Outcomes of sugar reduction policies, United Kingdom of Great Britain and Northern Ireland

Abstract Poor diets are the major cause of death and disease globally, driving high levels of obesity and noncommunicable diseases. Cheap, heavily marketed, ultra-processed, energy-dense and nutrient-poor food and drinks that are high in fat, sugar and salt play a major role. The high-sugar content of these products leads to consumption levels much higher than recommended. The World Health Organization recommends that sugar intake should be reduced to just 5% of energy intake by using fiscal policies and food and drink reformulation strategies. Over the previous decade, the government of the United Kingdom of Great Britain and Northern Ireland has implemented several policies aimed at reducing sugar intake. We compare the soft drinks industry levy and the sugar reduction programme, examining how differences in policy design and process may have influenced the outcomes. Success has been mixed: the mandatory levy achieved a reduction in total sugar sales of 34.3%, and the voluntary reduction programme only achieved a 3.5% reduction in sugar levels of key contributors to sugar intake (despite a target of 20%). Both policies can be improved to enhance their impact, for example, by increasing the levy and reducing the sugar content threshold in the soft drinks industry levy, and by setting more stringent subcategory specific targets in the sugar reduction programme. We also recommend that policy-makers should consider applying a similar levy to other discretionary products that are key contributors to sugar intake. Both approaches provide valuable learnings for future policy in the United Kingdom and globally.


Introduction
Excessive sugar consumption, increasing the risk of weight gain, is associated with an increased risk of type 2 diabetes, certain noncommunicable diseases and 13 types of cancer. 1,2here is also a causal relationship between sugar intake and tooth decay. 3In the United Kingdom of Great Britain and Northern Ireland, dental caries is the most frequently cited reason for the admission of children (age 6-10 years) to hospital for tooth extractions performed under general anaesthetic from 2016 to 2020. 4 One of the main contributing factors to excessive sugar intake is the unhealthy food system that exists in many countries. 5The global food system is dominated by multinational corporations who exercise significant power over the options available to consumers: 6 the largest 100 food and drink manufacturers account for 77% of all packaged food sold. 7][10] The addition of sugar is largely driven by an excessive supply of sugar.In the United Kingdom, for example, three times the amount of sugar recommended for consumption at a population level is supplied to the market, facilitated by the liberalization of the European sugar market in the mid-2000s and a strong domestic industry. 11ecause of the negative effect of high sugar intake on health, in 2015 the World Health Organization (WHO) issued a strong recommendation to reduce sugar intake to less than 10% of energy intake.WHO also issued the conditional recommendation that, for optimum health benefits, sugar intake be reduced to just 5% of energy intake. 1 The European Food Safety Authority stated that sugar intake should be "as low as possible, in line with a nutritionally adequate diet." 3 As a percentage of energy intake, sugar intake in adults ranges from 6.9% in Portugal to 18.1% in Austria. 12ugar consumption is especially high among children (age 4-10 years) and adolescents (age 11-18 years), averaging over 12% of energy intake in the United Kingdom. 13WHO recommends that countries reduce the sugar intake of their populations by using food and nutrition labelling, consumer education, restricted marketing of food and non-alcoholic beverages, fiscal policies, and food and drink reformulation strategies. 1

