Dietitians' and nutritionists' knowledge and views on aspects of health claims regulation in the UK: Do we inadvertently shoot the messenger?

Article 12(c) of the Nutrition and Health Claims Regulation (NHCR) prohibits authorised health claims in consumer-facing commercial communications which make reference to the recommendations of individual doctors or health professionals. However, this has been controversial amongst dietitians and nutritionists who work in commercial settings. Given the lack of empirical data, a survey was conducted amongst UK-based nutrition professionals to assess their knowledge of, and attitudes to, Article 12(c). The findings revealed confusion about the scope of the regulation and how it applies to working practices, with a considerable proportion of respondents being unable to recognise examples of commercial communications or health claims, indicating a need for additional training. There was also a broad interpretation of what nutrition professionals could, and could not, say about a hypothetical food product. This paper explores current guidance in Great Britain and debates the proportionality and fairness of Article 12(c), which, at present, does not regulate authorised health claims made by influencers or celebrities in commercial communications to consumers. It could be argued that consumers are better protected by the articulation of health claims by nutrition professionals who are guided by codes of practice rather than by unqualified, unregulated individuals. Hence, it is essential to level the regulatory playing field either by revising the NHCR to amend Article 12(c) or by updating the guidance to apply an interpretation of the Article's intention which enables a broader role for nutrition professionals in commercial communications. Such action would also be consistent with the UK's better regulation agenda to ensure evidence-based, proportionate regulation for industry.

Nature of the evidence base and strengths, challenges and recommendations in the area of nutrition and health claims: a position paper from the Academy of Nutrition Sciences.

The regulation of health claims for foods by the Nutrition and Health Claims Regulation is intended, primarily, to protect consumers from unscrupulous claims by ensuring claims are accurate and substantiated with high quality scientific evidence. In this position paper, the Academy of Nutrition Sciences uniquely recognises the strengths of the transparent, rigorous scientific assessment by independent scientists of the evidence underpinning claims in Europe, an approach now independently adopted in UK. Further strengths are the separation of risk assessment from risk management, and the extensive guidance for those submitting claims. Nevertheless, four main challenges in assessing the scientific evidence and context remain: (i) defining a healthy population, (ii) undertaking efficacy trials for foods, (iii) developing clearly defined biomarkers for some trial outcomes and (iv) ensuring the composition of a food bearing a health claim is consistent with generally accepted nutrition principles. Although the Regulation aims to protect the consumer from harm, we identify some challenges from consumer research: (i) making the wording of some health claims more easily understood and (ii) understanding the implications of the misperceptions around products bearing nutrition or health claims. Recommendations are made to overcome these challenges. Further, the Academy recommends that a dialogue is developed with the relevant national bodies about Article 12(c) in the Regulation. This should further clarify the GB Guidance to avoid the current non-level playing field between health professionals and untrained 'influencers' who are not covered by this Article about the communication of authorised claims within commercial communications.

Nature of the evidence base and frameworks underpinning dietary recommendations for prevention of non-communicable diseases: a position paper from the Academy of Nutrition Sciences.

This Position Paper from the Academy of Nutrition Sciences is the first in a series which describe the nature of the scientific evidence and frameworks that underpin nutrition recommendations for health. This first paper focuses on evidence which underpins dietary recommendations for prevention of non-communicable diseases. It considers methodological advances made in nutritional epidemiology and frameworks used by expert groups to support objective, rigorous and transparent translation of the evidence into dietary recommendations. The flexibility of these processes allows updating of recommendations as new evidence becomes available. For CVD and some cancers, the paper has highlighted the long-term consistency of a number of recommendations. The innate challenges in this complex area of science include those relating to dietary assessment, misreporting and the confounding of dietary associations due to changes in exposures over time. A large body of experimental data is available that has the potential to support epidemiological findings, but many of the studies have not been designed to allow their extrapolation to dietary recommendations for humans. Systematic criteria that would allow objective selection of these data based on rigour and relevance to human nutrition would significantly add to the translational value of this area of nutrition science. The Academy makes three recommendations: (i) the development of methodologies and criteria for selection of relevant experimental data, (ii) further development of innovative approaches for measuring human dietary intake and reducing confounding in long-term cohort studies and (iii) retention of national nutrition surveillance programmes needed for extrapolating global research findings to UK populations.

