Estimating the potential impact of the UK government's sugar reduction programme on child and adult health: modelling study

A systematic review of economic evaluations of interventions targeting childhood overweight and obesity

This systematic review critically appraised and synthesized evidence from economic evaluations of interventions targeting childhood excess weight. We conducted systematic searches in 11 databases from inception to April 19, 2023. Studies were eligible if they evaluated interventions targeting children up to 18 years and the study intervention(s) targeted childhood excess weight or sought to improve diet or physical activity, regardless of the type of economic evaluation or the underpinning study design. We synthesized evidence using narrative synthesis methods. One-hundred fifty-one studies met the eligibility criteria and were classified into three groups based on the intervention approach: prevention-only (13 studies), prevention and treatment (100 studies), and treatment-only (38 studies). The predominant setting and study design differed considerably between the three groups of studies. However, compared with usual care, most interventions were deemed cost-effective. The study participants' ages, sex, and socioeconomic status were crucial to intervention cost-effectiveness. Interventions whose effects were projected beyond childhood, such as bariatric surgery, lower protein infant formula, and home-based general practitioner consultations, tended to be cost-effective. However, cost-effectiveness was sensitive to the assumptions underlying the persistence and intensity of such effects. Our findings can inform future recommendations on the conduct of economic evaluations of interventions targeting childhood overweight and obesity, as well as practice and policy recommendations.

Modelling health and economic impact of nutrition interventions: a systematic review

Diet related non-communicable diseases (NCDs), as well as micronutrient deficiencies, are of widespread and growing importance to public health. Authorities are developing programs to improve nutrient intakes via foods. To estimate the potential health and economic impact of these programs there is a wide variety of models. The aim of this review is to evaluate existing models to estimate the health and/or economic impact of nutrition interventions with a focus on reducing salt and sugar intake and increasing vitamin D, iron, and folate/folic acid intake. The protocol of this systematic review has been registered with the International Prospective Register of Systematic Reviews (PROSPERO: CRD42016050873). The final search was conducted on PubMed and Scopus electronic databases and search strings were developed for salt/sodium, sugar, vitamin D, iron, and folic acid intake. Predefined criteria related to scientific quality, applicability, and funding/interest were used to evaluate the publications. In total 122 publications were included for a critical appraisal: 45 for salt/sodium, 61 for sugar, 4 for vitamin D, 9 for folic acid, and 3 for iron. The complexity of modelling the health and economic impact of nutrition interventions is dependent on the purpose and data availability. Although most of the models have the potential to provide projections of future impact, the methodological challenges are considerable. There is a substantial need for more guidance and standardization for future modelling, to compare results of different studies and draw conclusions about the health and economic impact of nutrition interventions.

Recent advance in technological innovations of sugar-reduced products

Sugar is crucial as an essential nutrient for humans as well as for providing texture, sweetness and so on to food. But with the rise in people's pursuit of health, it is becoming increasingly clear that excessive consumption of sugar can locate a load on the body. It has been that excessive sugar is associated with many diseases, such as dental caries, obesity, diabetes, and coronary heart disease. Therefore, researchers and industries are trying to reduce or substitute sugar in food without affecting the sensory evaluation. Substituting sugar with sweeteners is alternatively becoming the most traditional way to minimize its use. So far, the sweeteners such as stevia and xylitol have been are commercially applied. Several studies have shown that technological innovation can partially compensate for the loss in sweetness as a result of sugar reduction, such as cross-modal interactions that stimulate sweetness with aroma, nanofiltration that filters disaccharides and above, enzyme-catalyzed sugar hydrolysis, and microbial fermentation that turns sugar into sugar alcohol. This review summarizes these studies to enhance the safety and quality of sugar-reduced products, and will provide some theoretical frameworks for the food industry to reduce sugar in foods, meet consumers' needs, and promote human health.

