Con Fidcontial for Internal Use Only

Change4Life Sugar Smart

January 2016

 Contents

1. About sugar

2. Sugar guidelines and consumption

3. Nutrition labels

4. The Sugar Smart campaign

5. Sugar Smart app

6. Sugar Smart partners

1. About sugar

1.1 What is sugar? Sugar is a sweet crystalline substance obtained from various plants, especially sugar cane and sugar beet, consisting essentially of sucrose, and used, as a sweetener in food and drink.1 Sugar is a carbohydrate along with starch.2

Definitions of sugar vary. There are two main types of sugar, those that are contained within the cellular structure of foods and drinks and naturally present in dairy products, and those that are ‘free’ or ‘added sugars’.3

1.2 What are the different types of sugar? There are surprisingly large amounts of sugar lurking in everyday foods and drinks.  Added by manufacturers (such as fructose, sucrose, glucose and high fructose corn syrup)  Added at home (on cereal, hot drinks and whilst cooking)  Honey, syrups, fruit juice concentrates and nectars  In fruit juices (they do count towards your 5-a-day but limit the amount to 150ml per day)

1.3 What is the worst type of sugar for our health? Sugars occur naturally in foods such as fruit and milk, but it’s the sugars that are added to things by manufacturers (breakfast cereals, chilled desserts, yoghurts, sweets, cakes, biscuits, chocolate, and some fizzy drinks) as well as sugar added at home (on cereal, hot drinks and whilst cooking) that we should cut down on.3

1.4 What are the dfferences between...:

 added sugar and natural sugar?

Naturally occurring sugar is the sugar found in whole, unprocessed foods, such as milk, fruit, vegetables and some grains. The most common natural sugars are fructose, which is found in fruit, and lactose, which is found in milk products.4

Added sugar is the sugar added to processed food and drinks when they are being made, as well as sugar you may add to your food at home.3

Food manufacturers may add both natural sugars (such as fructose) and processed sugars (such as high-fructose corn syrup) to processed food and drinks.

 intrinsic and extrinsic sugars? Intrinsic sugars are those that present naturally within the cellular structure of food, these sugars are mainly found in fruits and vegetables. Extrinsic sugars are those that are added to food.5

 hidden and added sugars? Hidden sugar is the sugar found naturally in most foods. On the other hand, ‘added sugar’ is the sugar added to many foods to make them taste nicer.5

1.5 What types of sugar is Public Health England / Change4Life trying to get people to cut down on? It’s the sugars that are added to things such as breakfast cereals, chilled desserts, yoghurts, sweets, cakes, biscuits, chocolate, and some fizzy drinks and juice drinks that we should cut down on.

1.6 Are you suggesting that people should cut fruit out of their diet?

No. Fruit does contain sugar as part of its structure but it’s a healthier choice because it also contains fibre, vitamins and minerals. Fruit also contributes to your 5 A DAY. 6

1.7 What is the guidance from Public Health England about drinking fruit juice? Current Government guidance outlines one glass (150ml) of unsweetened 100% fruit juice counts toward your 5 A DAY. However, these drinks do contain sugar (and therefore calories) so the advice is to have no more than this a day. It is also recommended that fruit juice be consumed with meals to protect against dental cavities.7

1.8 What is the issue with fizzy drinks? In every age group, fizzy drinks are a key contributor of sugar in the diet and there is a significant amount of scientific evidence to prove that there is no place for them, especially amongst children. Soft drinks, including fizzy drinks, are the largest single source of sugar for teenagers. For younger children soft drinks, confectionery and fruit juice are the major sources of sugar. In adults table sugar and preserves and soft drinks are the main sources. 8

Families also need to be conscious that some flavoured waters contain large quantities of added sugar even though they may appear to be a healthier alternative.

1.9 Are you demonising fizzy drinks? No, a wealth of robust and scientific data has been published which has shown that there is no place in our diets for fizzy drinks. Soft drinks, including fizzy drinks, are the largest single source of sugar for teenagers. For younger children soft drinks, confectionery and fruit juice are the major sources of sugar. In adults table sugar and preserves and soft drinks are the main sources.8

1.10 Are diet drinks ok to drink? Clearly the ‘ideal’ would be to swap from sugary drinks to water but research shows there are no obesity/dietary related health risks to drinking diet versions of carbonated drinks. In fact, there are significant health benefits to switching from a sugary drink to a diet or sugar free version.

