A radical overhaul of how nutritional information is displayed on the front of the packaging of many food products has been announced.

The government, food makers and food retailers have agreed the new standardised front-of-pack labelling to help make it easier for people to make healthier choices about what they buy and eat.

The Department of Health has today set out what the new food labels will look like and outlined how a colour-coding scheme of energy, salt, sugar and fat will look and how their levels are set.

Currently, food and drink labels often differ in the range of nutritional information provided. Currently, there is no law forcing retailers and manufacturers to display such information and manufacturers are currently only required by law to provide nutritional information if the product makes a nutritional claim. For instance, nutritional information must be on a product that claims to be ‘low fat’ or if vitamins or minerals have been added to the product.

Under new European Union rules, manufacturers will be required to provide particular nutritional information by December 2016. But any manufacturer that chooses to provide front-of-pack information will have to comply with the EU regulation by the end of 2014.

The new style of labels will follow the same format as this example from a packet of breakfast cereal:

What changes are being made to food labels?

Nutrition labels, when they are displayed, are often provided on the back, side or on the front of packaging. The new, standardised food labels will be displayed on the front of food and drink products and they will routinely include the following information per portion of food:

• the amount of energy (presented in kilojoules (kJ) and kilocalories (kcal), known as calories)
• the amount of fat and saturated fat
• the amount of sugar
• the amount of salt

These amounts will be shown as ‘Reference Intakes’ (formerly known as ‘Guideline Daily Amounts’). Alongside the amounts listed above, food labels will show how much of the maximum daily intake a portion of food accounts for.

Food labels will also contain red, amber and green colour-coding to visually show the nutritional value of food portions. This will allow people to see at a glance if the food product has high, medium or low amounts of fat, saturated fat, sugars and salt:

• red means high
• amber means medium
• green means low

In short, the more green lights, the healthier the choice.

Read more about the terms used on food labels.

When are these changes being made?

Standardised front-of-label packaging will be in place by December 2014 by organisations that have signed up to make the changes. Some have already made the changes and some will make changes from today.

Why are food labels being changed?

Research has shown that the different nutrition labels on food are confusing. These different nutrition labels have arisen because companies have responded to their customers’ demand for more nutritional information, but until now there has been no agreement on a consistent format. The new labelling system aims to make it easier for people to make healthier choices, by comparing the same kinds of foods to see if there is a healthier option. 

As part of the government’s efforts to improve health through reducing obesity levels, the Department of Health is working with food manufacturers and supermarkets through a programme called the Responsibility Deal. This programme aims to get business to reduce the amount of calories, salt and saturated fat in foods. The standardised front-of-pack label is a new Responsibility Deal pledge that food and drink companies can sign up to. Many companies already have taken this pledge to change their food labels.

Public Health Minister, Anna Soubry, said: “The UK already has the largest number of products using a front-of-pack label in Europe, but we know that people get confused by the variety of labels that are used. Research shows that, of all the current schemes, people like this label the most and they can use the information to make healthier choices.

“We all have a responsibility to tackle the challenge of obesity, including the food industry. By having all major retailers and manufacturers signed up to the consistent label, we will all be able to see at a glance what is in our food – this is why I want to see more manufacturers signing up and using the label.” 

The labels are not designed to ‘demonise’ foods with lots of reds, but to have people consider what they are eating and make sure it’s part of a balanced diet. Download the eatwell plate (PDF, 1.6Mb) for more information about a healthy balanced diet.

Links To The Headlines

Food packaging 'traffic lights' to signal healthy choices on salt, fat and sugar. The Guardian, June 19 2013

New food labelling system launched. The Daily Telegraph, June 19 2013

Traffic light food labelling introduced by big supermarkets. Daily Mirror, June 19 2013

Food labelling: Consistent system to be rolled out. BBC News, June 19 2013

Major UK Supermarkets Launch New Food Labels. Sky News, June 19 2013

Red labels to warn of unhealthy food: Logos to appear on items considered 'bad' for health in anti-obesity drive. Daily Mail, June 19 2013

Rarely a month goes by without the papers reporting at least one health news story related to vitamin D. In recent weeks the media has reported that vitamin D can help relieve the symptoms of asthma and lower blood pressure.

