ALISON TEDSTONE MBE - WRITTEN EVIDENCE (FDO0117)
From: Dr Alison Tedstone MBE (personal views, not on behalf of any organisation). Chair of the Association for Nutrition and former Chief Nutritionist at Public Health England (PHE) and the Department of Health and Social Care (DHSC). Honorary fellowships from the Nutrition Society and Royal Colleges of Physicians and Paediatrics and Child Health and advisor to the World Health Organisation.
Declaration of interests: no interests in any food business.
These views are based on over 20 years’ as a civil servant in the government’s nutrition team. My responsibilities have included SACN and providing nutrition science to policy making on nutrition, diet and obesity. This has been as Principal Nutritionist (2001-06) and Head of Nutrition Science (2006-12) at the Food Standards Agency and following a machinery of government change at the Department of Health (2012-13), and subsequently as Chief Nutritionist at PHE (2013-21) and then DHSE (2021-22) after the closure of PHE.
I note that there has been criticism of SACN in the committee hearings. Some witnesses have called into question SACN’s independence and impartiality.
SACN’s independence has been questioned at times over the years by some who have not agreed with the committee’s conclusions or recommendations and by those who feared that the committee may be biased because of some of the declared interests by some members. This criticism reflects the complicated and contested area that SACN needs to navigate where there are many stakeholders who have strong and often opposing views and interests. While SACN has developed processes to enable their work, transparency and independence, it has not completely mitigated stakeholder concerns. I will now share my views with the enquiry on this.
I have not seen bias in the committee deliberations or reports. I have observed the committee and its secretariat going to extensive lengths to ensure impartiality and transparency. Indeed, part of my role as observer of SACN was to check for probity and to ensure the evidential basis for all recommendations.
SACN has various checks and balances in place to ensure independence and transparency. This includes appointment of members through independent process, Nolan principles, an open and transparent declaration of interest process (published on SACN’s webpages), public consultation of draft reports, open meetings and consideration of evidence against a published framework (1). The committee’s consideration of responses to consultations are detailed and published.
The SACN framework is designed to ensure robust conclusions. It prioritises long term large randomised controlled trials (RCTs) and well-designed large prospective studies that consider confounding and bias. The committee places a low degree of certainty on small studies or other types of studies where the risk of scientific bias is high (such as ecological studies that compare different countries). Laboratory or animal studies are used to develop plausibility and context. SACN do not consider unpublished or non-peer reviewed research.
Other nations committees consider evidence against similar criteria. These types of safeguards have proved to be important over the years. There has been a history in the wider nutrition community of claims being made prematurely for diet, nutrients and health interactions. For example, in the 1980’s, based on epidemiological studies showing an association between diets high in antioxidants (vitamins C, E and beta carotene from fruit and veg) and reduced cancer risk, taking of antioxidant supplements were promoted. RCTs subsequently found that the antioxidant group had a higher incidence of cancer. More recently during the pandemic it was claimed that taking vitamin D could reduce the risk of COVID. Detailed analysis by SACN of the evidence showed no benefit.
SACN members declarations mainly relate to research that has been funded by the Biotechnology and Biological Sciences Research Council (BBSRC). This is the main source of funding for nutrition and food science research in the UK. One of the key criteria for academics seeking BBSRC funding is partnership with businesses. While this criterion is in place, it is hard to secure funding for nutrition research without industrial partnership. It is worth noting that academics risk penalisation in their careers if they reject BBSRC funding as universities judge academic staff on funding and publication record. It should also be noted that Department of Environment, Food and Rural Affairs (DEFRA) is a sponsor of both the BBSRC and the food industry.
Generally independent scientific committees in the UK want academics who are research active and hold positions in prestigious universities or are very recently retired. This helps ensure knowledge and critical thinking is current. If a decision was made to exclude research active members from expert committees who are in receipt of funding such as that from the BBSRC, then there would be a risk of diminishing the committee and lowering the quality of deliberations and reports.
