Consensus Action on Salt, Sugar and Health – Written evidence (FPO0053)
- Poor diet is now the biggest cause of premature death and disability worldwide, according to The Global Burden of Disease5. This is attributed to the excessive amounts of calories consumed from fat and sugar, which can lead to obesity and subsequently increase the risk of type 2 diabetes, heart disease, cancer and stroke, as well as mental health problems such as depression, anxiety and low self-esteem. Dietary intake of free sugars is the main cause of tooth decay in children, and a high salt intake is linked to raised blood pressure, decreased bone health, chronic kidney disease and stomach cancer. Saturated fat is linked to increased blood cholesterol and increased risk of heart disease.
- Children growing up in lower socio-economic areas are more than twice as likely to be obese than those in higher income households, with those coming from black and minority ethnic families also being more likely to be overweight or obese than those coming from white families8,9. Low incomes and rising living costs are two of the main contributors to the cause of hunger, malnutrition and food insecurity, leading to many having to use Food Banks. The use of food banks has increased by 73.4% in the last five years, increasing by 18.8% in the past year3.
- Unhealthy food is more readily available and accessible than healthy food. Fast food outlets have been increasing over the years, with more fast food outlets being available in areas with a higher level of deprivation40. Those who are less mobile, either due to age, physical disability or lack of transport, whilst also living in ‘food deserts’ (areas without many food stores), may find it more difficult to access healthy, affordable food, with local stores often supplying more expensive products without a lot of fresh fruit and vegetables on offer44.
- Evidence has shown that promotions such as multi-buys can lead to people buying more in the short term and not necessarily reducing purchases on subsequent trips, potentially resulting in increased consumption57, 58. Multi-buy promotions help normalise buying and mislead customers into thinking these promotions will help them save money when in fact they are most likely spending and eating more59. Promotions generally cause people with less money to spend more, due to triggering impulse purchasing, while promoting overconsumption.
- Local initiatives are extremely important in their role to encourage healthier lifestyles, however for them to fully work, the food industry must accept their role in the health of their consumers. Measures must be put in place to create healthier environments, including limiting advertising and promotions of HFSS, and reformulating foods to reduce their salt, sugar and calorie content.
- Government-led reformulation programmes are an effective way of tackling these excess levels of fat, sugars and/or salt, as shown by the successful salt reduction programme originally set up by the Food Standards Agency and Action on Salt in the UK51. The nutritional composition of food and drink can be gradually improved and benefits the whole population, including children from the most deprived backgrounds52. Mandating reformulation programmes and extending the soft drinks industry levy to other categories such as confectionary would create a level playing field for companies 78. Mandating restrictions on advertising, promotions and mandatory labelling would encourage more healthy options for consumers. The funds raised should be ring—fenced for investing into improving children’s services.
- What are the key causes of food insecurity in the UK? Can you outline any significant trends in food insecurity in the UK? To what extent (and why) have these challenges persisted over a number of years?
- On average, 2.2 million people in the UK were living in food insecurity between 2015 and 20171. Of those, 47% were unemployed, 34% were in the lowest income quartile and women were more likely than men to live in a food insecure household (10% compared to 6%)2.
- Low incomes and rising living costs, universal credit and the benefit system, and cuts to funding for local social care services are the main contributors to the cause of hunger, malnutrition and food insecurity, leading to many having to use Food Banks3. The use of food banks has increased by 73.4% in the last five years, increasing by 18.8% in the past year3.
- Using the example of Universal Credit, these challenges will continue to persist as the changes to benefit systems, without a proper package of support measures, puts undue pressure on the third sector. Those affected by changes turn to advice centres and charities, many of whom have already faced cuts, for help and support which in turn impacts organisations operationally and lessens their ability to support in other areas4.
- What are some of the key ways in which diet (including food insecurity) impacts on public health? Has sufficient progress been made on tackling childhood obesity and, if not, why not?
- The consumption of products high in fat, salt and/or sugar (HFSS) are the biggest cause of premature death and disability according to The Global Burden of Disease5. Highly processed packaged foods, likely to be HFSS and low in fruit, vegetables and fibre, make up two thirds of the calories consumed by UK families and 47% of calories consumed by primary school children. When looking specifically at the diets of UK secondary school children, 85% are not eating enough fruit and vegetables, 90% aren’t eating enough fibre, and all are eating too much salt and sugar6,7.
- A person can be overweight or obese and still be malnourished. It is no surprise that, with the combination of a high intake of HFSS products and low intake of fruit vegetables and fibre, there is a high prevalence of obesity in England in both children and adults. Children growing up in lower socio-economic areas are more than twice as likely to be obese than those in higher income households, with those coming from black and minority ethnic families also being more likely to be overweight or obese than those coming from white families8,9.
- Obesity increases the risk of type 2 diabetes, heart disease, cancer and stroke, as well as mental health problems such as depression, anxiety and low self-esteem10, 11, 12. It is estimated that around 6,000 young people have type 2 diabetes in England and Wales13. Type 2 diabetes can lead to heart disease, nerve damage, limb amputation and vision loss14.
- Dietary intake of free sugars is the main cause of tooth decay in children, which has a huge impact over a shorter timeframe than other conditions associated with obesity. Almost one in four 5 year olds in England had obvious tooth decay in 201715. It is the number one reason children (aged 6-10years) are admitted to hospital, with an 18% increase in tooth extractions on children in hospitals since 201215. Between 2016 and 2017, more than a third of 5 year olds had dental decay in the most deprived areas, whereas just 12.5% of children in the least deprived areas were affected16.
