Improving diets and changing the food supply

Table of contents

3 - Obesity prevention

4 - Potential initiatives

There are numerous potential dietary health benefits in reducing salt, saturated fat and sugar consumption, including a reduction in mortality and morbidity linked to high consumption of these nutrients. Analyses conducted in the United Kingdom by the Food Standards Agency (FSA) and the Department of Health have estimated cancer risk reductions through increased fruit consumption in childhood, as well as the number of deaths that could be prevented annually by a unit reduction in salt, saturated fat and sugar. A change in children’s diets extrapolated into adulthood could prevent over 50,000 deaths annually in the United Kingdom (or around 5000 deaths annually if the policy were 10% successful).[36]

An increase of 100g in the childhood daily intake of fruit equates to an annual prevention of 31,050 adult deaths due to cancer.
An approximate 6.25% reduction in food energy intake for non-milk extrinsic sugars (NMES) would save 12,500 lives.
An average daily reduction of 0.9g in a child’s salt intake extrapolated to the adult population would equate to an annual prevention of 6050 deaths.
1550 lives would be saved from a 1% reduction in saturated fat.

Table 1
Illustration of the numbers of deaths which could be prevented by a reduction in salt, saturated fat and sugar and through increased fruit intake[36]

	Deaths prevented for 100% policy success	Deaths prevented for 10% policy success
Reduction of 0.9g of salt	6,050	605
Reduction of 1% in saturated fat	1,550	155
Reduction of 1% for NMES	12,500	1,250
Increase of 100g of fruit	31, 050	3,105
Total deaths prevented	51,150	5,115

The benefits to the public health of the United Kingdom of achieving recommended levels of consumption of fruit and vegetables, saturated fat, salt and added sugar are potentially as great as £20 billion a year in terms of quality-adjusted life-years.[37] Almost 70,000 premature deaths could potentially be prevented each year if UK diets matched nutritional guidelines, more than 10% of current annual mortality. For example, reaching the target for everyone to consume five portions of fruit and vegetables per day could see 42,000 premature deaths a year avoided (compared to 20,200 for salt and 3500 for saturated fat targets).[37]
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Update on the UK Food Standards Agency initiative to reduce population salt intake

As described in the Technical Report, the UK FSA set voluntary targets for the level of salt in 85 categories of food in March 2006, involving around 70 firms and trade associations, and a broad range of products. The Agency made a commitment to review the targets in 2008 to formally assess progress and to establish what further reductions were necessary to maintain progress towards the 6g daily intake target.

In May 2009 the UK FSA published revised salt reduction targets for 2012, for 80 categories of foods. These are more challenging than the previous targets for 2010.[38]

Outcomes of meetings held in early 2008 (at which industry was asked to report on progress towards achieving the targets, any significant challenges experienced and what further levels of salt reduction might be achieved) were used to help the FSA develop proposals for revised targets, together with data on the levels of salt in food on the market in 2007 and current intakes, expert advice on technical and safety issues, and ongoing research.[38]

The revised targets have been set at challenging levels that will have a real impact on consumers’ intakes, while taking into account the reductions that have already been achieved by the industry and technical and safety issues. Targets were set considering and reflecting reductions that had already been achieved by industry. These include:[38]

The average amount of salt found in branded pre-packed, sliced bread has been reduced by around one-third.
Reductions in salt of about 44% have been achieved in branded breakfast cereals.
Reductions of between 16% and 50% have been achieved in some top-selling cakes and biscuits between 2006 and 2007.
Reductions in the snack sector; for example, 13% reduction of salt in standard crisps in 2007.
Reductions in processed cheese products of 21–50%.
Reductions among a wide range of own-brand products for the United Kingdom’s major retailers: some have met the 2010 targets ahead of time in most or all of their products, and one retailer is using the original 2010 targets as maximum salt levels for all relevant products.

