Nutrition strategy and policy: what does the future hold?

Britain continues to lead the way in the provision of information for consumers on the composition of the foods they buy. The most recent developments concern provision of calorie information on menus and at point of choice in restaurants, following the lead of the pioneering work in New York, USA. This Food Standards Agency (FSA) initiative is in its early days and it remains to be seen how successful this approach will be in Britain because of the challenges described in the article in this issue by Bridget Benelam (pp. 289–290). Another recent development is the publication by the FSA of the independent research it has funded on front of pack (FOP) signpost labelling, which combined qualitative and quantitative phases. The research focused primarily on three key content-related signposting elements: traffic light colours, interpretative text (high, medium, low) and per cent guideline daily amount (GDA). The history to the research is that in March 2006, the FSA recommended that businesses adopt a voluntary FOP nutrition labelling approach, using traffic lights to interpret nutrient levels, on seven categories of food (sandwiches and similar products; ready meals (hot and cold); burgers and sausages; pies, pastries and quiches; breaded, coated or formed meat/poultry/fish; pizzas and breakfast cereals) (http://www.food.gov.uk/news/newsarchive/2006/mar/signpostnewsmarch). This scheme has since been taken up by some retailers, whereas others have chosen to adopt a format that provides information in terms of per cent GDA (see http://www.gdalabel.org.uk) and some have developed hybrid schemes with both sets of features. The aim of the research was to establish which FOP labelling scheme or which combination of elements of schemes best facilitates the accurate interpretation of key nutritional information by consumers, such that they are assisted in making informed choices about the foods they purchase. The research addressed three key questions. First, how well do individual schemes (or elements of schemes) enable consumers to correctly interpret levels of key nutrients? Second, how do consumers use FOP labels in real-life contexts in the retail environment and at home? And third, how does the coexistence of a range of FOP label formats affect accurate interpretation of FOP labels? The research found that levels of comprehension of the different formats tested are generally high (ranging from 58% to 71% when looking at labels on single products), but two formats were particularly favourable. One combined text (the words high, medium, low), traffic light colours and per cent GDA. This achieved comprehension of 70% and was one of the top two preferred formats. The other, with a comprehension of 71%, combined text and traffic light colours. The researchers reported that the balance of evidence favoured the combination of GDAs, traffic light colours and text – sometimes referred to as the hybrid format as it combines the FSA's traffic lights format with provision of GDAs information. The hybrid format is already used by several major retail chains. Expressed preference alone for a particular format was not a reliable indicator of ability to comprehend the information provided. Although provision of energy (calorie) information is not a prerequisite of the FSA traffic lights scheme, it is used in some current formats. The research found that although some shoppers do use energy information to decide how healthy a product is, the inclusion of energy has no effect on comprehension. Older adults (over 65), people from social classes C2, D and E, and those with lower educational attainment were less likely to be able to accurately interpret FOP labels. Also, some minority ethnic group included in the research had difficulty interpreting FOP labels, although the sample size was small. Although FOP nutrition information is valued by those who use it, other factors are also of considerable importance in determining purchasing decisions, such as price, brand loyalty, whether the product is considered to be a treat or a staple, information such as the appearance of the product and other packaging information indicating, for example, that it is part of a healthy range or organic. Shoppers were most likely to use the information when buying a product for the first time, comparing between different products, when shopping with children and when trying to control intake of particular nutrients or lose weight. In the research, the co-existence of a range of FOP formats in the marketplace was a negative factor in relation to consumer comprehension. But the researchers concluded that the generally high levels of comprehension, even among those who do not usually use FOP labels, provide a good starting point from which to address barriers to FOP label use. The findings of the research will be presented to the FSA Board and this will be followed by a formal consultation process. Meanwhile, the European Union (EU)-funded project Food Labelling to Advance Better Education for Life (FLABEL; http://www.flabel.org) released its first results in April 2009, which revealed that GDA labelling is now widespread across Europe (traffic light labelling has been a UK phenomenon). Over a period of 6 months, an audit was conducted to determine the penetration of nutrition labelling in Europe in 28 countries (27 EU member states plus Turkey). The audit included more than 37 000 products and recorded the number of products with nutrition information on pack (front or back), the main systems in use in each country, the prevalence of nutrition and health claim usage, and the prevalence of nutrition information on products that are attractive to children. FOP nutrition information appeared on 82% of products in the UK (the highest level across the survey) compared with a European average of 48%; GDA information was found on 63% of products in the UK (the highest level in the survey) compared with a European average of 25%. The lowest level was 2% in Turkey. On average, 85% of the products audited provided nutrition information on the back of pack, ranging from 70% for Cyprus and Slovenia to more than 95% for Ireland, the UK and The