Different Dose of Sucrose Consumption Divergently Influences Gut Microbiota and PPAR-γ/MAPK/NF-κB Pathway in DSS-Induced Colitis Mice

Sugar reduction and sugar control are advocated and gaining popularity around the world. Sucrose, as the widely consumed ingredient in our daily diet, has been reported a relation to gastrointestinal diseases. However, the role of sucrose in inflammatory bowel disease remains controversial. Hence, our study aimed to elucidate the potential role of three doses of sucrose on DSS-induced colitis in C57BL/6 mice and the underlying mechanisms. The results showed that low-dose sucrose intervention alleviated colitis in mice, reducing the expression of inflammatory cytokines and repairing mucosal damages. In contrast, high-dose sucrose intervention exacerbated colitis. Furthermore, three doses of sucrose administration markedly altered gut microbiota composition. Notably, the low-dose sucrose restored microbial dysfunction and enhanced the production of short chain fatty acids (SCFAs). Specifically, the abundance of SCFAs-producing bacteria Faecalibaculum, Bacteroides, and Romboutsia were increased significantly in the LOW group. Consistently, PPAR-γ, activated by SCFAs, was elevated in the LOW group, thereby inhibiting the MAPK/NF-κB pathway. Together, our study demonstrates the differential effects of sucrose on colitis at different doses, providing a scientific basis for measuring and modifying the safe intake level of sugar and providing favorable evidence for implementing sugar reduction policies.

Estimating the benefits of obesity prevention on productivity: an Australian perspective

Background/objectives

Obesity poses one of the biggest public health challenges globally. In addition to the high costs of obesity to the healthcare system, obesity also impacts work productivity. We aimed to estimate the benefits of preventing obesity in terms of years of life, productivity-adjusted life years (PALYs) and associated costs over 10 years.

Subjects/methods

Dynamic life table models were constructed to estimate years of life and PALYs saved if all new cases of obesity were prevented among Australians aged 20–69 years from 2021 to 2030. Life tables were sex specific and the population was classified into normal weight, overweight and obese. The model simulation was first undertaken assuming currently observed age-specific incidences of obesity, and then repeated assuming all new cases of obesity were reduced by 2 and 5%. The differences in outcomes (years of life, PALYs, and costs) between the two modelled outputs reflected the potential benefits that could be achieved through obesity prevention. All outcomes were discounted by 5% per annum.

Results

Over the next 10 years, 132 million years of life and 81 million PALYs would be lived by Australians aged 20–69 years, contributing AU$17.0 trillion to the Australian economy in terms of GDP. A 5% reduction in new cases of obesity led to a gain of 663 years of life and 1229 PALYs, equivalent to AU$262 million in GDP.

Conclusions

Prevention of obesity is projected to result in substantial economic gains due to improved health and productivity. This further emphasises the need for public health prevention strategies to reduce this growing epidemic.

Health Economic Aspects of Childhood Excess Weight: A Structured Review

An economic perspective is crucial to understand the broad consequences of childhood excess weight (CEW). These can manifest in the form of elevated health care and societal costs, impaired health status, or inefficiencies in the allocation of resources targeted at its prevention, management, or treatment. Although existing systematic reviews provide summaries of distinct economic research strands covering CEW, they have a restricted focus that overlooks relevant evidence. The overarching aim of this structured review was to update and enhance recent key reviews of four strands of economic evidence in this area, namely, (1) economic costs associated with CEW, (2) health utilities associated with CEW, (3) economic evaluations of interventions targeting CEW, and (4) economic determinants and broader consequences of CEW. Our de novo searches identified six additional studies for the first research strand, five studies for the second, thirty-one for the third, and two for the fourth. Most studies were conducted in a small number of high-income countries. Our review highlights knowledge gaps across all the research strands. Evidence from this structured review can act as data input into future economic evaluations in this area and highlights areas where future economic research should be targeted.

Estimating the potential impact of the Australian government's reformulation targets on household sugar purchases

BACKGROUND

Countries around the world are putting in place sugar reformulation targets for packaged foods to reduce excess sugar consumption. The Australian government released its voluntary sugar reformulation targets for nine food categories in 2020. We estimated the potential impact of these targets on household sugar purchases and examined differences by income. For comparison, we also modelled the potential impact of the UK sugar reduction targets on per capita sugar purchases as the UK has one of the most comprehensive sugar reduction strategies in the world.

METHODS

Grocery purchase data from a nationally representative consumer panel (n=7,188) in Australia was linked with a large database (FoodSwitch) with product-specific sugar content information for packaged foods (n=25,261); both datasets were collected in 2018. Potential reductions in per capita sugar purchases were calculated overall and by food category. Differences in sugar reduction across income level were assessed by analysis of variance.