- Foods high in fat and sugar have long been linked with weight gain. These foods are often also high in salt and there is some evidence to suggest there is an independent link between salt and obesity17, 18. Evidence suggests that obesity, coupled with a lack of exercise, are important factors involved in the development of high blood pressure. However, the strongest evidence links salt to the development of raised blood pressure, and the totality of evidence demonstrates that as salt intake is reduced, blood pressure falls both in hypertensive and normotensive individuals19.
- Raised blood pressure is a major cause of cardiovascular disease (which includes stroke, heart disease and heart failure) and is responsible for 62% of strokes and 49% of coronary heart disease. Cardiovascular disease is a leading cause of death and disability both in the UK and worldwide and due to the strength of evidence linking salt to blood pressure and cardiovascular disease, the World Health Organisation recommends salt reduction as a ‘best buy’ public health intervention due to its low cost and huge benefit to health20.
- The UK currently has an average salt consumption of 8.1g a day, a third more than the UK’s recommended limit of 6g a day. Most of our salt intake (75%) comes from salt added by the food industry to processed food or food eaten out of home, leading to many not realising they’re eating too much salt. Furthermore, 16 million people have high blood pressure but as high blood pressure is symptomless, approximately one third are undiagnosed21. A high salt intake is also linked to decreased bone health, chronic kidney disease and stomach cancer (with high biological plausibility) 22,23,24,25,26,27,28.
- A recent SACN (Scientific Advisory Committee on Nutrition) report (2019) concluded that a high saturated fat intake is linked to increased blood cholesterol and increased risk of heart disease and therefore should be reduced to no more than 10% of total dietary energy intake (currently ~12.5%), and replaced with unsaturated fat29. Currently there has been no active programme to reduce saturated fat or calories in the British diet.
- To date, there has been no significant progress in tackling childhood obesity. In 2015, the government published their Childhood Obesity Plan that included measures such as the Sugar Reduction Programme, which tasked the food industry to reduce the sugar content of the main contributors of sugar to children’s diets by 20% by 2020, and the Soft Drinks Industry Levy, which taxed manufacturers of soft drinks with more than 5g of sugar per 100ml30, 31. Chapter two of the plan was released in 2018 and detailed plans to implement a calorie reduction programme to cover the main contributors of calories to children’s diets, restrict price promotions on unhealthy food and restrict advertising of products high in salt, sugar and fat to children, among other measures32.
- However, the report detailing progress made in the first year of the Sugar Reduction Programme revealed mixed progress and while there have been several public consultations on measures detailed in chapter 2, so far there have been no actions despite some closing over a year ago33.
- Furthermore, the analysis of progress made towards the 2017 salt reduction targets highlighted that only half (52%) of all the average salt reduction targets were met, despite the targets being set in 2014. Progress within the out of home sector was poorer than the retail sector34.
- Salt reduction has stalled since the removal of strict monitoring by the Food Standards Agency to be replaced by little to no monitoring under the Public Health Responsibility Deal in 2011, with an estimated 9.900 extra cases of cardiovascular disease and 1,500 cases of stomach cancer between 2011 and 201735. The UK currently has no active salt reduction strategy and without any further action, it is estimated an extra 26,000 cases of cardiovascular disease and 3,800 cases of stomach cancer will occur between 2019 and 202535.
- The poor progress seen with both the salt and sugar reduction programmes is unsurprising due to a lack of transparent monitoring. For a voluntary reformulation programme to be successful, it is imperative that targets are fully monitored and enforced. Many businesses would prefer a mandatory reformulation approach to put everyone on a level playing field, including retailers represented by the British Retail Consortium36. As was seen after the implementation for the soft drinks industry levy (SDIL), when regulation is implemented, businesses are more willing to reformulate their products.
- How accessible is healthy food? What factors or barriers affect people’s ability to consume a healthy diet? Do these factors affect populations living in rural and urban areas differently?
- From health literacy to marketing and advertising, there are many factors that affect the ability to consume a healthy diet. Those living in more deprived areas are more likely to be obese and consume less fruit and vegetables than those living in less deprived areas37 ,38.
- The mean price of healthy food (defined by the Nutrient Profile Model) has been higher than the mean price of HFSS food over the last 10 years. 1 in 5 of the UK’s lowest income households would have to spend 42% of their after housing income if they were to eat the Government’s recommended diet, compared to just 8% in the highest income households. The current climate where healthy food is more expensive than HFSS food only exacerbates social inequalities in health as those with a limited budget will get more for their money by purchasing HFSS products 39.
- Unhealthy food is more readily available and accessible than healthy food. Fast food outlets have been increasing over the years, with more fast food outlets being available in areas with a higher level of deprivation40. It’s then unsurprising that those living in greater deprivation are more likely to be overweight or obese41.
- Children have easy access to buy unhealthy food. A study by Food Standards Scotland looking at the food environment around secondary schools found that more than three quarters (77%) of the 651 children in the study bought food outside school at least twice a week for lunch. A quarter of the children bought food from newsagents or sweet shops42.
- Food and drink is increasingly being sold in businesses where it is not their main source of business e.g. stationary shops and clothing stores. The majority of these products tend to be HFSS and are predominantly displayed at checkouts, encouraging impulse buying and feeding into pester power from young family members. A study of 330 non-food retail outlets by the UK Health Forum and Food Active in 2018 found that more than a quarter of stores sold sweets or chocolate confectionery 43. The study also collected consumer data and found that 42% of respondents had bought food or drink from a non-food retailer in the last month. Two thirds of products bought were ‘less healthy’, including sugary drinks43.