The FSA has stated that developments in food technology – including alternatives to salt and other sodium-based ingredients, manufacturing and distribution chain processes, and acceptable food safety testing – will all be necessary to ensure further progress, as will rebalancing product flavours to maintain consumer acceptability. The FSA has acknowledged that the current economic climate may make it more difficult for companies to fund this kind of work. It has reiterated its commitment to working in partnership with stakeholders to review barriers and solutions to achieving the targets and the timescales proposed, including providing ongoing support through research and dissemination of the results of research.[38]
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The Agency plans to next review progress towards the end of 2010, and then every two years. Monitoring of salt intakes in the United Kingdom will continue and will be carried out through urinary sodium surveys undertaken as part of the new rolling program of the National Diet and Nutrition Survey, which began fieldwork in April 2008. The method used for collecting and analysing the samples will be comparable with previous surveys. The first set of results will be available at the same time as the results of the next review of industry progress.[38]

Soft drinks and obesity

At the same time as obesity rates have increased, a steep increase in consumption of soft drinks has been seen. In the United States, soft drink consumption has tripled in recent decades, paralleling the dramatic increases in obesity prevalence.

Several countries have targeted taxation policies on widely available popular foods and beverages such as soft drinks, which are inherently high in energy and empty of any important nutrients. Results of a meta-analysis found that the intake of sugared beverages displaces the consumption of healthier beverages, and is associated with higher body weight and poor nutrition.[39] In addition, the risk of obesity and diabetes increases with rising intake. Drinks such as soft drinks that are rich in sugars (both added and natural) have also been shown to reduce appetite control, leading to increases in weight gain and increased risk of obesity.[40] Increased liquid carbohydrate consumption is not accompanied by a reduction in solid food consumption;[40] in fact, soft drink intake has been identified in a range of research as a key contributor to increasing levels of overweight and obesity,[39] as well as increased rates of dental decay.[41]

A clinical review by Wolff and Dansinger published in 2008 evaluated the extent to which current scientific evidence supports a causal link between sugar-sweetened soft drink (SSD) consumption and weight gain.[42] Six of 15 cross-sectional and six of 10 prospective cohort studies identified statistically significant associations between soft drink consumption and increased body weight. There were five clinical trials; the two that involved adolescents indicated that efforts to reduce SSD consumption slowed weight gain. In adults, three small experimental studies suggested that consumption of SSD caused weight gain; however, no trial in adults was longer than 10 weeks or included more than 41 participants. The authors concluded that observational studies support the hypothesis that SSD consumption causes weight gain; they also called for more clinical trials to clarify the specific effects of SSD on body weight and other cardiovascular risk factors.[42]

Gibson completed a systematic review re-examining the evidence on SSD and obesity from epidemiological studies and interventions up to July 2008.[43] Forty-four original studies (23 cross-sectional, 17 prospective and four interventions) in adults and children, as well as six reviews, were identified. These were critically examined for methodology, results and interpretation. Approximately half the cross-sectional and prospective studies found a statistically significant association between SSD consumption and BMI, weight, adiposity or weight gain in at least one subgroup. The majority of evidence was dominated by American studies in which SSD consumption tends to be higher and formulations different. Most studies suggest that the effect of SSD is small except in susceptible individuals or at high levels of intake. Methodological weaknesses meant that many studies could not detect whether soft drinks or other aspects of diet and lifestyle have contributed to excess body weight.

The authors concluded that progress in reaching a definitive conclusion on the role of SSD in obesity is hampered by the paucity of good-quality interventions which reliably monitor diet and lifestyle and adequately report effect sizes. Of the three long-term (>6 months) interventions, one reported a decrease in obesity prevalence but no change in mean BMI, while two found a significant impact only among children already overweight at baseline. Of the six reviews, two concluded that the evidence was strong, one that an association was probable, while three described it as inconclusive, equivocal or near zero.[43]

A literature review on associations between intake of calorically sweetened beverages and obesity relative to adjustment for energy intake found that the majority of the prospective studies found positive associations between intake of calorically sweetened beverages and obesity. The authors concluded that a high intake of calorically sweetened beverages can be regarded as a determinant for obesity.[44]
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Removing soft drinks from schools

