Why food reformulation and innovation are key to a healthier and more sustainable diet
Judith Buttriss
Abstract
The national diet in many parts of the world, and also here in the UK (DHSC 2020), is far from perfect and misaligned with dietary recommendations in a number of respects, and the World Health Organization (WHO)/Food and Agriculture Organization (FAO) recommend that countries adopt policies that will encourage the gradual reduction in saturated fatty acids, sugars, salt/sodium and trans fatty acids in foods and beverages to prevent excessive intake by consumers and improve the nutrient profile of foods (FAO/WHO 2014). For example, in the US about three-quarters of the population do not eat enough fruits, vegetables, dairy foods and oils and more than two-thirds eat too much saturated fat, sodium and added sugars (ODPHP 2015). In the UK, whilst average intake of total fat is in line with recommendations and trans fat intake is now substantially reduced compared with the recommendation of <2% energy intake, in all age groups intakes of free sugars and salt far exceed recommendations and average fibre intakes are universally low (Table 1) (Roberts et al. 2018). Indicative of energy intakes in excess of requirements, almost two-thirds of English adults (63%; 67% of men and 60% of women) are overweight (a body mass index ≥25) and more than 1 in 4 (27%; 26% of men and 29% of women) are obese (NHS Digital 2020a). Among English children, around 1 in 5 are already overweight at age 4–5 years, and by age 10–11 years, 1 in 3 is overweight. There has been an increase in the prevalence of obesity since 2017/2018 in children aged 4–5 years in England, from 9.5% to 9.7% in 2018/2019. In 10–11 year-olds in 2018/2019, obesity prevalence was 20.2% (similar to 2017/2018). Obesity prevalence is higher in boys than girls and, for children of both age groups living in the most deprived areas, obesity prevalence was more than double that seen in the least deprived areas (NHS Digital 2020b). Not only does obesity increase the risk of developing conditions such as type 2 diabetes, cardiovacular disease and some cancers, new evidence suggests it is also associated with an increased risk of developing COVID-19, and experiencing severe symptoms (PHE 2020a). Globally, 39% of adults are overweight and 13% obese, and in most countries of the world, overweight and obesity are now greater problems than underweight (WHO 2020). It is widely recognised that, alongside all other stakeholders, all sectors of the global food and beverage industry have an important role to play in tackling this major public health problem. Failure to achieve dietary recommendations is not restricted to macronutrients, and substantial proportions of some population groups, particularly adolescents and young adults, appear to have low intakes of various essential vitamins and minerals (including low nutritional status of some of these, in particular iron and vitamin D), indicating that the overall micronutrient density of diets warrants improvement (Roberts et al. 2018). Of particular concern is the proportion of adolescents with low intakes (below the lower reference nutrient intakes) of a number of micronutrients including iron, zinc, calcium, iodine, potassium, vitamin A, folate and riboflavin. For example, 54% of girls and 27% of women have low iron intakes. It is noteworthy that the Global Burden of Disease analysis concluded that what is absent from diets can be a greater marker of disease risk that what is present in excess, despite the focus in national and regional policy often being dominated by the latter. The authors stressed the importance of balancing ‘eat more’ messages (e.g. wholegrains, vegetables, fruit, nuts, seeds, milk, fibre, calcium and omega-3 fatty acids from seafood) with ‘eat less’ messages (salt, saturated fat, free sugars) (GBD 2017 Diet Collaborators 2019). A more detailed discussion and examples of how the nutritional picture has worsened over the past decade in the UK can be found in Buttriss (2019). In his recent report, National Food Strategy Part One, Henry Dimbleby called for measures to improve the nutrition of Britain's most disadvantaged children (Dimbleby 2020). Modelling studies, undertaken to configure the UK healthy eating guidelines (the Eatwell Guide) to align with UK government dietary reference values (Scarborough et al. 2016), illustrate the gulf between the current ‘average’ UK diet and the recommended diet (Fig. 1), the bridging of which would be expected to convey nutritional and health benefits (Cobiac et al. 2016), as well as having a lower environmental impact (Carbon Trust 2016). See Steenson and Buttriss (2020) for a detailed discussion. The importance nutritionally of the overall profile of a diet, rather than focusing on single nutrients in isolation, is increasingly recognised, and this has implications for reformulation strategies, which typically focus on correcting dietary intakes of a single nutrient yet need to be mindful of the wider implications on overall nutrient profile. There are many situations where failure to see the bigger picture may have led to unintended consequences. For example, failure to elicit a reduction in dietary energy density may result from strategies to reduce sugars that lead to an increase in fat within a product and, by association, energy contribution. Similarly, in the search for functional alternatives to animal fats high in saturated fat from a heart health perspective (Brouwer 2020), failure to be guided by science can result in no improvement in nutrient profile or even a detrimental effect. For example, although a number of plant-derived oils and blends exist, with a nutrient profile dominated by polyunsaturated or monounsaturated fatty acids (Bruce 2020), in recent years coconut oil has attracted a health halo and, perhaps inadvertently, it is now used widely as a fashionable ingredient, failing to recognise its exceptionally high saturated fatty acid content (Lockyer & Stanner 2016). With regard to protein, it makes good sense from both nutritional and environmental perspectives to broaden the variety of protein-containing foods eaten (to include more plant-derived sources) (Lonnie & Johnstone 2020), not least because of advice to moderate red meat consumption and the benefit of the additional dietary fibre present in pulses, such as beans and lentils, or the fatty acid profile of nuts. However, it is important to ensure that meals eaten in place of meat-containing meals provide at least a similar and ideally an enhanced overall nutrient profile, and that the substitute product is not inadvertently contributing additional salt or saturated fat or is less sustainable from an environmental perspective. The evidence concerning the importance of dietary fibre has strengthened over the past decade (Koç et al. 2020), and yet