Lauren Bandy

Food and beverage (F&B) manufacturers can support or hinder the transition towards a more sustainable food system. Yet, there is limited evidence about their potential to improve the nutritiousness and reduce the environmental impact of the F&B sector. Here we develop an approach to estimate the nutritional quality and environmental impact of the product lines of 44 major F&B manufacturers in the UK. We find considerable variation in terms of nutritional quality and environmental impacts across manufacturers operating within the same food retail category and within existing F&B product portfolios. We identify how changing the types of product sold by these manufacturers offers potential for nutritional and environmental benefits. For some of the F&B manufacturers assessed, changes to 10% or less of their product line could deliver more than half of the potential gains in nutritional quality or sustainability.

Background: To address high rates of diet-related disease, the UK Government has a series of voluntary targets for retailers, manufacturers, and the out-of-home sector (e.g., restaurants), to reduce the sugar, salt, and calorie content of food products. The sugar targets were intended to be met in 2020, the salt targets in 2024, and the calorie targets in 2025 (extended from 2024 due to Covid-19). There is limited evidence for how the out-of-home sector is performing against these targets, and individual company responses have not been evaluated. This study aimed to assess adherence to UK Government’s sugar, salt, and calorie reduction targets for menu items offered by the 21 highest-grossing restaurant chains in 2024. Methods and findings: Nutritional information was collected from restaurants’ online menus. Mean/median sugar, salt, and calorie content, per 100 g and per serving, was calculated for each restaurant and food subcategory. Sugar, salt, and calorie content for each menu item was compared against the UK Government’s targets, and the proportion of menu items meeting (i) each and (ii) every applicable target, was calculated for each restaurant and food subcategory. Three thousand ninety-nine menu items were included. Across all restaurants, 61% of menu items met their calorie targets, 58% met their salt targets, 36% met their sugar targets, and 43% met all of their applicable targets. Six of the 12 food subcategories, and nine of the 21 restaurants, had over 50% of menu items meeting all of their applicable targets. Menu items from Papa John’s were the lowest adhering for the calorie (35%) and salt (8%) targets, and menu items from Burger King, KFC, Nando’s, and Vintage Inns were the lowest adhering for the sugar targets (0%). Menu items from pizza restaurants had the lowest adherence to all applicable targets (32% overall) out of all the restaurant types, but items offered by restaurants with similar menu foci were also found to vary in their adherence. We were unable to account for heterogeneity in item-level sales due to the lack of accessible sales data from the out-of-home food sector, and therefore we could only assess performance against the targets for available items as opposed to purchased items. Conclusions: Our findings suggest that while menu items from certain restaurant types appear to perform worse than others against the sugar, salt, and calorie targets, items from restaurants with similar menu portfolios also vary in their adherence, highlighting the potential for restaurants to improve the nutritional quality of their products without changing their menu focus. Our study demonstrates that there is low adherence to voluntary schemes across the out-of-home sector, and therefore mandatory regulations may be a more effective approach to improving the nutritional quality of out-of-home food.

BACKGROUND: Excessive sodium intake is responsible for 3 million deaths a year globally. The UK is one of 64 countries to have a salt reduction program to help reduce the population’s sodium intake. It is a voluntary scheme with 108 category-specific salt content targets for the grocery and out-of-home sectors. This study aimed to estimate the potential impact of the 2024 targets on cardiovascular outcomes and health care costs for UK adults. METHODS: Long-term health modeling was based on the adult population in England. Changes in salt intake (g/d), whether the targets were met, were estimated using consumption data from the National Diet and Nutrition Survey 2018/19. Impact on ischemic heart disease and stroke, quality-adjusted life years, and health care costs were estimated using PRIMEtime, a proportional multistate life table model. RESULTS: If the salt reduction targets set for 2024 had been met, then salt intake would have reduced from 6.06 g/d (95% CI, 5.18–6.31) to 4.94 g/d (4.73–5.15), a reduction of 1.12 g/d (1.05–1.20). This would lead to 103 000 (UI, 41 000–161 000) fewer cases of ischemic heart disease and 25 000 (10 000–39 000) fewer cases of stroke over 20 years. A modeled 243 000 (94 000–383 000) quality-adjusted life years would be saved with a net saving of £1.00 billion (£0.35–1.73 billion) to the National Health Service over the remaining lifetime of the adult population. CONCLUSIONS: Reformulation of products to meet the targets could result in substantial reductions in cardiovascular disease without changes in dietary behaviors. Policymakers should consider options to strengthen salt reduction policies, including effective systems for monitoring and enforcement.