There have been long-standing claims that vitamin D brings a wide range of benefits, from preventing cancer risk to improving mental health, or even reducing your risk of getting multiple sclerosis.

But is there good evidence to back up the claims? And do you need to change your diet or take vitamin D supplements to reduce your risk of disease?

What is vitamin D?

Vitamin D is a group of related molecules that the body needs to help absorb calcium and phosphate. These are substances that help keep the bones healthy and strong.

Vitamin D is somewhat unusual in that we obtain it from two difference sources:

• sunlight
• dietary sources

How much sun is needed to get enough vitamin D?

When the skin is exposed to the ultraviolet B contained in sunlight, it generates the production of vitamin D. Most people generate around 90% of the vitamin D in their body from sunlight.

Your sunshine requirements differ depending on factors such as your skin tone and your weight. A 2010 consensus statement on vitamin D (PDF, 126.69kb), released by a combination of charities, recommended a "little and often" approach. It says regularly going out with sunscreen for a few minutes in the middle of the day should provide enough exposure to create sufficient vitamin D.

You certainly don't need to get a suntan, let alone risk sunburn. Overexposure to the sun in this way can increase your risk of skin cancer.

How to get enough vitamin D through your diet

Eating a healthy balanced diet should be sufficient to top up the remaining 10% or so that experts believe we need through our diet. Dietary sources of vitamin D include:

• oily fish, such as salmon, sardines and mackerel
• eggs
• fortified fat spreads
• fortified breakfast cereals
• powdered milk

What is vitamin D deficiency?

Vitamin D deficiency is when the body does not have enough vitamin D to properly absorb the required levels of calcium and phosphate.

Mild to moderate vitamin D deficiency can lead to bone pain and weakening of the bones (osteoporosis). This could make you more likely to fracture a bone if you had a fall.

More severe levels of deficiency can lead to the development of rickets in children and osteomalacia in adults.

Rickets, osteomalacia and vitamin D

Chronic severe vitamin D deficiency in children can disrupt the normal formation of bones, causing them to become soft and malformed and resulting in the condition known as rickets.

Symptoms of rickets include:

• bone pain
• deformities
• fragile bones vulnerable to fracture

Previously regarded as a disease of the past associated with Victorian slums, rickets is now making a comeback in some parts of England.

In 2012 the Royal College of Paediatrics and Child Health released a statement highlighting the problems of vitamin D deficiency in children, reporting that rates of rickets have risen fourfold in the last 15 years.

Osteomalacia, like rickets, develops because of softening of the bones. The main symptom of osteomalacia is a dull, throbbing and often severe bone pain that usually affects the lower section of the body. Osteomalacia can also result in muscle weakness.

Other health risks that have been linked with vitamin D deficiency

In a 2010 BMJ clinical review on vitamin D deficiency, researchers presented evidence that vitamin D deficiency may increase the risk of developing a number of chronic conditions, such as:

• heart disease
• bowel cancer
• breast cancer
• multiple sclerosis 
• diabetes

However, more research is required to prove these associations and provide evidence that people need to change their behaviour or take supplements because of potential health problems.

How common is vitamin D deficiency?

Vitamin D is thought to be much more common than most people realise. A 2007 survey estimated that around 50% of all adults have some degree of vitamin D deficiency.

In 2012 the Chief Medical Officer for the United Kingdom wrote to GPs highlighting the issue of vitamin D deficiency in high-risk groups (see below).

An independent advisory committee is also reviewing current recommendations on vitamin D, but the results of this extensive analysis are not expected until 2014.

What are the risk factors for vitamin D deficiency?

Lack of exposure to sunlight

Unsurprisingly, a significant risk factor for vitamin D deficiency is lack of exposure to the sun.

Possible factors that can result in limited exposure to sunlight include:

• overuse of sunblock
• being housebound or spending long parts of the day inside
• wearing clothes that cover up most of your body, often for cultural or religious regions

There are anecdotal reports that children may be more likely to develop vitamin D deficiency these days, as they are less likely to play outside than children did in the past.

Darker skin tone

Having a darker skin tone means you require a greater amount of sunlight exposure to generate vitamin D.

It is estimated that people with a naturally dark skin tone may require three to five times longer sunlight exposure to make the same amount of vitamin D as a white person.

