Options for action to support the reduction of
sugar intakes in the UK
A discussion paper produced by the UK Health Forum for Public Health England
Produced by the UK Health Forum for Public Health England
Authors:
Modi Mwatsama, Registered Nutritionist (Public Health) and Director, Global Health
Jane Landon, Policy Director and Deputy Chief Executive
Acknowledgements:
The authors wish to acknowledge the comments on earlier drafts of the paper made by Paul
Lincoln and the participants of the Public Health England and Department of Health stakeholder
meetings held on 3 and 5 June 2014. Preparation of this paper was funded by Public Health
England (PHE).
Published by the UK Health Forum
© UK Health Forum 2014
UK Health Forum
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Tel: +44 (0) 20 7832 6920
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2
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Introduction
Non-communicable diseases (NCDs) including coronary heart disease, stroke and cancers are the leading
killers in the UK and globally. The diet-related risk factors of increased blood pressure and high body mass
index are the second and third leading risk factors behind the disease burden in the UK after tobacco.1
Avoidable mortality rates from NCDs among adults in the UK have been found to be persistently and
significantly worse than comparable countries in the EU+15 and calls have been made for concerted
action to tackle them including through improved public health and prevention.1
In England 28% of five year old children and 31% of adults are affected by tooth decay, 2,3 and
consumption of sugary foods and drinks is the chief cause.4 Tooth decay is the major cause of pain and
suffering, and the main reason for administrating anaesthesia among young children.4 There is a strong
social gradient with higher rates among children and adults from socially deprived households.2, 3 The NHS
spends around £3.4 billion on dental treatment a year.5
In March 2014 the World Health Organization (WHO) published draft recommendations that intakes of
free sugars should contribute to no more than 10% of energy. Based on limited evidence, it further
proposed that a target intake of below 5% energy (or 6 teaspoons a day) would offer further health
benefits.6 The Committee on Medical Aspects of Food Policy (COMA) recommended in 1991 that not
more than 10% of the population’s average total energy intake should be consumed as non-milk extrinsic
sugar (NMES).7 The UK Scientific Advisory Committee on Nutrition (SACN) has reviewed the COMA
recommendations against current evidence and will publish draft guidance shortly.
Intakes of NMES in the UK population are summarised in Table 1 and exceed the maximum intake levels
recommended by COMA and proposed by WHO in all age groups. 8 Non-alcoholic beverages are the
largest contributors to sugar intakes in all groups under 65 years; within this category soft drinks form the
largest proportion of sugar intakes in all groups over 4 years old. Cereal and cereal products (especially
breakfast cereals, biscuits and buns, cakes, pastries and fruit pies), and sugars, preserves and
confectionery are also major contributors of sugars in all age groups.8 Consumption of NMES is
considerably and significantly higher among low income groups compared to the general population.9
About this discussion paper
This discussion paper was commissioned by Public Health England from the UK Health Forum. A draft
version was used to inform stakeholder meetings held in June 2014 with representatives from food
manufacturers, retailers, food service companies, public health organisations, charities and public interest
organisations, the research community and government. The paper mapped out some options for action
which could help to reduce intakes of free sugars in the UK. Participants were invited to consider the
possible actions specifically in relation to:




Their potential to reduce sugar intakes
The strength of the available evidence
Ease of implementation
Whether anything is missing?
3
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This rapid review included evidence from a variety of grey and published literature sources on
recommended and current actions to tackle obesity and excess sugar intakes. Among them were
documents from international organisations such as the WHO and OECD; business, trade and investment
sectors such as Credit Suisse and Bank of America Merrill Lynch; scientific and published articles; public
health and consumer organisations; and the mainstream media and trade press.10, 11,12,13 The review
looked at publicly available data but this did not include commercial data on sales or marketing activities
of the food companies (eg Nielsen or Kantar) due to cost considerations. The paper was updated to
incorporate further evidence and proposals from the stakeholder meetings in June.
The review identified broad agreement within the literature on the range of options presented. If
countries are to be successful at reducing sugar consumption, they will need to adopt a variety of actions
at the local and national levels, and be supported at the international level. High participation rates by
stakeholders and sustainability of interventions were identified as key to the success of all the options, 11
and government regulation and taxation were identified as measures that would be supportive.10-14,15 The
options have been organised into six potential themes for action (see Figure 1 below). For each theme,
some specific possible actions have been identified in Table 2. These include examples of implementation
where known, and brief observations about possible strengths, weaknesses and supporting evidence for
action (if any).
Theme 1: Produce Less
This theme explores options to reduce sugar consumption through reductions in agriculture production
and assessing the impact of other non-health policies on sugar consumption. Currently the equivalent of
13.3 million tons of white sugar is produced within the European Market, with over 90% used for human
consumption. The complex sugar market in Europe is governed by a combination of agriculture
production quotas (including subsidies), a minimum sugar beet price and trade mechanisms.16
Theme 2: Use less
This theme includes options to use less sugar through changes to food manufacturing. This theme focuses
on how food providers including manufacturers and the food service sector may reformulate their
products to contain less sugar or use non-calorific substitutes. Reformulation has led to an estimated 1530% reduction in added salt in the British diet through successful Government-led initiatives. 17
Theme 3: Sell less
This theme explores the potential options through which less sugar could be sold for human consumption.
