Tuesday, 5 June 2018

Taxing Sugar

On April 6thof this year, the Soft Drinks Industry Levy – more colloquially known as the ‘sugar tax’ – came into effect. Framed as part of attempts to tackle child obesity, the levy added 18p per litre for drinks containing 5-8g of sugar per 100ml, and 24p per litre for drinks containing more than 8g of sugar per 100ml. The levy was declared a success even at its outset, with a Treasury press release noting that since the announcement of the tax in the March 2016 budget, over 50% of manufacturers had already reduced the sugar content of their drinks in order to pre-empt the levy. The press release promised that the £240 million expected to be raised from the levy would be used to fund school sports programmes and breakfast clubs. As it came into effect, celebrity chef and anti-sugar activist, Jamie Oliver, tweeted an image of sugar cubes arrayed in front of bottles of soft drinks to show their added sugar content, along with the link to his website, where he applauded the move, describing sugary drinks as “the single largest source of sugar and empty calories in our children’s diets – action is essential”.

But amidst the self-congratulatory praise for the sugar tax from its advocates as striking a brave blow for child health in the face of industry opposition, the foundational assumptions upon which the sugar tax is built remain highly problematic, particularly in its loose relation to evidence and the dislocation of the desire for ‘action’ from the social and material inequalities which frame the consumption of sugar. In this blog post, I explore some of the debates and assumptions around the sugar tax and how these frame the ‘problem’ of sugar. 

Responses to the sugar tax ranged from cries of ‘nanny state’ interference to celebratory demands to extend the tax beyond sugary drinks to include all high sugar snack foods. But they find common ground in the construction of obesity as a problem, with the fat body figuring variously as a disease, as the cause of other diseases, as the visible proxy for (preventable) ill-health, and most importantly, as a problem about which, in Oliver’s terms, ‘action is essential’ – a compulsion to act which loosens the reliance on evidence in favour of immediate action. For example, the case of Mexico is commonly cited as evidence of the effectiveness of taxation. Following the introduction of a tax on sugary drinks in 2014, sales fell by approximately 12% by the end of 2014 (and up to 17% among the poorest communities), fuelling demands for similar measures elsewhere. However, the health effects of this reduction in sales remain entirely theoretical, and there is currently no evidence of the desired health benefits for which falling drinks sales are mobilised as a proxy. Closer to home, Jamie Oliver’s 2015 decision to add a 10p levy to the added-sugar drinks in his “Italian” chain of restaurants, resulting in a 9.3% decrease in sales over 6 months, was hailed as auguring well for the sugar tax, with reduced consumption functioning as a proxy for health biomarkers and as predictive of the effects of a tax at the national level. However, this fails to take into account the class profile of his customers, who will already have been strongly attuned to the moral hazards of sugary drink consumption and Oliver’s vocal role as an anti-sugar advocate. Furthermore, it is disingenuous to align the decision to drink, or not drink, Oliver’s ‘fairtrade and organic’ Karma Cola (£3.00) on a restaurant night out with the real targets of the sugar tax – those of lower socio-economic status whose consumption is prefigured as excessive, ill-informed and most in need of intervention. 

The construction of sugar as a ‘problem’ that affects us all, and of interventions aimed at middle class restaurant patrons as offering meaningful lessons across populations, entrenches and obscures social inequalities in ways that mitigate directly against structural change in favour of the coercive ‘nudging’ of food individualised food choices. For example, the channelling of the revenue from the tax into school sports smoothes quietly over the devastation of (state) school sports facilities by consecutive governments, while simultaneously shoring up the normative link between sport and the ‘war on obesity’. This forces those children already targeted because of their size to endure the shame of participating in a class whose specific goal is to eliminate bodies like theirs. 

Plans to use revenue to provide food for hungry children also conceal disturbing truths about life in contemporary Britain through their normalisation of poverty and deprivation. For example, in January this year, a group of Conservative MPs including Jacob Rees-Mogg, Nicky Morgan and Nicholas Soames teamed up with ex-Labour front-bencher, Frank Field to call for revenue from the sugar tax to be used to address ‘holiday hunger’ among children with no access to free school meals during school holidays. It’s hard to object to hungry children being fed, but this philanthropic largesse leaves unaddressed the reasons why such a thing as ‘holiday hunger’ even exists in the UK today. Furthermore, it obscures the many other forms of suffering and hardship that a family experiencing profound food poverty must be negotiating, as well as the role of austerity measures such as benefit cuts and sanctions in creating and exacerbating those hardships – government policies supported by these same Conservative politicians (see for example, Rees-Mogg’s voting record).

