Challenges and opportunities in the use of low‐energy sugar replacers

In 2015, the government adopted new recommendations on dietary carbohydrate intake proposed by the Scientific Advisory Committee on Nutrition (SACN) (2015), namely to increase dietary fibre intake to 30 g/day (proportionally lower levels for children, 15–25 g/day) and to decrease free sugars to below 5% of energy intake. Public Health England (PHE) will be publishing a set of working principles to allow the free sugar content of foods to be estimated. It is understood that these will centre on the following definition: free sugars include all monosaccharides and disaccharides added to foods by the manufacturer, cook or consumer, plus sugars naturally present in honey, syrups, and unsweetened fruit and vegetable juices and purées. A summary of the findings to support the recommendations on free sugars and fibre can be found in Buttriss (2017). For both fibre and free sugars, current average intakes are substantially different to these recommendations and achieving the recommendations will require major dietary changes for most of the UK population because, currently, only 4% and 13% of teenagers and adults, respectively, meet the sugar recommendation (expressed as non-milk extrinsic sugars, NMES) and few achieve the fibre recommendation. Fibre intakes among adults are currently about 18 g/day, on average, with the dominant sources being cereals and cereal products, vegetables and potatoes. Some of the challenges faced with regard to increasing fibre intakes are discussed in Lockyer et al. (2016). It will not have gone unnoticed that the revised sugar recommendations have attracted considerable media attention, with reports predominately focussing on concerns about the high prevalence of childhood obesity which affects close to 10% of children in England by the time they start primary school and almost 20% at age 11 years (NHS Digital 2016). There is clearly an urgent need to rebalance children's diets, and decreasing intake of free sugars is one of the steps that can be taken to help reduce the current overconsumption of calories in relation to energy requirements. Average intake of non-milk extrinsic sugars (the former descriptor of ‘free sugars’) is 12.3% of energy intake among adults. The highest intakes, providing more than three times the new recommendation, are found in teenagers. The National Diet and Nutrition Survey (NDNS) reveals that the dominant source for teenagers is sugars-sweetened beverages [providing 40% of the total NMES intake (Bates et al. 2016)]. There has been far less focus on fibre despite the fact that a shift towards a higher fibre intake is likely to have a beneficial effect on intakes of free sugars. A main feature of the government's Childhood Obesity Plan, published in 2016 (Department of Health 2016), is a set of measures to reduce sugars in the products that contribute most to children's sugar intake. As already mentioned, the biggest contributor is sugars-sweetened beverages, and the government has taken the step of introducing a levy on sugars-sweetened beverages containing more than 5 g added sugars per 100 ml, which comes into force in April 2018, as a means of driving reformulation to reduce sugar content. Other contributors to intake of sugars are being tackled via a programme being led by PHE on behalf of the government, which is initially focussing on the nine categories of foods that make the greatest contribution, according to the NDNS, namely yogurts and fromage frais; breakfast cereals; biscuits; cakes and morning goods; puddings; ice cream; sweet spreads; chocolate confectionery; and sweet confectionery. For each of these, three different aspects are being considered: reformulation to reduce sugar levels, portion size reduction and shifting purchasing towards lower sugar alternatives. All sectors of the food and drink industry [retailers, manufacturers and the out-of-home sector (e.g. restaurants, takeaways and cafés)] are being challenged to reduce overall sugar content across a range of product categories by at least 20% by 2020, including a 5% reduction in year one (PHE 2017). PHE is using 2015 food composition data as the baseline for this reduction programme, which enables developments since then to be recognised. PHE has also purchased 2014 data, which will help capture any sugar reductions that took place before 2015. Through a series of meetings with the various industry sectors, guidelines in the form of category-specific sales-weighted averages have been established for each of the nine initial categories, expressed per 100 g of product. Calorie caps for specific single-serving products are also being established for some categories. A time frame of 4 years has been set as a target for the food industry to reduce sugar levels to (or below) the sales-weighted averages referred to above, which were published in March 2017 (PHE 2017). This reformulation programme is voluntary, with the threat of further measures if progress is not made, although in fact many manufacturers and retailers have already made progress in sugar reduction. For example, according to the British Soft Drinks Association website, 60% of soft drinks sold in the UK are now low- or zero-calorie options. Data from Kantar Worldpanel (October 2016) show that sugars intake, from soft drinks, is down by 17.2% since 2012, and this trend is reflected in NDNS data for some age groups (Bates et al. 2016). The government is expecting progress across all sectors, including the out-of-home sector. The challenge to reduce free sugars is considerable, not least because PHE has stated that sugar reductions should be accompanied by reductions in calories and should not be compensated for by increases in saturated fat. Furthermore, work to achieve salt targets should continue alongside the sugar reduction programme. From 2017, the programme will be extended to include the setting of targets to reduce total calories in a wider range of products contributing to children's calorie intake, again across all sectors. The need for measures related specifically to saturated fat will be reviewed in the light of draft recommendations expected from SACN towards the end