The prevalence of overweight, obesity, and related non-communicable diseases (cardiovascular diseases, diabetes, and cancer) remains high in all European countries, including Spain [1
The impact of dietary risk factors on the mortality and morbidity associated with non-communicable diseases highlights the importance of implementing measures to improve the quality of citizens’ diets within national health policies [2
Diets must meet energy needs and provide a variety of foods of a high nutritional quality that are safe to consume. Moreover, these diets should be sustainable, affordable, accessible, and culturally acceptable [3
The European Union (EU) has long promoted initiatives to tackle obesity and to improve nutrition in European countries. One of the main initiatives of the European Commission was the adoption of the White Paper of 30 May 2007 entitled ‘A Strategy for Europe on Nutrition, Overweight and Obesity related health issues’ [4
], focusing on actions that can be taken at the local, regional, national, and European levels. One of the initiatives included in this document is for the food industry (including retailers) to reformulate its products, particularly by reducing the content of salt, sugar, and fats.
In this regard, the High Level Group on Nutrition and Physical Activity (HLGNPA), composed of representatives of EU Member States and the European Commission, launched two EU Frameworks for the reformulation of food products: the EU Framework for National Initiatives on salt reductions [5
] and the EU Framework for National Initiatives on Selected Nutrients [6
] with two annexes: Annex I on saturated fats [7
] and Annex II on added sugars [8
]. These EU frameworks and annexes establish benchmarks and timelines for nutrient content reduction, focusing their action on certain food categories while taking into account the priorities, health needs, baseline nutrient contents, traditions, and pattern of consumption of each member state.
For more than a decade, the Ministry of Health in Spain, through the NAOS Strategy (Strategy for Nutrition, Physical Activity and the Prevention of Obesity) of the Spanish Agency for Food Safety and Nutrition (Spanish acronym AESAN, formerly Spanish Agency for Consumption, Food Safety and Nutrition, AECOSAN) has promoted reformulation initiatives for food and beverages, following the recommendations outlined in the HLGNPA Frameworks. To establish these initiatives, different studies have been carried out to determine the nutrient consumption and main food sources of the population and to ascertain the nutrient content (mainly fats and salt) of processed products [9
]. The results of these studies have facilitated measures to reduce fats and salt in the main processed foods in Spain. Among these initiatives are the agreements between AESAN and food sector associations to achieve nutrient reduction targets, which were committed to all companies that belong to the sector association [14
]. A successful example of public–private collaboration to achieve the reduction of salt content is the agreement (legal document) between AECOSAN, the Spanish Confederation of Bakers (CEOPAN by its Spanish acronym), and the Spanish Association of Manufacturers of Frozen Dough (ASEMAC by its Spanish acronym) signed in 2004, in which a salt reduction from 22 g NaCl/Kg in bread flour in 2004 to a maximum of 18 g NaCl/kg by 2008 was agreed upon. The average NaCl content measured in 2008 was 16.3 g of NaCl/Kg in bread-making flour [14
]. In addition, a new study conducted in 2014 concluded that the salt content in bread in Spain has remained stable since 2008 [15
However, no study has yet been conducted to ascertain the sugar content in processed products in Spain in order to establish reference values for addressing public health food policies, such as the reformulation or improvement of processed food and beverage composition.
For this reason, at the end of 2016, AESAN conducted the present study to describe the sugar content in the food groups included in the Annex II of added sugar [8
] and in the most commonly consumed processed foods in Spain, especially by children and adolescents [16
]. In addition, the other secondary objectives were to compare the label value (LV) with the laboratory analysis value (AV) in order to assess the adequacy of the LV based on the EU labelling requirements, and to study the appropriateness of using the label values as reference data to monitor the reformulation of sugar and other nutrients or for strategies such as front-of-pack labelling or marketing restrictions.
To study the content of total sugar, we presented the AVs of 28 groups of processed food products that are most frequently consumed by the Spanish population. The groups whose reformulation could have the greatest impact on public health were identified by their high sugar content and dispersion, which indicates that there is room for the reduction of their sugar content and that reformulation is, therefore, possible.
The most commonly consumed groups, especially by children and adolescents, should also be distinguished and prioritized (compared to those consumed more rarely) based on their energy contribution to the diet (cereals and meats and derivatives, among others), added sugar contribution to the diet (sugar sweetened beverages, chocolate, and nectars), or both (dairy products, baking and pastries, and breakfast cereals, among others) [16
]. In Europe, high sugar consumption, especially in children and adolescents [29
], has become a major public health concern, which is highlighted by scientific reports and studies associating high sugar consumption with an increased risk of dental caries [30
], overweight [31
], cardiometabolic risk factors [32
], and adult cardiovascular mortality [33
This study, promoted by the Observatory of Nutrition and Study of Obesity of AESAN in the framework of the NAOS Strategy, answers the call to action of the EU from the Council Conclusions of June 2016 for the improvement of food to develop a national reformulation initiative (the “Collaboration Plan for the improvement of the composition of food and beverages and other measures 2020” [34
]), which is in line with the EU Plan of Action against Childhood Obesity 2014–2020 [35
] and the WHO European Action Plan for Food and Nutrition 2015–2020 [36
One of the limitations of this study is its small sample size, which was mainly due to our limited budget. For some subcategories, this reduced sample size was due to other specific reasons. For “pineapple in syrup”, the market is dominated by a single brand, and for “beverages with fruits” (included in the group “sugar sweetened beverages”), we decided to create a new subcategory, resulting in only three products; sugar content in fruit is very different from that in the rest of the group, so the groups could not all be considered together. For this reason (sample size) and to prevent the influence of the most distal values, the median was used as a measure of the central tendency. Moreover, to produce a snapshot of sugar availability in our food environment and to estimate the potential impact of reformulation, market shares should have been considered. In our more feasible approach, the products in each subcategory were selected according to the results of a food market study that identified the most commonly consumed food products.