Time will tell what effects – both desired and collateral – the sugar tax will have, but the aggressive pursuit of a single-nutrient solution to complex health and social problems should give us all pause for thought – not only in terms of who will bear the financial burdens of those interventions, but also what assumptions about individual responsibility, bodies and health underpin them. Just as Jamie Oliver’s campaign about sugary drinks isn’t really aimed at the consumers of his Karma Cola (or indeed his Epic Tiramisu dessert (£6.50, 40g of sugar)), the sugar tax targets the bodies and consumption habits of derogated Others, locking them into a narrative of exercise and education deficit to the exclusion of the broader social inequalities which they themselves might choose to prioritise as central to their own wellbeing. 

Sunday, 13 May 2018

The Daily Mile

There's been a lot of coverage in the news recently of The Daily Mile - a scheme for primary school children started by Elaine Wyllie, a head teacher in Stirling, Scotland in February 2012. The premise is very simple: at some point during the school day, all of the children go outside for 15 minutes of running around a pre-marked course (e.g. laps of the playground), aiming to jog or run a mile. The website claims that after 4 weeks, most children are able to run the full distance, and there are anecdotal reports of improvements in behaviour, concentration and sleep. In many ways, it sounds fun to be able to take a quick break between classes to blow off steam and stretch your legs; as for all of us, long periods of sitting are uncomfortable and stifling and it's hard to argue with introducing a short movement break into the children's day.

But there's a more disturbing side to the scheme that is going missing in the enthusiastic reporting: the direct linking of the Daily Mile with anti-obesity agendas. The stated aim of the scheme is "to improve the physical, social and mental health and well-being of our children - regardless of age, ability or personal circumstances", but it is obesity that is singled out as the crisis that needs to be addressed; the programme's letter to teachers, for example, states that "UK children are now the most overweight in Europe, and activity levels are worryingly low". The other anticipated benefits figure as collateral to the core aim, which Elaine Wyllie articulates as, "to help tackle our growing childhood obesity and physical activity crisis". This anti-obesity focus is demonstrated in the recent publication of research measuring the effects of the Daily Mile, in a BMC Medicine paper entitled: "The Daily Mile make primary children more active, less sedentary and improves their body composition: a quasi-experimental pilot study".  Using data from pedometers, BMI, skin fold tests and a shuttle run exercise, the study concluded that the results show a relative decrease of 18.2 mins / day in sedentary time; a relative increase of 9.1 mins / day in Moderate-Vigorous Intensity Physical Activity (MVPA); an increase in 39.1 metres in the shuttle run test; and a decrease of 1.4mm in the skin fold test. It hardly seem surprising that the introduction of an additional daily physical activity both increased activity rates and lessened sedentary time broadly in line with the time allocated to the activity; nor is it particularly surprising that children practising running get better at a test that measures running ability - a set of findings that seem relatively benign (although the definition of 'fitness' based on how far and fast you can run is very narrow).

But the skin fold test (which was conducted alongside height-weight measures) is more disturbing, given the assumption that a decrease in skin folds equates to 'improved' body composition - a non-too-subtle coding for the familiar coding of body fat as problematic - which in turn functions as a proxy for 'health'. There is no information on the Daily Mile website about how the scheme is pitched to the children, but those taking part in this study can have been under no illusions that a primary goal of the Daily Mile scheme was to get rid of undesirable fat through athletic performance as they were weighed and measured. The website also reveals the neoliberal discourses of personal responsibility into which the children are being inculcated through the scheme. The website's section on Health and Wellbeing, for example, argues that "children become more aware of their health and the need to take responsibility for it"; and the section on introducing the scheme into early learning and childcare settings describes it as "the opportunity to develop their 'physical literacy' and improve body composition for the rest of their lives". It's never too early to learn that the fat body can never be a 'good' body, and that we are individually responsible for our bodily condition. The aim that the scheme is for all children "regardless of age, ability or personal circumstance" is admirably inclusive, but at the same time flattens out the social factors that constitute health outcomes beyond the reach of 'individual responsibility'.