of 2017. Another challenge is mankind's innate preference for sweetness which is present at birth and thought to be partly heritable, although tends to decline with age (see Gibson et al. 2014). So what are the options for food producers? A key tool is the use of alternative sweetening agents that provide less energy per gram than sugar. However, sugars do more than sweeten foods, they provide bulk and have functional attributes that are difficult to replicate, such as moisture management and shelf life, texture and flavour generation. Use of these zero/low/reduced-calorie sweetening agents is backed by the European Food Safety Authority's (EFSA) safety assessments and referenced indirectly in Change4Life (www.nhs.uk/change4life-beta) and the Eatwell Guide (PHE 2016), for example ‘swap sugary soft drinks for diet, sugar-free or no added sugar varieties to reduce your sugar intake in a simple step’. Yet, standing in the path of use of these tools are consumer attitudes, perhaps fuelled by inaccurate depiction of the scientific evidence on the safety of these sweetening agents (for more information see the British Nutrition Foundation's website: http://bit.ly/2izPjoP), and regulatory restrictions on their use. Use of alternative sweetening agents is almost inevitably going to require trade-offs and the best choice is likely to depend on the food matrix and recipe, the legislative restrictions for some food categories, and of course consumer expectations and preferences. High-intensity sweeteners (also referred to as high-potency sweeteners, non-nutritive sweeteners or low-calorie sweeteners) are regulated food additives, which substitute for sugar's sweetness while contributing significantly less (or no) food energy. They are subject to safety evaluation prior to market authorisation and the regulatory hurdles include specified maximum levels of use and types of food in which use is permitted (i.e. restrictions by category). The intense sweeteners now commonly used in Europe are acesulfame-K, aspartame, neotame, saccharin, steviol glycosides and sucralose (Gibson et al. 2017). The use of intense sweeteners is permitted only in certain product categories and the maximum doses allowed are specified under European Union (EU) Regulation 1333/2008. These sweeteners are typically used in low/lower calorie soft drinks, desserts, dairy products, confectionery, chewing gums and powdered milk-based drinks. Most are also available as tabletop sweeteners. The use of steviol glycosides (E960), extracted from the leaves of the stevia plant, has been permitted in the EU since 2011 (Regulation EU 1131/2011). As with other high-intensity sweeteners, conditions of use apply. Publicity about the ‘natural’ source of this sweetener has been widespread and stevia has attracted a relatively positive consumer response, although there can be practical limitations associated with its effect on the product's flavour profile and texture. Further information about high-intensity sweeteners can be found on the British Nutrition Foundation's website: http://bit.ly/2mWI6ie. As detailed in Article 7 of EU Regulation 1333/2008, high intensity sweeteners and polyols (described below) can be used only in products with no added sugars or where calories have been cut by at least 30%, in other words in situations that comply with the energy reduction claim defined in the EU Nutrition and Health Claims Regulations 1924/2006. Category specific conditions of use also exist in the legislation. These restrictions add to the technical challenges encountered with sugar reduction, leading to calls for rules to be relaxed where feasible. Although this is unlikely to happen at the current time, once the UK leaves the EU it could potentially become a consideration. Where sugars have a functional role other than simply providing sweetness, for example to provide the required texture, consistency, stability, preservation, freezing point depression or flavour, an alternative physical replacer has to be identified. One option is polyols, sugar alcohols found naturally in some fruits and also synthesised commercially, such as sorbitol, lactitol and xylitol. Absorption in the upper gut and fermentation in the large bowel are reported to vary markedly among the polyols, causing caloric values to vary from almost 0 to about 3 kcal/g (SACN 2015), compared with 4 kcal/g for sugars and starch. The European regulation (Directive 90/496/EC) prescribes a single value of 2.4 kcal/g for all permitted polyols (except erythritol for which 0 kcal/g applies) but in the US, Canada and Australia, individual polyol-specific values are laid down in food legislation. Polyols can cause laxative effects and their incorporation at levels greater than 10% triggers the need for on-pack warnings about this risk. Another option is maltodextrins, derived from starch hydrolysis. These are digested and absorbed in the small intestine and so their calorie contribution will be essentially the same as sugars. So, where sugars have functional roles other than providing sweetness, where its physical bulk is important, reducing the amount in the recipe can be challenging. Yet another option is to replace some of the sugars with non-digestible carbohydrates, in other words dietary fibre, which comprises a range of different carbohydrate structures, including non-starch polysaccharides, resistant starches (Lockyer & Nugent 2017) and oligosaccharides such as fructo-oligosaccharides (FOS), raffinose, stachyose and verbascose (with a degree of polymerisation of 3–9) and inulin. Dietary fibre is assigned a caloric value of 2 kcal/g. Among the oligosaccharides, there is considerable structural diversity and they are widespread in the plant foods we eat. In general, studies to date showing a beneficial effect of oligosaccharides have used quantities that are in excess of the amounts typically present in foods or diets. This is discussed in the SACN report on carbohydrates and health (SACN 2015). Polydextrose resists digestion in the upper gastrointestinal tract, resulting in a negligible glycaemic response. It is then partially digested in the colon; thus, it conforms to the European definition of dietary fibre. It is approved for