Expert consensus on low-calorie sweeteners: facts, research gaps and suggested actions.

A consensus workshop on low-calorie sweeteners (LCS) was held in November 2018 where seventeen experts (the panel) discussed three themes identified as key to the science and policy of LCS: (1) weight management and glucose control; (2) consumption, safety and perception; (3) nutrition policy. The aims were to identify the reliable facts on LCS, suggest research gaps and propose future actions. The panel agreed that the safety of LCS is demonstrated by a substantial body of evidence reviewed by regulatory experts and current levels of consumption, even for high users, are within agreed safety margins. However, better risk communication is needed. More emphasis is required on the role of LCS in helping individuals reduce their sugar and energy intake, which is a public health priority. Based on reviews of clinical evidence to date, the panel concluded that LCS can be beneficial for weight management when they are used to replace sugar in products consumed in the diet (without energy substitution). The available evidence suggests no grounds for concerns about adverse effects of LCS on sweet preference, appetite or glucose control; indeed, LCS may improve diabetic control and dietary compliance. Regarding effects on the human gut microbiota, data are limited and do not provide adequate evidence that LCS affect gut health at doses relevant to human use. The panel identified research priorities, including collation of the totality of evidence on LCS and body weight control, monitoring and modelling of LCS intakes, impacts on sugar reduction and diet quality and developing effective communication strategies to foster informed choice. There is also a need to reconcile policy discrepancies between organisations and reduce regulatory hurdles that impede low-energy product development and reformulation.

A simple cut-off for waist-to-height ratio (0·5) can act as an indicator for cardiometabolic risk: recent data from adults in the Health Survey for England.

The National Institute for Health and Care Excellence (NICE) has acknowledged the value of waist-to-height ratio (WHtR) as an indicator for 'early health risk'. We used recent UK data to explore whether classification based on WHtR identifies more adults at cardiometabolic risk than the 'matrix' based on BMI and waist circumference, currently used for screening. Data from the Health Survey for England (4112 adults aged 18+ years) were used to identify cardiometabolic risk, indicated by raised glycated Hb, dyslipidaemia and hypertension. HbA1c, total/HDL-cholesterol and systolic blood pressure (BP) were more strongly associated with WHtR than the 'matrix'. In logistic regression models for HbA1c ≥ 48 mmol/mol, total/HDL-cholesterol > 4 and hypertension (BP > 140/90 mmHg or on medication), WHtR had a higher predictive value than the 'matrix'. AUC was significantly greater for WHtR than the 'matrix' for raised HbA1c and hypertension. Of adults with raised HbA1c, 15 % would be judged as 'no increased risk' using the 'matrix' in contrast to 3 % using WHtR < 0·5. For hypertension, comparative values were 23 and 9 %, and for total/HDL-cholesterol > 4, 26 and 13 %. Nearly one-third of the 'no increased risk' group in the 'matrix' had WHtR ≥ 0·5 and hence could be underdiagnosed for cardiometabolic risk. WHtR has the potential to be a better indicator of cardiometabolic risks associated with central obesity than the current NICE 'matrix'. The cut-off WHtR 0·5 in early screening translates to a simple message, 'your waist should be less than half your height', that allows individuals to be aware of their health risks.

Potential for waist-to-height ratio to detect overfat adolescents from a Pacific Island, even those within the normal BMI range.