I had other questions. If one of the goals is to inculcate exercise habits that they will carry forward into their adult lives, is making them run outside whatever the weather really the best plan? And how, for example, is the experience of the Daily Mile gendered? In particular, girls often have to wear skirts that will cling to / wrap around legs restricting movement; they might also be wearing tights, the crotch of which every girl and woman knows will slide down her legs as soon as she moves around; and girls' shoes are notoriously flimsy and unsupportive compared to boys', as we can see in this promotional shot from the Daily Mile website:

And this leads me to my final question: does it have to be running? I can see that the singular focus on running is central to the scheme's commitment to making the intervention as simple, practical and unobtrusive into the school day as possible, but it also ties one particular mode of exercise (and one easily coded as 'healthy') to positive outcomes in ways that exclude others and cement the normative link between exercise and anti-obesity. What results would we see if children enjoyed a 15 minute break to sing songs, dance, go outside to see how many different birds or insects they can spot, or learn to juggle....? I suspect that busy teachers everywhere are now rolling their eyes at the prospect of such potentially complicated interventions into their already over-stuffed days, and they're right of course (although this is more an argument for changing the appalling working conditions of teachers in this country than one for sticking with running for simplicity's sake). But it is important to separate out what might be the benefits of a break from studying, and what is specific to running. And following on from that, what about those children for whom this is a nightmare? The website highlights the enthusiasm with which the scheme has been greeted by children, and I don't doubt that for many, it is joyful and invigorating, but what about those children whose bodies are most obviously the targets of this intervention (and who are already identified by other children as such)? Or those who just don't like to run, or can't' run?

I suspect that all of this makes me seem like a bit of a grouch. But the tethering of this potentially fun and positive activity for kids to the forceful prejudices of anti-obesity casts a dark shadow over its possibilities. What if we were to encourage playful exercise and activity without ever mentioning body size (or 'composition') or using it as code for 'health'? What if all children's bodies were already good enough and not subject to demands for 'improvement' in order to be counted as good citizens? The clinging of the scheme to anti-obesity goals makes it a terrible opportunity lost to think about bodies differently.

As the Daily Mile story circulated online and through social media, a few people posted on Twitter that it would be great to introduce this into our workplaces, and all I could think was that collective running in unsuitable clothing at my place of work in order to 'improve my body composition' was a vision of hell. Children are not adults and their school lives are very different to adult work lives, but I did find myself wondering how many feel the same way and what long term effects this might have. What memories and practices will those children whose bodies don't fit the narrative of self-mastery and 'improvement' carry into their adulthood? This seems like a much more pressing question than how many millimetres of fat they have lost.

Friday, 11 May 2018

Poverty and obesity

The Conversation recently published a piece by Martin Cohen, visiting research fellow in Philosophy at the University of Hertfordshire, entitled: It's poverty, not individual choice, that is driving extraordinary obesity levels. The article is headed with the familiar visual trope of fat stomach, ready to burst its shirt buttons - a lazy, fat-phobic suggestion (albeit probably picked by editors rather than the author himself) of the barely contained threat obesity is perceived to pose, and a reminder that sites of fat accumulation offer a direct means through which flaws and failings of fat bodies can be known.

Contra recent high profile campaigns by celebrity chefs like Jamie Oliver and Hugh Fearnley Whittingstall, Cohen argues that "finger wagging at sugary treats" doesn't even come close to addressing the 'problem' of obesity, which he argues is "a product of social inequality and requires a collective response". In doing so, he rejects the prevailing focus on individual choice and responsibility, drawing instead an analogy with nineteenth century public sanitation programmes to tackle typhoid and cholera. He doubles down on this analogy in his concluding sentence that "we need to collectively tackle the places where obesity germs breed - in stressed communities characterised by insecure and erratic employment, inadequate education, stress, depression and a lack of social cohesion". Although I doubt that Cohen intends us to think literally of 'obesity germs', the phrase is unfortunate, gesturing towards the rhetorics of 'epidemics' and contagion in ways which feed the already overwhelming stigma and fear that fatness ignites. This feeding of fear is the overall thrust of the piece - that the "obesity epidemic" needs more attention and more intervention, rather than less, and particularly in those areas, and in relation to those people, where poverty and obesity have coalesced.