Off-shelf displays are frequently used to increase sales. Confectionery and snacks, for example, have
become a mainstream feature of retail checkouts ranging from supermarkets, to news agents and petrol
stations. A recent study found end-of-aisle displays increased the sales volumes of carbonated drinks by
52%. 18 A variety of mechanisms to sell less sugar to the population are explored, ranging from taxes to
environmental changes in the community and within retail stores.
Theme 4: Market less
Food marketing is known to drive purchasing and consumption and this theme explores potential options
through which the marketing of sugary products to the population could be reduced. The commercial
sector is estimated to have spent £838 million promoting confectionery, snacks, fast food and sugary
4
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drinks in the UK in 2007.19 Options for action explored include marketing restrictions, removal of tax
incentives20 and regulating health claims.
Theme 5: Recommend less
Implemented as part of a package of wider measures, the provision of information, communications and
education all have important roles in supporting behaviour change through improved knowledge and
skills, and changing social norms.14 Options for action explored range from public awareness and social
marketing campaigns to professional and workforce education on sugar.
Theme 6: Eat less
Consumer research has identified the need for information which supports rapid judgements on the
nutritional content of individual products, as well as comparisons between products ‘at a glance’ while
shopping.21 This theme explores the provision of information on sugars to support consumers to eat less,
through mechanisms which range from labels on food packaging to menus and displays in the out of home
food service sector.
Figure 1: Six potential areas for action
Theme 1
Produce /
import less
Theme 2
Use less
Theme 3
Sell less
Theme 4
Market less
Theme 5
Recommend
less
Theme 6
Eat less
a. Review EU
and UK sugar
market
a.
Reformulation
a. Taxes &
duties
a. Marketing
codes
a. Food-based
dietary
guidelines
a. Front of
pack labelling
b.
Substitution
b. In-store
promotions
b. Marketing
taxdeductibility
b. Health
Impact
Assessment
in all policies
c. Portion sizes
d. Diversify
e. Public and
private sector
procurement
f. Planning
restraints
Page: 8
Pages: 9
Pages: 10-11
c. Nutrient
profiles &
claims
d. Guidelines
to rate
companies for
sponsorship
Pages: 12-13
5
b. Public
awareness
and social
marketing
campaigns
b. Reference
intakes for
sugars
c. Codex
standards
c. Professional
education
d. Health
warnings
d. Education in
schools
e. Menu labels
Pages: 14-15
Pages: 15-16
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How does this fit with the Public Health Responsibility Deal?
Many companies report actions to improve public health through the Government’s Responsibility Deal.
Four pledges are directly relevant to sugar intake reduction: there are currently 49 signatories to pledge
F1 (Out of Home Calorie Labelling), 37 signatories to pledge F4 (Calorie Reduction), and there are 24
organisations signed up to at least one of the Front of Pack Labelling pledges F7a & 7b.22 See examples in
Appendix 2.
Some of the areas for action (such as those relating to prices) that are identified in this paper fall outwith
the scope of the Responsibility Deal.
About the stakeholder engagement process
This paper was intended to initiate discussions at workshops co-hosted by Public Health England about
how to reduce sugar consumption in the UK. The discussions and this paper helped inform the PHE paper
Sugar Reduction: Responding to the Challenge published on the 26th June.
About the UK Health Forum
The UK Health Forum is a charity and an alliance of professional and public interest organisations working
to reduce the risk of avoidable non-communicable diseases through expert-based public health policy
development and advocacy.
Glossary and definitions
A glossary of terms and standard definitions for sugars is included in Appendix 1 on page 16.