INTRODUCTION: Waist-to-height ratio (WHtR) is a simple anthropometric proxy for central body fat; it is easy to use from a health education perspective. A WHtR value >0.5 has been proposed as a first level indicator of health risk. The first aim of this study was to compare WHtR with values based on body mass index (BMI) in their prediction of the percentage of body fat (%BF) in a multi-ethnic population of adolescents from New-Caledonia (age 11-16year). Secondly, to see whether WHtR >0.5 could be used to detect overfat subjects whose BMI was in the normal range. MATERIALS AND METHODS: Body fat percentage (%BF, based on skinfold measurements), BMI and WHtR were calculated for New Caledonian adolescents from different ethnic backgrounds. The relationship between %BF, BMI and WHtR was determined using quadratic models and from linear regression equations. The sensitivity and specificity of WHtR for detecting overfat adolescents (%BF >25% in boys and >30% in girls) were assessed and compared with those from the BMI-based classification. RESULTS: WHtR showed better correlation with %BF than BMI-based measurements. WHtR >0.5 was also more accurate than BMI in detecting overfat adolescents. Moreover, using this boundary value, 8% of adolescents in the normal BMI range were shown to be over-fat. CONCLUSIONS: WHtR is a good anthropometric proxy to detect overfat adolescents. Detecting overfat adolescents within the normal BMI range is particularly important for preventing non communicable diseases. We therefore recommend using WHtR for health education programs in the Pacific area and more generally.

A structured literature review on the role of mindfulness, mindful eating and intuitive eating in changing eating behaviours: effectiveness and associated potential mechanisms.

The role of mindfulness, mindful eating and a newer concept of intuitive eating in modulating eating habits is an area of increasing interest. In this structured literature review, a summary of the current evidence is presented, together with details of interventions undertaken and the tools to measure outcomes. It is broad in scope given the emerging evidence base in this area. The review yielded sixty-eight publications: twenty-three interventions in obese/overweight populations; twenty-nine interventions in normal-weight populations; sixteen observational studies, three of which were carried out in overweight/obese populations. Mindfulness-based approaches appear most effective in addressing binge eating, emotional eating and eating in response to external cues. There is a lack of compelling evidence for the effectiveness of mindfulness and mindful eating in weight management. Mindfulness-based approaches may prevent weight gain. Reduced food intake was seen in some of the studies in overweight and obese populations, but this was less apparent in the studies in normal-weight populations. The evidence base for intuitive eating is limited to date and further research is needed to examine its potential in altering eating behaviours. Mindfulness appears to work by an increased awareness of internal, rather than external, cues to eat. Mindfulness and mindful eating have the potential to address problematic eating behaviours and the challenges many face with controlling their food intake. Encouraging a mindful eating approach would seem to be a positive message to be included in general weight management advice to the public.

What can the food and drink industry do to help achieve the 5% free sugars goal?

AIMS: To contribute evidence and make recommendations to assist in achieving free sugars reduction, with due consideration to the broader picture of weight management and dietary quality. METHODS: An expert workshop in July 2016 addressed options outlined in the Public Health England report 'Sugar reduction: The evidence for action' that related directly to the food industry. Panel members contributed expertise in food technology, public heath nutrition, marketing, communications, psychology and behaviour. Recommendations were directed towards reformulation, reduced portion sizes, labelling and consumer education. These were evaluated based on their feasibility, likely consumer acceptability, efficacy and cost. RESULTS: The panel agreed that the 5% target for energy from free sugars is unlikely to be achievable by the UK population in the near future, but a gradual reduction from average current level of intake is feasible. Progress requires collaborations between government, food industry, non-government organisations, health professionals, educators and consumers. Reformulation should start with the main contributors of free sugars in the diet, prioritising those products high in free sugars and relatively low in micronutrients. There is most potential for replacing free sugars in beverages using high-potency sweeteners and possibly via gradual reduction in sweetness levels. However, reformulation alone, with its inherent practical difficulties, will not achieve the desired reduction in free sugars. Food manufacturers and the out-of-home sector can help consumers by providing smaller portions. Labelling of free sugars would extend choice and encourage reformulation; however, government needs to assist industry by addressing current analytical and regulatory problems. There are also opportunities for multi-agency collaboration to develop tools/communications based on the Eatwell Guide, to help consumers understand the principles of a varied, healthy, balanced diet. CONCLUSION: Multiple strategies will be required to achieve a reduction in free sugars intake to attain the 5% energy target. The panel produced consensus statements with recommendations as to how this might be achieved.

Waist-to-height ratio as an indicator of 'early health risk': simpler and more predictive than using a 'matrix' based on BMI and waist circumference.