In my previous posts, I have repeatedly reiterated my frustrations at the ways in which the attack on sugar, and by extension, on obesity, overlooks the social, economic and environmental contexts within which sugar is consumed and within which demands to cut back on sugar are made. However, I am categorically not arguing, as Cohen does, that we need to take social inequalities into account in order to effectively tackle obesity. The proper response to the correlation between poverty and obesity is not to ask "what social or collective interventions would be required to stop poor people being fat?", but rather, "what can we do to stop socially disadvantaged people being socially disadvantaged?" The measure of success for interventions driven by this second question wouldn't be something as facile as how fewer litres of pop were sold in local shops, or how many people lost weight, but instead would focus on access to education, respectful health care, employment, safe living environments and food security as social goods in their own right. The linking of poverty alleviation with anti-obesity campaigns and interventions elevates obesity as the over-determining problem, and at the same time constructs a frame whereby fat bodies are always bodies-out-of-place; the eradication of fat bodies is the only possible measure of success for anti-obesity campaigns, whether focused on sugary treats or social inequality. As such, they will always be campaigns of social exclusion, rather than inclusion.

Friday, 4 May 2018

More sugar in the news....

A couple of months ago, I posted the first, very preliminary breakdown of my dataset of sugar articles in the news which showed how the newspaper coverage of sugar had ballooned from 2013. I've been working away on this over the last few months, classifying each of the articles with a single keyword reflecting the core theme of the piece, and then coding the newspaper text across multiple emerging themes. And here are some preliminary findings.

Firstly, this chart breaks down the annual article headcount into months, revealing key moments in the contemporary UK story of sugar:

Apologies if the detail doesn't come out too clearly, but what you can see in this is some clear spikes of media interest which map on to key events that then require further exploration. For example, the spike in January 2014 marks the launch of Action on Sugar - an influential anti-sugar voice with a sustained media presence since its inauguration; the highest spike (in October 2015) reflects the delayed release of the Public Health England report Sugar Reduction: the Evidence for Action; and the second highest spike reflects George Osborne's March 2016 budget announcement of plans to introduce a tax on sugary drinks. I'm developing a more detailed timeline of events, publications and announcements that sits alongside this chart, with all of the associated documents being incorporated into the dataset.

My next question was ask to which newspaper are reporting sugar:

The Guardian comes out a clear winner here, perhaps reflecting the classed nature of concerns about sugar and the threat that it is perceived to pose (and by whom). 

And following on from this, we need to know what aspects of sugar are being reported on; what is it about sugar that is grabbing media attention: 

I need to explain this one. I attributed a key word to each newspaper article in an attempt to capture its overarching theme - the top 8 of these are shown in blue here. As you can see, questions of regulation, including taxation, prevail; second in line is the category 'hidden', which refers to the familiar "hidden sugar shock" stories which highlight the invisibility of sugar in everyday foods. But beyond the overarching theme, a number of these key words recur in multiple articles, and these were coded as themes as shown in the red columns here. So, for example, while almost 150 articles were attributed the keyword 'regulation', almost 300 discussed regulation in their content; and while fewer than 50 took 'health' as their main theme, over 250 made reference to health concerns in the content. The recurrence of these themes across content, regardless of the overarching theme of the article, highlights the discursive repertoires available to the media in their reporting of sugar.

This prompts a further question about whether different newspapers are reporting different aspects of sugar's story. The short answer is that they are, and I have a breakdown of the key words attributed to the articles from different newspapers, but I am struggling to find a way to visualise that effectively. This is a work in progress, but for now, I can say that while issues of regulation take primacy across the board, tabloid coverage includes far more 'hidden sugar shock', 'health' and 'giving up' stories, often pairing 'real people' with expert commentary to offer dietary guidance; conversely, broadsheet coverage is heavily weighted towards 'regulation' stories, particularly in relation to taxation. Part of the ongoing analysis is to explore the different ways in which the newspapers reported key events as a means of exploring the vocabularies of sugar.

There's so much more to do beyond these fairly simple acts of quantification, which are really only a means of ordering the data as a springboard for closer textual analysis. In particular, in addition to pairing up reporting with key events and documents for analysis, I'm also beginning much more detailed critical discourse analysis of the key themes, working my way through all of the data coded to those themes in search of patterns, contradictions and insights into the ways in which sugar is being made meaningful. I've started with "addiction", which is an excellent example of a theme that was only rarely taken as the overarching focus of an article, but which is invoked repeatedly and in diverse (and often taken-for-granted) ways in the body of the articles - a below-the-radar presence that speaks to a set of assumptions about our embodied relations with sugar.