It is worth noting that occasionally SACN have been accused of over-interpreting evidence as well as of being too cautious. For example, when SACN published the draft report on Carbohydrates and Health some parts of the food industry said that SACN were over-playing the link between sugar consumption, sugary drinks and obesity while some public health professionals were concerned that the committee would side with industry. The final report halved dietary recommendations from 10 to 5% of energy from sugars (lower than any other country at the time) and advised sugary drinks consumption be minimised.
Critical scrutiny of SACNs deliberations is positive and welcomed, as it helps ensure the committee test their interpretation of evidence and that Ministers get the best possible advice. SACN reports need to be robust as they are important in policy and legislation on nutrition and obesity. For example, the Soft Drinks Industry Levy (SDIL) was based on a report on Carbohydrates and Health, as were the recently introduced controls on the promotion of high fat, salt and sugar (HFSS) foods in prominent places in supermarkets (end of aisle etc). SACN’s evidence was drawn on extensively throughout the policy and legislative process. I can assure the enquiry that it was subject to serious critical scrutiny by interested parties, and it is only because it was based on carefully and impartially developed robust evidence that it withstood the test. Another example is a judicial challenge by Kellogg’s of the HFSS place based promotional controls. The final judgement makes it clear how important the robust evidential basis of SACN’s advice was on sugar, health and nutrient profiling (2).
Of course, the credibility of expert committees, including SACN stands or falls on their integrity and impartiality as well as their scientific expertise. There is always scope for improving processes including those around handling member interests.
In my experience it has proven hard to progress nutrition or obesity policies that may impinge on business growth. This is for a range of reasons, but vested interests certainly play a part in legislative and policy drag. These range from government departments, outside health, representing the views of the industries they sponsor such as food, advertising, and sport (which is often funded by food business), constituency interests, lobbying and access. There is also the media, commentators and influencers who can present a one-sided view or be driven by thinktanks with a libertarian bias, or those who may have vested interests (for example because of selling books, treatments including pharmaceuticals or services), or by academics who seek to promote their own research or ideas. These types of biases are often not transparent or apparent. In my experience the interests of business can be very loud.
I suspect that it is SACNs framework that has led to some concerns expressed at the enquiry around the committee’s conclusions on UPF. In upholding standards of scientific review SACN have not been able to include some sources of information seen as key by others (small statistically under-powered RCTs, invitro and unpublished studies). SACN were however clear that increasing consumption of UPF is consistently associated with worsening health outcomes. They also drew attention to some limitations in the evidence. In my view, SACN has made a fact-based statement on evidence on UPF, rather than giving a biased opinion.
The various merits of classifying the healthiness of foods by either a HFSS or UPF systems has become a hot and public topic amongst experts. I am concerned that this debate could easily be used as a reason to delay policy progress because ‘not even experts agree’. This would be unfortunate given the burden to the NHS and society of diseases caused by poor diets. The HFSS classification system is established in UK legislation and similar systems in other countries. This has taken many years and been subject to test by many challenges. In my view, it is unlikely that this could be easily replaced by a more complicated UPF system, and the integrity of existing legislation could be damaged. That said as a nation we are being sold, and eating, too much UPF and HFSS foods. Given that the majority of UPF is HFSS perhaps the debate is academic.
Over the years many interventions have been tried to improve the nation’s diet. The majority have been low level (in a behaviour change hierarchical sense). They have largely relied on education or information and voluntary measures, and more recently treatment of obesity.
The food industry has consistently pitched to government that nutrition education and physical activity will combat obesity, while the evidence is limited that these alone cannot improve diet or energy balance in the long term. This is not least because the intention to eat healthily is undone by the saturation of our environment with food and an economic model that is designed to grow profitability by selling more food.
Companies will often say consumers just need to choose healthier food, but analysis of the portfolios of leading companies shows that most food sold by them is unhealthy (3) and these are the foods which are most often marketed (4).