- Those who are less mobile, either due to age, physical disability or lack of transport, whilst also living in ‘food deserts’ (areas without many food stores), may find it more difficult to access healthy, affordable food, with local stores often supplying more expensive products without a lot of fresh fruit and vegetables on offer44. Whilst there is online shopping, this often requires a minimum spend as well as access to, and understanding of, the internet.
- Even when trying to consume a healthy diet, mixed messages in the public domain can be confusing for consumers, especially when unhealthy products are marketed as ‘healthy’, using key phrases such as ‘natural’, ‘fat / sugar free’, ‘wholegrain’ and/or ‘fruity’ despite containing high levels of salt, sugar and/or fat. An example of this is Mr Kipling slices that are ‘made with real fruit’, ‘no hydrogenated fat, a ‘source of calcium’ and ‘100% natural flavours & no artificial colours’, yet has high fat, saturated fat and sugar content, with medium levels of salt45.
- The recently published report by Royal Society for Public Health (RSPH) found that the majority of children visited a fast food outlet on their way home from school. The report recommends transforming the street environment through addressing junk food on offer (ending discounts offered by unhealthy fast food outlets near schools), promoting other places to go (youth-led improvements to green spaces), making travelling to and from school safer (segregated cycle lanes), and limiting the reach of advertisements (limit shop front advertisements for unhealthy food)46.
- What role can local authorities play in promoting healthy eating in their local populations, especially among children and young people, and those on lower incomes? How effectively are local authorities able to fulfil their responsibilities to improve the health of people living in their areas? Are you aware of any existing local authority or education initiatives that have been particularly successful (for example, schemes around holiday hunger, providing information on healthy eating, or supporting access to sport and exercise)?
- As the majority of unhealthy foods consumed are produced and sold through national chains, the priority should be on national, top down activity. However, local authorities have a particularly important role to play in the out of home sector, particularly in monitoring and implementation of new out of home policies such as calorie labelling, maximum portion sizes and also in monitoring and reporting on irresponsible marketing, advertising and promotion practices.
- Leeds Health and Wellbeing Service created a 3 week packed lunch toolkit that would cost just £1 a day to help those in deprived areas, with many resources online and direct interaction with school caterers to reduce sugar and portion sizes in puddings47.
- Charlton Manor Primary School is another example, where the school uses food as a vehicle to teach other subjects, making learning practical. A vegetable garden can teach biology and geography by looking at the weather, birds and bees; it can teach maths, by allowing pupils to measure the garden, calculating how many vegetables should be planted and grown; and cooking the vegetables they grow again teaches maths, English, science, geography, history and time management47.
- The Soil Association’s Food For Life Programme encourages schools to grow their own food, take trips to farms, run cooking clubs, and serve freshly prepared well-sourced meals. 50% of primary schools in England now serve menus that are certified by Food For Life ‘Served Here Award’. Children in schools that were signed up to the Soil Association Programme were twice as likely to eat 5 a day and a third less likely to eat no fruit and vegetables, with 45% of parents also found to eat more vegetables. Free school meals increased by an average of 13% over 2 years, thus having the potential to help ‘close the gap’ for disadvantaged children48.
- The Brighton and Hove Food Partnership is another example of a local initiative that encourages vegetable growing, community cooking classes, surplus food donation and offers healthy eating advice to residents49.
- Local initiatives are extremely important in their role to encourage healthier lifestyles, however for them to fully work, the food industry must accept their role in the health of their consumers. Measures must be put in place to create healthier environments, including limiting advertising and promotions of HFSS, and reformulating foods to reduce their salt, sugar and calorie content, otherwise there will be a constant battle between consumers wanting to eat healthily and a food industry focused solely on profit, not health.
- The growing use of delivery services undermine the work done by local authorities to reduce the amount of fast food outlets being opened by allowing easy access to affordable unhealthy food.
- What impact do food production processes (including product formulation, portion size, packaging and labelling) have on consumers dietary choices and does this differ across income groups?
- The majority of foods available on the supermarket shelves are processed and packaged. It is not easy to determine, by sight alone, what the healthiest choices are, despite good evidence that people, given the correct information, will make a healthier choice50.
- Nutrition labelling needs to be in an easily understood format and government should invest in measures to improve consumer understanding of calories and food labelling alongside legislation. Low socio-economic groups may benefit from such a policy because of the indirect effects clear food labelling has, e.g. reformulation, and because choosing food of lower calorie density could become a normative behaviour in the population.
- Government-led reformulation programmes are an effective way of tackling these excess levels of fat, sugars and/or salt, as shown by the successful salt reduction programme originally set up by the Food Standards Agency and Action on Salt51. The nutritional composition of food and drink can be gradually improved and benefits the whole population, including children from the most deprived backgrounds52. Due to this gradual reformulation, the population did not notice the change in salt content and as a result the average salt intake has successfully been reduced in people from all socio-economic backgrounds53, 54. The salt reduction strategy did not require any behaviour change in individuals of any population subgroup and therefore reduced health inequalities.
- To be successful, reformulated products must replace existing ones, not sold as new products that are ‘healthier’, or at premium prices. All products across the board, not just the main contributors of saturated fat and sugar to the diet, should be targeted, so that food preference for high sugar or fat products are reduced, as has occurred for salt.
