Spoonful of sugar - Should government dictate our diet?

The latest advice from the UK’s Chief Medical Officers is that men should drink no more than 14 units of alcohol a week. This latest figure brings them down from 21 units per week to the same level as women.

Responses from some commentators, on both the right and the left, was that the new guidelines represented a “patronising” nanny state. Simon Jenkins in the Guardian said the new limit was “about a vague national self-image of puritanism, not health”.

However, the decision was based on research evidence, collated by the Committee on Carcinogenicity (COC), that alcohol is linked to seven types of cancer, including a greater risk of breast, mouth, throat and oesophageal cancers from even low-level drinking.

If other food and drink types present risks to our health, should government intervene in a similar way? Would even stronger measures such as advertising bans, minimum pricing or even taxation constitute a nanny state?

Speaking to Holyrood, public health minister Maureen Watt says: “Well ultimately, of course, it’s down to the individual what he or she eats or drinks. But there is a clear role for government - and the food and drink industry - to try and make it as easy as possible for people to eat healthily.”

When Food Standards Scotland (FSS) was launched on 1 April last year, it was given an expanded role. As well as responsibility over food safety and standards, the new public body was to advise on nutrition and labelling with an eye to people’s health.

This came from overwhelming evidence showing the Scottish diet is too high in calories, fats, sugars and salt, and too low in fibre, fruit and vegetables. What’s more, poor eating patterns appear to be ingrained, with most Scots thinking their diet is healthier than it actually is and many parents not recognising when their children are overweight.

At FSS’s conception in parliament in 2013, the then First Minister Alex Salmond pledged that the new food body would remain independent from government, and so it proved to be in its first major report published in January this year. 

The FSS issued a call to the Scottish Government to begin preparations for a tax on sugar, and an ultimatum to industry to come up with alternative radical proposals in 12 months if they wanted to avoid it.

The Scottish Government moved quickly to reiterate a sugar tax is not policy, but the FSS call is not a solitary voice. 

Indeed, the imminent publication of the UK Government’s obesity strategy may contain a tax on sugary drinks, after Public Health England made a case for it recently. 

Even David Cameron said he wouldn’t rule out the idea, despite the Conservatives tending to avoid embracing new taxes or ideas which could be perceived as nanny state. 

Kawther Hashem, nutritionist and researcher at campaign group Action on Sugar, said UK Government action is essential.

“Parents and children are currently drowning in a world full of aggressively marketed and promoted sugary foods and drinks. It is high time the government took responsibility for the health of the nation and set sugar reduction targets and restrictor rules on all forms of marketing and promotion of unhealthy foods and drinks,” she said.

A petition for a 20 per cent tax on sugary drinks by TV chef Jamie Oliver has garnered 150,000 signatures, and the idea is backed by the British Medical Association, UNISON and several medical professional organisations.

More recently, a two-year report from the World Health Organisation also backed the move.

This momentum has grown after analysis of a 4p tax on sugary drinks in Mexico, implemented in 2014, saw prices increase around 10 per cent, and surveys suggested consumption had reduced by up to 17 per cent in the most deprived communities. 

Mexico has the second highest obesity rate in the world at 32 per cent, according to the OECD, and Mexicans consume on average half a litre of Coca-Cola a day.

In the UK, children consume three times the recommended amount of sugar, with one in five obese by the time they leave primary school.

In Scotland, levels of those overweight or obese were recorded as the second worst in OECD countries in Europe in 2010, and evidence gathered by the Scientific Advisory Committee on Nutrition (SACN) reveals there has been no improvement since.

On current trends it is projected 40 per cent of the population will be obese by 2030, with a knock-on effect of an increase in several serious non-communicable diseases including cardiovascular disease, type 2 diabetes, certain cancers and other health-related problems.

There are also clear differences based on socio-economic circumstances. Children aged 2-15 in the most deprived areas are at a greater risk of obesity (22 per cent) than children in the least deprived areas (13 per cent) as they rely more on cheaper sugars and fats for their calories.

“Given where we are now it is appropriate to consider all possible options, including tax and regulation,” the FSS advice reads, noting there had been a “poor” response from industry to the Scottish Government’s voluntary framework, ‘Supporting Healthy Choices’.