Obesity

Obesity could be an overlooked cause of vitamin D deficiency. A recent study published in February 2013 suggested there is a direct relationship between increasing body mass index (BMI) and falling vitamin D levels.

The authors of the study speculated that vitamin D may become "trapped" inside fat tissue, so there is less available to circulate inside the blood.

How is vitamin D deficiency treated?

Mild to moderate vitamin D deficiency can usually be treated by making lifestyle changes such as getting more sun and eating foods rich in vitamin D. In some cases your GP may also recommend you take vitamin D supplements.

In more severe cases where the deficiency has affected bone growth and density, such as rickets, a vitamin D injection may be recommended.

Foods fortified with vitamin D

Unlike in some other countries, in England staple food items such as milk, flour and cereals are not routinely fortified with vitamin D. Fortified versions of goods such as cereals and milk are available from most supermarkets. You can read the food labels to compare the levels of vitamin D between products.

Some argue that people in the UK, especially in the north of England and Scotland, would benefit from fortification. However, the vitamin D we get from dietary sources is thought to stay in the body longer than the vitamin D we get from sunlight. Fortifying staple foods and drinks could potentially lead to dangerously high levels of vitamin D in a small number of people (vitamin D toxicity).

Other benefits of vitamin D

Links To Science

Avenell A et al. Vitamin D and vitamin D analogues for preventing fractures associated with involutional and post-menopausal osteoporosis. Cochrane Database of Systematic Reviews. April 2009

Bjelakovic G et al. Vitamin D supplementation for prevention of mortality in adults. Cochrane Database of Systematic Reviews. July 2011

Garland CF et al. Vitamin D for Cancer Prevention: Global Perspective. Annals of Epidemiology. July 2009

Holick MF et al. Evaluation, Treatment, and Prevention of Vitamin D Deficiency: an Endocrine Society Clinical Practice Guideline. Journal of Clinical Endocrinology and Metabolism. July 2011

Jagannath VA et al. Vitamin D for the management of multiple sclerosis. Cochrane Database of Systematic Reviews. December 2010

Pearce SH, Cheetham TD. Diagnosis and management of vitamin D deficiency. BMJ. January 2010

Urashima M et al. Randomized trial of vitamin D supplementation to prevent seasonal influenza A in schoolchildren. American Journal of Clinical Nutrition. March 2010

Vimaleswaran KS et al. Causal Relationship between Obesity and Vitamin D Status: Bi-Directional Mendelian Randomization Analysis of Multiple Cohorts. PLOS Medicine. Published online February 5 2013

“A glass of wine every day in pregnancy could be good for your baby,” is the entirely incorrect headline in The Daily Telegraph today. Other newspapers reported that drinking while pregnant does ‘no harm’, these claims are also misleading.

The news is based on a new study investigating the link between alcohol exposure before birth and childhood balance, which is considered an important sign of children’s development. Previous research has found that alcohol consumption during pregnancy is linked to poorer outcomes on several markers of neurodevelopment, but the effect on balance is uncertain.

Researchers found no evidence of an adverse effect of low-to-moderate maternal alcohol consumption on childhood balance. They also found moderate alcohol exposure seemed to have a beneficial effect compared to no alcohol. However, the researchers say that this positive effect is possibly due to them not being able to fully adjust for the fact that higher alcohol use was linked to social advantage.

This study adds to knowledge about the effects of alcohol in pregnancy on children’s balance. However, uncertainty remains over whether there is a ‘safe’ level of alcohol consumption during pregnancy. For this reason, current guidance suggests that women avoid alcohol completely during the first three months of pregnancy. If women choose to drink after this time, they should not drink more than one to two units of alcohol once or twice per week, and avoid binge drinking altogether. Contrary to media suggestions, this study does not change this advice.

Where did the story come from?

The study was carried out by researchers from the University of Bristol and University Hospital Bristol NHS Foundation Trust and was funded by the UK Medical Research Council, the Wellcome Trust, the University of Bristol and the Alcohol Education and Research Council (AERC). The study was published in the peer-reviewed, open access medical journal, BMJ Open.