- Research shows that children as young as three show a preference for branded foods over identical unbranded products55. Cartoon animation on packaging is one of the most frequently used ways of marketing to children. Animation ranges from the use of licensed TV, book and film characters such as Peppa Pig and Roald Dhal characters, through to unlicensed characters created by the manufacturers themselves.
- Currently, these characters are not being used responsibly. A recent survey found half of over 500 food and drink products which use cartoon animation on pack were high in fat, saturated fat, sugar and/or salt. Products that wouldn’t be able to be advertised on TV during kids programmes, were able to use cartoons on packaging to advertise to children in stores56.
- The Advertising Code set by the Committee for Advertising Practices (CAP/BCAP) for broadcast advertising does not allow broadcasting of adverts for products classified as high in fat, salt and/or sugars, using the Department of Health nutrient profiling model, during programming with an audience of more than 25% aged under 16 years. Transport for London applies a similar criteria for high fat, salt and/or sugar food for advertising on its network. However, there are major loopholes which undermine a parent’s ability to choose healthy options; advertising is still permitted on major network shows which attract a family audience and child friendly characters are permitted on packaging and promotions.
- What impact do food outlets (including supermarkets, delivery services, or fast food outlets) have on the average UK diet? How important are factors such as advertising, packaging, or product placement in influencing consumer choice, particularly for those in lower income groups?
- Evidence has shown that promotions such as multi-buys can lead to people buying more in the short term and not necessarily reducing purchases on subsequent trips, potentially resulting in increased consumption57, 58. Multi-buy promotions help normalise buying and mislead customers into thinking these promotions will help them save money when in fact they are most likely spending and eating more59.
- 71% of respondents to a Food Active survey had bought a food or drink item on promotion during their last shopping trip. The survey highlighted how promotions can drive purchases of less healthy food, with more than half (57%) of promotional purchases being unplanned impulse buys60.
- An analysis of Kantar WorldPanel purchasing data from 2017 by Cancer Research UK found that people who buy a high proportion of food and drink on promotion buy a significantly higher percentage of HFSS products and less fruit and vegetables compared to people who buy little on promotion61.
- The research also found that higher income families purchase the most on promotion as a proportion of their overall basket, contrary to some claims that low-income families will suffer if food is not promoted61. Promotions generally cause people with less money to spend more, due to triggering impulse purchasing, while promoting overconsumption. Therefore, failing to implement restrictions on promotions and marketing, for example, impact those from lower socio-economic backgrounds the hardest. Local authorities have highlighted that families on low incomes tend to shop at local, smaller outlets. If microbusinesses were excluded from any regulations then the inequality gap in childhood obesity prevalence could be widened, as childhood obesity is associated with deprivation. Any restrictions that come about from the government consultations, should not apply to healthier staple foods.
- The positioning of products - e.g. at end of aisle, window or entrance displays, displays at eye level or checkout displays can also influence consumers choice62,63. 83% of shoppers across the country reported being ‘pestered’ by their children to buy junk food at checkouts, with 75% giving in 64. One study found that placing carbonated soft drinks at end-of-aisle displays increased sales by 51.7%, whilst supermarkets adhering to a voluntary policy of removing crisps and confectionery from checkout areas saw 76% fewer purchases of these ‘on the go’ products in comparison to supermarkets without the voluntary policy65,66.
- Advertising of HFSS products also influences children’s food choice and consumption, altering their food preference, often leading them to ‘pester’ parents to buy the advertised unhealthy products 67, 68, 69, 70, 71. 36% of the food and drink adverts shown during peak time TV programmes popular with children in 2017 (OHA, University of Liverpool) were for fast food and takeaways – the largest category in the studies analysis 72. Most recently, it was found that fast food and delivery brands accounted for 27% of HFSS food adverts (CRUK) 73. An example of the impact out of home advertisement has on peak time tv is when Dominos had a 25% sales lift when they ran advertising during the X-Factor final 74.
- An Australian modelling study found that legislation to restrict HFSS TV advertising before 9.30pm is likely to be cost-effective, with children (aged 5-15) in low socio-economic groups likely to gain greater health benefits and healthcare cost savings 75. It has also been found that marketing influences teens from the most deprived communities more, where they are 40% more likely to remember junk food advertisements every day compared to teenagers from less deprived communities 76.
- Delivery service apps such as Deliveroo and Just Eat are a new industry that influencing consumer choice. Not only does it make it easier for consumers to eat unhealthy food, it also increases the amount of HFSS advertised to children, particularly to those in the most deprived communities.
- Deliveroo was found to promote party buckets to poorer postcodes with higher levels of obesity, compared to sushi and noodles being promoted to more affluent areas with lower levels of obesity, further limiting the access to nutritious foods at affordable prices to those in the poorer postcodes 77. These delivery services undermine the work done by local authorities to reduce the amount of fast food outlets being opened by allowing easy access to affordable unhealthy food.
- Do you have any comment to make on how the food industry might be encouraged to do more to support or promote healthy and sustainable diets? Is Government regulation an effective driver of change in this respect?
- The UK’s world-leading Soft Drinks Industry Levy (SDIL) has successfully removed the equivalent of over 45,000 tonnes of sugar from our shelves with 457 live traders registered for the levy. Between April and October 2018, the Soft Drinks Industry Levy raised £153.8 million, much less than the forecast £520 million per year due to manufacturers reformulating their drinks to include less sugar and avoid paying – the intended consequence of the levy.
- Mandating reformulation programmes and extending the SDIL to other categories such as confectionary would create a level playing field for companies 78. Mandating restrictions on advertising, promotions and mandatory labelling would encourage more healthy options for consumers. The funds raised should be ring—fenced for investing into improving children’s services.