OBJECTIVES: There is now good evidence that central obesity carries more health risks compared with total obesity assessed by body mass index (BMI). It has therefore been suggested that waist circumference (WC), a proxy for central obesity, should be included with BMI in a 'matrix' to categorise health risk. We wanted to compare how the adult UK population is classified using such a 'matrix' with that using another proxy for central obesity, waist-to-height ratio (WHtR), using a boundary value of 0.5. Further, we wished to compare cardiometabolic risk factors in adults with 'healthy' BMI divided according to whether they have WHtR below or above 0.5. SETTING, PARTICIPANTS AND OUTCOME MEASURES: Recent data from 4 years (2008-2012) of the UK National Diet and Nutrition Survey (NDNS) (n=1453 adults) were used to cross-classify respondents on anthropometric indices. Regression was used to examine differences in levels of risk factors (triglycerides (TG), total cholesterol (TC), low-density lipoprotein (LDL), high-density lipoprotein (HDL), TC: HDL, glycated haemoglobin (HbA1c), fasting glucose, systolic (SBP) and diastolic blood pressure (DBP)) according to WHtR below and above 0.5, with adjustment for confounders (age, sex and BMI). RESULTS: 35% of the group who were judged to be at 'no increased risk' using the 'matrix' had WHtR ≥ 0.5. The 'matrix' did not assign 'increased risk' to those with a 'healthy' BMI and 'high' waist circumference. However, our analysis showed that the group with 'healthy' BMI, and WHtR ≥ 0.5, had some significantly higher cardiometabolic risk factors compared to the group with 'healthy' BMI but WHtR below 0.5. CONCLUSIONS: Use of a simple boundary value for WHtR (0.5) identifies more people at 'early health risk' than does a more complex 'matrix' using traditional boundary values for BMI and WC. WHtR may be a simpler and more predictive indicator of the 'early heath risks' associated with central obesity.

Stevia, Nature's Zero-Calorie Sustainable Sweetener: A New Player in the Fight Against Obesity.

Stevia is a plant native to South America that has been used as a sweetener for hundreds of years. Today, zero-calorie stevia, as high-purity stevia leaf extract, is being used globally to reduce energy and added sugar content in foods and beverages. This article introduces stevia, explaining its sustainable production, metabolism in the body, safety assessment, and use in foods and drinks to assist with energy reduction. The article also summarizes current thinking of the evidence for the role of nonnutritive sweeteners in energy reduction. Overall, stevia shows promise as a new tool to help achieve weight management goals.

A proposal for a primary screening tool: 'Keep your waist circumference to less than half your height'.

BACKGROUND: There is now overwhelming scientific evidence that central obesity, as opposed to total obesity assessed by body mass index (BMI), is associated with the most health risks and that the waist-to-height ratio (WHtR) is a simple proxy for this central fat distribution. This Opinion reviews the evidence for the use of WHtR to predict mortality and for its association with morbidity. A boundary value of WHtR of 0.5 has been proposed and become widely used. This translates into the simple screening message 'Keep your waist to less than half your height'. Not only does this message appear to be suitable for all ethnic groups, it also works well with children. DISCUSSION: Ignoring this simple message and continuing to use BMI as a sole indicator of risk would mean that 10% of the whole UK population, and more than 25% of the UK population who are judged to be normal weight using BMI, are misclassified and might not be alerted to the need to take care or to take action. SUMMARY: Accepting that a boundary value whereby WHtR should be less than 0.5 not only lends itself to the simple message 'Keep your waist to less than half your height' but it also provides a very cheap primary screening method for increased health risks: A piece of string, measuring exactly half a person's height should fit around that person's waist.

A web-based weight loss programme including breakfast cereals results in greater loss of body mass than a standardised web-based programme in a randomised controlled trial.

OBJECTIVE: To test the hypothesis that promoting breakfast cereal consumption, as part of a web-based programme, results in loss of body mass. METHODS: Single centre, single blind, randomised parallel study. Test group followed a fully interactive website (B) with 'prescribed' breakfast cereals. Control group followed website (A) giving standard advice on weight loss.Study site visits at 0, 4, 12 and 24 weeks for measurements of height, weight, skinfolds, body fat, waist and hip circumference. 180 subjects were randomly allocated to two equal groups.Subjects were in good health and aged 19­50 years, with a BMI ranging from 25­40 kg/m 2 .At baseline there was no difference in mean age or BMI between the two groups. RESULTS: The percentage change in body mass loss was greater when following website B than website A (n = 90; ITT repeated measures p = 0.013). For completers (website A: n = 62, website B: n= 64), the percentage change in body mass loss was also greater for website B than website A (repeated measures p = 0.023). CONCLUSION: The advice and motivation offered by an interactive website, including provision and consumption of breakfast cereals, results in significantly greater loss of body mass compared to the use of a standard website. It is not possible to discern which of the three factors is responsible.