“Industry needs to demonstrate a more radical approach to addressing diet and health than has been apparent to date,” the report said.

“We’re very aware there is no single silver bullet solution to reducing our obesity and overweight problem,” said FSS chief executive Geoff Ogle.

“Exercise and being more active plays a vital role too. But we do believe that the measures we are proposing are vital pieces of the jigsaw.”

Holyrood’s powers do not cover excise duty, but the ability to set local taxation could be a loophole to exploit, or there is the option of forming an agreement with Westminster over the implementation of such a tax.

The FSS recommendations are explicit, though. The language of the report shifts the discussion on regulation and taxation of Scotland’s food  from if it should happen to when and how, but the Scottish Government appears to remain unconvinced.

Is taxation a fair or appropriate route? What role should government play? Can it learn from successes in tackling tobacco and alcohol? The FSS report certainly suggests so. The case of minimum unit pricing for alcohol, which is currently being challenged through the courts by the Scotch Whisky Association, seems to suggest the Scottish Government is willing to play hard ball with industry over public health issues.

Watt says the policy is specific to alcohol. “Minimum unit pricing is a very specific case, where we strongly believe we can reduce alcohol harm by targeting the price of the cheap, high strength alcohol that causes the most damage. We are looking forward to making our case when this returns to the Scottish courts. 

“On sugar and salt, we’re working with the food and drink industry, particularly to encourage the reformulation of products. There has been quite a bit of progress when it comes to reducing the amount of salt and sugar in recipes, but of course there’s still more that could be done,” she says.

Confirmation, then, that a sugar tax is off the table? Watt says there are still “no plans” for a tax, but with three reviews of the effects of targeted food taxation under way as well as the FSS report, government will “consider all this evidence going forward”.  

National Director of Diabetes Scotland, Jane-Claire Judson, agrees food is a separate issue from alcohol.

“Food is essential for life – we can’t survive without it – and so the relationship with food and drink is different to that of tobacco or other substances we might use. And this is what makes tackling our relationship with food so complex and challenging.”

Over 240,000 Scots have type 2 diabetes, 45,000 undiagnosed and a further 500,000 at high risk of developing it. For the vast majority of those, being overweight is a factor, but Judson points out people with type 1 diabetes also have to maintain a close interest in what they are eating. 

“For everyone with diabetes, food and how it is produced, marketed and consumed is important,” she says.

That said, Diabetes Scotland supports a sugar tax along with other prominent third sector organisations, but only with “the caveat that people living with type 1 and type 2 diabetes who may rely on high sugar products to treat hypoglycaemia are not disadvantaged,” argues Judson, adding, “and we also believe that tax and regulation should be used at the production and industry end of the food journey and not just be aimed at the consumer.”

However, the tax would only form part of an “all-round approach” to the issue, says Judson, a sentiment shared by Professor Annie Anderson of Dundee University, who took part in the research which ultimately informed the FSS report.

Speaking at a recent event on the sugary drinks tax in Edinburgh, Anderson said of the FSS report, “we can decide to ignore it or act on it. Looking at the evidence, having spent millions on it, it would be silly to ignore it.”

The rise in type 2 diabetes, she argues, is preventable. “We need to look at the range of things we can do,” she said.

A tax on sugary drinks would be a “good place to start”, she said, a sentiment backed by Mike Small, director of sustainable food scheme, the Fife Diet. “We need to actually do something, or all talk of a ‘good food nation’ needs to be shelved,” he said. 

Watt argues the Government has been proactive. “We need an all-round approach that looks at a range of tactics. On the question of advertising, we believe there should be a ban on advertising high fat, salt or sugar food and drink before the 9pm watershed. 

“This is currently a reserved power, but I’ve written to the UK Government to ask them to do this. Working with industry is something we’re already doing, and new taxes aren’t something we have direct control over.”

As well as working with industry on reformulation, Watt says the Eat Better Feel Better campaign is helping encourage families look at healthier alternatives, a scheme which is being supported by the supermarkets.