RESULTS

In 2018, the total sugar acquired from packaged food and beverage purchases consumed at-home was 56.1 g/day per capita. Australia's voluntary reformulation targets for sugar covered 2,471/25,261 (9.8%) unique products in the FoodSwitch dataset. Under the scenario that all food companies adhered to the voluntary targets, sugar purchases were estimated to be reduced by 0.9 g/day per capita, which represents a 1.5% reduction in sugar purchased from packaged foods. However, if Australia adopted the UK targets, over twice as many products would be covered (n=4,667), and this would result in a more than four times greater reduction in sugar purchases (4.1 g/day per capita). It was also estimated that if all food companies complied with Australia's voluntary sugar targets, reductions to sugar would be slightly greater in low-income households compared with high-income households by 0.3 g/day (95%CI 0.2 - 0.4 g/day, p<0.001).

CONCLUSIONS

Sugar-reduction policies have the potential to substantially reduce population sugar consumption and may help to reduce health inequalities related to excess sugar consumption. However, the current reformulation targets in Australia are estimated to achieve only a small reduction to sugar intakes, particularly in comparison to the UK's sugar reduction program.

Health Impact and Cost-Effectiveness of Achieving the National Salt and Sugar Reduction Initiative Voluntary Sugar Reduction Targets in the United States: A Microsimulation Study

BACKGROUND

High intake of added sugar is linked to weight gain and cardiometabolic risk. In 2018, the US National Salt and Sugar Reduction Initiative proposed government-supported voluntary national sugar reduction targets. This intervention's potential effects and cost-effectiveness are unclear.

METHODS

A validated microsimulation model, CVD-PREDICT (Cardiovascular Disease Policy Model for Risk, Events, Detection, Interventions, Costs, and Trends), coded in C++, was used to estimate incremental changes in type 2 diabetes, cardiovascular disease (CVD), quality-adjusted life-years (QALYs), costs, and cost-effectiveness of the US National Salt and Sugar Reduction Initiative policy. The model was run at the individual level, incorporating the annual probability of each person's transition between health statuses on the basis of risk factors. The model incorporated national demographic and dietary data from the National Health and Nutrition Examination Survey across 3 cycles (2011 through 2016), added sugar-related diseases from meta-analyses, and policy costs and health-related costs from established sources. A simulated nationally representative US population was created and followed until age 100 years or death, with 2019 as the year of intervention start. Findings were evaluated over 10 years and a lifetime from health care and societal perspectives. Uncertainty was evaluated in a 1-way analysis by assuming 50% industry compliance and probabilistic sensitivity analyses through a second-order Monte Carlo approach. Model outputs included averted diabetes cases, CVD events and CVD deaths, QALYs gained, and formal health care cost savings, stratified by age, race, income, and education.

RESULTS

Achieving the US National Salt and Sugar Reduction Initiative sugar reduction targets could prevent 2.48 million CVD events, 0.49 million CVD deaths, and 0.75 million diabetes cases; gain 6.67 million QALYs; and save $160.88 billion net costs from a societal perspective over a lifetime. The policy became cost-effective (<150 000/QALYs) at 6 years, highly cost-effective (<50 000/QALYs) at 7 years, and cost-saving at 9 years. Results were robust from a health care perspective, with lower (50%) industry compliance, and in probabilistic sensitivity analyses. The policy could also reduce disparities, with greatest estimated health gains per million adults among Black or Hispanic individuals, lower income, and less educated Americans.

CONCLUSIONS

Implementing and achieving the US National Salt and Sugar Reduction Initiative sugar reformation targets could generate substantial health gains, equity gains, and cost savings.

Simulation Modeling for the Economic Evaluation of Population-Based Dietary Policies: A Systematic Scoping Review

Simulation modeling can be useful to estimate the long-term health and economic impacts of population-based dietary policies. We conducted a systematic scoping review following the PRISMA-ScR (Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews) guideline to map and critically appraise economic evaluations of population-based dietary policies using simulation models. We searched Medline, Embase, and EconLit for studies published in English after 2005. Modeling studies were mapped based on model type, dietary policy, and nutritional target, and modeled risk factor-outcome pathways were analyzed. We included 56 studies comprising 136 model applications evaluating dietary policies in 21 countries. The policies most often assessed were reformulation (34/136), taxation (27/136), and labeling (20/136); the most common targets were salt/sodium (60/136), sugar-sweetened beverages (31/136), and fruit and vegetables (15/136). Model types included Markov-type (35/56), microsimulation (11/56), and comparative risk assessment (7/56) models. Overall, the key diet-related risk factors and health outcomes were modeled, but only 1 study included overall diet quality as a risk factor. Information about validation was only reported in 19 of 56 studies and few studies (14/56) analyzed the equity impacts of policies. Commonly included cost components were health sector (52/56) and public sector implementation costs (35/56), as opposed to private sector (18/56), lost productivity (11/56), and informal care costs (3/56). Most dietary policies (103/136) were evaluated as cost-saving independent of the applied costing perspective. An analysis of the main limitations reported by authors revealed that model validity, uncertainty of dietary effect estimates, and long-term intervention assumptions necessitate a careful interpretation of results. In conclusion, simulation modeling is widely applied in the economic evaluation of population-based dietary policies but rarely takes dietary complexity and the equity dimensions of policies into account. To increase relevance for policymakers and support diet-related disease prevention, economic effects beyond the health sector should be considered, and transparent conduct and reporting of model validation should be improved.

