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Copyright 2025 - Integrated Care Services Association

Sugar Reduction: Preventing Ill Health and Protecting the NHS via Reformulation - Mhairi Brown, Policy and Public Affairs Lead, Graham MacGregor CBE, Chair of Action on Sugar and Action on Salt and Professor Graham MacGregor CBE

Excess sugar intake is linked to various health issues. There is a causal relationship between sugar intake and tooth decay, which has a large impact on child physical and mental health (1). Oral diseases are the leading reason children aged 5-9 years are admitted to hospital, with 32,140 admissions in 2018-2019 (2). There is also evidence of a link between sugar – particularly in the form of sugar-sweetened drinks - and type 2 diabetes, obesity, liver disease and high LDL cholesterol (1). These health conditions have a huge toll on individuals, families, communities and our overburdened NHS.

As a nation, we consume excess sugar and many would likely not realise it. The UK’s food system is dominated by a highly globalised food industry who extensively produce and market processed and nutrient-poor food and drinks – high in fat, sugar and salt (HFSS). These products are cheaper than nutrient-dense products and are at the centre of the billions in profit made by global food companies annually; profits that are often made at the expense of workers’ wages and consumer health (3).

Our food system not only impacts our health, but our environment too, with the conversion of natural ecosystems to crop production or pasture. The production of sugar beet, for example, is causing irreversible damage to soils, with British Sugar being responsible for the removal of hundreds of thousands of tonnes precious of topsoil every year (4).

To address the impact of the UK’s diet on health, the government has implemented numerous policies, including colour-coded front of pack nutrition labels, food and drink procurement guidelines for the public sector and some restrictions on the placement of HFSS products in prominent retail locations. In particular, the government’s reformulation programme is a key policy with the potential for a huge, positive impact on our food system and population health.

UK Sugar Reduction Programme

Reformulation involves food companies improving the nutrition profile of their products, gradually reducing harmful elements such as excess sugar. This removes the barrier of behaviour change or financial considerations from customers, who can continue to buy the same products they always have, but over time they will become healthier. Food companies have gradually reduced salt levels for many years, following the introduction of a Salt Reduction Programme in 2003, and correspondingly, the nation’s blood pressure has reduced alongside a reduction in cardiovascular disease mortality (5). In 2017, the government introduced a Sugar Reduction Programme, with a 20% reduction in sugar levels in certain key contributors to children’s sugar intake expected by 2020, including (6):

  • Breakfast cereals
  • Yogurts
  • Biscuits
  • Cakes
  • Morning goods (e.g. croissants, English muffins, waffles)
  • Puddings
  • Ice cream, lollies and sorbets
  • Chocolate confectionary
  • Sweet confectionary
  • Sweet spreads and sauces (e.g. chocolate spread, peanut butter, dessert toppings)
  • Juice and milk-based drinks (added 2018)
  • Fermented yogurt drinks (added 2019)

PHE proposed that the 20% reduction in sugar content could be achieved by:

  1. Reformulating products to lower the levels of sugar present
  2. Reducing the number of calories in, and/or portion size, of products that are likely to be consumed by an individual at one time
  3. Shifting consumer purchasing towards lower/no added sugar products

With this programme, the UK became one of the first countries to implement sugar reduction targets and WHO Europe was recently tasked with sharing learnings from the UK on sugar and calorie reduction. However, the third progress report, published in 2019, showed that the Sugar Reduction Programme had not achieved the targeted reductions in sugar levels. The fourth and final report (originally due to be published in autumn 2021) has still not been made public so the final state of the programme is unknown and its future unclear.

Factors Impacting Sugar Reduction Progress

There are many factors that may have impacted on the programme’s progress. Targets were set as overall, percentage reductions as opposed to evidence-based and data backed specific targets at the category level (as used in the Salt Reduction Programme). Alongside this, by giving the food industry the option to shift sales to lower or no added sugar products in their portfolios, sugar reduction became a short term marketing opportunity rather than a long term strategic aim. As an example – of which there are many - Mondelez invested heavily in research and marketing for Dairy Milk ‘30% less sugar’, but did not take the risk of reformulating their main product with less sugar (7). However, if provided with motivation, leadership and guidance throughout the process, Mondelez could have successfully reduced the sugar content of many of their products by using the 30% reduced version without advertising this to customers.

Furthermore, sugar reduction was PHE’s flagship policy, but they did not have final say on the structure of the programme as an “executive agency” of the Department of Health and Social Care. PHE’s role was one of providing guidance as opposed to independent and transparent policy making, with the authority to set and enforce strict targets. With PHE’s closure in 2020, the Sugar Reduction Programme lost leadership, credibility and momentum.

By far the leading reason for a lack of progress is that the programme is voluntary, rather than mandatory, supported by legislation. This means that a company can choose to invest as much or as little into reducing sugar in its products as it wants, making full compliance unlikely, as the programme’s progress shows. Indeed, CEO’s of the UK’s major food retailers told the National Food Strategy team – and their nutrition teams have told us directly – that they will not reformulate all products without government legislation, and that “they need a level playing field if they are to start making their products healthier, otherwise the competition will simply move in and undercut them” (8).