Sugar reduction policies
Evidence shows that sugary drinks taxes are associated with higher prices and often lower sales, which can contribute towards reducing sugar consumption. 14Taxes on sugary drinks have been implemented in more than 45 countries and several local jurisdictions. 14eformulation involves companies improving the nutrition profile of products, by gradually reducing harmful elements such as excess sugar. 15The key advantage of reformulation is that it removes the individual burden of behaviour change or financial considerations from consumers, who can continue to buy the same products that become healthier over time.The well-proven approach of a government-led reformulation programme, and one that has demonstrated to be effective for salt, is to implement a set of average and/or maximum limits for the target nutrient in relevant food and drink product categories. 16The United Kingdom was one of the first countries to implement this approach for salt reduction in the early 2000s, setting targets for the 80 categories of food contributing most salt to the diet.This implementation resulted in reductions of salt content in relevant foods of 20-40%, alongside an overall reduction of 1.4 g salt per day in population intake. 16dentified as a leader in sugar reduction policy by WHO, 17 the United Kingdom has developed and implemented several policies over the last decade aimed at reducing population sugar intake.The Scientific Advisory Committee on Nutrition independently reached the same conclusion as WHO, and recommended the adoption of the population target of reducing energy intake from sugar to 5%. 1 This recom-mendation was based on government analysis that found that such action could prevent 3500 deaths and 173 000 dental caries cases annually, saving the National Health Service 396 million pounds sterling (£) each year. 18e compare two critical policy actions: the soft drinks industry levy and the sugar reduction programme (Fig. 1; Fig. 2; and Table 1).We examine how differences in policy design and process, which were mainly focused on encouraging reformulation of products high in sugar, may have influenced outcomes.We also highlight potential improvements to these policies that can provide valuable learning for other countries.

Development
In 2008-2012, soft drinks (defined as high-sugar drinks) accounted for 17% of the free sugar intake in children aged 4-10 years, 30% in adolescents aged 11-18 years and 16% in adults aged 19-64 years in the United Kingdom. 20he concept of introducing taxes on soft drinks was initially proposed in recommendations made to the government by the independent agency Public Health England in their 2015 sugar reduction report. 18This recommendation suggested the introduction of a tax, already implemented in many other countries, in the form of a minimum price increase of 10-20% on high-sugar products including soft drinks.The introduction of a tax was encouraged by health organizations in the United Kingdom, as well as

Policy & practice
the announcement of one of its biggest retailers to reduce the sugar content of their own soft drinks by 5% each year from 2015. 21he soft drinks industry levy was formally announced in the 2016 budget, when it was stated that the government would introduce an industry levy in 2018 on manufacturers, packagers and importers of soft drinks, excluding small companies. 22The levy varies according to the sugar content of the drink, from no levy for drinks with less than 5 g sugar/100 mL; £0.18/L for drinks with 5-8 g sugar/100 mL; and £0.24/L for drinks with more than 8 g sugar/100 mL.
The first tax of this kind, the levy aimed to directly incentivize the reformulation of products.The government promised to allocate the funds generated by the levy towards improving children's health, including investment in children's breakfast clubs and school sports facilities and activities.Ring-fencing the raised funds in this way assisted in the proposed levy becoming accepted policy, despite opposition from the food industry. 23he Office for Health Improvement and Disparities (previously Public Health England) monitored progress of the levy on behalf of the tax authority of the United Kingdom (His Majesty's Revenue and Customs), publishing reports in 2018, 2019, 2020 and 2022.All relevant companies are required to comply with the levy by registering with the tax authority, submitting a levy return every quarter and paying any levy due.Interest, penalties and, in some cases, criminal charges are liable if the process is not followed. 24

Successes and failures
The tiered structure of the levy meant that many companies were incentivized to reformulate, despite some initial consumer backlash.As a result, there was a 34.3% reduction in total sugar sales from soft drinks from 135 391 tonnes in 2015 to 89 019 tonnes in 2020. 19During this period, the sales-weighted average sugar content of soft drinks subject to the levy decreased from 3.8 to 2.1 g/100 mL from 2015 to 2020 (by 44.7%, although quoted as 46.0%) for retailer own-brand and manufacturer-branded products. 19here was a reduction in the out-ofhome sector (i.e.those businesses that sell food and drink consumed at locations other than at home) from 5.8 g/100mL in 2017 to 3.2 g/100 mL in 2020 (by 44.8%, although quoted as 44.3%), reported as a simple average because of data limitations. 19Because the levy was mandatory, no company was disadvantaged for taking action that their competitors did not. 25ecent evidence also suggests that the levy may have prevented over 5000 cases of obesity in girls aged 10-11 years, and may have reduced the number of adolescents requiring hospital tooth extractions by 12.1% (95% confidence interval: 7.2-17.0). 26,27espite large reductions in sugar content, the volume of sales of soft drinks increased by 21.3% from 2015 to 2020 driven by a large shift towards lower sugar products; industry fears that the levy would lead to a loss of sales and profit were therefore allayed. 19Interviews with industry representatives have revealed that companies used surrogate marketing to ensure that sales of highsugar drinks continued to increase. 28