Netherlands. Nutrition claims were present, on average, on 25% of the products audited, ranging from 12% in Estonia to 37% in Ireland and Portugal. Nutrition claims and GDAs were the most prevalent nutrition information on the FOPs. The next stages in this 3-year project will be looking at use and comprehension of nutrition labelling formats across Europe and how nutrition information on food labels affects dietary choices and consumer habits. GDAs were developed by the Institute of Grocery Distribution (IGD) in 1998 in collaboration with the government, consumer organisations and the food industry. They were initially developed for calories, fat and saturates for men and women, and were subsequently reviewed and extended to include total sugars, carbohydrate, protein, fibre, salt and sodium (http://www.igd.com). GDAs have also been developed for foods designed specifically for children. The GDA value identified for total sugars, 90 g, has been controversial. The thinking behind a total sugars approach was that the EU labelling law requires total sugars to be calculated and displayed (European Council Directive No. 90/496/EEC); non-milk extrinsic (‘added’) sugars – the other obvious alternative option – cannot be distinguished analytically from other sugars and are not defined in the labelling law; and all forms of sugar contribute to energy intake (see the article by Caswell 2009 in this issue, pp. 273–288). For application of traffic light labelling for the sugars content of foods to the seven categories recommended by the FSA for its FOP labelling scheme, the FSA decided to opt for a lower value of 60 g. Although this value works as a discriminator in foods in which the sugars are predominantly ‘added’ sugars (those targeted for reduction in the diet), if applied to fruit-based or dairy-based foods (in which the sugars are entirely or predominantly naturally present and not targeted for reduction in dietary guidelines), the outcome may result in confusion for consumers. At the European Commission's (EC) request, the European Food Safety Authority's (EFSA) Panel on Dietetic Products, Nutrition and Allergies (NDA) was asked to provide an opinion on this and other GDAs (labelling reference values). In May 2009, EFSA published its scientific opinion on labelling reference intakes for energy (2000 kcal, 8400 kJ), total fat (70 g), saturates (20 g), total carbohydrates (260 g), salt (6 g) and sugars (90 g), hence agreeing with the 90 g figure for total sugars suggested by the IGD (EFSA 2009). EFSA's NDA Panel commented that 90 g corresponds to 18%E for a 2000 kcal diet, which is at the lower end of the range of average intakes of total sugars in adults in EU countries (about 17%E–26%E). Furthermore, they stated that it has been estimated that sugars naturally present in fruits, vegetables, cereals and dairy products provide about 45 g for adults; assuming the remaining 45 g (up to the proposed 90 g) are added sugars, this would correspond to 9% of energy intake for a 2000 kcal diet, which is below the 10%E upper limit set in the UK in 1991 in the Dietary Reference Values report (DH 1991). With the exception of the total carbohydrates GDA (which is 230 g in the IGD set of values), the EFSA values are in total agreement with the IGD values. The decision to opt for a slightly higher carbohydrate value was to bring it into line with the lower limits of intake of carbohydrate (50%E–55%E) recommended for individuals in the general population in EU countries and by other authorities. A value of 260 g corresponds with 52%E for a 2000 kcal diet. GDAs are also under discussion in the context of the proposed Food Information Regulation that will replace the Food Labelling Directive in due course. Progress with the draft regulation has been delayed by the European Parliamentary elections but the initial draft recommended GDA-based FOP labelling. In this issue of Nutrition Bulletin, a paper by Roodenburg and colleagues describes another approach to on-pack information provision, namely the development and introduction in The Netherlands of the Choices Programme, in which foods that meet a series of nutrient criteria qualify to carry a ‘healthier option’ logo (pp. 318–323). In the UK, in response to the Cabinet Office's Food Matters report published in 2008 (http://www.cabinetoffice.gov.uk), consideration is being given to developing a ‘healthier food mark’, to be used specifically in public sector canteens. The new kite mark, being developed by the Department of Health, would be awarded to catering companies operating in the public sector (e.g. hospitals, prisons, armed forces). Unlike the approaches advised by government for the private sector, for example, traffic light labelling, the draft criteria for the ‘healthier food mark’ also include a hygiene criterion and a sustainability criterion (procuring environmentally sustainable food), as well as nutritional criteria (ingredients that are lower in saturates, salt and sugar, and menu design) (http://nds.coi.gov.uk/environment/fullDetail.asp?ReleaseID=373041&NewsAreaID=2&NavigatedFromDepartment=True). In May 2009, the FSA published its revised salt targets for 2010 and 2012, after a review of the existing targets during 2008. In most cases, there has been no change to the levels proposed in the 2008 review. Considerable progress in salt reduction has already been achieved in the manufacturing and retail sectors in particular, reflected in reductions in average urinary sodium levels in the population, and so the new targets will be technically challenging. In launching the new targets, the FSA emphasised the reductions that had already been achieved across the food industry: the average amount of salt in pre-packed bread is down by a third; there have been reductions of the order of 44% in the salt content of branded breakfast cereal; in 2007 alone, there was a 13% reduction in the salt content of standard crisps, 32% in extruded snacks and 27% in pelleted snacks (some standard crisps have been reduced by up to 55%); 30% reduction in popular brands of cooking and pasta sauces and 25% in leading brands of soups; and salt in cheeses has been reduced (e.g. 50% less in a range of soft white cheeses and 32% in some standard