Reformulation of products, reducing portion sizes and the introduction of front-of-pack labelling are all under way, backed with £10m investment in encouraging healthy eating, she said. 
While some research suggests price has the biggest impact on behaviours, the McKinsey Global Institute reports portion control and food reformulation are the two intervention groups with the biggest estimated impact.   

In its obesity report of 2014, the institute said: “Education and personal responsibility are critical elements of any program aiming to reduce obesity, but they are not sufficient on their own. Other required interventions rely less on conscious choices by individuals and more on changes to the environment and societal norms. They include reducing default portion sizes, changing marketing practices, and restructuring urban and education environments to facilitate physical activities.”

The Food and Drink Federation said the industry wants to play its part in finding a solution to obesity, pointing to successes in salt, waste and portion sizes, but warned legislation might affect jobs. Chief executive David Thomson said the Scottish Government should continue the partnership approach.

“Punishing and legislating against an industry that employs 34,000 people in Scotland – 19 per cent of all our manufacturing jobs – would be a retrograde step, in particular when there is no evidence of the long-term effectiveness of additional taxes on single nutrients, foods or drinks,” he said.

If not taxation then, reduction targets might prove to be more popular with industry. Reformulation has been seen on a global scale, particularly with salt, but Anderson believes it is insufficient. 
In a recent Holyrood roundtable, she said: “We’ve very good NGOs who have been very involved in helping get support for low salt foods, but in Scotland, our salt intake has not gone down. In England, it has. Our sodium measurements are bad news. We’ve got reformulation across the world, and we don’t know why it’s not gone down. Are people putting more salt on food, or what is it?”

One of those NGOs is the British Heart Foundation (BHF), which campaigns for the adoption of the World Health Organisation’s prevention targets in Scotland. Director for Scotland James Cant says although BHF has not actively campaigned on a sugary drinks tax, it would be supportive.

“Industry has to be quite realistic, that if they don’t come and work in proactive partnership then the chances are they will be encouraged to come to the table through a more proactive, legislative approach from government,” he says.

BHF itself, he says, is not interested in telling people what to eat. “We, as an organisation, will give people the best advice we have available, in terms of the evidence base we have, but we’re not an organisation that will be telling people what to do. 

“But I think it’s fair to say there’s been this gradual but significant increase in the levels of sugar and salt in processed food, so working in partnership with industry and government to try and significantly reduce that over time? I don’t think I would see that as nanny state, it’s more in terms of helping inform choice,” he says.

With households increasingly having two working partners, and with less options available for grocery shopping, Cant believes people are susceptible to what food manufacturers put in their convenience food. Supermarkets, in particular, are where the vast majority of people access their food, and with that power comes responsibility, according to Cant.

“I pretty much go from salary to Tesco, particularly how much my kids eat, so the supermarkets play an absolutely pivotal role in defining and nuancing the public health of this country. That brings with it a responsibility on their part, but it gives them a huge opportunity to work with us on this,” he says.

Shop-bought sandwiches, for example, often contain around a third of an adult’s daily recommended intake of salt and fat, and Cant points to the example of an investigation by Action on Sugar and the Telegraph which revealed a sweet and sour chicken ready meal from Sainsbury’s contains 61.2g of sugar – equivalent to almost 13 teaspoons. 

“Supermarkets are absolutely pivotal in this, because they play a dual role. They are purveyors of food from the large multinationals, and in other ways they are producers themselves in their own right. Some of the things they can do in terms of BOGOF offers and end-of-aisle presentations,” says Cant.

Watt says the supermarkets have been working with government, pointing to the shift to move sweets from checkout aisles in the last few years, led by German-owned budget chain Lidl in 2014. 
“I’d like to see fewer multi-buy price promotions on high sugar products, for example. However, as I’ve said, the supermarkets are working with us, and we’ll continue that work. There’s some good work going on. For example, some chains have removed confectionary from the checkout areas, and measures like that have to be welcomed.”

Judson says the supermarkets have often been portrayed as “the bogeymen of our dietary quandary”, but says Diabetes Scotland has successfully worked with Tesco to promote healthy choices and raise awareness of type 2 diabetes.

“While supermarkets can and should do more, they are also a main avenue for people to access affordable food. In working with Tesco, we have built a relationship of trust and we have shared knowledge and expertise and that has helped both organisations to develop and understand better the challenges we are facing, and to change. 

