Development of a framework for action to advocate for a coherent prevention policy for tobacco, alcohol, and foods high in fats, salt, or sugar: a mixed-methods approach.

BACKGROUND: Tobacco, alcohol, and foods high in fats, salt, or sugar (HFSS) are health harming products. Limited progress in prevention is partly due to health-harming industry lobbying. Action on Smoking and Health (ASH), Alcohol Health Alliance, and Obesity Health Alliance collaborated with the aim of developing a framework for action to address the saturation of these products in our environment. METHODS: We used a mixed-methods approach. Focus groups with academic experts, local government, and national government, recruited through snowball sampling were held in Nov 3, 2022 (14 participants); April 25, 2023 (20 participants); and June 15, 2023 (20 participants). Iteratively, data analysis was presented, and key themes tested. Commissioned economic analysis of national survey datasets quantified consumer spend on tobacco, alcohol, and food products above government recommendations (all tobacco use, >14 units of alcohol, and national dietary guidelines) and industry percentage of revenues (net of tax). Public opinion data from the ASH YouGov Smokefree Survey 2022 on a nationally representative sample of 13 088 adults were descriptively analysed for specific policy options. FINDINGS: The framework for action to achieve a coherent prevention approach across products included three key enablers (secure funding for prevention, a comprehensive strategy, and protecting health policy from industry interference). Five key actions were: regulate advertising to limit harm, regulate product use and environments they can be used in, promote healthy messaging, raise the price of health-harming products, and fund treatment services. Economic analysis identified 100% of tobacco usage, 43·4% of alcohol purchased, and 28·8% of food purchased by households was above government recommendations. Post-tax industry revenue was £7·3 billion for tobacco, £11·2 billion for alcohol, and £34·2 billion for HFSS foods. Strong public support for levies (5%, n=8495) and protecting health policy from industry influence (69%, n=9006) was apparent. INTERPRETATION: A coherent approach to prevention across health-harming products is effective and has public support. Strengths include the iterative process to develop the framework for action among focus groups and use of nationally representative datasets. Limitations include the snowball sampling. The findings were built into a strategy intended to inform future collaborative work in the area. FUNDING: Cancer Research UK (grant PICADV-Feb22\100004).

The nutritional content of supermarket beverages: a cross-sectional analysis of New Zealand, Australia, Canada and the UK.

OBJECTIVE: To compare the nutritional content, serving size and taxation potential of supermarket beverages from four different Western countries. DESIGN: Cross-sectional analysis. Multivariate regression analysis and χ 2 comparisons were used to detect differences between countries. SETTING: Supermarkets in New Zealand (NZ), Australia, Canada and the UK. SUBJECTS: Supermarket beverages in the following categories: fruit juices, fruit-based drinks, carbonated soda, waters and sports/energy drinks. RESULTS: A total of 4157 products were analysed, including 749 from NZ, 1738 from Australia, 740 from Canada and 930 from the UK. NZ had the highest percentage of beverages with sugar added to them (52 %), while the UK had the lowest (39 %, P<0.001). CONCLUSIONS: There is substantial difference between countries in the mean energy, serving size and proportion of products eligible for fiscal sugar taxation. Current self-regulatory approaches used in these countries may not be effective to reduce the availability, marketing and consumption of sugar-sweetened beverages and subsequent intake of free sugars.

Differences in the sodium content of bread products in the USA and UK: implications for policy.

