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  1. Annalijn I Conklin, assistant professor and scientist12
  1. 1Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, BC V6T 1Z3, Canada
  2. 2Centre for Health Evaluation and Outcome Sciences (CHEOS), Providence Health Research Institute, Vancouver, BC, Canada
  1. Correspondence to: A I Conklin aconklin{at}

Substantial benefits are forecast but only if sugar reduction targets are met in full

In recent years, many governments have been experimenting with structural interventions to address the growing burden of nutrition related chronic diseases, particularly obesity and diabetes. One of the most effective strategies to improve diet is reducing sugar intake,1 and England has implemented a public health collaboration with the food industry to reduce sugar by 20% in cereals, morning goods (such as waffles and pancakes), and other products popular with children.

In a linked article, Amies-Cull and colleagues (doi:10.1136/bmj.l1417) make an important contribution to the current knowledge of the population benefits of public health collaborations.23

The authors performed an extensive investigation of the programme’s potential impact on both child and adult calorie intakes, weight, and body mass index (BMI). Their most valuable contribution is in modelling how these expected BMI changes might subsequently reduce 10 year chronic disease incidences and also reduce healthcare costs from cardiometabolic diseases, cirrhosis, and five cancers in adults. Models showed reductions in average energy consumption among younger ages—more so for boys—as well as reductions in weight and BMI, such that the baseline obese population would shrink by nearly 6% in children and in adults.

A further addition to the literature is the sex specific finding that the programme had a greater potential impact on reducing women’s BMI, which would lead to greater health benefits for women than men over 10 years (except for liver cirrhosis and liver cancer). Future models could include an equity lens to determine whether the health benefits of the programme are likely to be greater for women and men from lower socioeconomic groups that have a disproportionate burden of chronic disease and child obesity.4

Importantly, however, the modelled health benefits and cost savings would be lost if any one of the programme’s three mechanisms fail to be implemented in full: reformulation, reducing portion size, and shifting sales from high sugar products to lower sugar alternatives (sales weighting). The food industry may reformulate their products in ways that could undermine any reductions in obesity and chronic disease burden associated with the lower sugar content.

Equally, compensatory behaviours of consumers can be triggered by lower sugar levels in food, reduced portion sizes, or both, such that diets contain the same (or perhaps even higher) levels of energy. In the US, although companies participating in the Healthy Weight Commitment Foundation (HWCF) exceeded their pledge to reduce sales of packaged foods,5 achieving these commitments did not translate into a reduction in calories purchased by consumers.6 Hence, Amies-Cull and colleagues are right to caution that a lower burden of nutrition related conditions is possible only if both consumers and industry respond to the 20% sugar reduction as predicted.2

Full implementation as predicted would be more likely if the food industry was already working to reformulate, reduce, and shift sales before the UK government published its programme. This was the case for a previous public health collaboration in England called the 2011 Public Health Responsibility Deal, where more than two thirds of the voluntary pledges by industry and other stakeholders were already clearly or possibly in progress before the deal was launched.1 Pre-existing declines in sales might also underpin companies’ pledges to the Healthy Weight Commitment Foundation in the US.6

Future studies could usefully assess whether the UK government’s programme is also an extension of “business as usual,” and thus whether the beneficial effects modelled by Amies-Cull and colleagues can be truly attributed to the programme rather than a pre-programme trajectory. If the latter, this public health collaboration on sugar reduction may be doomed to fail anyway as long as food companies can make profits out of selling unhealthy foods. “Business as usual” always entails an inherent conflict of interest between public health and the legally required profit making of food companies.7

To provide the projected gains in quality of life and reduced healthcare spending, industry mechanisms for sugar reduction must be sustained long term, which will require vigilant and continuous monitoring by both the UK government and civil society organisations. More importantly, the government must set clear incentives for compliance, and enforce sanctions against companies that fail to make progress against programme targets8; otherwise, the aim of a healthier nation will not be realised through less sugar in children’s food.

Finally, although the programme may contribute, a complete solution to the challenge of improving diets and reducing the burden of nutrition related chronic diseases requires a multi-sectoral package of policies, which also includes the UK sugar tax, other fiscal tools, and hard regulation for improving public health.79


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