6
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Table 1. Snapshot of current intakes of total NMES as a % of total energy intake by age in the UK, and contributions of major food categories to the NMES totals8
Population
group
#
1.5 to 3 years
Total
NMES
intakes
11.9%
4-10 years
14.7%
Non-alcoholic drinks, 30%
 Fruit juice, 13%
 Soft drinks, 17%
11-18 years
15.6%
Non-alcoholic drinks, 40%
 Fruit juice, 10%
 Soft drinks, 30%
19-64 years
12.1%
Non-alcoholic drinks, 25%
 Fruit juice, 8%
 Soft drinks, 16%
Over
65 years
11.5%
Non-alcoholic drinks+
Non-alcoholic drinks, 27%
 Fruit juice, 14%
 Soft drinks, 12%
++Alcoholic drinks, 10%
Non-alcoholic drinks, 16%
 Fruit juice, 8%
 Soft drinks, 8%
++Alcoholic drinks, 6%
Major contributors to total NMES intakes by food category and main sub-groups*
Cereal and cereal products**
Sugars, preserves, confectionery
Cereal and cereal products, 25%
 Breakfast cereals, 6%
 Biscuits, 8%
 Buns, cakes, pastries, fruit pies, 6%
 Puddings, 3%
Cereal and cereal products, 29%
 Breakfast cereals, 8%
 Biscuits, 8%
 Buns, cakes, pastries, fruit pies, 9%
 Puddings, 3%
Cereal and cereal products, 22%
 Breakfast cereals, 6%
 Biscuits, 7%
 Buns, cakes, pastries, fruit pies, 6%
 Puddings, 2%
Cereals and cereal products, 21%
 Breakfast cereals, 6%
 Biscuits, 6%
 Buns, cakes, pastries, fruit pies, 7%
 Puddings, 2%
Cereals and cereal products, 29%
 Breakfast cereals, 5%
 Biscuits, 7%
 Buns, cakes, pastries, fruit pies, 13%
 Puddings, 4%
Milk and milk products
Sugars, preserves, confectionery, 19%
 Table sugar, preserves, sweet spread, 7%
 Sugar confectionery, 5%
 Chocolate confectionery, 7%
Milk and milk products, 18%
 Other milk, cream, 1%
 Yogurt & dairy desserts, 13%
 Ice cream, 3%
Sugars, preserves, confectionery, 22%
 Table sugar, preserves, sweet spread, 7%
 Sugar confectionery, 7%
 Chocolate confectionery, 7%
Milk and milk products, 12%
 Other milk, cream, 2%
 Yogurt & dairy desserts, 6%
 Ice cream, 4%
Sugar, preserves, confectionery, 21%
 Table sugar, preserves, sweet spread, 8%
 Sugar confectionery, 5%
 Chocolate confectionery, 8%
Milk and milk products, 7%
 Other milk, cream, 2%
 Yogurt & dairy desserts, 3%
 Ice cream, 3%
Sugar, preserves, confectionery, 26%
 Table sugar, preserves, sweet spread,
17%
 Sugar confectionery, 2%
 Chocolate confectionery, 7%
Sugar, preserves, confectionery, 26%
 Table sugar, preserves, sweet spread,
21%
 Sugar confectionery, 1%
 Chocolate confectionery, 4%
Milk and milk products, 6%
 Other milk, cream, 1%
 Yogurt & dairy desserts, 3%
 Ice cream, 2%
Milk and milk products, 8%
 Other milk, cream, 1%
 Yogurt & dairy desserts, 5%
 Ice cream, 3%
#Mean intakes of non-milk extrinsic sugars as a % of food energy
*Major sub-groups within each category have been included for illustrative purposes and the sub-group percentages may not add up to the category totals. For a full breakdown of current NMES
intakes see NDNS Table 5.8 https://www.gov.uk/government/publications/national-diet-and-nutrition-survey-results-from-years-1-to-4-combined-of-the-rolling-programme-for-2008-and-2009-to2011-and-2012
+ soft drinks values include low calorie drinks values ranging from 1-2% in children’s groups.
++ alcoholic drinks intakes for adults included for comparison
** breakfast cereal values include high fibre cereals
7
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Table 2: Options for action on sugar reduction
Option for
action
Level
Population
groups that
may benefit
Strengths
Weaknesses
Supporting evidence
Examples of
implementation
(where they exist)
Potential
unintended
consequences
Who to action
CAP reforms in
2017 are
predicted to
lead to a rise in
high-fructose
corn syrup
production and
fall in sugar
24,17
price.
This
may influence
sugar intakes &
public health.
Potential for the
Transatlantic
Trade and
Investment
Partnership to
impact on sugar
–related policy
27
eg food labels.
Government,
academia,
NGOs, industry
1.Produce / import less
1a. Review EU
and UK sugar
market for
impact on
consumption
(including the
Common
Agriculture
Policy – CAP)
International
national
Whole
population.
May reduce
inequalities.
Could implement
alternatives to
sugar production
eg growing fruits
and vegetables.
Or non-food uses
for sugar beet eg
biofuels.
Challenging to get
public health
considerations
prioritised.
The EU sugar market
is regulated by
production quotas, a
minimum beet price &
trade mechanisms.
The UK is one of the
biggest producers of
sugar beet in
16
Europe.
US study linking corn
subsidies to excess
sugar intakes &
23
obesity.
1b. Undertake
Health impact
assessments
(HIA) in all
policies eg
trade,
investment.
International
national
Whole
population, or
could target
specific
groups. May
reduce
inequalities.
Identify and
quantify the
impacts of other
policies on sugar
and health and/or
health equity, and
possible actions
to mitigate them.
Build on existing
mechanisms eg
Regulatory Policy
Committee to
include health &
social impacts
within its
25
assessments.
Health and/or
health equity
considerations may
not be a priority in
other sectors. Nonhealth policies are
outside of the
direct control of
Public Health
England and the
Department of
Health.