In 2006, former President Bill Clinton and the American Heart Association (through a partnership launched in 2005, the Alliance for a Healthier Generation) brokered a deal with the beverage industry in the United States, removing most soft drinks from almost every US primary and secondary school by the 2009–10 school year.⁵ Following the introduction of the agreement, the level of calories due to beverages delivered to schools in the 2007–08 school year decreased by 58%.[45] Under further agreements with the Alliance involving more than 30 companies and trade associations in the beverage, food and dairy industries, there has been a 41% decrease in calories shipped to school vending machines.⁶

Pricing and taxation policies

Pricing policies are a potential policy instrument to address the increasing prevalence of obesity. A recent comprehensive review of evidence on the effects of food prices on weight outcomes examined whether altering the cost of unhealthy, energy-dense foods compared with healthy, less-dense foods through the use of fiscal pricing (tax or subsidy) policy instruments would, in fact, change food consumption patterns and overall diet enough to significantly reduce individuals’ weight outcomes.[46]

The review examined empirical evidence regarding the food and restaurant price sensitivity of weight outcomes in peer-reviewed English-language articles published between 1990 and 2008. When statistically significant associations were found between food and restaurant prices (taxes) and weight outcomes, the effects were generally small in magnitude, although in some cases they were larger for low SES populations and for those at risk for overweight or obesity. The authors found the evidence supported a multi-pronged approach to changing prices – that is, taxing unhealthy foods and subsidising healthier products.

The review concluded that fiscal policies could be used to improve weight outcomes, noting that substantial price changes are required to ensure significant improvements. Small taxes on unhealthy foods or small subsidies applied to healthy food products were unlikely to be associated with substantial reductions in BMI or obesity rates. Importantly, these effects were particularly likely to be observed among populations of low SES, those most at risk for overweight, and children and adolescents. The authors also concluded that, while price interventions might only affect individual behaviour to a small degree, if applied broadly these policies had a potentially large population-level impact.[46]

In the United States, soft drink taxes have been introduced by individual states to reduce consumption, raise revenue and improve public health (as the taxes have been extremely low, impacts on health would not be expected to be large). During the 1990s, around half of all states taxed soft drinks and 20 states changed their soft drink tax rate. An evaluation of the impact of changes in state soft drink taxes on BMI indicated that soft drink taxes modestly reduced BMI. The impact varied across demographic groups. The results were extrapolated to conclude that if the soft drink tax was as high as cigarette tax, the proportion of obese adults would decrease by nearly 1 percentage point.[39] Using taxation revenue from a tax on sugared beverages to subsidise healthy foods has been described as the most ‘defensible’ approach, countering any regressive effect of the tax and demonstrating to consumers the association between tax and benefit.[47]

In Denmark, it has been estimated that the population’s diet would be consistent with national guidelines if tax exemptions for ‘healthy’ products such as fruit, vegetables, rice, pasta and fish products were combined with a 30% tax increase on ‘unhealthy’ products.[48] In February 2009, the Danish Government announced extensive restructuring of its income tax system. While the reform will result in a deficit in the short term in order to stimulate the economy, the government plans to generate additional revenues through increasing taxation on unhealthy lifestyles. Under the government’s proposals, pollution, cigarettes and unhealthy food (foods and drinks with a high sugar and fat content) will be subject to higher taxation. Ice cream, candy and chocolate will see a duty increase of 25%, while saturated fats in dairy products and oils will be levied at 20 kroner per kilo.⁷
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Forty states in the United States have small taxes on sugared beverages and snack foods.[47] Large taxes on sugared beverages have been proposed in Maine and New York (NY) State; in New York, for instance, an 18% tax on non-diet soft drinks has been proposed for implementation in June 2009. While the tax is part of the state’s strategy to tackle childhood obesity, it has also been cited as one component of a raft of measures to address the state’s projected budget shortfall of US$14 billion.[49] It has been estimated that a tax of a penny per ounce could reduce consumption by more than 10% and raise US$1.2 billion a year in New York State alone.[47] There is significant community support for the introduction of a tax (52%) among New Yorkers, rising to 72% if taxation revenue were to be used for obesity prevention.[47]

