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Why food reformulation and innovation are key to a healthier and more sustainable diet

2020; Wiley; Volume: 45; Issue: 3 Linguagem: Inglês

10.1111/nbu.12455

1471-9827

Judith Buttriss,

Birth, Development, and Health

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'. The power of nudges and use of consumer insight to guide promotions and campaigns is widely recognised by successful businesses and is increasingly being used as a tool by public health professionals and policy makers. A nudge may be defined as an individual component of choice architecture – put simply, a single element that alters the context surrounding a choice (Forberger et al. 2019), making that choice more attractive. Choice architecture is a framing device used to alter the presentation of a choice, in order to attempt to influence the outcome of that decision (Science & Technology Select Committee 2011). As well as reformulation programmes, nudges and levers already in place in the UK or proposed by the COP and the new obesity strategy (DHSC 2020) include front-of-pack nutrition labelling; calorie labelling for products consumed outside the home; banning of promotions of foods and drinks considered to be less healthy (e.g. high in fat, sugars or salt) through a strategy linked to price and store location; 'taxation' of sugar-containing soft drinks via the UK's Soft Drinks Industry Levy; legislation to ban the sale of energy drinks to children; and advertising restrictions to limit children's exposure to advertisements for foods high in fat, sugars or salt. Some of these are discussed in more detail in Stanner and Spiro (2020). Progress with these plans, as well as other initiatives such as infant food reformulation, salt reformulation, the proposed calorie reduction programme and continued monitoring of the sugar reduction programme, is at various stages (some more advanced than others) and has been delayed by the COVID-19 pandemic. The new obesity strategy, published in July 2020, sets out a timetable for the implementation of a series of policies and includes a new health promotion campaign led by Public Health England. Often flagged as a successful example of what can be achieved in public health terms through a partnership approach is the UK's salt reduction programme. A strength of this initiative was the combination of a government-led public health campaign (via the FSA) focusing on the health implications of excessive salt intake, with a programme of food reformulation with the food industry. Voluntary salt reduction targets were first set in 2006 for the range of food categories that made the greatest contribution to the population's salt intakes and were further revised in 2009, 2011 and 2014. The two-pronged initiative resulted in a fall in average salt intake over time, towards the recommended maximum for adults and children over the age of 11 years (6 g/day). Evidence shows initial success in reducing salt levels in a variety of foods including bread, the largest contributor of salt in the UK diet at the time, for which the salt content was reduced by about 20% between 2001 and 2011. However, across a range of food categories, improvement slowed as further reduction became more challenging (technically or from a consumer acceptance perspective) and there has been no statistically significant change in estimated intakes since 2014 (PHE 2020b). In March 2020, Public Health England published its latest assessment of sodium intake data for adults in England (for 2018/2019). In adults aged 19–64 years, average salt intake was estimated to be 8.4 g/day (40% higher than the government recommendation); 9.2 g/day for men and 7.6 g/day for women. As in previous surveys, the distribution of estimated salt intakes in the adult population was wide; the 2.5th and 97.5th percentiles were 2.7 g/day and 17.8 g/day (PHE 2020b). Public Health England has recently consulted with the food industry on a new set of draft salt targets, to be achieved by 2023. Almost all of the previous 2017 targets have been made stricter, and there are additional new categories for meal accompaniments, savoury snacks, dips and condiments. Whilst these have the potential to encourage a further reduction in salt intakes, success will be dependent on consumer acceptance and whether technical hurdles can be overcome. The coming months – indeed years – will be dominated by the anticipated recession combined, for food businesses operating in the UK, with the yet to be fully determined outcomes of the UK severing ties with the European Union. According to the United Nation's June 2020 Policy Brief, COVID-19 mitigation measures and the emerging global recession could cause a global food crisis, with disruption on a scale not seen for more than half a century (United Nations 2020). The United Nations has called for large-scale co-ordinated action to protect health and nutrition globally. Even in countries such as the UK, the list of food chain disruptions caused by COVID-19 includes slower or incomplete harvests because of lockdowns and labour shortages; temporary shutdowns of meat processing plants because of COVID-19 outbreaks among workers; wastage of some perishable products such as milk because of disrupted supply chains; and the widely publicised difficulties in keeping supermarket shelves stocked with everyday basics. In addition, disruption to schooling has meant that vulnerable children are potentially missing out on the school meals that help to ensure their nutrition. Whilst stocks of most staple foods are in good shape following good harvests in 2019 and food supply chains are starting to normalise, loss of income is making it harder for some people to access affordable food. The Policy Brief estimates that the number of people with 'crisis level' food insecurity by the end of 2020, globally, could double from 135 million because of COVID-19 (United Nations 2020), and in the UK, there has been evidence of increased use of food banks. The Trussell Trust has reported a record 81% increase in provision of emergency food parcels during the COVID-19 lockdown compared to the same period last year (The Trussell Trust 2020). The FSA's survey, mentioned earlier, revealed that, in April and May, respectively, 18% and 16% reported skipping meals or reducing meal size because of insufficient money to buy food, and 8% in April and 7% in May accessed food via emergency providers (i.e. food banks and charities), this being greatest in those aged 16–24 years (20% in May) and in households with a child (13% in May) (FSA 2020). At the end of April 2020 (a month after the lockdown began), the Food Foundation estimated that 1.8 million people living in UK households with children under 18 years had experienced food insecurity over the past month, due to the lack of supplies in shops, and that a further 3.2 million (11% of households) experienced food insecurity for other reasons including loss of income or isolation (Food Foundation 2020). See Dimbleby (2020) for a discussion. On 2 June, Public Health England published its review on disparities in the risk and outcomes of COVID-19 (PHE 2020c). The largest