OBJECTIVE: Americans consume Na in excess of daily recommendations. Most dietary Na comes from packaged foods, and bread is a major contributor. In the UK, national Na reduction strategies contributed to lower Na levels in packaged foods and lower population Na intake. Similar initiatives are emerging in the USA and require surveillance to assess effectiveness. We aimed to examine Na levels in bread products in the USA and compare levels with similar UK products. DESIGN: Na data for bread products were obtained from the US Label Insight Open Data Initiative (n 4466) and the FoodSwitch UK database (n 1651). Mean, median and range of Na content, and proportion of products meeting Na targets established by the National Salt Reduction Initiative (NSRI) and the UK Department of Health (DH) were calculated overall, by bread type and by country. RESULTS: Mean (sd) Na content in bread was 455 (170) mg/100 g in the USA and 406 (179) mg/100 g in the UK. In both countries, savoury bread had the highest mean Na (USA=584 mg/100 g, UK=543 mg/100 g) and fruit bread the lowest mean Na (USA=345 mg/100 g, UK=277 mg/100 g). Na content of US bread products was 12 % higher than in the UK, with 21 % of US bread products and 31 % of UK bread products meeting the NSRI and DH targets, respectively. CONCLUSIONS: US bread products have, on average, 12 % more Na than similar products in the UK. Variation in Na content within product categories, and between countries, suggests the feasibility of manufacturing products with lower Na to lower dietary Na intake.

How much sugar is hidden in drinks marketed to children? A survey of fruit juices, juice drinks and smoothies.

OBJECTIVE: To investigate the amount of sugars in fruit juices, juice drinks and smoothies (FJJDS) marketed to children. DESIGN: We surveyed the sugars content (per 100 ml and standardised 200 ml portion) of all FJJDS sold by seven major UK supermarkets (supermarket own and branded products). Only products specifically marketed towards children were included. We excluded sports drinks, iced teas, sugar-sweetened carbonated drinks and cordials as being not specifically marketed towards children. RESULTS: We identified 203 fruit juices (n=21), juice drinks (n=158) and smoothies (n=24) marketed to children. Sugars content ranged from 0 to 16 g/100 ml. The mean sugars content was 7.0 g/100 ml, but among the 100% fruit juice category, it was 10.7 g/100 ml. Smoothies (13.0 g/100 ml) contained the highest amounts of sugars and juice drinks (5.6 g/100 ml) contained the lowest amount. 117 of the 203 FJJDS surveyed would receive a Food Standards Agency 'red' colour-coded label for sugars per standardised 200 ml serving. Only 63 FJJDS would receive a 'green' colour-coded label. 85 products contained at least 19 g of sugars-a child's entire maximum daily amount of sugars. 57 products contained sugar (sucrose), 65 contained non-caloric sweeteners and five contained both. Seven products contained glucose-fructose syrup. CONCLUSIONS: The sugars content in FJJDS marketed to children in the UK is unacceptably high. Manufacturers must stop adding unnecessary sugars and calories to their FJJDS.

Cross-sectional survey of the amount of free sugars and calories in carbonated sugar-sweetened beverages on sale in the UK.

OBJECTIVES: To investigate the free sugars and calorie content of carbonated sugar-sweetened beverages (CSSB) available in the main UK supermarkets. STUDY DESIGN: We carried out a cross-sectional survey in 2014 of 169 CSSB. METHODS: The free sugars (sugars g/100 mL) and calorie (kcal/100 mL) were collected from product packaging and nutrient information panels of CSSB available in 9 main UK supermarkets. RESULTS: The average free sugars content in CSSB was 30.1±10.7 g/330 mL, and 91% of CSSB would receive a 'red' (high) label for sugars per serving. There was a large variation in sugars content between different flavours of CSSB and within the same type of flavour ranging from 3.3 to 52.8 g/330 mL. On average, ginger beer (38.5±9.9 g/330 mL) contained the highest amounts of sugars and ginger ale (22.9±7.7 g/330 mL) contained the lowest. Cola flavour is the most popular flavour in the UK with an average free sugars content of 35.0±1.1 g/330 mL. On average, the supermarket own brand contained lower levels of sugars than branded products (27.9±10.6 vs 31.6±10.6 g/330 mL, p=0.02). The average calorie content in CSSB was 126.1±43.5 kcal/330 mL. Cola flavour had a calorie content of 143.5±5.2 kcal/330 mL. Among the 169 products surveyed, 55% exceeded the maximum daily recommendation for free sugars intake (30 g) per 330 mL. CONCLUSIONS: Free sugars content of CSSB in the UK is high and is a major contributor to free sugars intake. There is a wide variation in the sugars content of CSSB and even within the same flavour of CSSB. These findings demonstrate that the amount of free sugars added to CSSB can be reduced without technical issues, and there is an urgent need to set incremental free sugars reduction targets. A reduction in sugars content and overall CSSB consumption will be very beneficial in reducing obesity, type 2 diabetes and dental caries.