Recommendations
To encourage more companies to reformulate, the value of the levy could be increased.To encourage further reformulation among the companies that have already reformulated their products, while also addressing some of the increase in sales due to aggressive marketing, we recommend reducing the sugar thresholds.
Because reformulation to reduce sugar content (especially in the highsugar drinks category) has resulted in an increase in the use of non-sugar sweeteners, further sugar reductions will probably mean further increases in the use of non-sugar sweeteners.Although previously seen as a viable way to reduce sugar content, 29 this stance is shifting as new evidence emerges.WHO has reported that policy-makers should avoid the use of non-sugar sweeteners for long-term weight management or chronic disease prevention, and has recently issued a guideline on this topic. 30This recommendation raises the question of how to design policies that not only reduce sugar content but also discourage its replacement with non-sugar sweeteners.Some countries have started to incorporate non-sugar sweeteners into sugar reduction policies, for example: soft drink levies apply to high-sugar and non-sugar-sweetened drinks in France, Saudi Arabia, United Arab Emirates and the United States of America; the public health product tax in Hungary has recently expanded to apply to the content of non-sugar sweeteners as well as sugar; 31 and the mandatory front-of-pack warning label system in Mexico includes information on non-sugar sweetener content.The use of non-sugar sweeteners is currently not monitored in the United Kingdom; we recommend a reduction in use as well as requiring companies to state the amount in products on nutrition labels.
There is potential to expand highsugar drinks taxes to a wider range of products; for example, milk-based drinks and fruit juices are currently excluded from the levy, but are consumed in similar volumes as high-sugar drinks.Specific attention should also be given to alcoholic drinks, a major contributor to sugar intake but largely excluded from sugar reduction policies.In 2020, a survey of ready-to-drink alcoholic beverages found that an average serving contained 20 g sugar, something that consumers are largely unaware of because of a lack of nutrition labelling. 32inally, although the funds raised by the levy were earmarked for public health initiatives, low revenue is indicative of a successful reformulation scheme; this contradiction is something that policy-makers must be aware of.

Development
In the previously mentioned 2015 sugar reduction report, 18 Public Health England also recommended that the government introduce a "broad, structured and transparently monitored programme of gradual sugar reduction in everyday food and drink products, combined with reductions in portion size."In the 2016 childhood obesity plan, 33 the government announced the introduction of a "broad, structured sugar reduction programme to remove sugar from the products children eat most," including breakfast cereals, yoghurts, cakes, biscuits, sweets and chocolate, reducing calories where possible. 29fter extensive engagement and discussion with 40  Critical analysis of sugar reduction policies, United Kingdom ous government policies, such as the salt reduction programme, were also considered. 34he programme was aimed at manufacturers, retailers and out-ofhome businesses with a significant market share in the top 10 food categories (breakfast cereals; yoghurts and fromage frais; biscuits; cakes; morning goods; puddings; ice cream, lollies and sorbets; chocolate confectionery; sweet confectionery; and sweet spreads and sauces) that contribute to the sugar intake of children. 29The government agency determined the food categories via the National Diet and Nutrition Survey, and calculated market share using data purchased from Kantar Worldpanel, representative of United Kingdom population intake.Following engagement with key stakeholders, who were also invited to provide written feedback, the agency published the aims of the programme: a 20% target reduction in sugar between 2015 (baseline) and 2020, including a 5% target in the first year.Companies could achieve this via three mechanisms: reformulation, portion size reductions and shifting sales to healthier alternatives.To aid progress, the agency also published baseline sales-weighted average sugar content by product category and the corresponding sugar content that would represent a 20% reduction. 29he key success marker was a reduction in the sales-weighted average sugar content per 100 g, calculated by weighting sugar levels of individual products by their volume sales.A popular product with high-sugar content drives the salesweighted average upwards, whereas a popular product with low-sugar content drives it down. 29nalysis suggested that if the programme targets were met, average sugar consumption would fall by 1000-3600 g per person per year, 35 with a resulting reduction in calorie intake capable of halting weight gain at a population level. 36The increased and healthier workforce could grow the United Kingdom's economic output by £2.2-5.7 billion, and save the National Health Service £1.6-4.1 billion and the social care system £1.9-4.8 billion. 35ublic Health England was tasked with managing the programme, using annual reports to track industry progress.A commitment was made that ministers would consider alternative levers if enough progress was not made. 29he agency published interim progress reports in 2018, 2019 and 2020; following its dissolution in 2020, the Office of Health Improvement and Disparities took responsibility and published the final report in December 2022.The report provided a detailed assessment, by food category and business, of progress over the 4-year programme towards the 20% reduction goal. 19