The Need for Mandatory Policies

The Soft Drinks Industry Levy provides a useful model for mandated sugar reduction, as it has been instrumental in the reformulation of sugar-sweetened drinks. Due to the tiered structure, companies have been incentivised to reformulate and by 2018, the estimated revenue from the SDIL was downgraded as more than half of companies had reduced the sugar content of drinks since it was announced in March 2016 – the equivalent of 45 million kg of sugar every year - to avoid paying the levy (9). Many drinks companies have the revenue to absorb the cost and continue selling high sugar products, but chose not to.

PHE found that there had been a 43.7% reduction in total sugar content of drinks between 2015 and 2019 (10). Sales of drinks subject to the levy increased, meanwhile, allaying industry fears that the levy would lead to a loss of sales and profit, but the total sugar purchased per household from drinks decreased across all socio-economic groups. Sugar reduction is technically easier to achieve in drinks compared to solid food products, but the SDIL was successful in uniting drinks manufacturers to reformulate to avoid penalties.

What Should Happen Now?

Education is not the answer; despite marketing campaigns like Change4Life and Better You, as well as an app to help make healthier choices, these initiatives have not resulted in sustained or widespread behaviour change (11). The UK needs a Sugar Reduction Programme, and with the expiry of the previous target in 2020, now is the time for the government to implement a comprehensive and mandated sugar reduction programme. The UK’s long-standing Salt Reduction Programme provides an example of an effective public health initiative, launched in 2003 it is still going strong 20 years later. This is because the programme, which comprises specific, data-based targets for a comprehensive range of contributors to the nation’s salt intake, works for the food industry and therefore benefits the nation’s health. Sugar reduction could have that same success if designed in a similar way, with bold government leadership and a strong monitoring framework.

Programme Structure

Building on the model of the salt reduction programme, universally agreed as a well-designed, successful programme by industry and NGOs alike, we need a simple programme with specific, but comprehensive, mandatory upper limits for all contributing categories of sugar to the diet.

The targets can be based on an agreed maximum sugar limit and enforcement could include imposing financial penalties based on individual cases, or a levy applied to a manufacturer in the case of multiple/repeat offences.

In addition to existing categories, additional categories are needed so that all the top contributors to sugar intake are included, including pre-mixed alcoholic drinks, ready meals, sauces, baked beans and bread products.

Governance

The National Food Strategy proposed a statutory duty on sugar (and salt) for all food companies with more than 250 employees – including retailers, restaurant and quick service companies, contract caterers, wholesalers, manufacturers and online ordering platforms – to publish an annual report on the following set of metrics (8):

  • Sales of food and drink high in fat, sugar or salt (HFSS) excluding alcohol
  • Sales of protein by type (of meat, dairy, fish, plant, or alternative protein) and origin†
  • Sales of vegetables
  • Sales of fruit
  • Sales of major nutrients: fibre, saturated fat, sugar and salt
  • Food waste
  • Total food and drink sales

This must be implemented by the government (as per its commitment in the Government Food Strategy (12)) to help support governance of the Sugar Reduction Programme, by providing accessible data to government departments and the wider health community to track progress, and ‘name and shame’ companies.

Early Years

Early years (infants and young children aged 0-3 years old) is a black hole of policy making. Despite being a crucial period in a child’s development, to date public health policies fail to cover products marketed for the early years. Products designed for infants and young children, including all products displaying cartoon characters and child friendly packaging, must have strict sugar targets to help ensure infants and young children have access to a range of tastes, rather than products that encourage sweet taste preferences and lead to health issues, particularly tooth decay in the short term.

Benefits of Sugar Reduction

Suboptimal diet is a leading cause of death and disability in the UK and worldwide, costing healthcare services - and the wider economy due to the impact on workforce - billions of pounds each year. Frontier Economics estimated that the total economic impact of obesity alone in 2022 would be £58 billion, accounting for NHS and social care costs, lost productivity, workforce inactivity and welfare payments (13). A similar assessment by McKinsey in 2014 estimated the economic impact of obesity in the UK to be equivalent to 3% of its GDP (14). Therefore, the benefits associated with reducing population sugar intake in the UK are clear, both from a health and an economic standpoint.

Public Health England’s own analysis showed that reducing average energy intake from sugar to 5% over the next 15 years would prevent 3,500 deaths and avoid 173,000 dental caries cases annually, whist also saving the NHS £396m each year (15). More recently, analysis in the National Food Strategy showed that if the Sugar Reduction Programme targets were met, average sugar consumption would reduce by 1 kg to 3.6 kg of sugar per person annually, bringing consumption levels 16% and 83% closer, respectively, to the target intake of 30g sugar per person per day (8). The corresponding reduction in average daily calories per person would be 15-38kcal, which according to experts, could prevent weight gain at a population level (16).