- Food businesses receive hygiene training on how to prepare and store food safely to minimise foodborne disease with the ultimate goal of protecting public health, and they are required to be able to provide allergen information, so the same principle should be applied to calories in food in relation to overweight and obesity risk.
- Food companies have been quick to respond to allergen labelling and to restricting sales of energy drinks, as they have been properly motivated by the threat of government intervention.
- All mandatory and voluntary programmes must have routine assessments to be monitored well, ensuring the food industry has a point of contact for any queries.
- The food industry would need extra support including but not limited to; training, recommendation of software, standardised systems, small grants to support small businesses or to councils that ensure they have the means to provide training.
- A Public Health England report has concluded that “considerable and largely unprecedented” dietary shifts are required to meet Government guidance on healthy diets. What policy approaches (for example, fiscal or regulatory measures, voluntary guidelines, or attempts to change individual or population behaviour through information and education) would most effectively enable this? What role could public procurement play in improving dietary behaviours?
- As evidenced in previous and latter questions
- Mandatory front of pack colour coded labelling in retail
- Mandatory point of sale nutrition labelling in the OOH sector
- Extending the SDIL to include other energy-dense categories such as confectionery and milk based drinks. The funds should be Ring-fenced.
- Legislation to restrict HFSS advertising to a 9pm watershed across all media platforms
- Legislation to restrict promotions and product placements of HFSS in stores
- Mandatory reformulation programmes such as new strict salt reduction targets that are monitored rigorously
- Restriction of new fast food outlets in certain areas such as new schools or areas already densely populated with fast food outlets
- Making fruit and vegetables more affordable and accessible, especially in food deserts
- Restrictions on food delivery services on advertising and price promotions
- Economies of scale can be reached by smaller outlets joining forces on procurement – something the large aggregators such as JustEat, Deliveroo and Uber Eats, as well as the public sector, could implements
- Restrictions of cartoons and animations on food and drink high in fat, sugar and/or salt
- Saturated fat/calorie reduction by means of a comprehensive and strictly monitored reformulation programme
- Sugar reduction by means of a comprehensive and strictly monitored reformulation programme
- Salt reduction by means of comprehensive and strictly monitored reformulation programme
- What can the UK learn from food policy in other countries? Are there examples of strategies which have improved access and affordability of healthy, sustainable food across income groups?
Mandatory reformulation programmes
- In 2013, Argentina introduced a ‘sodium reduction law’ (Act 26905) which came into effect in December 2014. The law mandated salt reduction targets with expected reductions in salt content of 5-18%, across three main food categories (with a total of 18 sub-categories):
- meat and meat products
- bread products
- soups, dressings and preserves
- The law also includes public awareness campaigns and a restaurant strategy to restrict salt shakers and create low-salt menus 79.
- A 2015 analysis found that, of the 18 sub-categories covered by the legislation, 15 had already met their salt reduction target before the law was introduced. Between 2011 and 2016 the average daily consumption of salt fell from 11.2g/day to 9.2g/day, an 18% reduction. In 2018, a joint resolution ensured that the targets were reset to lower targets and a 2019 analysis found that 90% of products complied with their targets 80, 81.
- In 2013, South Africa’s Minister of Health introduced legislation to make salt reduction in the food industry mandatory. The first set of mandatory targets were due to be met by 2016, with a second set of targets due to be met by 2018. The targets cover a wide range of food categories including:
- breakfast cereals
- meat products
- snack foods
- soup mixes
- A 2017 analysis found that when the 2016 targets were implemented, two-thirds of products already met their targets and many more products had salt levels close to the target 82.
- Bread is a common staple food worldwide and is a main contributor of salt to diets in the UK, and many countries worldwide, due to the quantity of bread consumed each day. Therefore, bread has been a key target for salt reduction efforts worldwide. Mandated salt targets for bread exist in many countries including83:
- As part of the Chilean Food Labelling and Marketing Law, mandatory front of pack warning labels were implemented in Chile in June 2016 on all products with84:
- Calories – more than 200kcal per serve
- Salt – more than 0.75g per serve
- Sugar – more than 18g per serve
- Saturated fat – more than 3g per serve
- While the impact evaluation of these labels is ongoing, initial results indicate that the labels are well known by mothers and children from different socioeconomic backgrounds and children in particular have positive attitudes towards the labels, acting as ambassadors for healthier products in their households85. In 2017, Peru’s Ministry of Health announced that they would also implement mandatory warning labels on products, following Chile’s criteria, which were implemented in 201886.
- In recognition of the impact the out of home sector has on our intake of products high in salt, sugar and fat, New York City was the first city to implement calorie labelling in the out-of-home sector (New York City Labelling Law). A modelling study suggests that since its implementation, the point‐of‐purchase provision of calorie information on chain restaurant menus reduced body mass index (BMI) by 1.5% and lowered the risk of obesity by 12% 87. Another study analysed over 100 million transactions in Starbucks stores before and after the Implementation of the New York Labelling Law and found a statistically significant 6% reduction in mean calories per transaction. The reduction was mainly due to calories from foods rather than for drinks 88. In May 2018 the US Food and Drug Administration made calorie labelling on menus mandatory in all restaurants and similar food establishments that have 20 or more locations89.
- The UK’s world-leading Soft Drinks Industry Levy (SDIL) has successfully removed the equivalent of over 45,000 tonnes of sugar from our shelves with 457 live traders registered for the levy. Between April and October 2018, the Soft Drinks Industry Levy raised £153.8 million, much less than the forecast £520 million per year due to manufacturers reformulating their drinks to include less sugar and avoid paying – the intended consequence of the levy.