A prospective population-based multicentre study on the impact of maternal body mass index on adverse pregnancy outcomes: Focus on normal weight

Background

Maternal body mass index (BMI) below or above the reference interval (18.5–24.9 kg/m²) is associated with adverse pregnancy outcomes. Whether BMI exerts an effect within the reference interval is unclear. Therefore, we assessed the association between adverse pregnancy outcomes and BMI, in particular within the reference interval, in a general unselected pregnant population.

Methods

Data was extracted from a prospective population-based multicentre cohort (Risk Estimation for PrEgnancy Complications to provide Tailored care (RESPECT) study) conducted between December 2012 to January 2014. BMI was studied in categories (I: <18.5, II: 18.5–19.9, III: 20.0–22.9, IV: 23.0–24.9, V: 25.0–27.4, VI: 27.5–29.9, VII: >30.0 kg/m²) and as a continuous variable within the reference interval. Adverse pregnancy outcomes were defined as composite endpoints for maternal, neonatal or any pregnancy complication, and for adverse pregnancy outcomes individually. Linear trends were assessed using linear-by-linear association analysis and (adjusted) relative risks by regression analysis.

Results

The median BMI of the 3671 included women was 23.2 kg/m² (IQR 21.1–26.2). Adverse pregnancy outcomes were reported in 1256 (34.2%). Linear associations were observed between BMI categories and all three composite endpoints, and individually for pregnancy-induced hypertension (PIH), preeclampsia, gestational diabetes mellitus (GDM), large-for-gestational-age (LGA) neonates; but not for small-for-gestational-age neonates and preterm birth. Within the reference interval, BMI was associated with the composite maternal endpoint, PIH, GDM and LGA, with adjusted relative risks of 1.15 (95%CI 1.06–1.26), 1.12 (95%CI 1.00–1.26), 1.31 (95%CI 1.11–1.55) and 1.09 (95%CI 1.01–1.17).

Conclusions

Graded increase in maternal BMI appears to be an indicator of risk for adverse pregnancy outcomes even among women with a BMI within the reference interval. The extent to which BMI directly contributes to the increased risk in this group should be evaluated in order to determine strategies most valuable for promoting safety and long-term health for mothers and their offspring.

The potential health and revenue effects of a tax on sugar sweetened beverages in Zambia

The global burden of non-communicable diseases (NCDs) has been rising. A key risk factor for NCDs is obesity, which has been partly linked to consumption of sugar sweetened beverages (SSBs). A tax on SSBs is an attractive control measure to curb the rising trend in NCDs, as it has the potential to reduce consumption of SSBs. However, studies on the potential effects of SSB taxes have been concentrated in high-income countries with limited studies in low-income and middle-income countries. Using data from the 2015 Zambia Living Conditions Monitoring Survey (LCMS) data, the 2017 Zambia NCD STEPS Survey, and key parameters from the literature, we simulated the effect of a 25% SSB tax in Zambia on energy intake and the corresponding change in body mass index (BMI), obesity prevalence, deaths averted, life years gained and revenues generated using a mathematical model developed using Microsoft Excel. We conducted Monte Carlo simulations to construct 95% confidence bands and sensitivity analyses to account for uncertainties in key parameters. We found that a 25% SSB would avert 2526 deaths, though these results were not statistically significant overall. However, when broken down by gender, the tax was found to significantly avert 1133 deaths in women (95% CI 353 to 1970). The tax was found to potentially generate an additional US$5.46 million (95% CI 4.66 to 6.14) in revenue annually. We conclude that an SSB tax in Zambia has the potential to significantly decrease the amount of disability-adjusted life years lost to lifestyle-related diseases in women, highlighting important health equity outcomes. Women have higher baseline BMI and therefore are at higher risk for NCDs. In addition, an SSB tax will provide government with additional revenue which if earmarked for health could contribute to healthcare financing in Zambia.