The government’s decision not to introduce a higher rate tax for the most sugary drinks is good news for industry but not for public health, argue Lauren Bandy and Peter Scarborough

Background Excessive sodium intake is responsible for three million deaths a year globally. The UK is one of 64 countries to have a salt reduction programme to help reduce the population’s sodium intake. It is a voluntary scheme with 108 category-specific salt content targets for the grocery and out of home sectors. The aim of this study was to estimate the potential impact of these targets on cardiovascular outcomes and healthcare costs for UK adults. Methods Long-term health modelling was based on the adult population in England. Changes in salt intake (grams/day) were estimated using consumption data from the National Diet and Nutrition Survey 2017/18. Impact on ischaemic heart disease (IHD) and stroke, QALYs and healthcare costs were estimated using PRIMEtime, a proportional multistate lifetable model. Results If the salt reduction targets set for 2024 were met, then salt intake would reduce from 6.06g/day (95% CI 5.18 – 6.31) to 4.94g/day (4.73 – 5.15), a reduction of 1.12g/day (1.05 – 1.20). This would lead to 103,000 (UI 41,000-161,000) fewer cases of IHD and 25,000 (10,000 – 39,000) fewer cases of stroke over 20 years. A modelled 243,000 (94,000-383,000) QALYs would be saved with a net saving of £1.00 billion (£0.35-1.73 billion)) to the NHS over the remaining lifetime of the adult population. Discussion Reformulation of products to meet the targets could result in substantial reductions in cardiovascular disease without changes in dietary behaviours. Policymakers should consider options to strengthen salt reduction policies, including effective systems for monitoring and enforcement.

Objective: This systematic review investigates the characteristics, effectiveness and acceptability of interventions to encourage healthier eating in small, independent restaurants and takeaways. Design: We searched five databases (CENTRAL, MEDLINE, Embase, CINAHL and Science Citation Index and Social Science Citation Index) in June 2022. Eligible studies had to measure changes in sales, availability, nutritional quality, portion sizes or dietary intake of interventions targeting customer behaviour or restaurant environments. We evaluated study quality using the Mixed Methods Appraisal Tool. Results are synthesised narratively, and interventions’ impact on personal autonomy is assessed using the Nuffield intervention ladder. Setting: Small, independent or local restaurants or hot food takeaway outlets, with no restrictions by year or country. Participants: Anyone selling or purchasing food in intervention settings (e.g. restaurant staff/owners, customers). Results: We screened 4624 records and included 12 studies describing 13 interventions in 351 businesses. Most studies were of poor quality. Customer-level intervention components mostly operated on the lower rungs of the Nuffield ladder, and most had limited positive effects on increasing demand, measured as sales or orders of healthy options. Whilst rare, most interventions measuring business outcomes operated on higher ladder rungs and showed small positive results. There was insufficient evidence to investigate differences in impact by intervention intrusiveness. Acceptability was greater for interventions that were low-effort, inexpensive and perceived as not negatively impacting on customer satisfaction. Conclusions: Despite some evidence of small positive effects of healthy eating interventions on healthier purchases or restaurant/hot food takeaway practices, a weak evidence base hinders robust inference.