The Telegraph’s headline was incorrect and potentially dangerous. While the researchers found a positive effect of alcohol in one measure, they clearly and categorically said that this likely to be a statistical blip. This headline also ignores the fact that the research was into just one aspect of children’s development and that alcohol consumption was measured at only one point in time.

Because of these limitations, women should stick to the existing advice on alcohol in pregnancy. Fortunately, in its online edition, the Telegraph used a more accurate headline. All other newspapers’ headlines suggested that drinking in pregnancy was “OK”, or does “no harm” – and are also misleading.

What kind of research was this?

This was a prospective cohort study that aimed to determine whether there was a link between alcohol exposure during pregnancy and balance in 10-year old children. Although this is the ideal study design to address this question, cohort studies can only show association, and cannot prove a cause-and-effect relationship. This is because other factors (confounders) may be responsible for any association seen.

This problem is demonstrated by this study. Despite the fact that the researchers collected information on a number of socioeconomic factors, and adjusted for them in their analyses, they conclude that the associations seen are probably due to not fully being able to adjust for social advantage.

What did the research involve?

The researchers used information on 6,915 children and their parents, who were participating in the Avon Longitudinal Study of Parents and Children.

This study used children who were born singly (who were not twins or another multiple birth) between April 1991 and December 1992, who had undergone balance assessment at 10 years of age and for whom they had information on the mother’s alcohol intake.

The balance assessment evaluated three types of balance:

• dynamic balance: time to cross a 2m balance beam, walking heel to toe 
• static balance, eyes open: heel to toe balance on a beam, eyes open and standing on one leg, eyes open. Both balances were held for a maximum of 20 seconds
• static balance, eyes closed: heel to toe balance on a beam, eyes closed and standing on one leg, eyes closed. Both balances were held for a maximum of 20 seconds

Children were said to have ‘good balance’ if they were in the top 25% fastest times for crossing the balance beam (good dynamic balance), if they maintained the static balances with their eyes open for 20 seconds (good static balance with eyes open), and if they were in the top 25% longest times for holding the static balances with eyes closed (good static balance with eyes closed).

Alcohol exposure was measured by asking mothers and fathers to self-report their alcohol intake at 18 weeks of pregnancy.

At 18 weeks of pregnancy, mothers reported both their current consumption and their consumption prior to pregnancy. For each time point, the mothers reported the total number of glasses (defined as a pub measure of spirits, half a pint of larger or cider, a small glass of wine) consumed per week, categorised into none (0 glasses), low (1-2 glasses), moderate (3-7 glasses), and high (more than 7 glasses) consumption. Mothers were also asked how many days in the previous month they had drunk the equivalent of at least four units of alcohol (binge drinking). Similarly, fathers reported alcohol consumption and binge drinking.

Information on other factors that could explain any association seen (confounders) was also collected. These included marital status, crowding index (number of people in the household and number of rooms), home ownership, parity (the number of previous children the mother has), maternal education, ethnicity, maternal age, maternal social class, smoking, cannabis use, caffeine consumption, number of stressful maternal life events during pregnancy, and maternal depression.

The researchers looked to see whether there was a link between alcohol exposure during pregnancy and the balance ability of 10-year old children after adjusting for these potential confounders.

What were the basic results?

Few mothers reported drinking heavily during pregnancy, with 95.5% of mothers reporting no alcohol consumption to moderate alcohol consumption.

In general, higher total levels of maternal alcohol consumption were associated with higher socioeconomic status and higher maternal age, whereas higher levels of binge drinking were associated with lower socioeconomic status and lower maternal age.

No evidence was found of an adverse effect of maternal alcohol consumption on childhood balance.

• There was no association between any level of alcohol consumption during pregnancy and childhood dynamic balance.
• Compared to no alcohol consumption at 18 weeks of pregnancy, moderate maternal alcohol consumption was significantly associated with good static balance with both eyes open and eyes closed.
• There was no significant difference in static balance (eyes open or eyes closed) between no alcohol, low alcohol or high alcohol (the only significant association seen was for moderate alcohol).

Regular heavy maternal binge drinking (more than 10 times per month) was also associated with good static balance (eyes shut) in children. There was no significant association between any other level of binge drinking, or any other measure of balance.