disparity was found to be age, but people with underlying health conditions (e.g. diabetes, heart disease) and those living with obesity also appear to have a greater risk of poor outcomes. The review also highlighted the increased susceptibility to infection and poorer outcomes in Black, Asian and Minority Ethnic Groups. An analysis of survival among confirmed COVID-19 cases shows that, after accounting for the effect of sex, age, deprivation and region, people of Bangladeshi ethnicity had around twice the risk of death when compared to people of White British ethnicity. People of Chinese, Indian, Pakistani, Other Asian, Caribbean and Other Black ethnicity had between 10 and 50% higher risk of death when compared to White British (PHE 2020c). The report notes that these analyses did not take account of occupation, obesity or co-morbidities such as type 2 diabetes, which may influence risk. In light of the apparent direct and indirect effects of obesity on COVID-19 risk (PHE 2020a), it is widely speculated that, in the UK (and perhaps elsewhere), there will now be a redoubling of efforts from governments to tackle obesity, in adults as well as children, with the possibility of further taxation measures as well as restrictions on advertising and promotions of high energy density foods, especially those which are relatively nutrient-poor. Work on the National Food Strategy for England has now resumed, and an initial report was published on 29 July 2020, which focuses on urgent issues linked with the COVID-19 pandemic and the UK's exit from the European Union (Dimbleby 2020). These major public health challenges, in combination, set the scene for the opportunities that lie ahead. The need to cope with huge issues such as food insecurity and food system disruption associated with the COVID-19 pandemic, the high prevalence of obesity in the UK and the majority of other countries around the world, and the environmental impact of food production does not mean that reformulation is unimportant. Indeed, the challenges faced reinforce the importance of reformulation and, in particular, innovation to improve the nutrient profile of food. Not everyone has the inclination, time, resources or skills to cook from scratch, to soak and cook dried beans, toast their own granola or bake their own bread. In any case, almost everyone in countries such as the UK is reliant on processed foods to some extent, such as flour, pasteurised milk and dairy products such as cheese and yogurt, bread, breakfast cereals …. the list goes on …… and most of us have store cupboards with tins, packets and jars of ready prepared ingredients that can speed up the process of providing a healthy meal for the family. In the BNF-commissioned YouGov survey mentioned earlier, the top priorities as lockdown measures are lifted are as follows: becoming more active; losing weight; and eating more healthily overall. As we emerge from lockdown and face renewed government efforts to tackle obesity, as well as the prospect of a recession, there is an opportunity for food businesses and all other stakeholders to work together to help make these positive intentions a reality, by raising awareness that eating healthily and being active are important, that neither strategy has to be expensive, and importantly that following healthy eating guidelines and minimising food waste can help reap environmental benefits. One of the conclusions of the guiding principles for sustainable and healthy diets from FAO/WHO (FAO/WHO 2019) is that shifting long-established dietary habits presents a significant challenge for cultural, political and economic reasons, and will require actions from governments, businesses, and individuals that go beyond information and education programmes. This will include interventions to change both the supply of and demand for food, not least shifting social norms away from heavily meat-based diets to a more diverse 'flexitarian' pattern that integrates a wider range of protein sources. According to the FAO/WHO report, there is no 'silver bullet' solution to create a sustainable food system. Instead, many changes across multiple sectors of the food system are needed. This will require a series of co-ordinated approaches tailored to the social, political, economic and cultural values of countries and communities, which is sensitive to current dietary habits. Reformulation, on its own, can only take us so far on the journey to healthier and more sustainable dietary patterns but it certainly has an important part to play alongside innovation, new product development and reconnection with the principles of good nutrition. Ultimately, we all need to play our part in improving appreciation of the personal and wider social and economic benefits of a healthier diet and lifestyle, of the building blocks of good nutrition, and their practical application in terms of meals and overall dietary pattern. In this Special Issue of Nutrition Bulletin, we consider the public health rationales for sugar and saturated fat reduction and the benefits of increased fibre intake. Also considered is the justification and opportunities for diversifying sources of protein, in the context of the environmental impact of current global food systems and the challenges associated with feeding a more prosperous and expanding global population now and in the decades to come (Steenson & Buttriss 2020). These papers are provided by Sara Stanner and Ayela Spiro (public health rationale for sugars reformulation and the use of sweeteners); Professor Ingeborg Brouwer (public health rationale for reduction of saturated fat – why is it important and what methods can we use to reduce saturated fat); Marta Lonnie and Professor Alex Johnstone (public health perspective on plant protein as part of a sustainable and healthy diet); and Professor Catherine Stanton and colleagues (benefits of dietary fibre with a focus on gut microbiota) (Koç et al. 2020). For each of these four topics, we also consider the opportunities that exist for future innovation and the associated challenges, providing examples of success stories. These food technology perspectives are provided by Dr Shawn Erikson and Dr Jim Carr (sugar reformulation), Johanna Bruce (saturated fat), Dr Simon Loveday (protein) and Carole Bingley (fibre). The eight papers are accompanied by a multi-author paper (Poole et al. 2020) providing a series of case studies on cocoa pulp (Lucy Barruad), a sweet culture (Jessica Bentley), sweet proteins (Dr Ilan Samish), oleogelation (Professor Steve Euston and colleagues), algae fed salmon (Jill Kauffman Johnson and Chris Haacke) and fibre from butternut squash peel (Michael Adams and colleagues) with a foreword from Jon Poole, Chief Executive of the Institute of Food Science and Technology. Finally, the papers are complemented by a perspective from Professor David Julian McClements, entitled 'Future foods: Is it possible to design a healthier and more sustainable food supply?' (McClements 2020). BNF is grateful to Tate & Lyle for financially supporting this Special Issue with an educational grant which enabled BNF and the journal's Editorial Advisory Board to maintain full editorial control.