In the mean time, it's hard not to be distracted by the coming into effect on April 6th of the sugar tax; there's been a torrent of media commentary, including new campaigns to include sugary sweets and snacks within the remit of the tax. In my imagination, there will be a book from this project, and an analysis of 2018 will definitely be included. But for now, I'm sticking with 2013-17, not least because I suspect that this is a story that will run and run without an obvious stopping point and I've got more than enough to be getting on with (although I do have a blog coming out shortly on another site about the sugar tax launch that I'll also post here).

Monday, 30 April 2018

Giving up sugar and the inequalities of abstinence

This April saw the publication of the first paper from the Sugar Rush project. It's called "Giving up sugar and the inequalities of abstinence" and is now out in the Sociology of Health and Illness. For those with institutional subscriptions, the article can be downloaded here, but if you would like to read the paper and have difficulty accessing it, please get in touch.

In a new departure for me, SHI also invited me to prepare a video abstract for the paper, which could be posted online to draw in new readers. I'm not entirely happy with the final result - I think I look a bit too tense and uncomfortable, plus I really should have had something more interesting in the background - but i love the idea of the video extract and think that it has huge potential for increasing the accessibility of our work. 

Anyway, I hope you enjoy both the video and the paper - all feedback is welcome, so please feel free to leave a comment below if you would like to join the debate. 

Thursday, 29 March 2018

The Pioppi Diet and the mysterious disappearing women

I have just finished reading The Pioppi Diet: A 21-Day Lifestyle Plan. It is co-written by cardiologist and omnipresent anti-sugar advocate, Aseem Malhotra, and documentary filmmaker and former international athlete, Donal O'Neill, and presents a low-carb, high-fat (LCHF) revision of the Mediterranean diet. The book is a follow-on from the documentary, The Big Fat Fix, during which Malhotra and O'Neill visited the Italian village of Pioppi (formerly home to Ancel Keys, whose research in the 1950's linked saturated fat and heart disease  and whose work is habitually dismissed by LCHF advocates as corrupt junk science). The book tells us that the people of Pioppi (pop: 197) are unusually long-lived (although we never see evidence of this beyond examples of anecdotal encounters with sprightly elderly men) and that this is due to a diet low in refined carbohydrates and rich in saturated fats (and particularly olive oil), fruit, vegetables, nuts, fish and modest amounts of red meat and red wine. They also credit the health-promoting, stress free atmosphere of the village, the positive effects of of lifetime of physical labour and the restorative effects of a regular siesta for the longevity of its inhabitants. These diet and lifestyle characteristics are then strategically appropriated in the book to form the Pioppi Diet (which is given the oxymoronic subtitle: 'A'21 day lifestyle plan').

The early chapters of the book adopt the familiar 'myth-busting' posture of popular LCHF books, mobilising claims to a science uncorrupted by the influences of Big Food to debunk received wisdoms surrounding the role of sugar and saturated fat in health; exercise; cholesterol; insulin resistance; and energy balance. While there are clearly interesting debates to be had here about food and health, I'm with Ben Goldacre when he argues that "the most important take-home message with diet and health is that anyone who ever expresses anything with certainty is basically wrong, because the evidence for cause and effect in this area is almost always weak and circumstantial, and changing an individual person's diet may not even be where the action is" (2009: 129).  Their cherry-picking of the science and the reliance on single nutrient accounts of complex health problems are trademarks of the genre, and readers should also question how turmeric and coconut oil - hardly Pioppi staples - end up taking such pride of place. I would also like to see the look on an Italian waiter's face if I ordered an espresso mixed with a teaspoon of coconut oil, a teaspoon of turmeric, a teaspoon of organic raw cacao powder and a teaspoon of ground cinnamon. They also maintain a contradictory position towards weight, claiming that there is no such thing as a 'healthy weight' but rather a 'healthy person' while wielding of obesity statistics in a horrified manner. But these are all topics for another day. Instead, I want to focus on the dislocation of the diet, in spite of the book's insistence to the contrary, from the everyday lived experiences of the people of Pioppi. And in particular, I want to focus on Pioppi's mysterious disappearing women (and their invisible labour).

