & type 2 diabetes mellitus High dietary fibre intake, mainly from whole-grain products, reduces the risk of obesity, type 2 diabetes mellitus, & cardiovascular disease . WHO: Review of sugars and obesity. Honey, syrup and fruit juice are now included in added sugar. New ideal target of free sugars <5% of energy. European Food Safety Authority (EFSA): Have not updated their recommendations recently (45-60% of energy as carbohydrate, 25g of fibre). Insufficient evidence to set an upper limit on added sugar intake 13 UK: Has recently updated recommendations for carbohydrates and cardio-metabolic health. Fibre recommendation has increased to 30g AOAC (from approx 25g) and sugar has reduced from 10% to 5% total energy (population intake). Fibre intakes are well below recommended and sugar intakes are over twice the recommended levels. USA: Maximum upper limit on added sugars of 25%, high fibre intakes recommended are double the average intake. Wholegrain foods are encouraged. Australia and New Zealand: Recommendations (for adequate intake) are 25g of fibre for women and 30g fibre for men. Dietary recommendation for sugar is to limit intake.
- 14. Carbohydrates: recommended & consumed Nutrient Old UK Recommendation New 2015 UK recommendation UK* consumption Energy intake KJ/kcal Women 9MJ/day (2000kcal) Men 11MJ/day (2500kcal) Women 8.7 MJ/d (2079kcal/d) Men10.9 MJ/d (2605kcal/d) Men 8.86 MJ/day (2107 kcal/day) Women 6.71 MJ/day (1595 kcal/day) Total carbohydrate 50% of energy 50% of energy ~50% Fibre – AOAC/non starch polysaccharides (NSP) 25g/18g 30g/25g 18/13g Non milk extrinsic (added) sugars 10% of total energy (including alcohol) 11% of food energy 5% of total energy (population) 12.3% 14 Recommendation for Sugar sweetened beverages (SSB) is to reduce intake but no specific acceptable intake provided *NDNS rolling programme 5-6 year summary 2012-2014
- 15. British Nutrition Foundation meal planner (30g AOAC fibre & 5% free sugars) 15
- 16. Public Health England (PHE) https://www.gov.uk/government/publications/sugar- reduction-from-evidence-into-action 16
- 17. Obesity prevalence by deprivation decile and year of measurement National Child Measurement Programme 2006/07 to 2014/15 17Patterns and trends in child obesity Child obesity: BMI ≥ 95th centile of the UK90 growth reference Children in Year 6 (aged 10-11 years) 0% 5% 10% 15% 20% 25% 30% Most deprived Least deprived Obesityprevalence Index of Multiple Deprivation (IMD 2010) decile 2006/07 2007/08 2008/09 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15
- 18. 8 areas for action from PHE 1.Reduce price promotions (supermarkets) 2.Reduce marketing (food industry)* 3.Clarity with nutrient profiling (PH Nutritionists) 4.Reformulation and reduced portion sizes (food industry, restaurants/cafes)* 5.Sugar tax (government)* 6.Improved buying standards (government) 7.Accredited training (various) 8.Raise awareness of health issues and provide practical steps to help reduce sugar (nutritionists, media)*
- 19. Reducing advertising is effective
- 20. SALT Changes in salt intake as measured by 24 h urinary sodium excretion (UNa), blood pressure, stroke and ischaemic heart disease (IHD) mortality in England from 2003 to 2011. *p<0.05, ***p<0.001 for trend. Feng J He et al. BMJ Open 2014;4:e004549 Reformulation is effective TRANS FATS Percentage of the population meeting the recommended intake of 2% of energy (UK recommendation) has increased (using national diet and nutrition survey data): • In adults the percent meeting the recommended levels for trans fats has increased from 96.0% (in 2001) to 99.5% • In children and young people the percent meeting the recommended levels for trans fats has increased from 98% (in 1997) to 99.5%. We are submitting results from the national diet and nutrition survey (NDNS) comparing trans fats intakes with the WHO recommendations of 1% of total energy – watch this space!