Evidence of limited
use of HIAs in Europe,
despite their
relevance to NCD
26
prevention. See
option 4b for example
from the US of tax
deductibility of
marketing.
____
8
Government,
academia,
NGOs, industry
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Option for
action
Level
Population
groups that
may benefit
Strengths
Weaknesses
Supporting evidence
Examples of
implementation
(where they exist)
Potential
unintended
consequences
Who to action
2a.
Reformulation
to reduce free
sugar content
National or
company
level
Whole
population if
implemented
across the
board.
Otherwise
could risk
widening
inequalities.
A national model
would support
monitoring &
create a level
playing field.
Population level
benefits. May
reduce health
inequalities.
Technical
challenges for
some categories.
Lack of a level
playing field may
stall progress.
Voluntary
approach may
focus on niche, not
all products.
Responsibility deal:
voluntary Food
pledge F4 includes
calorie reduction.
Companies have
global reformulation
targets for sugar eg
Unilever, PepsiCo,
13
Kellogg’s.
Industry-led Project
Neptune
collaboration
reduced salt in soups
& sauces product
category by 2528
29%. Similar
model(s) could apply
18
to sugar.
Risk of replacing
sugars with fats
in some
categories and
thereby
increasing the
calorie content.
Replacement of
sugar (as a bulk
ingredient) may
increase the
concentration
of fat and/or
salt.
Government to
set national
binding
standards, OR
food industry to
adopt voluntary
standards
2b. Substitution
of sugar with
non-calorific
sweeteners
Company
level
Whole
population
Possible cost
savings to
producers where
sweeteners are a
cheaper
commodity than
sugar.
Sweeteners have
completed EFSA
safety
assessments for
human
consumption.
Maintains
preference for
sweet foods. Issues
with palatability
and acceptance?
Applicability to
established
positioning /
brands? Technical
challenges?
Perceived safety
29
concerns eg US.
National salt
reduction targets have
led to significant
reductions in salt
levels across a broad
range of food
18
categories.
Reported significant
rise in the use of
added sugars to
increase the
palatability of
processed foods - in
part attributed to the
relatively inexpensive
commodity price of
sugar and initial
health concerns
12
around dietary fats.
Assessment of the
feasibility of selling
artificially sweetened
soft drinks at lower
prices than sugary
30
drinks.
Newer products
such as Coca Cola
Zero and Pepsi Max.
Some examples of
shift from sugarsweetened to noncalorific sweetened
soft drinks eg Tesco
31
own brands.
Consumers
reject noncalorific
sweeteners and
revert to sugary
products.
Increased
acidity could
raise dental
caries risk.
Consumers get
accustomed to
sweet taste.
Food
manufacturers
2.Use less
9
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Option for
action
Level
Population
groups that
may benefit
Strengths
Weaknesses
Supporting evidence
Examples of
implementation
(where they exist)
Potential
unintended
consequences
Who to action
3a. Tax or duty
on sugar or
products high
in sugars
National
Whole
population.
Children &
young people.
See strengths
and
weaknesses
for potential
impact on
inequalities.
Could use existing
tax mechanisms.
Revenue raising.
Progressive
health gains. A
reinforcing signal.
May drive
reformulation or
incentivise
diversification.
Sugary drinks a
‘low hanging
13
fruit.’
Risk of regressive
impact on income.
Could be reduced
by subsidies on
healthier options.
Risk to
competitiveness of
companies. Tax
costs may be
absorbed by
32
industry and not
influence
purchasing.
Evidence from
modelling studies that
a 20% tax on sugar
sweetened drinks in
the UK could reduce
33
consumption and
prevalence of obesity
34
in adults by 1.3%.
Public support,
especially when
health benefits are
35
emphasised &
children benefit most.
A tax on sugar
could lead to an
increase in the
use of
alternative
ingredients such
as fats in some
products.
Removal of
sugar may
increase the
concentration
of fat/salt.
Treasury
3b. Switch instore retail
promotions
away from high
sugar foods
Company
level
Whole
population.
May reduce
inequalities
due to current
distributions
of intakes.
Supported by
customers. May
encourage
promotion of
healthier
products.
May be challenging
on a voluntary
39,40
basis,
needs a
level playing field.
Confectionery
promotions are
attractive to
retailers.
____
Government,
retailers, out of
home food
service
providers
3c. Reduce
portion sizes of
high sugar
foods
Company
level
Whole
population
Could target food
categories which
are major
contributors to
sugar intakes.
Uptake in the
responsibility deal
is on a voluntary
basis, and coverage
could be improved.
Risks consumer
backlash as it
reduces value for
money (if the price
is not reduced).
Systematic review of
evidence for altering
choice architecture in
41
micro-environments.
End-of-aisle displays
increased the sales
volumes of fizzy drinks
by 52% in a recent
19
study.
Some concerns that
the trend towards
larger portion sizes of
45
sugary products has
led to ‘portion
distortion’ &
46
overconsumption.
Studies have reported
effect of portion size
46,47
on consumption.