1.11 Aspartame has been documented in the media as causing cancer, surely PHE should not be promoting drinks with sweetners as an alternative.

In December 2014 the European Food Safety Authority (EFSA) completed a full risk assessment on aspartame, taking into account all available scientific research and concluded it is safe at current levels of exposure.

Ideally families could cut down on sugar by swapping to healthier alternatives, for example by swapping sugary drinks for milk (ideally semi-skimmed, 1% fat or skimmed) or water, but our research has shown that many people find it hard to make long term changes if they have to cut out their favourite foods or drinks, in which case swapping to reduced and sugar free versions can help them to do this, whilst still having significant benefits over eating sugar.

1.12 What are the health implications of consuming too much sugar? According to recently published data from the National Child Measurement Programme (NCMP), almost one in ten children aged 4-5 years is obese, rising to one in five children aged 10-11 years. Even more are overweight.

Evidence shows that eating too much sugar results in extra calories which causes fat to build up inside the body, which can lead to weight gain and obesity. Children who are overweight or obese are more likely to develop illnesses such as type 2 diabetes, go onto experience weight and health problems in adolescence, and are more likely to become overweight or obese adults.

If an individual is overweight or obese they are more prone to a range of serious health problems. These include cardiovascular disease; type 2 diabetes; endometrial,

breast and colon cancer; as well as psychological and social problems such as stress, low self-esteem, depression, stigma, prejudice and bullying.

1.13 How confident is Public Health England about the evidence behind sugar causing tooth decay? There is clear evidence to support the connection between sugar and tooth decay and recent estimates suggest poor dental health costs the NHS alone £3.4 billion a year.12 In 2012, almost one-third of five year olds in England had tooth decay with stark inequalities across the country.1 A systematic review commissioned by the World Health Organisation found that when less than 10% of total energy (calorie) intake is made up of free sugar there are much lower levels of cavities. Dental decay progresses with age and the effects from sugars on teeth are lifelong.13

1.14 How confident is Public Health England about the evidence behind sugar causing obesity and deadly/chronic diseases? Data from the National Diet and Nutrition Survey clearly demonstrates that we are all eating too much salt, saturated fat and sugars. In addition, the Scientific Advisory Committee on Nutrition (SACN) which updated it’s guidance in July 2015 highlighted that eating too much sugar results in extra calories, which causes fat to build up, and could lead to heart disease, cancer or type 2 diabetes. NHS costs attributable to being overweight and obese are projected to reach £9.7 billion by 2050, with wider costs to society estimated to reach £49.9 billion per year.15

Helping people choose, cook and eat a diet lower in salt, saturated fat and sugars (and higher in fruit and veg, fibre and oily fish) will lead to longer, healthier lives.

2. Sugar guidelines and consumption

2.1 What is the recommended daily allowance for sugar for adults and children? No more than 5% of people’s (from 2 years old and above) daily energy intake should come from free sugars. This is a new recommendation announced by the Scientific Advisory Committee on Nutrition (SACN) in July 2015.14

2.2 Why can we only eat 5% free sugars of our daily energy intake? The Government’s advice on sugar intake is based on robust evidence compiled by an independent expert body - the Scientific Advisory Committee on Nutrition (SACN). The evidence considered by SACN shows that reducing free sugars intake to below 5% of total energy intake reduces the risk of eating too many calories.14

SACN have proposed a recommendation of around 5% of total energy intake from total sugars on the bases that it could help reduce obesity, and tooth decay. They have also taken into account evidence on type 2 diabetes. A diet where sugars intake is 5% of daily energy intake approximately equates to 30g or 7 cubes of sugar per day on average.14

2.3 When do we expect to achieve the 5% sugar intake figure? Is it realistic? The new recommendations on sugar pose a significant challenge but are achievable in the long-term. The scientific evidence shows that we all have to reduce our sugar consumption in order to protect our health. This is why a broad range of measures is needed in response - there is no single solution. We need to change our environment to help the nation make healthier choices.