Prospective food diaries demonstrate breastfeeding characteristics in a UK birth cohort.

Breastfeeding duration and exclusive breastfeeding rates are universally below those recommended by World Health Organization. Due to limitations and challenges associated with researching breastfeeding characteristics, the times when exclusivity is likely to be lost and when women are most likely to discontinue breastfeeding have not yet been identified. Prospective food diaries allow reliable description of the dynamics of breastfeeding to be made to help identify these key time periods. Food diaries detailing intake from birth until the cessation of breastfeeding were analysed for 718 infants recruited into a national arm of an international multicentre birth cohort study (EuroPrevall). Analyses included linear regression analysis and Kaplan-Meier time course analysis. Breastfeeding and exclusive breastfeeding cessation rates for younger mothers (<25 years) are high in the first few weeks after delivery but slow markedly in the period 10-12 weeks after delivery. Cessation rates are consistent from 0 to 26 weeks in older mothers. This difference in feeding patterns led to significant differences between the two different age groups at 26 weeks for breastfeeding (P = 0.006) and exclusive breastfeeding at 8 weeks (P = 0.009). Forty-nine per cent of younger mothers (<25 years) stopped breastfeeding before their infant was 3 weeks old. To increase breastfeeding duration, further work is required to investigate the attitudes and perceptions associated with such high breastfeeding cessation rates in younger mothers during these very early post-natal weeks.

Cross-sectional survey of salt content in cheese: a major contributor to salt intake in the UK.

OBJECTIVE: To investigate the salt (sodium chloride) content in cheese sold in UK supermarkets. STUDY DESIGN: We carried out a cross-sectional survey in 2012, including 612 cheeses available in UK supermarkets. METHODS: The salt content (g/100 g) was collected from product packaging and nutrient information panels of cheeses available in the top seven retailers. RESULTS: Salt content in cheese was high with a mean (±SD) of 1.7±0.58 g/100 g. There was a large variation in salt content between different types of cheeses and within the same type of cheese. On average, halloumi (2.71±0.34 g/100 g) and imported blue cheese (2.71±0.83 g/100 g) contained the highest amounts of salt and cottage cheese (0.55±0.14 g/100 g) contained the lowest amount of salt. Overall, among the 394 cheeses that had salt reduction targets, 84.5% have already met their respective Department of Health 2012 salt targets. Cheddar and cheddar-style cheese is the most popular/biggest selling cheese in the UK and has the highest number of products in the analysis (N=250). On average, salt level was higher in branded compared with supermarket own brand cheddar and cheddar-style products (1.78±0.13 vs 1.72±0.14 g/100 g, p<0.01). Ninety per cent of supermarket own brand products met the 2012 target for cheddar and cheddar-style cheese compared with 73% of branded products (p=0.001). CONCLUSIONS: Salt content in cheese in the UK is high. There is a wide variation in the salt content of different types of cheeses and even within the same type of cheese. Despite this, 84.5% of cheeses have already met their respective 2012 targets. These findings demonstrate that much larger reductions in the amount of salt added to cheese could be made and more challenging targets need to be set, so that the UK can continue to lead the world in salt reduction.

Surveys of the salt content in UK bread: progress made and further reductions possible.