Waist-to-height ratio is more predictive of years of life lost than body mass index.

OBJECTIVE: Our aim was to compare the effect of central obesity (measured by waist-to-height ratio, WHtR) and total obesity (measured by body mass index, BMI) on life expectancy expressed as years of life lost (YLL), using data on British adults. METHODS: A Cox proportional hazards model was applied to data from the prospective Health and Lifestyle Survey (HALS) and the cross sectional Health Survey for England (HSE). The number of years of life lost (YLL) at three ages (30, 50, 70 years) was found by comparing the life expectancies of obese lives with those of lives at optimum levels of BMI and WHtR. RESULTS: Mortality risk associated with BMI in the British HALS survey was similar to that found in US studies. However, WHtR was a better predictor of mortality risk. For the first time, YLL have been quantified for different values of WHtR. This has been done for both sexes separately and for three representative ages. CONCLUSION: This study supports the simple message "Keep your waist circumference to less than half your height". The use of WHtR in public health screening, with appropriate action, could help add years to life.

Does regular breakfast cereal consumption help children and adolescents stay slimmer? A systematic review and meta-analysis.

OBJECTIVE: To review systematically the evidence on breakfast cereal consumption and obesity in children and adolescents and assess whether the regular consumption of breakfast cereals could help to prevent excessive weight gain. METHODS: A systematic review and meta-analysis of studies relating breakfast cereal consumption to BMI, BMI z-scores and prevalence of obesity as the outcomes. RESULTS: 14 papers met the inclusion criteria. The computed effect size for mean BMI between high consumers and low or non-consumers over all 25 study subgroups was -1.13 kg/m2 (95% CI -0.81, -1.46, p < 0.0001) in the random effects model, which is equivalent to a standardised mean difference of 0.24. Adjustment for age and publication bias attenuated the effect sizes somewhat but they remained statistically significant. The prevalence and risk of overweight was lower in children and adolescents who consume breakfast cereals regularly compared to those who consume them infrequently. Energy intakes tended to be higher in regular breakfast cereal consumers. CONCLUSION: Overall, the evidence reviewed is suggestive that regular consumption of breakfast cereals results in a lower BMI and a reduced likelihood of being overweight in children and adolescents. However, more evidence from long-term trials and investigations into mechanisms is needed to eliminate possible confounding factors and determine causality.

Documentation of functional and clinical effects of infant nutrition: setting the scene for COMMENT.

The Early Nutrition Academy and the Child Health Foundation, in collaboration with the Committee on Nutrition, European Society for Paediatric Gastroenterology, Hepatology and Nutrition, held a workshop in March 2011 to explore guidance on acquiring evidence on the effects of nutritional interventions in infants and young children. The four objectives were to (1) provide guidance on the quality and quantity of evidence needed to justify conclusions on functional and clinical effects of nutrition in infants and young children aged <3 years; (2) agree on a range of outcome measures relevant to nutrition trials in this age group for which agreed criteria are needed; (3) agree on an updated 'core data set' that should generally be recorded in nutrition trials in infants and young children, and (4) provide guidance on the use of surrogate markers in paediatric nutrition research. The participants discussed these objectives and agreed to set up six first working groups under the auspices of the Consensus Group on Outcome Measures Made in Paediatric Enteral Nutrition Clinical Trials (COMMENT). Five groups will aim to identify and define criteria for assessing key outcomes, i.e. growth, acute diarrhoea, atopic dermatitis and cows' milk protein allergy, infections and 'gut comfort'. The sixth group will review and update the 'core data set'. The COMMENT Steering Committee will discuss and decide upon a method for reaching consensus which will be used by all working groups and plan to meet again within 2 years and to report and publish their conclusions.