Successes and failures
The 20% reduction goal was quickly criticized by industry, 37 who claimed it was unachievable; however, there were some supportive voices among industry members. 38verall, the programme achieved a 3.5% reduction in sales-weighted average sugar levels in retailer (6.3%) and manufacturer (1%) branded products between 2015 and 2020. 19Encouraging reductions were seen in the categories of breakfast cereals (by 14.9%) and yoghurts and fromage frais (by 13.5%), in which the programme demonstrated the potential of a reformulation approach. 19There were large differences between what the various companies achieved, with an average of 18 percentage points between the best and worst performers in each product category.
However, despite the reductions seen, there was a 7.1% increase (51 986 tonnes) in total sugar sales from foods. 19,38Out-of-home companies such as fast-food outlets and restaurant chains only achieved a 0.2% reduction in average sugar content.Calculating a meaningful measurement of sugarweighted sales was not possible as the available data did not match purchases with nutrition information at the product level.At a company level, data were scarce and were not broken down for each food category.
The programme was criticized for being simplistic in its design, with a blanket 20% target reduction in sugar across all categories.This design did not follow the proven model of other successful reformulation programmes, such as the salt reduction programme, with specific and data-driven targets for each category. 16Given the three available methods to achieve the 20% reduction target, companies had the flexibility to easily overcome technical challenges to meet this goal.However, as the programme was voluntary, less responsible companies chose to make no or little changes, with many lower-sugar versions of high-sugar products being introduced to the market. 39he outcome of the 20% reduction was determined by sales-weighted average sugar content, but this outcome was not only affected by the sugar content of products; as sales changed, perhaps because of sales promotions, the absolute sugar content required to achieve the 20% target changed.This sales-weighting method also encouraged some companies to develop products with 30% less sugar, apply this claim to packaging, and market them alongside full-sugar product lines to bring consumers to the category.This strategy may explain some of the increase in total sugar sales.Furthermore, some companies were then unwilling to reformulate their main full-sugar products as the 30%-less-sugar variants would lose their status.The design of the programme may therefore have made sugar reduction a short-term marketing opportunity for some companies, rather than a longterm strategic aim to reduce sugar intake across the population.

