in Saudi Arabia and Chile

TABLE 8.1 Nutrients of concern and threshold values for nutrient-profiling models in use in Saudi Arabia and Chile

NUTRIENTS OF CONCERN AND THRESHOLDS CURRENTLY USED FOR VOLUNTARY MTL FOP LABELS IN SAUDI ARABIA FOR MANDATORY FOP & MARKETING RESTRICTIONS IN CHILE (3RD/FINAL PHASE)

Low Medium High Warning

100 g of food Total fat ≤ 3.0 g >3.0 g to ≤ 17.5 g >17.5 g

Saturated fat ≤ 1.5 g >1.5 g to ≤ 5.0 g >5.0 g >4.0 g

Total sugars ≤ 5.5 g >5.0 g to ≤ 22.5 g >22.5 g >10.0 g

Salt ≤ 0.3 g >0.3 g to ≤ 1.5 g >1.5 g >1 g Sodium: >400 mg

Calories 275 kcals

100 ml of beverage Total fat

Saturated fat

Total sugars Salt

Calories ≤ 1.5 g >1.5 g to ≤ 8.75 g >8.75 g

≤ 0.75 g >0.75 g to ≤ 2.5 g >2.5 g

≤ 2.5 g >5.0 g to ≤ 11.25 g >11.25 g

≤ 0.3 g >0.3 g to ≤ 0.75 g >0.75 g >3.0 g

>5.0 g

>0.25 g Sodium: >100 mg 70 kcals

Sources: Data for Chile from Corvalán et al. 2019; data for Saudi Arabia from SFDA 2020. Note: FOP = front of package; g = grams; kcal = kilocalorie; mg = milligram; ml = milliliter; MTL = multiple traffic light.

format for liquids. Thus, using this approach is also practical. There are two possible approaches for the proposed NPM: a threshold (cutoff point) approach and a continuous (score-based) approach.

Threshold- or cutoff-based NPMs identify predetermined cutoff points that will classify foods in a binary manner. Different cutoff points can be used for different nutrients within one food (for example, a different cutoff point each for sugar, sodium, and saturated fat). No calculations or comparisons need to be made before classifying a food, as it either meets the cutoff point or it does not, which makes the approach easy to use. This has been used for mandatory policies in Chile and Mexico, as well as the voluntary MTL FOPL approach in Saudi Arabia.

Continuous, score-based NPMs award points based on various criteria for various nutrients, and a summative healthfulness score is calculated from this score, depending on the NPM’s criteria. To date, this has been used only on voluntary approaches such as Australia’s Health Star Rating and France’s NutriScore labels. The rationale is that foods are composed of many nutrients and a single cutoff would result in the loss of valuable information. However, this argument holds true only when both positive and negative nutrients are considered or when the NPM is being used to underpin a positive logo that focuses only on whole, minimally processed foods.

For Saudi Arabia’s NPM to be able to underpin policies that aim to change unhealthy consumption patterns, a cutoff-point model will be most appropriate. It needs to be straightforward and make it easy to identify which products are less healthy and need to be regulated by policy. Continuous models require making a number of different calculations; these models can be human resource heavy and, ultimately, when used together with labels or claims, a cutoff point is

still used to determine whether a product complies or not, or is red, yellow, or green. In this sense, a scoring approach is always used in conjunction with a threshold approach.

Deciding which nutrients and food components to incorporate into the NPM

A key goal of NPMs, given the diets in Saudi Arabia, would be to identify foods high in nutrients or food components that are harmful to health. According to a review of NPMs used in government-led nutrition policies, all 78 NPMs included nutrients that need to be limited. The most common nutrients of concern were salt (sodium), saturated fat, and total sugar (Labonté et al. 2018).

There is a strong basis for the inclusion of salt (sodium), saturated fat, and total sugar based on current evidence and for consistency in including them in all government-led NPMs, but the inclusion of total fat is not necessary. In both the SFDA NPM for MTL and the Saudi NNC NPM, the nutrients included are total fat, saturated fats, salt (sodium), and total sugar. WHO recommends an intake of between 15 percent and 30 percent of total calories from all forms of fat. However, fat, per se, is not harmful to health, but rather the type of fat is what matters. Indeed, certain components, such as mono- and polyunsaturated fatty acids, are beneficial to health and are protective against certain NCDs such as cardiovascular disease. Recently, the US dietary guidelines have removed total fat as a nutrient of concern to focus instead on unhealthy saturated fats, including trans fats (Dietary Guidelines Advisory Committee 2020). Since January 2020, the SFDA has implemented its regulation number SFDA.FD 2483, issued in 2018, banning the use of partially hydrogenated oils (trans fats) in all food products (SFDA 2018). Assuming this trans-fat ban is well enforced, the inclusion of trans fat as a criterion may not be necessary. If the trans-fat ban is not well enforced, however, then its inclusion as a criterion should be strongly considered. Given the obesity and NCD trends in Saudi Arabia, excessive caloric intake appears to be a concern in the country, so it may be wise to also include calories and caloric density as a criterion in the NPM, in place of total fats. This switch would also more appropriately educate the public about the nutrients of concern.

Nonsugar sweeteners (NSS) are a food component that has been getting more attention in recent years, yet there is no global consensus on the longer-term health implications of prolonged and/or larger doses of NSS intake. With growing recognition of the need to lower sugar density in products, manufacturers are turning to NSS (often also referred to as nonnutritive sweeteners or artificial sweeteners) for maintaining sweet taste with far fewer or no calories (Bandy et al. 2020; Dunford et al. 2018; Piernas, Ng, and Popkin 2013; Popkin and Hawkes 2016; Scarborough et al. 2020). One fear around the increase in NSS in foods and beverages is the impact on sweetness preference and habituation among children. Among adults, we see different outcomes in widely conflicting human studies looking at gut health, brain response, and heart health (de Koning et al. 2011, 2012; Duffey et al. 2012; Lutsey, Steffen, and Stevens 2008).

NSS also have a negative environmental impact, which is an important consideration under the current context of climate change. Their development requires the use of scarce water resources and generates solid waste (Borges et al. 2017). They do not degrade but remain present as trace pollutants in