OBJECTIVES: To explore the salt reductions made over time in packaged bread sold in the UK, the biggest contributor of salt to the UK diet. STUDY DESIGN: Cross-sectional surveys were carried out on the salt content of breads available in UK supermarkets in 2001(40 products), 2006 (138) and 2011 (203). MAIN OUTCOME MEASURES: The primary outcome measure was the change in salt content per 100 g over time. Further measures included the proportion of products meeting salt targets and differences between brands and bread types. RESULTS: The average salt level of bread was 1.23±0.19 g/100 g in 2001, 1.05±0.16 in 2006 and 0.98±0.13 in 2011. This shows a reduction in salt/100 g of ≈20% between 2001 and 2011. In the 18 products which were surveyed in all 3 years, there was a significant reduction of 17% (p<0.05). Supermarket own brand bread was found to be lower in salt compared with branded bread (0.95 g/100 g compared with 1.04 g/100 g in 2011). The number of products meeting the 2012 targets increased from 28% in 2001 to 71% in 2011 (p<0.001). CONCLUSIONS: This study shows that the salt content of bread has been progressively reduced over time, contributing to the evidence base that a target-based approach to salt reduction can lead to reductions being made. A wide variation in salt levels was found with many products already meeting the 2012 targets, indicating that further reductions can be made. This requires further progressive lower targets to be set, so that the UK can continue to lead the world in salt reduction and save the maximum number of lives.

The variability of reported salt levels in fast foods across six countries: opportunities for salt reduction.

BACKGROUND: Several fast food companies have made commitments to reduce the levels of salt in the foods they serve, but technical issues are often cited as a barrier to achieving substantial reductions. Our objective was to examine the reported salt levels for products offered by leading multinational fast food chains. METHODS: Data on salt content for products served by six fast food chains operating in Australia, Canada, France, New Zealand, the United Kingdom and the United States were collected by survey in April 2010. Mean salt contents (and their ranges) were calculated and compared within and between countries and companies. RESULTS: We saw substantial variation in the mean salt content for different categories of products. For example, the salads we included in our survey contained 0.5 g of salt per 100 g, whereas the chicken products we included contained 1.6 g. We also saw variability between countries: chicken products from the UK contained 1.1 g of salt per 100 g, whereas chicken products from the US contained 1.8 g. Furthermore, the mean salt content of food categories varied between companies and between the same products in different countries (e.g., McDonald's Chicken McNuggets contain 0.6 g of salt per 100 g in the UK, but 1.6 g of salt per 100 g in the US). INTERPRETATION: The salt content of fast foods varies substantially, not only by type of food, but by company and country in which the food is produced. Although the reasons for this variation are not clear, the marked differences in salt content of very similar products suggest that technical reasons are not a primary explanation. In the right regulatory environment, it is likely that fast food companies could substantially reduce the salt in their products, translating to large gains for population health.

WASH-world action on salt and health.

There is overwhelming evidence that our current high-salt intake is the major factor increasing blood pressure (BP) and, thereby, a major cause of cardiovascular disease and kidney disease worldwide. A reduction in salt intake to the recommended level of <5-6 g/day is very beneficial, and could prevent millions of deaths each year and make major savings for healthcare services. Several countries, e.g., Finland and the UK, have already reduced the amount of salt being consumed by a combined policy of getting the food industry to decrease the amount of salt added to foods, clear labelling on food products, and increasing public awareness of the harmful effects of salt on health. Many other developed countries, e.g., Australia, Canada, and the US, are also stepping up their activities. The major challenge now is to spread this out worldwide, particularly to developing countries where ≈80% of global BP-related disease burden occurs. In many developing countries, most of the salt consumed comes from salt added during cooking or from sauces; therefore, public health campaigns are needed to encourage consumers to use less salt. A modest reduction in salt intake across the whole population will result in major improvements in public health and have huge economic benefits in all countries around the world. World Action on Salt and Health (WASH) is a coalition of health professionals from different countries who know very well the harm of high BP and has a major role in implementing changes in their own countries. We welcome nephrologists to join (http://www.worldactiononsalt.com).