Current estimates of UK sugar intakes from the National Diet and Nutrition Survey programme (NDNS), show that average intakes are three times higher than the 5% maximum recommended level in school-aged children and teenagers (15% of energy

intake) and around twice the maximum recommended level in adults (12% of energy intake).

2.4 Currently how much sugar does the average person consume in the UK? The average person in Britain consumes 700g of sugar a week – equivalent to 175 sugar cubes of sugar!

2.5 Does this differ between age groups? The below shows a breakdown of daily total sugar intake14  Children aged 1 and a half to 3 consume on average 36.1g of sugar (11.9%)  Children aged 4-10 consume on average 60.8g of sugar (23.8%)  Teenagers aged 11 – 18 consume on average 74.2g of sugar (15.4%)  Adults aged 19 - 64 consume on average 58.8g of sugar (12.1%)  Adults aged 65+ consume on average 51.6g of sugar (11.5%)

2.6 Which foods and drinks consumed by 4-10 year olds in England contain the most sugar? Children’s sugar consumption, as a percentage of energy intake, is up to 55% greater than the current SACN recommendation. The highest contributor to added sugar in the diet 4 to 10 year olds is: • 30% drinks (including 17% from soft drinks). This is not low calorie drinks

• 29% cereals (mainly from biscuits, cakes and breakfast cereals)

• 22% sugar, preserves and confectionery

• 12% milk and milk products

2.7 Why are people in England eating and drinking too much sugar? There does not seem to be one definitive reason for people in England eating too much sugar. However, could include, but are not limited to:  A lack of awareness around the level of sugars of food  Confusion over the levels of sugar in food  People ignoring health messages

 A lack of access to healthy foods  Preference for the taste of high sugar foods  A perception that healthy foods are more expensive than unhealthy foods

The Change4Life Sugar Smart campiagn aims to raise awareness of what is considered an acceptable level of sugar consumption and illustrate how consumption builds up throughout the day, so people can make informed decisions about whether their own diet is healthy.

The launch of the Sugar Smart app will allow families to find out exactly how much sugar is in the food and drink they eat in a quick and easy way. The Change4Life website will provide additional support and offer lower sugar alternatives and recipes.

3. Nutrition labels

3.1 How do people know if they are buying foods with too much sugar? Nutrition labels often tell you how much sugar a food contains. You can compare labels and choose foods that are lower in sugar. Some food labels use red, amber and green colour coding which makes it easier to choose food that is lower in sugar. A food is classified as high in sugar if it contains more than 22.5g of total sugars per 100g or more than 27g per portion of product. It is low in sugar if it contains 5g of total sugars or less per 100g. A drink is high in sugar if it contains more than 11.25g of total sugars per 100g or more than 13.5g of total sugars per portion of product. It is low in sugar if it contains 2.5g of total sugars or less per 100g. An example of a nutrition label can be found below:

A food containing lots of fruit or milk will be a healthier choice than one that contains lots of added sugars, even if the two products contain the same total amount of sugars. You can tell if the food contains lots of added sugars by checking

the ingredients list. Sometimes you will see a figure for "Carbohydrates", and not for "Carbohydrates (of which sugars)".

The "Carbohydrates" figure will also include starchy carbohydrates, so you can't use it to work out the sugar content. In this case, check the ingredients list to see if the food is high in ‘added sugars’.

3.2 What is classified as a sugar on nutrition labels? The sugars figure in the nutrition label is the total amount of sugars in the food. It includes sugars from fruit and milk, as well as the sugars that have been added.

4. The Sugar Smart campaign

4.1 What is the Sugar Smart Campaign The Change4Life Sugar Smart campaign aims to raise awareness of the high levels of sugar consumed and the associated health harms. It will do this by encouraging families to download the Sugar Smart app and find out exactly how much sugar is in everyday food and drink so that they can make the changes needed to protect their kids.

We will also have a series of Sugar Smart episodes, which will feature a well-known mum learning about the sugar content in their family’s food and how to monitor and curb the amount of sugar that their children consume from a leading nutritionist.