France: €0.72/L tax
on sugar &
sweetened drinks
introduced in 2012.
2012 soft drink sales
volumes declined by
0.03%, reversing
36
previous growth.
Other countries:
taxes on sugary
products in Mexico,
Finland, Hungary,
US, Nauru, Romania,
13,37,38
Samoa.
Lidl and Tesco sweet
42,43
free checkouts
Sainsbury’s & Co-op
have set targets for
44
healthier offers.
Tesco profiles
products to shape its
reformulation &
32
promotion policies.
Responsibility Deal:
pledge F4 commits
to reviewing
portions sizes.
Pledge H4 commits
to provision of
‘responsibly sized
23
portions of food’.
US: Coca-Cola cans
47
portion controlled.
Consumers may
compensate by
eating more
portions or
more
frequently.
Food
manufacturers
and out of
home food
service
providers
3.Sell less
10
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Option for
action
Level
Population
groups that
may benefit
Whole
population
Strengths
Weaknesses
Supporting evidence
3d.
Diversification
into other
products
Company
level
3e. Public and
private sector
procurement
standards and
guidelines to
restrict sugar
and promote
alternatives
3f. Planning
restraints on
outlets selling
food high in
sugar
Risk reduction for
businesses and
investors in light
of increasing
health footprint
12,13
scrutiny.
Food business
diversification from
sugary products to
healthier alternatives
identified as a
strategy by business
12
analysts.
National,
local,
company
level
Particularly
vulnerable
groups eg
children,
health service
users,
prisoners.
May reduce
inequalities.
National,
local
Whole
population,
children
Good potential
reach. Reinforce
norms for sugar
intake reduction.
Could be
supported by tap
water provision in
schools & public
places and
inclusion within
trading standards
food safety
inspections.
Potential for
targeting to
specific zones
such as around
schools.
Market gap
replaced by
competitors.
Impact on sugar
producers. May
affect companies
growth rate or
share of market in
short term.
Sole focus on sugar
could lead to
distortion in other
nutrients. Some
schools have been
exempt, although
48
this is changing.
Implementation is
not included in
Ofsted inspections.
Not applicable
retrospectively.
Definitional issues
for outlets other
than hot food
takeaways. Not
tested on high
sugar products.
11
Examples of
implementation
(where they exist)
Evidence that some
companies have
diversified their
12,13
portfolios.
Potential
unintended
consequences
Gap in market is
replaced by
other
manufacturers.
Who to action
Strong parental
support for schools to
adhere to national
school meal
standards, which
prohibit sugary drinks
and snacks in
49,50
schools.
UK: School meal
standards set limits
for NMES & prohibit
snacks & drinks with
51
NMES in schools
UK: Government
Buying Standards set
limit for added
sugars in breakfast
cereals & advise best
practice on sugary
52
drink servings.
____
Government,
out of home
food service
providers and
companies
Review of regulatory
options to promote
53
healthy eating.
Some studies linking
access to fast food
restaurants with
54,55
obesity.
UK: Exclusion policy
in Barking &
Dagenham to reduce
the ‘snacking habits’
56
of children.
Economic
impacts on
small
businesses
National and
local
government
Food
manufacturers
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Option for
action
Level
Population
groups that
may benefit
Strengths
Weaknesses
Supporting evidence
Examples of
implementation
(where they exist)
Potential
unintended
consequences
Who to action
National
Whole
population or
target
vulnerable
groups like
children. May
reduce
inequalities.
Help change
social norms on
consumption of
sugary foods.
Could stimulate
reformulation or
diversification.
Could use existing
Ofcom/BCAP
nutrient profiling
57
system to
extend scope of
UK regulations to
other areas eg.
packaging and
sponsorship.
Reliant on effective
co- and selfregulation. Likely to
impact on some
sectors of food
industry severely,
eg. confectionery.
Advertising and
marketing campaigns
are supported by large
body of commercial
research but this is
not publicly available.
Restricting
single nutrient
could lead to
possible
movement of
advertising
effort into high
fat or high salt
products if
these other
nutrients are
not included
within the
restrictions at
the same time.
Ofcom,
Committee of
Advertising
Practice and
Advertising
Standards
Authority
Whole
population.
May reduce
inequalities.
Less incentive to
market sugary
foods. Could use
existing tax
instruments.
Potential to raise
tax revenues.
Public opposition
unlikely.
Likely definitional
issues
UK: BCAP TV food ad
regulations for HFSS
foods to children.
CAP regulations on
food ads to
58
children.
France: TV & radio
ads for sugary or
sweetened products
must carry approved
25
health messages.
Chile: ban on sales
promotions
attractive to kids.
South Korea: ban on
free toys with fast
59
food.
US: Proposal for a
federal Stop
Subsidizing
Childhood Obesity
61,62
Act.
Marketing
activities might
be
commissioned
from companies
based in other
tax jurisdictions.
