Intended for healthcare professionals


Sugar, salt, and the limits of self regulation in the food industry

BMJ 2017; 357 doi: (Published 07 April 2017) Cite this as: BMJ 2017;357:j1709
  1. Martin Caraher, professor of food and health policy1,
  2. Ivan Perry, professor of public health2
  1. 1City University, London, UK
  2. 2University College Cork, Ireland
  1. Correspondence to M Caraher m.caraher{at}

Globally, policies are shifting towards mandatory reformulation, subsidies, and taxation

A recent report from Consensus Action on Salt and Health (CASH) shows that only one out of the 28 food categories surveyed are on track to meet Public Health England’s (PHE) 2017 salt reduction targets.1 The food industry will also fail to hit a PHE target to achieve a 20% reduction in sugar content across nine food categories— including breakfast cereals, cakes, and yogurts—by 2020, confirming the long held view of some experts that voluntary agreements aren’t working and we should now move from soft to hard regulation.2

Modest progress towards reducing the salt content of the British diet has stalled, and efforts to reach agreement with the food industry on a voluntary reformulation strategy for sugar look unlikely to succeed. This is not surprising because voluntary agreements between industry and government (including the UK public health responsibility deal) have been shown repeatedly to be ineffective in improving public health.3 Sharma and colleagues have suggested minimum standards for any effective food industry self regulation, including transparency, meaningful objectives, accountability, objective evaluation, and independent oversight.4 However, failed attempts at voluntary agreements on tobacco, alcohol, and food show that strategies based on self regulation are typically self serving, deceptive, and generally designed to stall government legislation and protect business as usual.4

Our best hope of achieving ongoing reductions in the salt and sugar content of processed foods lies in mandatory regulation and taxation in specific areas, as advocated by the National Institute for Health and Care Excellence in 2010.5 Any partnership between government and the food industry should be supported by mandatory 2020 targets for the salt and sugar content of processed foods and taxes on specific food items that contribute disproportionately to consumption.3 The sugary drinks levy (scheduled for April 2018) will not be enough without concurrent public health interventions.

Sugar is a global problem.6 Nineteen countries have already introduced so called sin taxes on food and drinks, and more are likely to follow, with the aim of reducing sugar consumption by 20%.7 Globally, we may be at the start of a long overdue shift towards food policy actions upstream, including mandatory reformulation, subsidies, and taxation.

The food industry response to these developments is that initiatives such as the sugary drink tax in Mexico8 and the saturated fat tax in Denmark9 have not resulted in demonstrable improvements in health and have the potential to cause job losses in affected sectors. Fortunately, evidence exists to counter these narratives, including data from Mexico showing that a 10% tax on sugar sweetened beverages (equivalent to 1 peso (4p) per litre of sugary drink) was associated with a decline in purchases averaging 7.6% over two years8 with the biggest effect on the poorest households. Denmark’s tax on saturated fat didn't survive, but research published soon after it was repealed showed that consumption of saturated fat had declined in Denmark while the levy was in force.910

The core issue is not about the effectiveness or otherwise of taxes on unhealthy foods but about what Smith terms the war of ideas.11 Industry arguments often fall back on ideas of personal freedom. Strategies include reframing soft drinks or fat taxes as issues of consumer rights and examples of the alleged excesses of the “nanny state” and then promoting public-private partnerships and corporate social responsibility deals that essentially allow the “fox to guard the hen house.”12

In addition to the evidence from authoritative studies, we need a clear, simple, and compelling narrative opposing these misleading arguments in a way that resonates with the general public and policy makers. Perhaps we need greater emphasis on the idea of healthy food as a matter of children’s rights.

Two recent developments show this war of ideas in action. The first was high profile media reports of industry representatives saying that a 20% sugar cut “won’t be technically possible or acceptable to UK consumers,” and that even a 5% cut would not be universally achievable.13 Then, a week later, PHE published a document outlining progress in consultations with industry and the development of a sugar reduction programme.14 The document includes no sanctions or legislation to guide such reductions. It is effectively toothless and shows the importance of timing, framing, and publicity in gaining the upper hand.

PHE, the devolved administrations of Northern Ireland and Scotland, and the Department of Health need to stand firm and hold the food industry fully accountable for its actions.15 Meanwhile, public health advocates must continue to encourage political will and public support for “hard regulations” such as taxes and subsidies. These are the interventions most likely to achieve real change in the salt and sugar content of our food and real improvements in public health.


  • Competing interests: We have read and understood BMJ policy on declaration of interests and declare that IP is a share holding non-executive director of Food Choice at Work, a commercial company.

  • Provenance and peer review: Commissioned; not externally peer reviewed.


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