average fibre intakes fall well short of the recommended 30 g/day. The opportunity to contribute to efforts to improve fibre intakes has been grasped by many businesses, sometimes through choice of ingredient, for example use of wholemeal flours or pulses, but often through the addition of isolated fibres (Bingley 2020). One in common use is inulin, which has the advantage from a ‘clean label’ perspective that it can be labelled as chicory fibre. However, some people experience gut-related symptoms (e.g. flatulence) when they eat this type of fermentable fibre, and over-reliance on particular dietary fibre structures runs the risk of not benefiting fully from the array of health benefits that the different non-digestible carbohydrates, which together comprise ‘dietary fibre’, can deliver. Consumer surveys repeatedly show that factors such as cost, quality and taste preference are the most important determinants of purchase decisions, with perceived healthiness typically coming lower in the list, as illustrated by research from IGD (see below). Therefore, simply expecting the public to ‘get a grip’ and comply with healthy eating guidance is unlikely to work in isolation. This makes reformulation of existing products to improve their nutrient profile, including ‘health by stealth’ where the change is not publicised, an important activity. In a survey conducted by IGD in 2018, quality and price were the major determinants, followed by special offers and practical aspects such as pack size, ease of use and convenience (Fig. 2). The importance of health had increased over time, but was still relatively low in the pecking order. The biggest increases were reported in packaging, ethical production and origin, perhaps reflecting the increased media and consumer attention on these topics. IGD predicts that food shoppers of the future will be time optimisers; more health conscious, with both health and wellbeing growing in importance; more individual, open to a more personalised experience but only if there is a clear benefit to them with minimum effort; more experimental; and more socially conscious with regard to sustainability and ethical choices, although price, availability and quality with still come first (IGD 2018). This reconfirms that, fundamentally, positive behaviour change is more likely when healthier choices are readily accessible and priced appropriately, and when they are perceived as having some direct benefit to the purchaser. There is some evidence that the importance of personal and family health, when it comes to diet and activity patterns, has risen up the agenda for many during the lockdown associated with the COVID-19 pandemic, and this is something to build on as restrictions are removed. For example, in June 2020, the Food Standards Agency (FSA) published findings from its COVID-19 Consumer Tracker Survey for England, Wales and Northern Ireland (FSA 2020). Twenty-six per cent of respondents said they were eating healthy meals more often (11% reported less often) but there was a net increase of 28% in those reporting snacking more frequently on cakes, biscuits and savoury snacks. It also found that there had been a move towards buying food locally (35% reported ‘more often’ vs.11% less often) and wasting less food (35% increase) (FSA 2020). Increased snacking was also evident in a YouGov survey for the British Nutrition Foundation (BNF) of around 2000 British adults, conducted during the first week of June 2020 (BNF 2020). Over a quarter (26%) reported eating habits becoming less healthy, with 63% eating more food out of boredom (eating less healthily was highest in 25–34 year-olds; 35%). But the survey also revealed a greater connection with food for some, during the lockdown, with more people planning meals in advance (29%), trying new recipes (23%) and baking/bread making (20%). Although 29% admitted being less active than usual, 25% had started going for regular walks, and 1 in 10 (9%) had taken up running or cycling. Perhaps not surprisingly, given the emerging evidence suggesting a link between obesity and severity of symptoms of COVID-19 (PHE 2020a), the top three concerns in the survey were gaining weight during lockdown (39%), becoming unfit (34%) and eating too many unhealthy snacks (27%). The top priorities as lockdown measures are lifted were becoming more active (47%); losing weight (43%); and eating more healthily overall (29%). As discussed in the paper by Stanner and Spiro (2020), following a recommendation by WHO (WHO 2016), taxes on sugar-sweetened beverages have now been introduced in about 40 countries around the world to encourage reformulation and influence consumer behaviour by economic incentives. Reformulation of sugar-sweetened beverages has been relatively successful and is reasonably straightforward but, for most food categories, reformulation is fraught with technical challenges and legislative hurdles, and as such, it can only be part of the solution. Innovation, potentially including introduction of novel sources of nutrition (in accordance with the associated legislation), is increasingly recognised as important, and fortification in general and biofortification in particular (Lockyer et al. 2018) are other options for ensuring nutritional needs are met. One of the potential opportunities afforded by the UK exiting the European Union is the ability to make adjustments to the EU food legislation currently in place in the UK (e.g. to relax barriers that currently limit reformulation or promotion of healthier food options). For example, fibre is not among the obligatory list of nutrients for nutrition labelling that appears on food packaging and cannot be included under EU legislation in front-of-pack labelling schemes, which limits opportunities to highlight fibre content on pack. With sugars, current legislation requires that comparative claims, such as ‘lower’ or ‘reduced’, can only be made for total sugars (not free sugars), and such claims can only be used on products with at least a 30% lower (total) sugar content than similar products, which prevents manufacturers and retailers from communicating smaller changes. Low-calorie sweeteners and polyols are a common means of reducing sugar content but, again, can only be used in products with no added sugars or where calories have been cut by at least 30% compared to a typical full-calorie product. In other words, their use is limited to situations that comply with the energy reduction claim defined in the EU Nutrition and Health Claims Regulations (see Stanner & Spiro 2020). Many of the proposed components of the UK government’s Childhood Obesity Plan (COP), which was initiated in 2016 (HM Government 2016), and the new obesity strategy published on 27 July 2020 (DHSC 2020) have focused on nudges and so-called ‘levers’. 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