4.2 Why are you only focusing on sugar? Last year’s Smart Swaps campaign was our most successful healthy eating campaign yet in terms of behaviour change, registrations and partnership contributions. Public Health England wants to build on this to make the 2016 campaign bigger and better. Data from the National Diet and Nutrition Survey clearly demonstrates that we are all eating too much sugar and therefore the January 2016 activity has an even tighter campaign, focusing on raising awareness of content of everyday foods through a

specially designed app. Fat and salt reduction will continue to be secondary messages.

4.3 Sugar has received increased amounts of attention from the media and political environment, has this influenced your decision to focus on sugar once again? No. People eat more sugar than they should and the nation’s health would benefit if average sugar intakes were reduced. Eating too much sugar results in extra calories, which causes fat to build up that could lead to heart disease, cancer or type 2 diabetes. Public Health England is committed to help improve the diet of the nation and in January 2016 is launching the Change4Life Sugar Smart campaign to help people reduce their sugar intake. Wider Change4Life activities will also continue to encourage a much wider range of healthier swaps with fat and salt reduction continuing to be important, additional messages.

4.4 What is the aim of the campaign? In January 2016 Public Health England will launch the Change4Life Sugar Smart campaign. We will see the introduction of a Sugar Smart app, which will allow families to see how much sugar is in everyday foods by simply scanning a bar code. The campaign will encourage and support families in reducing the amount of sugar they consume.

4.5 Who will the campaign target? The Change4Life Sugar Smart campaign targets everyone in England, particularly families with children aged 5-11 from a C2DE background.

4.6 Why have you decided to launch this campaign now? The New Year is a time when people are more willing to consider making positive changes. This therefore provides an opportunity to tap into this mindset and encourage as many families as possible to make healthier choices about what they eat and drink.

4.7 How do you plan to help families reduce their sugar intake? The Change4Life Sugar Smart campaign will raise awareness of the high levels of sugar consumed and the health harms of sugar. It will do this by encouraging families to download the Sugar Smart app and find out exactly how much sugar is in everyday food and drink so that they can make the changes needed to protect their kids.

4.8 How long will the campaign run? The Change4Life ‘Sugar Smart’ campaign launches on 14 January 2016 with media throughout January and early February. App availability and support on the Change4Life website will run throughout the year.

5. Sugar Smart app

5.1 What is the Change4Life Sugar Smart app? The Sugar Smart app enables users to scan the barcode of over 75,000 food or drink products and see a visualisation of the number of 4 gram sugar cubes it contains. They can then share a ‘sugar reveal’ using the share-sheet on their device to encourage others to go to the Change4Life website.

5.2 Why have you developed the app? We know from our user research that people are often shocked at how much sugar is in seemingly healthy products. We have good evidence that visualising sugar in this way drives behaviour change.

5.3 Why sugar cubes? The clear visualisation of sugar content is popular with Change4Life’s audience. Sugar cubes are a tangible unit that can be ‘stacked up’ to show sugar content and are a uniform measurement that doesn’t invite potential confusion associated with teaspoons where volume could be variable, e.g. level or heaped teaspoon. In the previous Sugar Swaps campaign TV advertisement, the visualisation of sugar cubes in

a can/bottle was received as ‘very high impact’ bringing ‘sugar content to life’. It is important that we are consistent with our advertising.

5.4 What about fruit and veg? Does the app show total or added sugar? The app shows total sugar, in line with front of pack labeling, so it does include fruit and vegetable items. We have added Sugar Smart badging across 4 main product categories such as plain dairy milks and whole fruit and veg to make it clear that you don’t need to worry about the sugar in these products as it isn’t added sugar – see below:

 Plain milks: This product contains naturally occurring sugars. You don’t need to worry about the sugar in plain milks, as this isn’t added sugar.  Plain natural yoghurts: This product contains naturally occurring sugars. You don’t need to worry about sugar in plain yoghurts, as this isn’t added sugar.  Whole fruit & veg: This product contains naturally occurring sugars. You don’t need to worry about sugar in whole fruit/vegetables, as this isn’t added sugar.  Tinned fruit & veg: This product may contain naturally occurring sugars in the fruit or veg, added sugars and/or juice. Check the label and choose those with less sugar.