Treasury
4. Market less
4a. Controls on
marketing of
foods high in
sugar,
saturated fat
and salt (HFSS)
4b. Disallow
marketing of
sugary food as
a taxdeductible
expense for
21
companies
National
There is some
evidence of
reformulation by
companies in
response to UK TV ad
rules.
12
Advertising and
marketing costs are a
tax deductible
expense in the UK
(with some
21
exceptions). US
study estimated that
eliminating the tax
deductibility of
marketing fast foods
would reduce
overweight in children
aged 8-11 by 5% and
those aged 12-18
60
by 7%.
Produced by the UK Health Forum for Public Health England
Option for
action
Level
4c. To agree a
nutrient profile
model eg for
use in the EU
health claims
63,64
regulation
WHO,
Europe,
national
4d. Develop
guidelines to
rate food and
beverage
companies
suitability for
sponsorship (eg
of local
authority
activities)
International
national,
local
Population
groups that
may benefit
Whole
population.
May reduce
inequalities.
Whole
population.
May reduce
inequalities.
Strengths
Weaknesses
Supporting evidence
Scientifically
standardise
definitions of
healthy and
unhealthy foods.
Help to consider
overall health
impact of
multiple nutrients
simultaneously.
Prevents health
or nutrition
claims on sugary
64,65
products.
Guidelines may
help minimize
exposure to
marketing of
foods high in
sugars (saturated
fat and salt),
leading to
reduced
consumption.
Challenge in
achieving
consensus among
stakeholders on a
nutrient profile
system.
Use of nutrient
profiling promoted by
WHO for variety of
uses including
marketing, health and
nutrition claims,
product labelling &
economic tools to
orient food
64,65
consumption.
May be difficult to
keep track of as
companies
regularly refresh,
reformulate and/or
diversify products
and portfolios.
WHO global
marketing guidelines
to children
recommend avoiding
sponsorship
from commercial
entities associated
with foods high
in sugars, saturated
66
fats, or salt.
Industry sponsored
activities can increase
brand loyalty &
consumption of
products high in sugar
(saturated fat and
11
salt).
13
Examples of
implementation
(where they exist)
Australia & New
Zealand: FSANZ
nutrient profiling
scoring criterion for
health claims and
certain nutrition
65
claims.
UK: Ofcom nutrient
profile system used
in TV advertising
regulation.
Potential
unintended
consequences
Poor quality
model could
undermine
rather than
support sugar
reduction.
Who to action
Australia: Western
Australia Healthway
(health promotion
foundation)
Sponsorship Risk
Matrix. Assesses the
overall risk of a
particular brand
and/or sponsorship
linked with
Healthway cosponsored
67
activities.
Could reduce
support for and
therefore access
to health
promoting
activities, such
as physical
activity
opportunities.
WHO?
Department of
Health or Public
Health England?
Local
Government
Association?
WHO, European
Commission,
National
government
(DH or PHE)?
Produced by the UK Health Forum for Public Health England
Option for
action
Level
Population
groups that
may benefit
Strengths
Weaknesses
Supporting evidence
Examples of
implementation
(where they exist)
Potential
unintended
consequences
Who to action
Provide practical
guidelines for
policy makers and
consumers.
Support
awareness raising
& policy action eg
to assess food
supply and
marketing.
Increase
awareness of
health harms and
sources of sugars.
Tackle myths &
misinformation.
Raise knowledge
of how to reduce
sugar
consumption and
use FOP labels.
Needs supportive
environments to be
effective at
individual level.
May be hampered
by competing
messages from
other sources.
Must be up-to-date
to be effective.
Needs supportive
environments to be
effective. May be
hampered by
mixed messages
from other sources.
Hard to evaluate.
Not cost-effective
71
on their own.
May be less
effective if not
focused on sugar.
Competition with
other priorities.
Effectiveness may
be hampered by
competing
messages from
other sources. May
need to be
mandatory to be
effective cf. food
safety.
FBDG are information
or communication
tools which translate
scientific nutrient
recommendations
into qualitative or
quantitative food
68
based guidelines.
UK: Eatwell plate
recommends: cut
down on sugar by
eating fewer sweets,
cakes and biscuits,
and drinking fewer
69
sugary soft drinks.
US: guidelines are
updated every 5
70
years.
UK: Change 4 Life
and Start 4 Life
encourage reduction
of food and drinks
73
high in sugar.
Other countries:
Sugar-sweetened
drink campaigns in
Hungary, US, Tonga,
74
Thailand.
____
Government
Risk of widening
inequalities if
not targeted.
National and
local
government
Responsibility Deal:
pledge H4 – work
with caterers to
reformulate recipes
____
Professional
bodies, NHS,
government,
caterers, food
service
companies
5. Recommend less
5a. Review
food based
dietary
guidelines
(FBDGs) in light
of new SACN
sugar
guidelines
National
Whole
population.
Impact on
inequalities
will depend on
usage.
5b. Public
awareness &
social
marketing
campaigns
National,
local
Whole
population.
Target groups
if segmented.