Formerly PHE and now DHSC oversee the programmes of voluntary reformulation of food in salt, sugar and calories. These programmes have been operating for years yet, despite some good progress by some companies, little overall progress has been made and shopping baskets have worsened. For example, the sugar content of breakfast cereals has reduced by 14.9% and that of yogurts by 13.5% per 100g since 2015, but there has been no meaningful change in high sugar products such as confectionary (5). In contrast the SDIL has delivered a 46% reduction in sugar in drinks. Since 2015, the sales of high sugar products (chocolate, biscuits etc) have grown substantially. This has effectively negated the gains through voluntary reductions in sugar and from the SDIL. There is now more sugar in shopping baskets than before.
The voluntary calorie reduction programme has achieved no meaningful reductions (6). It is particularly worrying as it includes the out of home sector where portion sizes are high (7), and fast-food businesses who are in growth (8). It is not unreasonable to assume that much of the growth of fast food has been driven by marketing and partnerships with on-line delivery platforms.
In 2015 PHE advised that sugar reduction would only be achieved if multiple actions were undertaken in parallel, these included a sugary drinks tax or levy, advertising and promotional restrictions. Only the SDIL and voluntary sugar reformulation programme were introduced in 2016/17 and it was not until 2023 that restrictions on HFSS placement in supermarkets were introduced. Planned restrictions on advertising and price promotions of HFSS products have been delayed. Without these measures in place it is not surprising that much of industry have not responded to calls for voluntary reformulation. Nor is it surprising that the fast-food industry has largely not improved their food and indeed have sold more, given that they have been excluded from most of the pending legislation and benefited from other incentives during the pandemic.
The food habits of the nation will only improve if legislative controls to limit the sales of unhealthy food across all sectors of the food industry including fast food and other businesses including the delivery platforms, who currently take little responsibility for what they sell, are included. These need to include marketing and promotional restrictions on unhealthy foods, and possible further taxes or levies to encourage reformulation and healthier portfolios. Without serious and sustained intervention market forces and incentives will continue to expand unhealthy food sales. Regulation also helps ensure consistency and an even playing field for businesses.
Voluntary measures have been robustly tested, and despite what some of industry say there is no reason to expect that different voluntary systems will be any more successful. The expansion of fast food needs to be addressed urgently including by controlling direct brand marketing and sponsorship which are out of scope of delayed advertising controls.
Softer measures such as school food and nutrition education also need improving. This is best done through enforcement of existing legislation, not by investing political capital in new legislation that is unlikely to be enforced. Children deserve better food than they often get in schools, however action in schools cannot be a standalone solution considering the saturation of their physical and virtual environments with unhealthy food. Similarly, food labels need to be improved so that all products have front of pack nutrition information, however the format of the label is less important than consistency.
6 April 2024
References
1. https://www.gov.uk/government/groups/scientific-advisory-committee-on-nutrition#framework-for-the- evaluation-of-evidence
2. https://www.judiciary.uk/wp-content/uploads/2022/07/Kellogg-v-SSHSC-judgment-040722.pdf
3. https://accesstonutrition.org/index/global-index-2021
4. https://www.biteback2030.com/the-gut-punch/the-fuel-us-dont-fool-us-report/
5. https://assets.publishing.service.gov.uk/media/6388cd71d3bf7f328c0ded27/Sugar-reduction-and- reformulation-progress-report-2015-to-2020.pdf
6. https://www.gov.uk/government/publications/calorie-reduction-programme-industry-progress-2017-to- 2021/calorie-reduction-programme-industry-progress-2017-to-2021
7. https://www.gov.uk/government/publications/calorie-reduction-guidelines-for-the-food-industry
8. https://www.kantar.com/uki/inspiration/brands/fast-food-brands-among-the-most-resilient-in-2023- kantar-brandz-most-valuable-global-brands-report