Life-Course Implications of Pediatric Risk Factors for Cardiovascular Disease

The concept that origins of cardiovascular disease (CVD) begin in childhood is supported by substantial evidence. Prospective studies beginning in childhood report associations of childhood obesity, abnormal blood pressure (BP), dyslipidemia, diabetes, and tobacco use with intermediate CVD markers, including left ventricular hypertrophy and vascular stiffness in young adulthood. Trajectory analyses from longitudinal studies describe discrete BP pathways from childhood to young adult status of hypertension and prehypertension. Among individuals with familial hypercholesterolemia, abnormal low-density lipoprotein cholesterol levels are present in childhood. Some children are at risk for future CVD owing to hereditary factors, psychosocial stress, race, low birth weight, or other nonmodifiable exposures. Behavioural factors, including suboptimal diet, sedentary activity, and tobacco use, in childhood augment risk and can be modified to reduce risk. Pharmacologic treatments are reserved for those at high levels of the BP and cholesterol distributions and for those with diabetes and additional risk factors.

Addressing the low consumption of fruit and vegetables in England: a cost-effectiveness analysis of public policies

BACKGROUND

Most adults do not meet the recommended intake of five portions per day of fruit and vegetables (F&V) in England, but economic analyses of structural policies to change diet are sparse.

METHODS

Using published data from official statistics and meta-epidemiological studies, we estimated the deaths, years-of-life lost (YLL) and the healthcare costs attributable to consumption of F&V below the recommended five portions per day by English adults. Then, we estimated the cost-effectiveness from governmental and societal perspectives of three policies: a universal 10% subsidy on F&V, a targeted 30% subsidy for low-income households and a social marketing campaign (SMC).

FINDINGS

Consumption of F&V below the recommended five portions a day accounted for 16 321 [10 091-23 516] deaths and 238 767 [170 350-311 651] YLL in England in 2017, alongside £705 951 [398 761-1 061 559] million in healthcare costs. All policies would increase consumption and reduce the disease burden attributable to low intake of F&V. From a societal perspective, the incremental cost-effectiveness ratios were £22 891 [22 300-25 079], £16 860 [15 589-19 763] and £25 683 [25 237-28 671] per life-year saved for the universal subsidy, targeted subsidy and SMC, respectively. At a threshold of £20 000 per life-year saved, the likelihood that the universal subsidy, the targeted subsidy and the SMC were cost-effective was 84%, 19% and 5%, respectively. The targeted subsidy would additionally reduce inequalities.

CONCLUSIONS

Low intake of F&V represents a heavy health and care burden in England. All dietary policies can improve consumption of F&V, but only a targeted subsidy to low-income households would most likely be cost-effective.

Reducing children's sugar intake through food reformulation: methods for estimating sugar reduction program targets, using New Zealand as a case study

BACKGROUND

Reducing sugar in packaged foods and beverages could help protect children's future health. Clear methods for the development of feasible yet impactful sugar reduction program targets are needed.

OBJECTIVES

To outline methods for the development of program targets that would reduce, by 20%, the total sugar content of packaged foods and beverages commonly consumed by children. New Zealand (NZ) is used as a case study.

METHODS

Sugar content and pack size targets were developed using a 6-step process informed by the UK sugar and salt reduction programs. Food groups contributing ≥2% to children's total sugar intake were identified using national dietary survey data. Consumption volume, sugar content, and pack size were obtained from household panel data linked with a packaged food composition database. Category-specific targets were set as 20% reductions in sales-weighted means adjusted for feasibility, i.e., ∼1/3 of products already meeting the target, and alignment with existing, relevant targets.

RESULTS

Twenty-two food groups were identified as major contributors to NZ children's total sugar intake. Mean reductions required in sugar content and pack size to meet the targets were 5.2 g  per 100 g/mL (26%) and 61.2 g/mL/pack (23%), respectively. The percentage of products already meeting the sugar targets ranged from 14% for electrolyte drinks and flavored dairy milk to 50% for cereal bars, and for pack size targets compliance ranged from 32% for chocolate confectionary to 62% for fruit juices and drinks. Estimated reductions in annual household sugar purchases if the sugar and pack size targets were met were 1459 g (23%) and 286 g (6%), respectively.