Our results provide novel information on the presence of total sugars in our food environment. This study quantifies the total sugar content in the main groups of processed products on the Spanish market, assesses the adequacy of label values based on the tolerance ranges for sugar according to EU labelling requirements, and assesses the appropriateness of using the LV as reference data. These are relevant aspects for designing and implementing actions aimed at reducing sugar consumption, which will help tackle obesity and its consequences for health.
Reformulation policies aimed at reducing the content of certain nutrients are some of the measures recommended by international institutions and organizations (European Union, WHO, OECD) to improve the quality of diets, reduce the consumption of foods high in salt, fats, and sugars, and prevent obesity and its related non-communicable diseases [37
The Annex II on added sugars [8
] proposes that the Member States should set a general benchmark for a minimum of 10% added sugar reduction in food products against their baseline levels or to move towards a ‘best in class’ level of sugar content.
In Spain, in order to establish the sugar reduction objectives of the “Collaboration plan for the improvement of the composition of food and beverages and other measures 2020” [34
], AESAN opted in 2017 to deploy the first strategy mentioned in Annex II, which entails the reduction of a percentage of sugar from the basal median content, which was considered a viable and realistic method. Thus, all companies in the sector related to each food subcategory made a commitment to follow this plan. The evaluation of this plan, after its completion in 2020, will allow us to determine the degree of compliance with the objectives and to draw pertinent conclusions about the contribution of this initiative and its possible “drag effect” on other subsequent initiatives.
This work shows that most of the analyzed processed products (98.4%) meet the European Union tolerances for nutrient values declared on the labels. A very low percentage of products in our study did not meet the tolerance values because they had a lower LV than AV (0.45%). A study conducted with a sample of products that contribute the most to sodium intake in the United States [38
] concluded that the majority of the labeling and analytical values agree with each other; thus, label under-declaration is limited. However, the authors observed that the differences in total sugars were greater and more systematic and that 19% products did not meet tolerance requirements because their labelled total sugars were lower than their analytical data. In our study, each of the five products that did not meet tolerance levels (due to a lower LV than AV) belonged to a different group (baking and pastries, breakfast cereals, special packaged bread, desserts, and dairy-based desserts), which also included a considerable number of other products that did meet the tolerance requirements.
To our best knowledge, this is the first time that the LVs and AVs of the studied processed products groups were compared in Spain, showing that the total sugar values are similar under both methods for most of the products and subcategories, according to the tolerance requirements for the nutritional information established by the European Union. Of the 28 food and beverage groups and the 77 subcategories analyzed, only the “meat products” group and, specifically, the “cured ham” subcategory, showed significant differences between their median AV and LV data. Taking into account the low sugar content of cured ham and the specific characteristics of its manufacturing and maturation process, such as the infiltration variability of additives depending on the part of the product (fat, bone, etc.), these differences are not considered relevant.
In light of these findings, we conclude first that a reduction in sugar content is feasible in a wide range of products. We recommend setting benchmarks at the subcategory level because this level includes similar products to which the same quality standards apply and allows one to compare the nutrient content of each product within a subcategory to its median, thus facilitating the identification of products with the greatest potential for reformulation.
Moreover, our results show a remarkably high compliance with the tolerance requirements and the appropriateness of the declared total sugar content in the MNL for most sold packaged processed products in Spain.
Thus, the MNL provides an accessible and efficient tool for various aims: to inform consumers truthfully, to conduct studies on the sugar content or other nutrients in labeled products, to establish and monitor reformulation initiatives, to implement front-of-pack initiatives, to apply nutritional profiles for different objectives, and for food advertising policies, among others. Regulation (EU) No. 1169/2011 [25
] establishes (starting from 13 December 2016) the mandatory obligation to provide a nutritional declaration on the labels of most processed food products. This declaration must include the energy values and six nutrients, one of them being the sugar content.
Briefly, the groups identified to boost reformulation policies based on their sugar content, the differences in sugar content between similar products, and their contributions to energy, added sugars, or both to the diet are the following: sweets, other sweets, jam, chocolate, confitures, desserts, baking and pastries, breakfast cereals and cereals bars, biscuits, ice cream, sauces, meat products, sugar sweetened beverages, nectars, and dairy products [16
The results obtained from this research may help make the nutritional composition of food products more visible, to better explore the feasibility of improving nutrition and evaluate related actions.