The longevity of Pioppi's inhabitants is not evenly spread according to Malhotra and O'Neill, and we are told during an introduction to the village that "in this region, the men, who work for eight hours a day, every day, in the fields, their entire adult life, outlive the local women"; and "If the research aligning mobility with ten-year mortality rates (death from any cause) points to the importance of strength, balance and power as we age, the men of Pioppi need not worry" (pp. 12-13). No mention is made of why the men outlive the women, and no consideration is given to the ways in which women's lives might be facilitating male longevity. For example, we are offered a vision of an 8-hour day of male physical work embedded in a life of relaxed sociality, but it is unlikely that the women are fortunate enough to have only an 8 hour working day given that they are likely to be responsible for the domestic and reproductive labour of the household, continuing long after the men of the village have completed their labouring day. Malhotra and O'Neill also celebrate social interaction and community, highlighting how the elderly people could be seen walking and chatting in groups around the village, but they do not consider the unpaid labour performed primarily by women of caring for elderly relatives; and in celebrating what they imagine (but cannot demonstrate) to be the sound Pioppian sleep, they ignore the sleeplessness of those caring for young children, the elderly, the sick or people with disabilities. Indeed, in this idealised world, and in common with many lifestyle programmes that so thoroughly celebrate male physicality, there is no serious consideration of disability or chronic illness beyond the assumption of its preventability. As Malhotra notes, "given a choice, I'd rather drop dead healthy than live the last decade of my life with a disability I could have avoided" (p. 21). Revelling in the absence of "negative rumination" among those they met in Pioppi, the private realm to which women are so easily relegated remains hidden, and they certainly made no effort to seek it out in their visit to the village, focusing only on its public face - a face which, given that tourism is a key part of village life (it has UNESCO protection as the home of the Mediterranean diet), is likely to be a carefully curated one which fits the narrative of healthful longevity for which it has become famous. A further question along these lines arises in claims that both men and women would historically have experienced periods of food scarcity - a finding that they translate into a recommendation of intermittent fasting. We are offered the vision of men heading out to work in the fields without food, but it is also important to ask how available supplies were divided up within the household. For example, as in many other cases of scarce resources globally, male needs could have been prioritised to the detriment of women and children. I'm only speculating here, but without evidence, we cannot assume that men and women experienced this scarcity and fasting equally.

This inability to consider the everyday lives of women is evident in a discussion of stress and the long-term impacts of trauma. They cite a 2012 paper describing a study of women who were the long-term carers for chronically ill children. The women experiencing the highest levels of distress were identified as having the shortest telomere lengths, which is interpreted as equivalent to 10 years of ageing. But...never fear, because according to Malhotra and O'Neill, "just three months of stress-reduction interventions such as meditation, Pilates or yoga, combined with changing one's diet and doing the right type of regular activity can reduce telomere attrition and may even slow down the ageing process" (p. 79-80). Aside from the heavily qualified possibility of a positive outcome from all this stress-reduction activity, the prospect of advising a woman weighed down with onerous caring responsibilities for her sick child to do some Pilates and change her diet is crass and callous, rendering her distress her own problem to solve. One can imagine that well-funded social care and support might go a lot further in improving her health and quality of life. In a similar vein, we are told that Malhotra recommends walking to all his patients since it is "freely available, super-effective and open to all. No excuses" (p. 121). Except this too fails to take into account the woman who can't leave her sick child or elderly relative, whose neighbourhood isn't safe for a woman to walk alone, or whose disability means that walking isn't safely accessible.

The absence of women from the idealised and fanciful story of Pioppi is only one of its discrediting features, but for me, constitutes a fatal flaw.

Saturday, 24 March 2018

The Blueberry Muffins Survey

Earlier this week, Action on Sugar and the Obesity Health Alliance reported the results of their "Blueberry Muffins Survey" - a survey of the sugar content of a range of blueberry muffins available at supermarkets and in other out of home (OOH) outlets such as coffee shops. Drawing on nutritional information provided by outlets, or in a handful of cases, analysing the muffins in a lab to determine sugar content, the report compared sugar content, concluding:

1. Blueberry muffins are not a healthy snack, with 17 / 28 samples exceeding the daily sugar allowance for a small child (6 teaspoons)
2. Muffins from OOH outlets were bigger and more sugary than those from supermarkets.
3. The sugar content of the muffins varies between outlets.
4. The variation in sugar content and portion size shows that there is plenty of room to adjust content and portion sizes to meet the Public Health England of a 20% sugar reduction by 2020.
5. 42% of products provided full nutrition info at the point of sale, with a further 29% displaying limited information.

