Confrontation or collaboration?

In the accompanying article, Professor Kaare Norum, Chair of a Reference Group set up to help the World Health Organization (WHO) headquarters to make a Global Strategy (GS) on Diet, Physical Activity and Health, describes the strong confrontations behind the scene, with intense lobbying, especially ‘‘from sections of the food industry selling products high in sugar and salt’’. In the implementation process of the GS, i.e. the next step during the coming years, however, it is of prime importance to find ways for an efficient collaboration between the global and national public health organizations and authorities, as well as nongovernmental organizations, and the food industry.

In the accompanying article, Professor Kaare Norum, Chair of a Reference Group set up to help the World Health Organization (WHO) headquarters to make a Global Strategy (GS) on Diet, Physical Activity and Health, describes the strong confrontations behind the scene, with intense lobbying, especially ''from sections of the food industry selling products high in sugar and salt''. In the implementation process of the GS, i.e. the next step during the coming years, however, it is of prime importance to find ways for an efficient collaboration between the global and national public health organizations and authorities, as well as nongovernmental organizations, and the food industry.
The sugar limit One of the most debated recommendations in the WHO Expert Report 916 on Diet, Nutrition and the Prevention of Chronic Disease (TRS 916) was the recommendation to limit ''free sugars'' to a maximum 10% of energy intake (E%). This recommendation did not survive into the final GS but was exchanged for the more general recommendation to ''limit the intake of free sugars''. But on the other hand, TRS 916, including the 10E% ''free sugars'' limit is now also an officially accepted WHO Technical Report.
But what then is the ''right'' limit, and do we really have hard scientific facts to underpin one fixed figure for maximum sugar intake to be optimal and valid for all populations in all the world? The answer is obviously no. All the recommendations on macronutrient levels, usually expressed as E%, have the character of overall summary evaluations, or even educated guesses, rather than absolute science-based figures. They are based on the totality of evidence regarding dietÁ/health interactions, as well as feasibility in practice in relation to present dietary habits and food supply. The acceptable level of sugar intake may be quite different depending on the person to whom advice is given: 10E% may be too high a level for a woman to obtain enough iron and folate to cope with menstrual losses and/or frequent pregnancies, whereas for a young, physically active man with normal body mass index, who had already learned to clean his teeth in kindergarten, e.g. 15E% sugar may be compatible with good health and there is no evidence that it would increase the risk of diabetes, coronary heart disease or other diseases.
The 10E% sugar limit in TRS 916 did not come as a surprise or a controversial issue in the Nordic countries. We have had that recommendation for planning of diets for heterogeneous groups for 30 years (although TRS 916 included sugars in fruit juices in that figure, which is not the case in the Nordic recommendations). But flexibility in evaluation of diets has also been stressed. In the 1996 version of the Nordic recommendations the 10E% limit of refined sugars was specifically directed towards adults with low energy intake ( B/8 MJ) and children to ensure an adequate nutrient density and to diminish the risk of dental caries. In the recently issued Nordic Nutrition Recommendations, NNR 2004 (1, 2), the 10E% limit of refined sugars is kept generally for planning purposes, but commented on again as being especially important for children and adults with low energy intake. The flexibility and relativity of recommendations regarding macronutrient composition are further illustrated by the fact that NNR 2004 recommends 10Á/20E% protein (compared with 10Á/15E% in NNR 1996 and TRS 916) and 25Á/35E% fat (not more than about 30E% in NNR 1996 and 15Á/30E% in TRS 916). A main point of criticism of TRS 916 was that it did not address the fact that another prestigious group of experts [FNB within the US National Academy of Sciences (3)] at the same time set the sugar limit as high as 25E%. The recommendation to ''limit the intake of refined sugars'' appears in many recommendations, including the FAO/WHO expert consultation report ''Carbohydrates in human nutrition'' (4), but there *The commentary is the view of the author and does not express any position taken by the SNF Swedish Nutrition Foundation. is no scientific basis to carve the 10E% figure in stone.

''Good'' and ''bad'' companies
It is tempting to travesty a common saying: ''There are no 'good' and no 'bad' food producers, only good and bad diets''. It is often impossible to differentiate between producers of ''products high in sugar and salt'' and the ''responsible'' companies with which collaboration should be promoted. For instance, food companies that are mainly suppliers of carbonated drinks may also produce fish products. Successful producers of snacks, chocolate and confectionery may also have far-reaching policies and programmes regarding nutritional adaptation of other relevant products, as well as regarding nutrition information to consumers. A producer of super-sized ice-creams high in saturated fat may be a leader in the development of products with healthpromoting fat composition. The same dairy companies produce butter that should be used sparsely, and milk and milk products with reduced fat content. Furthermore, the main retail chains have increasing power in deciding which products they want to sell (and now even produce as private brands), and the retail sector should therefore be an important target of and partner in public health measures. These facts have to be recognized in order to succeed with collaboration with the private (and co-operative) sector, to stimulate production of nutritionally sound products and decent marketing methods.
Collaboration is essential Efficient collaboration between all sectors in society is necessary to combat diet-related disease and the food sector has its obvious responsibility to provide nutritionally sound foods, and to abstain from exaggerated marketing of foods without consideration of the limited space for calories, especially from sugar and fat in a healthy diet. But as nutrition experts, we also have to differentiate between what is firmly substantiated scientifically and what has the character of overall evaluations from the totality of evidence. The 10E% sugar limit belongs to the latter category. Although it is a helpful round figure to use in the planning of diets, and also, for example, in evaluations of the adequacy of sugar production and supply, a somewhat flexible approach in its implementation would increase the possibilities for collaboration and reduce confrontation.