Paternal drinking during the first three months was associated with good static balance (eyes open) in children, with fathers that reported drinking less than one glass per week, at least one glass per week and at least one glass per day having children with better static balance than those that reported never drinking.

The researchers then analysed the data differently, using a technique called “Mendelian randomisation”. This approach is based on the assumption that a person’s DNA is not linked to socioeconomic status.

It is known from previous research that particular variations in a gene that codes for alcohol dehydrogenase (an enzyme that breaks down alcohol) predisposes people to lower alcohol consumption. The researchers looked at this variant. Mothers carrying this variant consumed less alcohol before, during and after pregnancy.

There was no evidence that mothers carrying this variant had children with poorer balance, which is not what would be expected if alcohol exposure improves balance. The researchers use this result to suggest that the previous association between maternal alcohol consumption and balance outcomes may have been due to the fact that the current analysis could not completely adjust for socioeconomic status.

How did the researchers interpret the results?

The researchers suggest that the most correct interpretation of their results is that they, “provide no strong evidence of an effect, either beneficial or detrimental, of moderate maternal alcohol use during pregnancy on offspring balance.”

Conclusion

This large, well-designed prospective study has found no evidence that moderate maternal alcohol consumption at 18 weeks of pregnancy has an adverse effect on offspring balance at age 10.

The study is limited by the fact that, as a cohort study, it cannot show a cause-and-effect relationship. This is because other confounding factors may be responsible for any association seen.

Despite the fact that the researchers collected information on a number of socioeconomic factors, and adjusted for them in their analyses, they conclude that the small benefits seen for some outcomes with some drinking patterns are probably due to not fully being able to adjust for social advantage.

Also, maternal and paternal alcohol use was self-reported and alcohol use during pregnancy was assessed at only one point in time, which could be subject to bias. The researchers also reported that the balance measures used had low test-retest reliability.

Although the results of this study will add to knowledge about the effects of alcohol in pregnancy on one particular developmental outcome, uncertainty remains over what is a ‘safe’ level of alcohol consumption during pregnancy.

Current guidance suggests that women avoid alcohol completely during the first three months of pregnancy due to increased risk of miscarriage, and if they choose to drink after this time, should not drink more than one to two units of alcohol once or twice per week, and avoid binge drinking altogether. This study does not change this advice.

For more advice, read Can I drink alcohol when pregnant.

Analysis by Bazian. Edited by NHS Choices. Follow Behind the Headlines on twitter.

Links To The Headlines

A glass of wine a day in pregnancy could be good for your baby. The Daily Telegraph. June 18 2013

Moderate drinking during pregnancy 'does not harm baby's development'. The Guardian. June 18 2013

Pregnant women told moderate drinking will not harm the baby. The Independent. June 18 2013

Mums-to-be 'CAN have a glass of wine a day without harming their child's development'. Daily Mail. June 18 2013

Glass of wine per day OK during pregnancy, study claims. Daily Mirror. June 18 2013

Glass of wine does no physical harm, pregnant women told. The Times. June 18 2013

Links To Science

Humphriss R, et al. Prenatal alcohol exposure and childhood balance ability: findings from a UK birth cohort study. BMJ Open. Published online June 18 2013

“Anti-baldness drug can cause men to lose interest in alcohol,” reports the Mail Online.

This report is based on a small survey of young men who had been taking the drug, finasteride, for hair loss. Impotence and decreased libido are recognised side effects of this anti-male-hormone drug, and all 83 men in this study had experienced sexual side effects that lasted at least three months after they stopped taking it.

The survey found that the men reported drinking less at the time of the survey than before they started taking the drug. However, this was on average five years earlier, so it is not clear how well these men could remember what they drank so far in the past.

Also, as the study had no control group who didn’t take the drug, it’s not possible to say that these changes wouldn’t have happened naturally over time as the men aged. The results may also not be representative of what might be seen in older men, men taking the drug for its other use (enlarged prostate), or men who do not experience the sexual side effects of the drug.

Overall, these findings are inconclusive. Larger studies, ideally with a control group, are needed to assess the effects of the drug on alcohol consumption.

Where did the story come from?

The study was carried out by a single researcher from The George Washington University in the US. No sources of funding were reported. It was published in the peer-reviewed journal Alcoholism: Clinical and Experimental Research.