use in the EU (as E1200) and comprises randomly bonded polymers of glucose with some sorbitol end groups, and with citric acid and phosphoric acid residues attached to the polymers. The average degree of polymerisation is approximately 12 monosaccharide units and the caloric value is <1 kcal/g. Polyols, inulin, FOS and modified starches are examples of substances that can fulfil some of sugar's functional roles and in the majority of cases have a lower caloric value than sugars or normal starch. In addition, efforts to develop new technologies are underway, for example combination of dietary fibres and water to generate gel particles. In their recent paper, Gibson and colleagues propose a combination of polyols for sweetness and dietary fibre for bulk (Gibson et al. 2017). A number of health claims applications have been submitted for sugar replacers. The outcomes of these can be found in the EFSA Journal and the online EU register on nutrition and health claims, and are summarised here. EFSA found a cause and effect relationship between consumption of foods/drinks containing xylitol, sorbitol, mannitol, maltitol, lactitol, isomalt, erythritol, D-tagatose, isomaltulose, sucralose or polydextrose, instead of sugar, and reduction in postprandial blood glucose responses, compared to sugars-containing foods. Specific conditions of use also apply, including laxative warnings for polyols. A cause and effect relationship was also found between consumption of foods/drinks containing xylitol, sorbitol, mannitol, maltitol, lactitol, isomalt, erythritol, D-tagatose, isomaltulose, sucralose or polydextrose, instead of sugar, and maintenance of tooth mineralisation by decreasing tooth demineralisation. EFSA has also approved claims that intense non-calorific sweeteners lead to a lower rise in blood sugar levels after meals, if consumed instead of sugars, and maintain tooth mineralisation by decreasing tooth demineralisation (if consumed instead of sugars). Two proprietary claims have also been authorised, one for native chicory inulin and normal bowel function (increased stool frequency) with conditions of use indicating a minimum dose of 12 g/day of chicory inulin, and a second for slowly digestible starch and glycaemic response, again with detailed conditions of use. A paper summarising the outcome of an expert panel workshop concluded that the strategies with greatest potential to help consumers reduce their free sugars intake (taking into account feasibility, cost, effectiveness and likely consumer acceptability) are wider use of intense sweeteners and a gradual reduction in portion sizes of food and drinks high in sugars but relatively low in micronutrients (Gibson et al. 2017). Although low-calorie sweeteners have been approved as safe many times and have been subjected to extensive scientific testing, there remains confusion about their dietary role. A YouGov survey conducted by the British Nutrition Foundation in 2010 found that many people are unsure about how these sugar replacers are used, concerned about their safety and unclear whether they are beneficial for weight loss. The role of low-calorie sweeteners in reducing energy intake and weight management has been debated in the media and this coverage is likely to have added to the confusion. Their role is discussed by PHE in its review of sweetness published in 2015, concluding ‘as the evidence considered by SACN also shows, the review found that replacing foods and drinks sweetened with sugars with those sweetened with no/low-calorie sweeteners can be useful in the management of energy intake and weight’ (PHE 2015). Drinks sweetened with these ingredients are also referenced in the Eatwell Guide (Buttriss 2017; this issue) in preference to sugars-sweetened options. Despite the apparent controversy in the media, a recent systematic review and meta-analysis by Rogers et al. (2016) concluded that ‘the preponderance of evidence from all human randomised controlled trials indicates that low-energy sweeteners do not increase energy intake or bodyweight, whether compared with caloric or non-caloric (e.g. water) control conditions. Overall, the balance of evidence indicates that the use of low-energy sweeteners in place of sugars, in children and adults, leads to reduced energy intake and bodyweight’. This point of view aligns with a previous review which reached similar conclusions (Miller & Perez 2014). Further information can be found on the British Nutrition Foundation's website (http://bit.ly/2izPjoP). In this issue of Nutrition Bulletin is a paper that summarises the conflicting and confused literature on the effects of non-nutritive sweeteners in the gastrointestinal tract (Stamataki & Mclaughlin 2017), concluding that the majority of the literature supports the notion that these ingredients do not exert metabolic effects, such as increased gut peptide release and gastric emptying rate, but noting that contradictory results are still being published. To ensure that the sugar reformulation programme has the best chance of success, leadership is needed in combating confused messaging about safety of no/low-calorie sweeteners, on the one hand, and their potential benefits as a means to reduce energy intakes, on the other. To date, there has been little overt official support for use of these or effort to tackle adverse public opinion about safety. This is perhaps because foods sweetened in this way often remain very sweet and so reformulation does not help adjustment to a preference for a less sweet taste. However, given the desire many people have for sweetness in their diets, these ingredients are an important strand in efforts to reduce calorie intake. PHE endorses scientific opinion on sweeteners in its published technical report on sugar reduction (PHE 2017). PHE that have been approved are a safe and alternative to using sugar and to if and how they to use PHE that some use these sweetening agents as a means to lower the sugar content of their products, while do because of legislative restrictions or to consumer PHE that foods and drinks containing low-calorie or non-caloric sweeteners can be useful in to reduce calorie intake. 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