5.5 What is the data source behind the app? The app works by tapping into two data sources which we have combined: (1) a dataset from Action on Sugar of over 100,000 food and drink products (this is the same dataset behind the Health X winning FoodSwitch app) and (2) a supplementary data feed from MySupermarket, providing data on an additional 20,000 products, as well as updates every month on new products entering the market.

Both datasets take the barcode information and sugar information from the nutritional label on the food or drink product, and simply divides that by 4 grams to show the number of 4 gram sugar cubes in the pack/per 100g/per manufacturer’s portion size, depending on what data we hold. This is publically available information 14

– we are simply showing that in a more visual way that is easier for people to understand.

5.6 How many products does the app cover? The app covers over 75,000 food and drink products and we are adding more products every month.

5.7 What does the result screen show after I’ve scanned something? The ‘sugar reveal’ screens show the amount of total sugar in the pack, in 100g/ml and in the manufacturer’s portion size, wherever we hold the data for all three measures. As the app shows the amount of total sugar, when you scan one of our Sugar Smart badged products (plain dairy milks, plain natural yoghurt, whole fruit and veg and tinned fruit and veg) a corresponding message will appear on screen to explain that you don’t need to worry about the sugar in that item as it isn’t added sugar. Where we don’t have the product at all, the app will return a message saying ‘Sorry, we don’t have that product yet. Try scanning something else.’

5.8 How has the amount of sugar in the pack been calculated? Examples of we have calculated the amount of sugar in a pack follow below – this approach is policy approved:

Action on Sugar data: Taking Kellogg’s Frosties (750g pack) as an example:  We calculated the amount of sugar per g from the sugar per 100g value: 37.0g / 100 = 0.37g  Then we multiplied this by the pack weight: 750g x 0.37 = 277.5g  Finally, we divided this value by 4 to calculate the number of sugar cubes in the pack: 277.5g / 4 = 69.4 sugar cubes

MySupermarket data: Tesco Bunched Carrots (500g) has a sugar value of 7.4g per 100 gram, so for 500 grams it's 37grams: 7.4/100 *500 (quantity of product)

5.9 When will the Sugar Smart app launch? 15

The iOS and Android apps will be submitted to the stores for approval on 7 December 2015. Exact live dates are subject to the stores’ own timings, but the apps will be live before the campaign launches on 5 January 2016.

5.10 How are we describing the app on the stores? Sometimes it's hard to know how much sugar is in food and drink. The Change4Life Sugar Smart app is designed to show quickly and easily how much sugar is in the things we’re eating and drinking. You just have to scan the barcode and see how much sugar it contains*. Let's get Sugar Smart and start scanning now! For more information search Change4Life.

*The number of sugar cubes featured is based on total sugar in grams per portion/100g/pack divided by 4 grams (the weight of one 4 gram sugar cube).

6. Sugar Smart partners

6.1 How will Local Authorities be supporting the campaign? The Change4Life Sugar Smart campaign has been designed to be flexible to suit local needs. We have named contacts across all 152 upper tier local authorities and many other boroughs, district and parish level, are engaged with Change4Life. We update them regularly via our newsletters and encourage them to order a range of Change4Life resources that they can use to engage their local populations.

6.2 How are you working with schools to deliver this campaign? From our campaign evaluation and numerous conversations with school representatives and teachers, we know many of them would like to engage with the campaign on a more in-depth level. They want guidance and information that fits with the curriculum and helps to facilitate the educational process in making children and their families eat better and keep active.

Change4Life will be providing teachers with resources and ideas for including healthy eating messages across the curriculum. Adverts in key trade publications and social media activity will be used to promote the resources available to teachers.

6.3 How is Change4Life working with charities? Change4Life is working with a range of charities which promote healthier eating to families. They will be promoting the campaign messages through their channels as well as distributing the campaign consumer leaflet.

6.4 How will advertising feature within this campaign? The Change4Life ‘Sugar Smart’ campaign launches on 4 January 2016 with media throughout January and early February. Following the success of last year’s ‘Sugar Swaps’ campaign, Change4Life continue to expand their dietary offering with the launch of the ‘Sugar Smart’ app.