5c. Professional
education of
health, social
care and
catering
workforce
National,
local
Patients,
clients of
services,
school pupils,
and the wider
workforce
Raise awareness
of health harms &
sources of sugar.
Tackle myths &
misinformation.
Support sugar
reduction.
14
Promoted by WHO &
others as part of
comprehensive
policies to improve
diets, including
reducing sugar
10,14
intakes.
UK survey found
consumers
underestimate the
sugar content of fruit
72
juice by 48%.
Promoted by WHO &
others as part of
comprehensive
policies to improve
diets, including
reducing sugar
10,14
intakes.
Produced by the UK Health Forum for Public Health England
Option for
action
Level
5d. Nutrition
education in
schools
including
practical
cooking skills
National (via
curriculum)
and local
Population
groups that
may benefit
School age
children and
their families.
May reduce
inequalities if
mandatory.
Strengths
Weaknesses
Supporting evidence
Provides practical
cooking & sugar
reduction skills.
Raise awareness
of sources &
harms of sugar.
Tackle myths &
misinformation.
Competition for
curriculum priority.
Hard to evaluate.
Industry sponsored
activities may be
counter-productive
(due to increased
brand loyalty &
11
consumption).
Promoted by WHO &
others as part of
comprehensive
policies to improve
diets, including
reducing sugar
10,14
intakes.
FSA research showed
consumers, including
those on low incomes,
performed best with
FOP hybrid food
76
labels. Similar EUwide consumer
preference for hybrid
labels & better
performance with
directive labels eg
77
colour-codes.
Evidence that a single
FOP label scheme is
78
best for consumers.
FSA set up an expert
group to recommend
suitable criteria for
total sugars for
purposes of the UK’s
food labelling scheme.
A 65g level was
83
established in 2007.
Examples of
implementation
(where they exist)
UK: The School Food
75
Plan
Potential
unintended
consequences
____
Who to action
Responsibility Deal
pledges F7 on the
FOP hybrid scheme.
Other countries with
colour coded FOP
labelling schemes
include South
79
75
Korea & Ecuador.
If portion sizes
used for
labelling are
unrealistic it
may confuse
consumers
about their
nutrient
80
consumption.
Government,
food
manufacturers,
retailers
UK: hybrid FOP label
scheme’s sugar
thresholds were
revised upwards
from 65g to 90g
following adoption
of the European FIR
84
in 2011.
The higher
sugar threshold
means fewer
labels coded red
in the UK, and
potentially less
avoidance of
sugary foods.
European
Commission,
Government
Department for
Education,
schools
6. Eat less
6a. Implement
UK FOP hybrid
nutrition labels
universally on
all food
products
National,
Europe
Whole
population.
May reduce
inequalities,
especially if it
drives
reformulation.
Otherwise
could widen
inequalities.
Comprehensive
UK FOP hybrid
scheme has been
developed
combining colourcodes & Guideline
Daily Amounts.
Drives
reformulation.
Interpretive &
supports
consumer choice.
Scheme is not
mandatory due to
EU regulation. Few
soft drinks and
cereal products
(high in free
sugars) feature FOP
hybrid scheme.
6b. EFSA to
review food
labelling
Reference
Intake levels for
total sugars
Europe
Whole
population.
May reduce
inequalities if
it leads to a
reduction in
sugar content.
EFSA set a
Reference Intake
level for total
sugars to support
standardised
labels in the EU
Food Information
Regulation (FIR).
EFSA’s 90g level for
81,82
total sugars
is
much higher than
the 65g level
previously adopted
by the FSA for the
UK FOP labelling
83
scheme.
15
Produced by the UK Health Forum for Public Health England
Option for
action
Level
6c. Codex
Alimentarius
Commission
(Codex) to set
standards for
front of pack
labels
International
6d. Consider
health
warnings on
products high
in sugar
Europe,
national
6e. Consider
menu and
display labels in
out of home
food service
outlets
National,
local
Population
groups that
may benefit
Whole
population
Whole
population.
May widen
inequalities if
price is a
bigger priority
for some
consumers.
Whole
population.
May widen
inequalities if
price is a
bigger
priority.
Strengths
Weaknesses
Supporting evidence
Codex standards
provide public
health criteria
admissible in the
World Trade
85
Organization.
Setting global
standards for FOP
labels would
support the UK
scheme or EU
initiatives.
Could help
consumers
identify foods
high in sugars and
reduce
consumption.
May drive sugar
reformulation.
Could help
consumers
identify foods
high in sugars and
reduce
consumption.
May drive
reformulation.
Codex procedures
are lengthy and
cumbersome. It has
only just started to
look at FOP
86
labels.
Codex standards are
the global reference
point for consumers,
food producers &
processors and
governments. At
present there is no
requirement for front
of pack labels or
labelling of added
sugars.
Not all consumers
read the labels.
Dependent on
positive behaviour
change. Possible
legal pitfalls.
Not all consumers
read the labels.
