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BMJ 2016 (see citations below)

This is not an unexpected comment from the Director General, Food and Drink Federation but a complete package of measures to address not only obesity, but other diseases associated with dietary excesses, chimes with the recommendations of many learned bodies.

These two abstracts, all summarised from commentaries published this year in The BMJ, examine some of the issues that underpin dietary guidelines, particularly those interventions aimed at reducing sugar consumption. Inculcated with implications of such guidelines are stakeholder opinions.

It has been reported (BMJ 2016;352: i1602) that the proposed English tax on sugar will raise £520 million each year; it has been pledged that over one half of this tax will be spent on promoting sports in primary schools. In order to give the drinks companies time to change their products, it is proposed that legislation will be enacted in the 2017 Finance Bill, and the tax implemented in 2018. A tax of 6p will be added to the price of a 330 mL can or bottle of drink with more than 5 g of sugar per 100 mL. There will be a sliding levy based on increasing sugar content. Small drinks companies will be exempt, as will pure fruit juices and milk-based drinks.

But in 2015 it was reported (BMJ 2016;352: i33) that David Cameron had ruled out a sugar tax. The government may have been persuaded otherwise by a study (BMJ 2016;352: DOI: 10.1136/bmj.h6704) reporting favourable changes in sugar consumption after Mexico imposed a tax on sugar-sweetened drinks. This Mexican study found there was a higher than expected drop in the consumption of sugary drinks and a compensatory rise in the consumption of bottled water. And, of note, the changes were greatest in poorer households. Such goes someway to refute the argument that 'a sugar tax is simply a tax on the poor'. But this change in heart of the English government could also have been influenced by the paper from Cancer Research UK and UK Health Forum: Short and sweet: why the government should introduce a sugary drinks tax (www.ukhealthforum.org.uk, Feb 2016). In this paper it is argued that a 20p per litre tax on sugary drinks and a 9 pm watershed ban on TV advertising of junk food should be part of a part of a comprehensive children's obesity strategy. If current trends were to continue, obesity levels in the UK could increase from 29% in 2015 to 34% by 2025. A one percent reduction in the number of overweight or obese people every year could save the NHS £300 million in 2035 alone. Among other conditions, obesity 'is the biggest single preventable cause of cancer after smoking'. Obesity is associated with ten types of cancer, including bowel and breast cancer.

Oral health was mentioned only once in seven commentaries on dietary guidelines published this year in The BMJ.

In the paper examining the effects of taxing sweetened beverages purchased from stores in Mexico (BMJ 2016;352: DOI: 10.1136/bmj.h6704), the Head of OECD Public Health Programme, Health Division, Organisation for Economic Co-operation and Development, argued taxes should be part of a broader anti-obesity strategy together with regulation and health education (BMJ 2016;352: DOI: 10.1136/bmj.h6904).

But no recommendations were made to introduce a sugar tax in the recently published 2015-2020 Dietary Guidelines for Americans (BMJ 2016;352: i146). However, the guidelines specified that consumers should 'limit their consumption of added sugars to less than 10% of daily energy intake...'. In addition, they departed from previous guidance that focussed on nutrients; instead they urged consumers to adopt healthy overall eating patterns 'that include a variety of vegetables, fruits, whole grains, low fat dairy or soy products, and low fat protein sources, such as fish, lean meats, legumes, and soy products.' Such an approach is supported by Marian Nestle, a professor in the Department of Nutrition, Food Studies, and Public Health at New York University. She argues dietary guidelines have been littered with euphemisms; 'saturated fat is a euphemism for meat', 'added sugars is a euphemism for...sugar-sweetened beverages' and 'sodium is a euphemism for processed foods and junk foods.' She also argued perceptively that when 'guidelines recommend that consumers eat more of something they specify a food but that when they recommend consumers eat less of something they specify nutrients'. The process in developing these American guidelines has been criticised sharply by both industry groups and conservative politicians. A congressional hearing considered there had been too much meddling in issues outwith their remit, such as sugar taxes and 'the effects of diet on the environment (were) considered when making dietary decisions'. The hearing warned that funding would be withdrawn if future guidelines were not 'based on significant scientific agreement'.

Another approach to combat obesity could be the introduction of 'activity equivalent' calorie labelling. It was reported only recently (BMJ 2016;353: i1856), that The Royal Society for Public Health argued the present 'traffic light' labelling' does little to bring about behavioural change. However, informing potential purchasers that 'the calories in a can of fizzy drink take a person...26 minutes to walk off' may facilitate change. But food packaging is governed by European legislation and there may be too many vested interests to implement such a change.

Returning to Marian Nestle: when challenged as to why guidelines do not state baldly 'eat less meat, cut down on sugary drinks, eat less processed and junk food', she says 'Politics, of course'.