- Other countries have implemented taxes on other categories of food, including Mexico. In 2014, the Mexican Ministry of Health implemented an 8% tax on nonessential food items with more than 285kcal per 100g. Such taxes led to a reduction in purchases of taxed foods by an average 6% over two years post-implementation 90.
- Are there any additional changes at a national policy level that would help to ensure efforts to improve food insecurity and poor diet, and its impact on public health and the environment, are effectively coordinated, implemented and monitored?
- Meals eaten out of home (OOH) tend to be larger portion sizes, and higher in salt, sugar and fat than food cooked at home 91. With 1 in 5 children eating OOH at least once a week (PHE), it can no longer be considered a treat. OOH food doesn’t have the same regulations when it comes to providing the nutritional content of a product. Nutrition labelling is mandatory for manufactured food and drink sold in supermarkets and other retailers and in part, due to this, many manufacturers have committed to improve the nutritional quality of the food and drink they sell. Those providing food and drink from OOH outlets should engage in a similar way to create a level playing field for the entire food and drink industry. It is not easy to determine, by sight alone, what the healthiest choices are, despite good evidence that people, given the correct information, will make a healthier choice 92.
- Spending on takeaway food has increased by a third in the UK since 2009 and this is likely to be linked to the rise of food delivery apps and online tools which make ordering and paying for food easier for the consumer 93. Takeaway dishes are also more likely to be less healthy, with a recent study finding takeaway meals profiled were higher in energy, macronutrients, salt and bigger in portion size 94. Businesses should be responsible for calculating the calorie content of their food and drink, with the takeaway provider being responsible for displaying that information at point of choice.
- Without nutrition labelling, consumers are unable to find the healthier options and out of home companies can continue to sell food laden with salt, sugar and calories, unchecked. Action on Sugar’s latest survey found 42% of products surveyed were high in sugar, whilst 39% were high in salt. Only 70 out of 191 products provided full nutrition information in store (if asked) or online, with most not providing this information on menus 95.
- In 2018 Action on salt conducted a survey on Chinese takeaways and ready meals. 97% of Chinese takeaway meals were high in salt (containing 2g or more salt per serving) and 43% of Chinese ready meals were also high in salt (over 1.5g/100g or over 1.8g per portion). Despite Chinese takeaways containing more salt than ready meals, they are not required to provide the nutritional information that ready meals do, leaving customers in the dark on what they are consuming 96.
- Nutrition labelling needs to be in an easily understood format and government should invest in measures to improve consumer understanding of calories and food labelling alongside legislation. Low socio-economic groups may benefit from such policy because of their indirect effects, e.g. reformulation, and because choosing food of lower calorie density could become a normative behaviour in the population. In the UK, the average salt intake has successfully been reduced in people from all socio-economic backgrounds due to a government-led reformulation strategy 97, 98. The salt reduction strategy did not require any behaviour change in individuals of any population subgroup, thus potentially reducing health inequality.
- In addition, we would recommend that an independent evaluation should be commissioned by government to measure the effectiveness of all policies and to measure its effectiveness on food choice and reformulation. The policies should be monitored for any unintended outcomes positive and negative. This will ensure that if needed, the policy can be adjusted and refined to better improve public health.
1) FAO, IFAD, UNICEF, WFP and WHO. The State of Food Security and Nutrition in the World. 2018, p.138
2) Food Standards Agency. The Food & You Survey. 2017, pp.27–28
3) The Trussell Trust. Record 1.6m food bank parcels given to people in past year as the Trussell Trust calls for end to Universal Credit five week wait. 2019
4) End Hunger UK. Fix Universal Credit. 2018
5) The Global Burden of Disease Study. http://ihmeuw.org/4dks. 2017
6) The Food Foundation. Forced-fed. 2016.
7) Food Standards Agency and Public Health England. NDNS: results from years 7 and 8 (combined). 2018.
8) NHS Digital. National Child Measurement Programme 2016/17. 2017
9) NHS Digital. National Child Measurement Programme 2015/16). 2016
10) NHS. Obesity. 2019
11) Luppino FS et al. Overweight, obesity, and depression: a systematic review and meta-analysis of longitudinal studies. Archives of General Psychiatry 2010;67(3):220-9.
12) Gariepy G, Nitka D, Schmitz N. The association between obesity and anxiety disorders in the population: a systematic review and meta-analysis. International Journal of Obesity 2010;34:407-19
13) Diabetes UK. Us, diabetes and a lot of facts and stats. 2019
14) NHS. Type 2 diabetes. 2017
15) Public Health England. Oral health survey of 5 year old children 2017. 2018
16) Public Health England. Chapter 4: health of children in the early years. 2018
17) Ma. Y, He. F, and MacGregor, G. 2015. High Salt Intake. Independent Risk Factor for Obesity?
18) Grimes. C et al. 2016. 24-h urinary sodium excretion is associated with obesity in a cross-sectional sample of Australian schoolchildren.
19) He. F, Li. J and MacGregor. G. Effect of longer-term modest salt reduction on blood pressure. 2013
20) WHO. ‘Best Buys’ and other recommended interventions for the prevention and control of non-communicable diseases. 2017
21) Blood Pressure UK. High blood pressure: facts and figures.