The Mail Online reports the results of the study, but not any of its fairly extensive limitations.

What kind of research was this?

This was a cross-sectional study reporting on the alcohol consumption among men taking the drug finasteride. This anti-male-hormone drug is licensed to treat benign (non-cancerous) enlargement of the prostate and male pattern hair loss.

The recognised side effects of the drug include sexual problems such as decreased libido, impotence and erectile dysfunction. It may also have effects on the nervous system. The researchers reported that finasteride has been shown to reduce alcohol intake in male mice, but no studies have assessed this in humans.

This study relied on men reporting their own alcohol consumption before and after taking the drug in a single survey. This is likely to be less reliable as men may not accurately remember their consumption in the past. Asking the men to keep an alcohol diary before and after they started taking the drug would be a more reliable approach.

The study also didn’t include a comparison group not taking the drug. Therefore, the result cannot conclusively show that the drug itself is definitely causing a change in alcohol consumption.

What did the research involve?

The researchers surveyed the alcohol consumption habits in 83 men aged under 40, who had been taking finasteride to treat or prevent male pattern hair loss. These men had experienced persistent sexual side effects but were otherwise healthy.

The men were reported to be recruited from the author’s previous studies on persistent sexual side-effects of finasteride. These men had side-effects for at least three months despite stopping finasteride. Men who had sexual dysfunction before taking finasteride, had chronic medical conditions, current or past psychiatric conditions, or had taken psychiatric medication were excluded.

The survey asked about their average weekly alcohol consumption before they started taking finasteride, and at the time of the interview. A glass of wine, can of beer, or shot of hard liquor was considered a standard drink.

What were the basic results?

Sixty-three of the men reported drinking at least one alcoholic drink per week before starting finasteride. Among these men, at the time of the survey:

• 65% reported reduced alcohol consumption 
• 32% reported no change in their alcohol consumption
• 3% reported an increase in their alcohol consumption

On average, of the men who reported drinking alcohol, the average number of drinks per week reduced significantly – from 5.2 before finasteride to 2.0 after finasteride. As the men had stopped taking finasteride, they were not taking the drug at the time of assessment.

The authors reported that although they were not asked about this specifically, some men volunteered the information that they could not tolerate alcohol as well after starting to take finasteride. Eighteen men reported giving up alcohol entirely.

How did the researchers interpret the results?

The researchers concluded that among men who developed persistent sexual side effects from finasteride and stopped taking the drug, almost two-thirds reported reduced alcohol consumption.

Conclusion

This relatively small study in a very select group of men provides only limited evidence of the effects of finasteride on alcohol consumption in men. Its limitations include:

• The study didn’t include a comparison group not taking the drug. Therefore, the result cannot conclusively show that the drug itself is definitely causing a change in alcohol consumption, rather than the men just having changing alcohol tolerance as they got older.
• The study asked men to remember what their alcohol consumption was before taking the drug – on average about five years previously. This is likely to be less reliable as men may not accurately remember their consumption in the past. Asking the men to keep an alcohol diary before and after they started taking the drug would be a more reliable approach.
• The study only used a crude assessment of the number of drinks consumed, the size and alcohol content of these drinks may vary and this could affect comparison of before and after findings.
• The study did not say exactly how men were selected to take part, or whether they knew the purpose of the study. The men’s responses may have altered if they knew that finasteride may have an effect on alcohol consumption.
• The men all had persistent sexual dysfunction following taking finasteride for male pattern hair loss. The results may not apply to other men taking the drug, for example those without these side effects, or those taking it for an enlarged prostate.
• The author reported that many of the men in the study experienced depressive symptoms, and this may have affected their alcohol consumption.

As the author acknowledges, more research would be needed to determine the effects of finasteride on the nervous system and alcohol consumption.

Analysis by Bazian. Edited by NHS Choices. Follow Behind the Headlines on Twitter.

Links To The Headlines

Anti-baldness drug can cause men to lose interest in alcohol. Mail Online. June 17 2013

Links To Science

Irwig MS. Decreased Alcohol Consumption Among Former Male Users of Finasteride with Persistent Sexual Side Effects: A Preliminary Report. Alcoholism: Clinical and Experimental Research. Published online June 13 2013