Dependent on
positive behaviour
change. Dependent
on adoption across
all outlets to be
effective.
16
Examples of
implementation
(where they exist)
Codex guidelines on
nutrition labels are
implemented in
87
many countries.
Potential
unintended
consequences
The
development of
guidelines at
the global level
could delay or
stall progress at
the EU or
national level.
Who to action
Supported by the
88
public in polls.
Worked for other
harmful products eg
tobacco.
Chile: law to develop
warning labels on
75
sugary foods, 2012.
US, California: Bill
proposing warnings
89
on sugary drinks.
____
European
Commission,
Government,
Food companies
One in six meals is in
the UK is now eaten
outside of the home.
These are estimated
to contribute 20% of
energy intake for
adult women and 25%
90
for men.
Responsibility Deal:
Pledge F1, out of
home calorie
labelling. Other
countries: calorie
label / display
legislation in South
Korea, Australia,
75
US.
____
National and
local
government
Codex (WHO
and FAO)
Produced by the UK Health Forum for Public Health England
Appendix 1
Glossary of terms
BCAP
The UK Code of Broadcast Advertising
COMA
Committee on Medical Aspects of Food and Nutrition Policy (predecessor to SACN)
CAP
Common Agriculture Policy
CAP
Committee of Advertising Practice
DfE
Department for Education
DH
Department of Health
FOP
Front of pack nutrition label
FSA
Food Standards Agency
EFSA
European Food Safety Authority
EU
European Union
FBDG
Food based dietary guideline
FIR
Food Information Regulation (European Union)
HIA
Health Impact Assessment
HFSS
High fat, sugar and salt
NCDs
Non-communicable diseases
NGO
Non-governmental organisation
NMES
Non-milk extrinsic sugars
NDNS
National Diet and Nutrition Survey
Ofcom
Office of Communications
RI
Reference Intake
SACN
Scientific Advisory Committee on Nutrition (successor to COMA)
WHO
World Health Organization
Definitions of sugars
Sugar description
Definition
Added sugars
Added sugars refers to sucrose, fructose, glucose, starch hydrolysates (glucose
syrup, high-fructose syrup) and other isolated sugar preparations used as such
or added during food preparation and manufacturing.91
Free sugars include monosaccharides and disaccharides added to foods by the
manufacturer, cook or consumer, and sugars naturally present in honey, syrups,
fruit juices and fruit concentrates.6
NMES are defined as all sugars except milk sugars and sugars contained in the
cell structure of a food, including sugars in fruit juices, table sugar, honey,
sugars added to food.92
Total sugars include both indigenous (sugars naturally present in foods such as
fruit, vegetables, cereals and lactose in milk products) and added sugars.91
Free sugars
Non-milk extrinsic sugars
or NMES
Total Sugars
17
Produced by the UK Health Forum for Public Health England
Appendix 2
The Government’s Public Health Responsibility Deal calorie reduction pledge
The Public Health Responsibility Deal has a pledge which asks companies to support and enable their
customers to eat and drink fewer calories through actions such as product/ menu reformulation, including
sugar, reviewing portion sizes, education and information, and actions to shift the marketing mix towards
lower calorie options. There is no specific pledge asking companies to reduce the sugar in the products
they produce and retail.
Currently, 37 companies are signed up to the calorie reduction pledge. These include eight major retailers,
fast food outlets and pubs (eg Subway and Weatherspoon’s); caterers (eg Compass and CH & Co); as well
as the makers of household-name brands (eg Mars, Coca-Cola, United Biscuits and PepsiCo). These
companies will be taking a range of actions to help people consume fewer calories. The Department of
Health is seeking further sign ups to the calorie reduction pledge and is looking for effective input from all
parts of the food industry, including the fast food industry.
Some examples, from 2013 and 2014 Annual Returns, of companies taking sugar out of the diet through
the Responsibility Deal:







Tesco: Reduced the number of calories sold in their own brand soft drinks by over 3 billion in 2012
and 2013.
Sainsbury’s: Reduced the sugar content of their own brand high juice squashes by between 4 and
10%, removing over 600 million calories from their customers’ baskets per year; as well as removing
23 tonnes of saturated fat from the pastry in their biggest selling mince pies.
Coca-Cola: Sprite now contains 30% fewer calories and they have introduced a new smaller slimline
250ml can of coca cola containing 105 kcal.
Britvic: now produce only their no added sugar Fruit Shoot in Great Britain. It is estimated this will
remove 2.2 billion calories from the children’s’ drinks market.
Mars: all single serve chocolate bars in the current portfolio are no more than 250kcal per portion.
Nestlé: 100% of confectionery products will contain 250 calories or less per serving by end 2014.
Mondelez: have committed to no longer make or sell single serve confectionery over 250 kcals in the
UK from the end of 2015.
More examples can be found at:
https://responsibilitydeal.dh.gov.uk/responsibility-deal-annual-updates-201314-published-today/
18
Produced by the UK Health Forum for Public Health England
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