22) D’Elia, F et al. 2012. Habitual salt intake and risk of gastric cancer: A meta-analysis of prospective studies. Clinical Nutrition, 31, 489-498
23) Takahashi, M. and Hasegawa, R., 1985. Enhancing effects of dietary salt on both initiation and promotion stages of rat gastric carcinogenesis. In Princess Takamatsu Symposia (Vol. 16, pp. 169-182)
24) Furihata, C., Ohta, H. and Katsuyama, T., 1996. Cause and effect between concentration-dependent tissue damage and temporary cell proliferation in rat stomach mucosa by NaCl, a stomach tumor promoter. Carcinogenesis, 17(3), pp.401-406
25) Charnley, G. and Tannenbaum, S.R., 1985. Flow cytometric analysis of the effect of sodium chloride on gastric cancer risk in the rat. Cancer research, 45(11 Part 2), pp.5608-5616
26) Tatematsu, M., Takahashi, M., Fukushima, S., Hananouchi, M. and Shirai, T., 1975. Effects in rats of sodium chloride on experimental gastric cancers induced by N-methyl-N¢-nitro-N-nitrosoguanidine or 4-nitroquinoline-1-oxide. Journal of the National Cancer Institute, 55(1), pp.101-106
27) Fox, J.G., Dangler, C.A., Taylor, N.S., King, A., Koh, T.J. and Wang, T.C., 1999. High-salt diet induces gastric epithelial hyperplasia and parietal cell loss, and enhances Helicobacter pylori colonization in C57BL/6 mice. Cancer research, 59(19), pp.4823-4828
28) Jones-Burton, C., Mishra, S.I., Fink, J.C., Brown, J., Gossa, W., Bakris, G.L. and Weir, M.R., 2006. An in-depth review of the evidence linking dietary salt intake and progression of chronic kidney disease. American journal of nephrology, 26(3), pp.268-275
29) Public Health England. Saturated fats and health: SACN report. 2019
30) HM Government. Childhood Obesity. A Plan for Action. 2016
31) HM Revenue & Customs. Check if your drink is liable for the Soft Drinks Industry Levy. 2018
32) HM Government. Childhood obesity: a plan for action. Chapter 2. 2018
33) Public Health England. Sugar reduction and wider reformulation programme: Report on progress towards the first 5% reduction and next steps. 2018
34) Public Health England. Salt targets 2017: Progress report. A report on the food industry’s progress towards meeting the 2017 salt targets. 2018
35) Laverty, A, et al. Quantifying the impact of the Public Health Responsibility Deal on salt intake, cardiovascular disease and gastric cancer burdens: interrupted time series and microsimulation study. 2019
36) Food Manufacture. Pressure mounts for mandatory fat, salt and sugar targets. 2016.
37) National Statistics. Health Survey for England 2017. 2018
38) Department for Environment Food & Rural Affairs. Food Statistics Pocketbook. 2015
39) The Food Foundation. The Broken Plate. 2019
40) Public Health England. Obesity and the environment. 2017
41) T Burgoine, N G Forouhi, S J Griffin, N J Wareham, P Monsivais. Does neighborhood fastfood outlet exposure amplify inequalities in diet and obesity? A cross-sectional study. The American Journal of Clinical Nutrition
42) Wills WJ, Kapetanaki A, Rennie K, et al. (2015). The influence of deprivation and food environment on food and drink purchased by secondary school pupils beyond the school gate. Research Project FS411002.
43) UK Health Forum and Health Equalities Group . Availability, placement, marketing & promotions of HFSS content foods in traditional non-food retail environments. 2018
44) Social Market Foundation. What are the barriers to eating healthily in the UK? 2018
45) Tesco. Mr Kipling Rockin Raspberry Slices 6 Pack. 2019
46) RSPH. Routing out childhood obesity. 2019
47) Evidence from Westminster Food & Nutrition Forum Presentation. Tackling childhood obesity in England – policy options, implementation practicalities, local approaches and the role of schools. 9th May 2019
48) Food For Life. Evaluation of the Food for Life programme. 2019
49) Brighton & Hove Food Partnership. The Brighton & Hove Food Partnership is all about food. 2019
50) Draper AK, et al. Front of pack nutrition labelling: are multiple formats a problem for consumers? 2011
51) MacGregor GA, He FJ, Pombo-Rodrigues S. Food and the responsibility deal: How the salt reduction strategy was derailed. BMJ. 2015;350
52) Public Health England. Archived. ‘Health inequalities’. 2016.
53) He FJ, Brinsden HC, MacGregor GA. Salt reduction in the United Kingdom: a successful experiment in public health. J Hum Hypertens 2014;28:345-52. doi: 10.1038/jhh.2013.105 [published Online First: 2013/11/01]
54) F Yau A, Adams J, Monsivais P. Time trends in adherence to UK dietary recommendations and associated sociodemographic inequalities, 1986-2012: a repeated cross-sectional analysis. European Journal of Clinical Nutrition. 2018 Nov 16:1.
55) Hastings G. et al, Review of research on the effects of food promotion to children, commissioned by the Food Standards Agency. 2003
56) Action on Salt. Children’s Packaging Survey. 2019
57) Hawkes C. Sales promotions and food consumption. Nutrition Reviews 2009. 67(6):333–342.
58) Sunstein C.R. (1996) Social Norms and Social Roles. Chicago Law & Economics Working Paper No.36: 903-968 (pdf).