“Tesco adopted the food labelling scheme they had originally rejected, in part because of our charity partnership. It is perhaps harder for industry and government to sit down in this way, given the sometimes confrontational nature of the political and business communities. However, this needs to be overcome,” she says.

For Judson, powers over regulation and tax is only the first of two main avenues governments can pursue when a voluntary approach has not worked as well as it was hoped. The second is based on the recommendations of the McKinsey Global Institute.

“To create an environment in Scotland, that means making health choices and accessing healthy, quality food becomes the norm rather than a privileged lifestyle choice or a financial burden on families. 

“This means looking at every aspect of our environment. Green spaces, how we build new infrastructure like roads, schools, housing and business areas, public transport, access to active travel. Also there’s our education and the national curriculum, how we support low income families and how we provide food at key points such as within public sector services,” she says.

Cant remains optimistic. He says he has “a lot of sympathy” with the position the Scottish Government finds itself in, dealing with reserved issues, matters of European legislation and multinational companies, but the shift in apparent thought at Westminster shows “signs of encouragement”.

“I think Scotland’s got a strong tradition of consensus on public health, and it’s something we should be quite proud of and celebrate. That’s what gives me heart looking towards the next parliament, and this is the kind of issue that transcends politics and I’m confident it’ll be treated in that way.”

Interestingly, however, while the notion of consensus on public health is attractive, when it comes to a tax on sugary drinks, the famous party discipline of the SNP has shown hints of being under strain.

In a Commons debate, Dr Philippa Whitford, Westminster SNP health spokesperson, was vociferous in her support for the idea, as part of a range of tactics recommended by the Health Select Committee, which she sits on.

“I know what it is like to move through a world where everything shouts ‘eat me’ all the time. We live in a totally obesogenic environment. The idea that it is easy to resist things is simply not true. Everything is geared towards making people eat unhealthily. 

“We spend a little more than £600 million on obesity prevention, but £256 billion is spent on advertising unhealthy foods. It is David and Goliath. It is difficult for people to make the right choices.”
There should also be a reformulation to drive down use of artificial sweeteners, she argued. “We need to reset our sweet tooth—we have all seen someone washing down a big slab of sticky cake with a diet soft drink—because the craving remains.”

At around the same time, in the Scottish Parliament’s Finance Committee’s investigation into different taxation options, Aberdeen MSP Mark McDonald was less keen on the idea.
“I suspect that it would fall disproportionately on people on lower incomes, because those people tend to be in the areas where we have problems with the intake of high sugar products. Is it not, essentially, a regressive indirect tax?” he said. 

The Scottish Government maintains it will wait for the evidence. Watt says: “Guidelines for healthy eating are all based on scientific evidence, and we’re always looking at new developments in that area. It’s true that unfortunately many people don’t follow guidelines, but our job as a government is to make sure they are accurate and that people understand what they are and why they’re important.”
These include incoming evidence on the effects of energy drinks on children from the European Food Safety Authority. “Once they’ve published their data, Food Standards Scotland will review it and offer any recommendations, and we’ll obviously consider that report,” she says. 

The truth is the consumer is bombarded, not just with food advertising and product choice, but also with dietary advice and recommendations. A sugar tax is the latest in a long line of suggested interventions which have seen facts and counter facts played out in the media, adding to an already confusing landscape.

Government interventions in food need not be about lowering the bad stuff, of course. The debate around adding fluoride to water saw accusations of the nanny state too.

Now, if reports are to be believed, Scotland is about to become the latest country to fortify flour with folic acid after a decision on the matter was delayed at Westminster.
Despite the ingredient playing a role in preventing birth defects, 85 per cent of women do not take enough, and the amount added to other foods has been reduced in anticipation of fortification of flour.

While folic acid supplements are recommended for women trying to have children, research suggests only around a third actually take them at the right time.
If the Scottish Government decided to press ahead with the idea, it is thought most commercial bakers would fortify all their flour, meaning Scottish legislation could impact UK-wide. 

If you like, the move would give the United Kingdom a Scottish nanny.