Recommendations
Although the programme covered a reasonably comprehensive range of products, it could be strengthened by dividing existing product categories into more specific targets (similar to the salt reduction programme targets), and expanding to include all top contributors to sugar intake for both adults and children.For example, baby and toddler foods should have been included in the programme with more stricter guidelines.Despite being a crucial period in a child's development, proposed policies have failed to cover products marketed for the early years.This failure has resulted in excessively sugary products: recent surveys of commercial baby and toddler products found that 37% of sweet snacks would receive a red (high) label for sugars (> 22.5 g of total sugars per 100 g) according to United Kingdom colour-coded labelling, 32,40 and that breakfast items contained up to 14.5 g sugar/pouch. 41ugar reduction targets must be mandatory; industry will only prioritize voluntary targets if aligned with commercial interests.The chief executives of the United Kingdom's major food retailers have stated that legislation is needed, emphasizing that "they need a level playing field if they are to start making their products healthier, other-Bull World Health Organ 2024;102:432-439| doi: http://dx.doi.org/10.2471/BLT.23.291013   Kawther M Hashem et al.

Policy & practice
wise the competition will simply move in and undercut them." 35The successful salt targets imposed by the South African government demonstrate the power of mandatory targets to incentivize widespread reformulation to improve population health.In 2016, legislation was implemented limiting salt levels in key contributors of salt, such as bread, and the resulting reformulation led to an estimated reduction in population salt intake of 1.2 g/day by 2018. 42

Discussion
The United Kingdom experience in sugar reduction policy has demonstrated mixed success with some clear reductions in sugar content (Fig. 1 and Fig. 2), but the impact of the interventions may have been moderated by an increase in sales.Because these policies are implemented within an environment of an ever-changing market and economy, interventions must be flexible enough to be able to adapt to how companies mitigate the impact of these policies on their products. 28th the soft drinks industry levy and the sugar reduction programme are examples of upstream measures that reach the whole population, without the need for individual action.These measures have been shown to achieve better health impacts than downstream measures, which attempt to change individual consumer behaviour. 43Both policies can be improved to continue their success and mitigate their failures, such as increasing the levy and reducing the sugar content threshold in the soft drinks industry levy, and setting more stringent subcategory specific targets in the sugar reduction programme (Table 1).
The poorest performing category in the sugar reduction programme was chocolate confectionery, with only a 0.9% reduction over 4 years.Given the proven success of the soft drinks industry levy at incentivizing reformulation, we therefore recommend that policymakers consider applying a similar levy to other discretionary products that are key contributors to sugar intake.In fact, one of the criticisms of the levy from the soft drinks industry was that their product was unfairly targeted and that a broader range of products should have been included. 25Hungary's public health product tax, which applies to all pre-packaged products with added sugar, was successful in incentivizing reformulation 44 and has recently been strengthened to include a new doublerate tax for particularly sweet products. 30ltimately, we recommend a comprehensive programme of complementary policies to reduce sugar intake, incorporating those measures recommended by WHO such as: updating food and nutrition labelling legislation to help consumers better understand the amount of free sugars in products; and restrictions on advertising of high-sugar products, currently being delayed in the United Kingdom as a result of industry pressure. 45

Fig. 1 .
Fig. 1.Average sugar content of beverages before and after the introduction of the soft drinks industry levy, United Kingdom

Fig. 2 .
Fig. 2. Average sugar content of food products before and after the introduction of the voluntary sugar reduction programme, United Kingdom

Table 1 . Summary of policy details and improvement recommendations of the soft drinks industry levy and sugar reduction programme, United Kingdom Feature Soft drinks industry levy Sugar reduction programme
£: pounds sterling.Bull World Health Organ 2024;102:432-439| doi: http://dx.doi.org/10.2471/BLT.23.291013Kawther M Hashem et al.
organizations who represented all sectors of the food industry, nongovernmental organizations and other government departments, Public Health England developed the details of the reduction programme in 2016-2017.Learnings from previ-Bull World Health Organ 2024;102:432-439| doi: http://dx.doi.org/10.2471/BLT.23.291013Kawther M Hashem et al.

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Competing interests: GAM is the chair of Blood Pressure UK and Consensus Action on Salt, Sugar and Health.Both are not-for-profit charitable organizations, from which the author receives no financial support.The remaining authors declare no competing interests.Bull World Health Organ 2024;102:432-439| doi: http://dx.doi.org/10.2471/BLT.23.291013