This year the campaign aims to motivate and enable families to change their dietary habits through the new ‘Sugar Smart’ app which allows users to scan the products they eat and drink and reveal the amount of sugar each contains.

The advertising campaign will feature a range of video content distributed across broadcast TV and Video on demand (VoD) to publicise the new recommended daily intake of sugar and the new app. There will also be messages to remind and encourage users to download and use the app across Out of Home (OOH) media, digital and social channels.

Throughout January, TV adverts featuring the Aardman animated Change4Life characters will depict scenarios which every mum will be familiar with; keeping their kids sugar intake under control. The ‘Little Monkeys’ 30 second spot shows how excess sugar from a chocolate bar can turn into fat inside the body and reveals the high levels of sugar in everyday products, using sugar cubes to demonstrate the amounts.

Finally, there are a number of products in the advert for which we reveal the sugar content. These products are based on the product categories which are the top contributors to children’s sugar intake, as defined by the National Diet and Nutrition survey (NDNS). Using Kantar Worldpanel Data we have matched calculations of the average sugar content per 100g to the illustrations. Using this average from a range of products means that it may not equate to any individual product.

We then calculated sugar content per portion (see below) in grams and divided this figure by 4 grams (based on the weight of one Silver Spoon sugar cube). This figure was rounded down to the nearest whole sugar cube.

References

1. Oxford Dictionaries Sugar Definition. Available at http://www.oxforddictionaries.com/definition/english/sugar [Accessed December 2015]

2. Diabetes.co.uk. Simple vs Complex Carbs. Available at http://www.diabetes.co.uk/nutrition/simple-carbs-vs- complex-carbs.html [Accessed December 2015]

3. Karim David. The Difference Between Natural Sugar & Added Sugar? Available at:

http://www.karimdavid.com/the-difference-between-natural-sugar-added-sugar/ [Accessed December 2015]

4. Family Doctor. Added Sugar: What You Need To Know. Available at http://familydoctor.org/familydoctor/en/prevention-wellness/food-nutrition/sugar-and-substitutes/added-sugar- what-you-need-to-know.html [Accessed December 2015]

5. European Food Information Council. Available at: http://www.eufic.org/page/en/page/FAQ/faqid/extrinsic-intrinsic- sugars/ [Accessed December 2015]

6. NHS Choices. Water, drinks and your health. http://www.nhs.uk/Livewell/Goodfood/Pages/water-drinks.aspx [Accessed December 2015]

7. NHS Choices. 5 A DAY: what counts? http://www.nhs.uk/Livewell/5ADAY/Pages/Whatcounts.aspx [Accessed December 2015]

8. Public Health England. Sugar reduction. Responding to the challenge. Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/324043/Sugar_Reduction_Respon ding_to_the_Challenge_26_June.pdf [Accessed December 2015]

9. NCMP. England 2014-2015. Available at http://www.hscic.gov.uk/article/2021/Website-Search? productid=19405&q=OBESITY&sort=Relevance&size=10&page=1&area=both#top [Accessed December 2015]

10. Singh AS, Mulder C, Twisk JW, van Mechelen W, Chinapaw MJ. (2008) Tracking of childhoodoverweight into adulthood: a systematic review of the literature. Obesity Review; 9(5): 474-88

11. Public health England Economics of Obesity. Available at http://www.noo.org.uk/NOO_about_obesity/economics [Accessed December 2015]

12. NHS England, (2014) Improving dental care and Oral Health - A Call to Action

13. Moynihan, P. J. and Kelly, S.A.M. (2013) effect on caries of restricting sugar intake: Systematic review to inform WHO guidelines. Journal of Dental Research. DOI:10.1177/0022034513508954

14. SACN 2015 Report. Available at https://www.gov.uk/government/publications/sacn-carbohydrates-and-health- report [Accessed December 2015]

15. Government Office for Science, Foresight (2007) Tackling Obesity: future choices summary of keymessages. https://www.gov.uk/government/publications/reducing-obesity-future-choices