59) Inews. Half of supermarket promotions are on unhealthy foods, Which? Survey reveals.2016
60) Food Active. Purchases of Price Promotions on Less Healthy Food and Drinks in the North West. 2019
61) Cancer Research UK. “Paying the price: New evidence on the link between price promotions, purchasing of less healthy food and drink, and overweight and obesity in Great Britain”. Timothy Coker, Harriet Rumgay, Emily Whiteside, Gillian Rosenberg, Jyotsna Vohra. 2019.
62) Wilson A, Buckley E, Buckley J and Bogomolva S. Nudging healthier food and beverage choices through salience and priming: Evidence from a systematic review. Food Quality and Preference 2016. 51:47–64.
63) Thornton L, Cameron A, McNaughton S et al. The availability of snack food displays that may trigger impulse purchases in Melbourne supermarkets. BMC Public Health 2012. 12:194.
64) British Dietetic Association and Children’s Food Campaign. BDA Calls for UK Government Action to Chuck Junk Food off the Checkout. 2013.
65) Martin L, Bauld L and Angus K. Rapid evidence review: The impact of promotions on high fat, sugar and salt (HFSS) food and drink on consumer purchasing and consumption behaviour and the effectiveness of retail environment interventions.
66) CEDAR. Removing sweets and crisps from supermarket checkouts linked to dramatic fall in unhealthy snack purchases. 2018
67) Public Health England. Sugar Reduction: The evidence for action. 2015
68) Boyland E, Nolan S, Kelly B (2016). Advertising as a cue to consume: a systematic review and meta-analysis of the effects of acute exposure to unhealthy food and nonalcoholic beverage advertising on intake in children and adults Am J Clin Nutr.
69) Hastings, G. (2006) The extent, nature and effects of food promotion to children: a review of the evidence. WHO 16. 11. McDermott L et al. (2006)
70) WHO. The extent, nature and effects of food promotion to children: a review of the evidence to December 2008. 2009
71) Cairns, G et al. Systematic reviews of the evidence on the nature, extent and effects of food marketing to children. A retrospective summary. 2013.
72) Obesity Health Alliance. A Watershed Moment. 2016.
73) Cancer Research UK analysis of Nielsen data for on linear television channels of ITV1, Channel 4, Channel 5 and Sky One in the month of May 2018.
74) BBC News. X Factor final boosts Domino’s pizza sales. 2018
75) Brown V, et al. The Potential Cost-Effectiveness and Equity Impacts of Restricting Television Advertising of Unhealthy Food and Beverages to Australian Children. Nutrients 2018, 10(5), 622;
76) Cancer Research UK. A Prime Time for Action. 2018
77) Food Active. Deliveroo dishes out junk food deals to the obese – Food Active response. 2019
78) Scheelbeek, P et al. Potential impact on prevalence of obesity in the UK of a 20% price increase in high sugar snacks: modelling study. BMJ 2019;366:l4786
79) LEY 26.905. Promoción de la reducción del consumo de sodio en la población, Buenos Aires. 2013
81) Allemandi et al. Monitoring Sodium Content in Processed Foods in Argentina 2017 – 2018: Compliance with National Legislation and Regional Targets. 2019
82) Peters, S et al. The sodium content of processed foods in South Africa during the introduction of mandatory sodium limits. 2017
83) Webster, J et al. Target salt 2025; A global overview of national programs to encourage the food industry to reduce salt in foods. 2014
84) Corvalan, C. et al. Structural responses to the obesity and non-communicable diseases epidemic: the Chilean law of food labelling and advertising. 2013
85) Correa, T et al. “Responses to the Chilean law of food labelling and advertising: exploring knowledge, perceptions and behaviours of mothers or young children”. 2019
86) Global Agricultural Information Network. Peru Publishes Warning Manual for Processed Product Food Labels. 2017
87) Restrepo BJ. Calorie Labeling in Chain Restaurants and Body Weight: Evidence from New York. Health Econ 2017;26(10):1191-209. doi: doi:10.1002/hec.3389
88) Bollinger, Bryan & Leslie, Phillip & Sorensen, Alan. (2010). Calorie Posting in Chain Restaurants. National Bureau of Economic Research, Inc, NBER Working Papers. 3. 10.1257/pol.3.1.91
89) FDA. Menu Labeling Requirements. 2019
90) Taillie, L. et al. Do high vs. low purchasers respond differently to a nonessential energy-dense food tax? Two-year evaluation of Mexico’s 8% nonessential food tax. 2017
91) Jaworowska A, et al. (2014) Nutritional composition of takeaway food in the UK, Nutrition & Food Science).
92) DELETE – SAME AS REFERENCE 50
93) IG. Just Eat and Deliveroo: what has the takeaway delivery market got on the menu? 2018
94) Jaworowska A, et al. (2014) Nutritional composition of takeaway food in the UK, Nutrition & Food Science
95) Action on Sugar. New product survey (the first of its kind) exposes the excessive amounts of hidden sugar and calories in waffles, pancakes, pretzels and crepes when eating out. 2019
96) Action on Salt. Salt Awareness Week 2018 survey. 2018
97) He FJ, Brinsden HC, MacGregor GA. Salt reduction in the United Kingdom: a successful experiment in public health. J Hum Hypertens 2014;28:345-52. doi: 10.1038/jhh.2013.105 [published Online First: 2013/11/01]
98) F Yau A, Adams J, Monsivais P. Time trends in adherence to UK dietary recommendations and associated sociodemographic inequalities, 1986-2012: a repeated cross-sectional analysis. European Journal of Clinical Nutrition. 2018 Nov 16:1
Zoe Davies, Consensus Action on Salt, Sugar and Health
12 September 2019