The evidence on the link between excess sugar intake and health has not changed, and our consumption has not gone down. The importance of a healthy, productive population has come into even sharper focus as the UK’s health and care service and economy come under increasing strain. It is vitally important that the government acts now to reduce population sugar intake and thereby protect our health, communities and the NHS.

References

  1. European Food Safety Authority. Sugar Factsheet. 2021. Available from: https://www.efsa.europa.eu/sites/default/files/2021-07/sugars-factsheet-en.pdf
  2. NHS Digital. Hospital Admitted Patient Care Activity 2018-19. 2019. Available from: https://digital.nhs.uk/data-and-information/publications/statistical/hospital-admitted-patient-care-activity/2018-19
  3. Hasnain S, Ingram J, Zurek M. Mapping the UK Food System – a report for the UKRI Transforming UK Food Systems Programme. Environmental Change Institute, University of Oxford, Oxford; Available from: https://www.eci.ox.ac.uk/research/food/downloads/Mapping-the-UK-food-system-digital.pdf
  4. Feedback. Too Much of a Bad Thing: The use and misuse of UK soil and land to grown sugar. 2019. Available from: https://feedbackglobal.org/wp-content/uploads/2019/11/Too-much-of-a-bad-thing-the-use-and-misuse-of-land-and-soils-to-grow-sugar-Feedback-2019.pdf
  5. He FJ, Pombo-Rodrigues S, MacGregor GA. Salt reduction in England from 2003 to 2011: its relationship to blood pressure, stroke and ischaemic heart disease mortality. BMJ Open. 2014 Apr 1;4(4):e004549.
  6. Public Health England. Sugar Reduction: Achieving the 20% A technical report outlining progress to date, guidelines for industry, 2015 baseline levels in key foods and next steps. 2017. Available from: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/604336/Sugar_reduction_achieving_the_20_.pdf
  7. The Grocer. Mondelez unveils Cadbury Dairy Milk 30% Less Sugar. The Grocer. Available from: https://www.thegrocer.co.uk/new-product-development/mondelez-unveils-cadbury-dairy-milk-30-less-sugar/595899.article
  8. Dimbleby H. National Food Strategy Independent Review: The Plan. 2021. Available from: https://www.nationalfoodstrategy.org/
  9. HM Treasury. Soft Drinks Industry Levy comes into effect [Internet]. GOV.UK. 2018. Available from: https://www.gov.uk/government/news/soft-drinks-industry-levy-comes-into-effect
  10. Public Health England. Sugar reduction: report on progress between 2015 and 2019. 2020; Available from: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/984282/Sugar_reduction_progress_report_2015_to_2019-1.pdf
  11. Croker H, Lucas R, Wardle J. Cluster-randomised trial to evaluate the ‘Change for Life’ mass media/ social marketing campaign in the UK. BMC Public Health. 2012 Jun 6;12(1):404.
  12. Department for Environment, Food & Rural Affairs. Government food strategy. 2022. Available from: https://www.gov.uk/government/publications/government-food-strategy/government-food-strategy
  13. Frontier Economics. Estimating the Full Costs of Obesity. 2022. Available from: https://www.frontier-economics.com/media/5094/the-full-cost-of-obesity-in-the-uk.pdf
  14. McKinsey Global Institute. Overcoming obesity: An initial economic analysis. 2014. Available from: https://www.mckinsey.com/~/media/McKinsey/Business%20Functions/Economic%20Studies%20TEMP/Our%20Insights/How%20the%20world%20could%20better%20fight%20obesity/MGI_Overcoming_obesity_Executive_summary.ashx
  15. Public Health England. Sugar Reduction The evidence for action. 2015. Available from: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/470179/Sugar_reduction_The_evidence_for_action.pdf
  16. Department of Health and Social Care. Statement of the Calorie Reduction Expert Group. 2011. Available from: https://www. gov.uk/government/publications/statement-of-the-calorie-reduction-expert-group

Contact

Action on Sugar
Action on Sugar is a group of scientific experts concerned with sugar and obesity and its effects on health. It is working to reach a consensus with the food industry and Government over the harmful effects of a high calorie diet, and bring about a reduction in the amount of sugar and fat in processed foods to prevent obesity and type 2 diabetes.
@actiononsugar, actiononsugar.org

Action on Salt
Action on Salt is a group concerned with salt and its effects on health, supported by 23 expert scientific members. Action on Salt is successfully working to reach a consensus with the food industry and Government over the harmful effects of a high salt diet, and bring about a reduction in the amount of salt in processed foods as well as salt added to cooking, and the table, to prevent high blood pressure and cardiovascular disease.
@actiononsalt, actiononsalt.org.uk

Content provided by Mhairi Brown, Policy and Public Affairs Lead & Graham MacGregor CBE, Chair of Action on Sugar and Action on Salt and Professor of Cardiovascular Medicine

Barts and the London, Queen Mary University of London

For more information please visit actiononsugar.org and actiononsalt.org.uk.

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