cheese slices). In addition, retailers have achieved salt reduction across a wide range of own-brand products. Generally, progress to date has been slower in the sector catering for foods consumed outside the home, although some high street chains have made substantial changes to the sodium content of the foods they offer, and good progress has also been made and further work is underway in the food service sector (http://www.food.gov.uk/news/newsarchive/2008/sep/catupdate0908). The next review against the targets is scheduled to begin in late 2010 and another phase of the FSA's salt awareness campaign is scheduled for autumn 2009. At a European level, the World Health Authority has established the World Health Organization European Salt Action Network to tackle salt reduction across Europe, but it is worth noting that the UK has already made far more progress than most other countries. The next phase in the FSA's reformulation strategy has been focusing on saturates (saturated fat) and energy reduction. The activity programme was published in February 2009 and proposed targets are awaited. The aim is to reduce average saturated fat intake from the current 13.3% of food energy to below 11%. In light of the reformulation that has already taken place and is scheduled to continue, it has become ever more difficult to keep food composition databases up to date. Yet, reliable data sets are of crucial importance in establishing current nutrient intakes at population levels. The FSA, which needs food composition data as part of its evidence base and, in particular, in support of the new National Diet and Nutrition Survey (NDNS) rolling programme, has commissioned a new 4-year project to update and extend the widely used McCance and Widdowson's The Composition of Foods series of food composition datasets. The overall objective of the project is to manage the FSA's programme of nutrient analysis surveys. Three new analytical surveys will be undertaken, the Composition of Foods Integrated Dataset (CoF IDS), launched in 2008 and available online (http://www.food.gov.uk/science/dietarysurveys/dietsurveys/), will be updated and extended, and a new (seventh) summary edition of the popular printed version of The Composition of Foods will be produced, with publication scheduled for 2013. In addition, the project will consider additional data sources and the potential for alternative funding of food composition work, as well as a range of dissemination outputs. The project is co-ordinated by researchers at the Institute of Food Research, Norwich, and the British Nutrition Foundation (BNF) is the partner responsible for dissemination and stakeholder engagement. We shall be organising a series of events for users, the first of which is scheduled for November and will target food companies. The first stage of the project will be a comprehensive review of the current CoF IDS and further information will be available at ukfoodcomp@bbsrc.ac.uk. In this issue of Nutrition Bulletin, an article by Susan Church entitled Food composition explained provides background information on the importance of food composition data and explains the processes involved in producing and compiling the datasets. It also discusses the strengths and limitations of the UK data, and catalogues the issues that those using food composition data need to take into account. This article is essential reading for all users of food composition data and is an output from the EC-funded project, EuroFIR, which is working to improve the quality of and accessibility to food composition data across Europe through the provision of a single, authoritative source of food composition data. EuroFIR activities have included harmonisation and standardisation of food composition data and the development of a quality framework for the compilation of data. In response to the 2007 Foresight report, Tackling Obesities: Future Choices, the government last year published its cross-departmental strategy to tackle obesity, Healthy Weight, Healthy Lives, which included action to reduce the portion sizes of energy-dense foods. In line with this strategy, the FSA is targeting portion sizes as part of its Saturated Fat and Energy Intake programme, and portion size is also a feature of the Change4Life campaign led by the Department of Health that was launched in January 2009 and has as its ambition a society-wide movement towards healthier lifestyles. As discussed in BNF's recent briefing paper (Benelam 2009), portion size is one of the drivers of food intake and excessive energy intake. As discussed in the June issue of Nutrition Bulletin, recent work from the IGD has mapped out current approaches to portion size and concluded that there is a need for: behavioural research to understand the relationship between excess intake and portion size in typical environments in which products are consumed; identification and promotion of good practice communication about portion size including development of a consistent terminology; and consumer research on purchasing and consumption behaviour, and responses to portion size information (Hackett 2009). An IGD working group is taking forward some of these recommendations in 2009 via two complementary streams of work that are determining the views of consumers and developing guidance on good practice in communication. The results of the consumer research are expected to be published during this summer. An update on implementation of the Nutrition and Health Claims Regulation was provided in a recent issue (Aisbitt 2008); progress by the EC and EFSA on several fronts is now behind schedule. A nutrient-profiling approach to underpin decisions about use of claims was due to be finalised in January 2009 but an agreed scheme has yet to emerge, perhaps not surprisingly given the complexity of such an approach. Following a consultation on EC proposals based on an opinion from EFSA, discussions are still taking place within the Commission and the outcome is now not expected until the autumn at the earliest, owing to the European Parliamentary elections. Another major area of activity is decisions by EFSA on the submitted Article 13 and 14 claims. 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