- 21. Reducing portion sizes ↓energy intake
- 22. Suggested ideas to reduce portion size
- 23. Effect of taxes and subsidies (%) on consumption of the target food/nutrient (%). Anne Marie Thow et al. Nutr Rev 2014;72:551-565 © 2014 International Life Sciences Institute SSB Taxing high sugar/fat foods is effective
- 24. Raising awareness: information How much sugar in the whole bottle?
- 25. Conclusions • High intakes of free sugars, particularly in drinks, promote weight gain and type 2 diabetes • New recommendations for intakes of free sugars are tough to meet • Action is needed from everyone (the food industry, supermarkets, restaurants, dietitians, public health nutritionists, government and the media) and has not gone far enough (yet) to curb the nation’s sweet tooth • Some progress has been made (percent free sugars has reduced from 14.4% to 13.4% in children) • We need to prioritise action that will reduce inequalities in diet and health (even if it means starting with more unpopular policies).
- 26. 26 Contact me on: c.e.l.evans@leeds.ac.uk Thank you and thanks also to my colleagues at the University of Leeds Dr Victoria Burley (Nutritional Epidemiology) Dr Darren Greenwood (Biostatistics) Professor Marion Hetherington (Psychology) Professor Janet Cade (Nutritional Epidemiology)
- 27. Fig 5 Isoenergetic exchanges of free sugars with other carbohydrates or other macronutrient sources. Te Morenga L et al. BMJ 2013;346:bmj.e7492 ©2013 by British Medical Journal Publishing Group
- 28. Weighted mean differences in BMI change (95% CI) between the intervention and control regimens from randomized controlled trials in children. Malik V S et al. Am J Clin Nutr 2013;98:1084-1102 ©2013 by American Society for Nutrition
Editor's Notes
- Europe starting importing raw cane sugar, processing it into white sugar in the 1300s then started extracting sugar from beet in 1700s Sugar intake was low until it became a modern and highly efficient sector at the beginning of the 19th century. Sugar intake increased until about 1990 then started to decrease. There are other countries that eat more sugar than in the UK – USA, Germany, the Netherlands.
- Shows the main contributors to added sugars in our diet in the uk. We are talking about added sugars or free sugars in this talk not sugars in fruit.
- Main risk factors for CVD associated with diet: High blood pressure High Lipids High blood sugars, insulin sensitivity obesity -but 10% of this mortality decrease was attributed to a relatively modest improvement in average cholesterol levels of 4% Indicating that CHD rates could poss be improved if cholesterol levels are improved in the general population High blood pressure accounts for half of the cvd risk – according to the global burden of disease Worsening obesity, physical activity and diabetes levels (1981-2000) estimated to have contributed to 8,000 more deaths
- What is the scientific evidence for including advice on sugars for good health?
- What is the scientific evidence for including advice on sugars for good health?
- Fig 4 Effect of increasing free sugars on measures of body fatness in adults. Pooled effects for difference in body weight (kg) shown for studies comparing increased intake (higher sugars) with usual intake (lower sugars). Overall effect shows increased body weight after intervention in the higher sugars groups. Data are expressed as weighted mean difference (95% confidence interval), using generic inverse variance models with random effects
- The recent recommendations from the Scientific advisory committee for nutrition (SACN) reduced the recommendations for sugars based on the systematic review and the associations with energy intake. There isn’t a review on sugars demonstrating risk with other risk factors for CVD such as blood pressure (check).
- Weighted mean differences (95% CI) in weight change (kg) between the intervention and control regimens from randomized controlled trials in adults. Interventions evaluated the effect of adding sugar-sweetened beverages. Horizontal lines denote 95% CIs; solid diamonds represent the point estimate of each study. Open diamonds represent pooled estimates of the intervention effect, and the dashed line denotes the point estimate of the pooled result from the random-effects model (D+L). Weights are from the random-effects analysis (D+L). Pooled estimates from the random-effects analysis (D+L) and the fixed-effects analysis (I-V) are shown based on 5 randomized controlled trials (n = 292). The I2 and P values for heterogeneity are shown. D+L, DerSimonian and Laird; I-V, inverse variance.
- A: Forrest plot of studies evaluating SSB consumption and risk of type 2 diabetes, comparing extreme quantiles of intake. Random-effects estimate (DerSimonian and Laird method). *Information from personal communication. B: Forrest plot of studies evaluating SSB consumption and risk of metabolic syndrome comparing extreme quantiles of intake. Random-effects estimate (DerSimonian and Laird method).