To counter the inequitable impact of taxes on unhealthy foods, it has been proposed that any such taxes be introduced in combination with subsidies or tax reductions for healthier options,[49] particularly if it was possible to target these to low-income households.[46] For example, Denmark is considering the exemption of healthier food products from a national value added tax of 25% on all foods.[49] The US Department of Agriculture Economic Research Service has estimated that providing a price discount on fruit and vegetables for low-income Americans would have a small but statistically significant positive effect on consumption. The study concluded that a 10% subsidy would increase low income earners’ fruit intake by 2.1–5.2% and vegetable intake by 2.1–4.9%. The study also concluded that these increases would not result in low income earners meeting recommended levels of consumption for fruit and vegetable, however.[50]

Food subsidies

International examples of food subsidy programs and equitable access to healthy foods

Local community-based initiatives can promote equitable access to healthy food. In Thailand, the major food and small goods market in the city of Sam Chuk was restored with the help of local intersectoral action including community architects, supporting local traders and tourism.[51] The London Development Agency plans to establish a sustainable food distribution hub to supply independent food retailers, restaurants and city-based institutions.[51]

US food subsidies for low income earners

Low-income individuals and families in the United States can access subsidised food through several programs, including the federal Food Stamp Program (Supplemental Nutrition Assistance Program or SNAP, run by the Department of Agriculture); the Women, Infants and Children (WIC) Supplemental Nutrition Program; the Child and Adult Care Food Program; and the National School Lunch and Breakfast Programs.[46]⁸

Funding of US$20 million has been provided through the 2008 Farm Bill for a project to examine point-of-purchase incentives for healthy foods through SNAP.⁹ In addition, under recently introduced legislation in California, a Healthy Purchase pilot program will target SNAP subsidies: for each dollar of food stamps spent on fresh produce, participants will be subsidised a portion of the cost.[46]
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The Farmers’ Market Nutrition Program (FMNP),¹⁰ associated with the WIC, was established by Congress in 1992 to provide fresh, unprepared, locally grown fruits and vegetables to WIC participants, and to expand the awareness, use of and sales at farmers’ markets. FMNP is administered through a federal/state partnership in which the Food and Nutrition Service (FNS) provides cash grants to state agencies including agriculture or health departments. WIC participants are issued FMNP coupons in addition to their regular WIC food instruments. These coupons can be used to buy fresh, unprepared fruits, vegetables and herbs from state agency-approved farmers, farmers’ markets or roadside stands, and farmers then submit coupons for reimbursement.¹¹

Nutrition education is provided through both the SNAP and WIC programs. There are some restrictions on the types of foods and products which may be purchased through the SNAP (for example, alcohol, tobacco and pet food are excluded). Federal regulations specify minimum nutritional requirements for WIC-eligible foods, which include juice, iron-fortified cereal, eggs, cheese, milk, peanut butter, dried beans or peas, iron-fortified infant formula, tuna and carrots. Foods in the program are high in one or more of the nutrients shown to be lacking in the diets of the population WIC serves.

UK food voucher system

The Healthy Start program in the United Kingdom¹² provides eligible low-income pregnant women and parents/carers of children under the age of four with vouchers to exchange for fresh fruit and other products.[52]

⁵See www.parentsjury.org.au/tpj_browse.asp?ContainerID=soft_drink_ban_in_us_schools.
⁶See www.clintonfoundation.org/what-we-do/alliance-for-a-healthier-generation/what-we-ve-accomplished.
⁷See www.cphpost.dk/culture/denmark-through-the-looking-glass/44873.html?task=view; www.forbes.com/feeds/reuters/2009/03/01/2009-03-01T182848Z_01_L1437267_RTRIDST_0_DENMARK-TAXES.html; www.lawandtax-news.com/asp/story.asp?storyname=35321.
⁸See www.fns.usda.gov/fsp/.
⁹See www.fns.usda.gov/fsp/rules/Legislation/about.htm
¹⁰See www.fns.usda.gov/wic/FMNP/FMNPfaqs.htm
¹¹See www.fns.usda.gov/wic/FMNP/FMNPfaqs.htm.
¹²See www.healthystart.nhs.uk/.

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