CONCLUSIONS

Methods for the development of sugar and pack size reduction targets are presented, providing a robust, step-by-step process for countries to follow. The results of the case study provide a suggested benchmark for a potential national sugar reduction program in NZ.

Sugar Reduction in Yogurt Products Sold in the UK between 2016 and 2019

The UK government has called for industry reformulation of foods that contribute most to sugar consumption in children’s diets, including yogurts. The aim of this work was to comprehensively survey yogurt products available in UK supermarkets in 2019 to determine whether sugar contents had been reduced since our baseline survey in 2016. Product information was collected for 893 unique yogurt, fromage frais and dairy dessert products, and nutrient contents were analysed in comparison to those previously examined. Examining all products, there was a highly significant (p < 0.0001) reduction in the median total sugar contents in 2019 compared to those in 2016: median (interquartile range): 10.4 g/100 g (6.6, 13.0) versus 11.9 g/100 (8.8, 13.6). However, notable product turnover was evident; while 60% of the 2019 products surveyed could be matched by brand and name to 2016, 40% were new. In scrutinising paired products closely, only 32% (173 of 539) had reduced sugar contents with a smaller mean difference of −0.65 g/100 g (p < 0.0001), suggesting that the overall median had dropped as a result of higher sugar products being discontinued. Categories showing the most improvements were children’s, drinks and fruit yogurts. Although only 15% of the 2019 products contained ≤5 g/100 g sugars, considered a ‘low-sugar’ product for labelling, this was an improvement over the 9% identified in 2016. Our results yield important insights into current market trends and demonstrate that the median sugar content of UK yogurt products has been reduced by 13% in two years. These data independently evidence modest, but encouraging changes in response to public policy initiatives aimed at preventing childhood obesity.

Direct, Absenteeism, and Disability Cost Burden of Obesity Among Privately Insured Employees: A Comparison of Healthcare Industry Versus Other Major Industries in the United States

OBJECTIVE

To compare obesity-related costs of employees of the healthcare industry versus other major US industries.

METHODS

Employees with obesity versus without were identified using the Optum Health Reporting and Insights employer claims database (January, 2010 to March, 2017). Employees working in healthcare with obesity were compared with employees of other industries with obesity for absenteeism/disability and direct cost differences. Multivariate models estimated the association between industries and high costs compared with the healthcare industry.

RESULTS

Obesity-related absenteeism/disability and direct costs were higher in several US industries compared with the healthcare industry (adjusted cost differences of $-1220 to $5630). Employees of the government/education/religious services industry (GERS) with obesity (BMI of 30 or greater) had significantly higher odds of direct costs at the 80th percentile and above (odds ratio vs healthcare industry = 2.20; P < 0.05).

CONCLUSIONS

Relative to the healthcare industry, employees of other industries, especially GERS, incurred higher obesity-related costs.

Reformulation and Priorities for Reducing Energy Density; Results from a Cross-Sectional Survey on Fat Content in Pre-Packed Cakes and Biscuits Sold in British Supermarkets

Cakes and biscuits contribute to energy, total and saturated fat and sugar in British diets. So far, the UK government has prompted manufacturers to reduce energy density in these products through a reduction of their sugar content. We conducted a cross-sectional survey of the fat content of cakes and biscuits available in nine UK supermarket chains. In cakes (n = 381), the mean total fat content was 17.9 ± 5.2 g/100 g (39% of the overall energy); range (1.4-35.6 g/100 g) and the average saturated fat content in cakes was 5.9 ± 3.4 g/100 g (13% of the overall energy); range (0.3-20 g/100 g). In biscuits (n = 481), the mean total fat content was 21.8 g ± 6.3 g/100 g (40% of the overall energy); range (0.7-38.9 g/100 g) and the average saturated fat content was 11.4 ± 4.9 g/100 g (23% of the overall energy); range (0.3-22.3 g/100 g). In both cakes and biscuits, total and saturated fat content was positively correlated with energy density. Our results show that cakes and biscuits sold in UK supermarkets are high in total and saturated fat, and that fat content contributes substantially to product energy density. Fat reformulation in these products would effectively reduce energy density, calorie intake and help prevent obesity. Fat reformulation should be implemented simultaneously with sugar reformulation and be focused on saturated fat, as this will have the additional effect of lowering LDL cholesterol.