The report concludes with the following recommendations:
1. Products should be reformulated to reduce sugar content and muffin size.
2. All manufacturers, retailers and OOH outlets should publish full nutrition information, including traffic light labelling, at point of sale.

I'm not sure that we needed either a survey or a big press fanfare to learn that cakes have sugar in them; that some cakes are bigger than others; and that bigger cakes have more sugar than smaller cakes. But the survey also raises some more serious questions for me about the way sugar is being reported and the assumptions upon which recommendations are being made.

First - the choice of the blueberry muffin. They claim they picked this particular item "due to their wide availability, indicating their popularity", but this must apply to many baked goods. The key findings, however, provide a further clue to the blueberry muffin choice, declaring that 'blueberry muffins are not a healthy snack" - an assertion that appears to counter a prior claim that they are. There is an unspoken assumption here that consumers are mistakenly motivated to buy the blueberry muffins (rather than, say, chocolate ones) because the presence of fruit codes them as a healthy option, although no evidence is provided to support this premise. Furthermore, no data is provided on who is purchasing and consuming the muffins, and how regularly. Following on from this, if we understand what constitutes a 'healthy' choice as contextual rather than absolute, then it's entirely possible that the selection of a blueberry muffin is an informed attempt to reduce dietary sugar. For example, the Costa blueberry muffin has 28.6g of sugar per muffin (approx 7 teaspoons)*, placing it 14/28 among the chain's cake offerings for sugar content. However, a health-conscious consumer might have switched from their regular carrot cake (56.9g of sugar) or the triple chocolate muffin (38.6 g of sugar) to the lower sugar blueberry option, achieving a sugar reduction that far exceeds the 20% PHE sugar reduction target.

Second - like all "hidden sugar shock" media stories, the report assumes, firstly, that reformulation is a benign process, and second, that it is a lack of information that leads people to foods identified as problematically high in sugar. In the case of reformulation, history has some warnings for us. Trans fats - now widely perceived as harmful to health - were introduced as part of efforts to reduce saturated fat in food, and the increased demand for low-fat foods led manufacturers to introduce higher levels of sugar to preserve texture and palatability. Calls for the reformulation of processed foods should always begin with questions about how those reformulations will be achieved and at what potential costs. And secondly, the belief in the power of information through labelling to change purchasing and consuming behaviour is not supported by the current evidence. A 2018 Cochrane review on nutritional labelling, looking across a range of laboratory and real-world contexts, concluded that while labelling may impact on purchasing and consumption, the evidence is of too low quality to reach confident conclusions. Problematically, the review also concludes that in "the absence of observed harms", labelling could be used as part of a wider set of anti-obesity measures, but as with reformulation, I would question the assumption here that even if not effective, a move towards visible labelling is at least benign. For example, if we take the demands from Change4Life to be "Sugar Smart", we can see a potentially stigmatising shift of responsibility for health through food onto individuals, whose 'bad' choices are patronisingly rendered failures to be 'smart'. Furthermore, the focus on labelling assumes that people select 'unhealthy' foods because they don't know any better, but that once they know, they will change their eating behaviours and tastes to more closely match those of those advocating dietary change. This assumption dislocates food from its social context in ways that have the potential to exacerbate rather than ameliorate social inequalities, and to strip food of its affective and cultural meanings. Consequently, when, as in this report, we are told that "we are all eating too much sugar", who is included in this 'we' requires careful consideration.

This may seem like a lot to make of a short report about something as banal as muffins, but it is precisely in these wide-eyed "hidden sugar shock" stories that we can see in action the reductive and dislocated understandings of health and food that govern mainstream anti-sugar discourse.

And if anybody is asking, mine's a (vegan) chocolate muffin, please.

*The OHA press release for the report includes a footnote from Costa Coffee which notes that that in the report, the Costa blueberry muffin is listed as containing 40.3g of sugar. This was the result of a mistake on the Costa nutrition information pages for January - March 2018 and has since been amended (to 28.6g per muffin).