- Different regions of the world have different recommendations but those that have updated their recommendations recently have reduced recommended sugar intake and increased fibre intake.
- The current recommendations for sugar intake are 5% of total energy (population average) which is reduced from 10%. This is the equivalent of 25g (contributing 100kcal) for a 2000kcal/day diet
- It is difficult to meet the fibre and free sugar recommendations. This diet is a long way from the typical diet of most people in the UK.
- Public Health England have published a report with details on how to reduce sugar consumption. One of the main remits for PHE is to reduce inequalities in health. Therefore it is important that policies do not widen inequalities which is what will happen if they are more effective in those with the best diets compared to those with the worst diets.
- How successful has nutrition policy been so far? I would say that it has failed. Inequalities in health have widened. Obesity rates continue to soar for children in low income families. The United Nations has reported that our austerity measures are a breach of human rights as they have encouraged more people to use food banks because they don’t have enough money to feed their families. The inequalities gap in child obesity appears to be widening. Prevalence of obesity shows a pattern of increase over time among the most deprived Year 6 children (age 10-11 years) whereas prevalence has remained relatively stable or is decreasing among the least deprived children. The United Nations has reported that our austerity measures are a breach of human rights. The deprivation deciles in this analysis have been assigned using the LSOA of residence of children measured. Data source: Health and Social Care Information Centre, http://www.hscic.gov.uk/ncmp.
- There are 8 areas for action from public health England but I am only going to cover 4 of these where I think the evidence is the strongest.
- There is encouragement from WHO to reduce marketing of unhealthy foods, particularly to children. There is evidence that marketing increases consumption of high fat, high sugar foods both in the short term and the long term.
- Improvements in salt and trans fats have both come about with changes in reformulation. Reformulation could therefore be useful for reducing sugar consumption. Changes in salt intake as measured by 24 h urinary sodium excretion (UNa), blood pressure, stroke and ischaemic heart disease (IHD) mortality in England from 2003 to 2011. *p<0.05, ***p<0.001 for trend.
- Effect of taxes and subsidies (%) on consumption of the target food/nutrient (%). Numbers in figures correspond to reference numbers. Data are presented only for studies that presented the following: 1) subsidies and taxes as a percentage, and 2) findings of effect as percent change in consumption of target food, nutrient, or calories. Details on all foods and study populations are found in Appendix 1.A: Subsidies for healthy foods.15,22,25,32,33,50,54B: Taxes and subsidies on sugar-sweetened beverages. Subsidies appear as negative taxes, i.e., a subsidy of 10% appears here as a tax of −10%.8,19,20,21,26,40,46,42,24,18,43,23C: Taxes on individual nutrients (fat, salt, sugar).25,30,35,41,45D: Taxes based on nutrient profiling.16,17,43,44,49,50,53,55*Nonsignificant.
- If providing information is confusing it risks only changing the diets of those who are educated. In this example, how much sugar is in the whole bottle? 5.2g x 4.4 = 23g More information is not always better – e.g. flying on a plane, I don’t want the pilot to tell me what is ahead!
- Fig 5 Isoenergetic exchanges of free sugars with other carbohydrates or other macronutrient sources. Pooled effects for difference in body weight (kg) for studies comparing isoenergetic exchange of free sugars (higher sugars) with other carbohydrates (lower sugars). Data are expressed as weighted mean difference (95% confidence interval), using generic inverse variance models with random effects
- Weighted mean differences in BMI change (95% CI) between the intervention and control regimens from randomized controlled trials in children. Interventions evaluated the effect of reducing sugar-sweetened beverages. Horizontal lines denote 95% CIs; solid diamonds represent the point estimate of each study. Open diamonds represent pooled estimates of the intervention effect, and the dashed line denotes the point estimate of the pooled result from the random-effects model (D+L). Weights are from the random-effects analysis (D+L). Pooled estimates from the random-effects analysis (D+L) and the fixed-effects analysis (I-V) are shown based on 5 randomized controlled trials (n = 2772). The I2 and P values for heterogeneity are shown. D+L, DerSimonian and Laird; I-V, inverse variance.