Background: In April 2018, the UK government implemented a levy on soft drinks importers and manufacturers, tiered according to the amount of sugar in drinks. The stated aim was to encourage manufacturers to reduce sugar and portion sizes. Previous evidence suggests that the policy has been successful in reducing sugar in drinks in the short-term since implementation, but their sustained effects have not been explored. This study aimed to assess the impact of the soft drink industry levy (SDIL) on sugar levels, price, portion size and use of non-sugar sweeteners in the medium-term. Methods and findings: Product data from 30 November 2017 to 14 March 2020 from one major UK retail supermarket were analysed (112,452 observations, 126 weekly time points). We used interrupted time series analysis, to assess the impact of the soft-drink industry levy (SDIL) on levy-eligible soft drinks, with exempt drinks (i.e. 100% fruit juices, milks, flavoured milks) acting as a comparator series. At the point of implementation of the SDIL (April 2018) there was a step change in the proportion of eligible drinks with sugar content below the SDIL levy threshold (5g per 100ml) (+0.08, 95%CI: +0.04, +0.12), with a similar sized decrease in the proportion in the highest levy category (> = 8g sugar per 100ml) (-0.06, 95%CI: -0.10, -0.03). Between April 2018 and March 2020, the proportion of eligible drinks below the SDIL levy threshold continued to gradually increase (p = 0.003), while those in the highest levy category decreased (p = 0.007). There was a step change in price of eligible drinks in the higher levy category at the point of implementation of +£0.049 (95%CI: +£0.034, +£0.065) per 100mL (for comparison, the levy is set at £0.024 per 100mL for this group). Trends in price for the high levy category were not altered by the SDIL. In the no levy category, there was a step change in price at the implementation (+£0.012 per 100mL, 95%CI: +£0.008, +£0.023), followed by a second step change in October 2018 (-£0.018p per 100mL, 95%CI: -£0.033, -£0.001p). The volume of products in the higher levy group decreased at the time of the implementation (-305mL on average including multipacks, 95%CI: -511, -99). The change in trend for the product volume of drinks in the higher levy group between April 2018 and March 2020 was in the increasing direction (+704mL per year, 95%CI: -95, 1504), but it did not meet our threshold for statistical significance (p = 0.084). There were no changes observed in the volume of lower levy drinks or no levy drinks. There was a step change in the proportion of drinks with non-sugar sweeteners at the implementation of the SDIL (+0.04, 95%CI: +0.02, +0.06). Conclusion: These results suggest that the SDIL was successful in [1] producing reductions in sugar levels that were maintained over the medium term up to March 2020 and [2] a reduction in product volume for higher tier drinks that may be diminishing over time. Our results also show that the SDIL was associated with a maintained price differential between high and low sugar drinks.

Context: Corporate engagement with food and beverage companies who produce food associated with health harms is a divisive topic in the global nutrition community, with high-profile cases of conflict of interest increasingly coming under scrutiny. There is a need for an agreed method to support health organizations in deciding whether and how to engage with large food and beverage manufacturers. Aim: The aim of this study was to develop a method to quantify the proportion of sales from food and beverage companies that are derived from unhealthy foods to support organizations in determining which companies might be considered high-risk for engagement. Methods: The 2015 WHO Euro nutrient profile model was applied to 35,550 products from 1294 brands manufactured by the top 20 global food and beverage companies from seven countries (Australia, Brazil, China, India, South Africa, UK and USA). For the purpose of this study, products that met the WHO Euro criteria were classified as “healthier” and those that failed were classified as “unhealthy”. Products were grouped by brand and weighted by the brand’s value sales for 2020. The primary outcome was the proportion of each company’s sales that were classified as unhealthy and healthier by company and category. Results: Overall, 89% of the top 20 companies’ brand sales were classified as unhealthy. For every USD$10 spent on the top 20 companies’ brands, only $1.10 was spent on products considered healthier. All companies saw the majority of their sales come from unhealthy foods, including soft drinks, confectionery and snacks. None of Red Bull or Ferrero’s sales were classified as healthier and less than 5% of total sales were healthier for Mondelēz, Mars, and PepsiCo. Some companies had higher proportions of sales deriving from healthier products, including Grupo Bimbo (48%), Danone (34%) and Conagra (32%), although the majority of their sales were still derived from unhealthy foods. Discussion: The results presented in this study highlight the reliance the leading food and beverage companies have on sales of unhealthy products that are contributing to diet-related disease globally. The method and steps we have laid out here could be used by organizations in the global health community to identify companies that have conflicts of interest when it comes to engaging with governments, international organizations and public health bodies on issues of policy and regulation.

Background and objectives: Dietary changes are necessary to improve population health and meet environmental sustainability targets. The present study aimed to analyse the impact of in-store promotional activities implemented in major UK supermarkets on purchases of healthier and more sustainable foods. Methods: Three natural experiments examined the impact of promotional activities on (a) no-added-sugar (NAS) plant-based milk (in 200 stores over 3 weeks), (b) products targeted during a ‘Veganuary’ event (in 96 stores over 4 weeks), and (c) seasonal fruit (in 100 non-randomised intervention and 100 matched control stores over 16 weeks). Data were provided on store-level product sales, in units sold and monetary value (GBP), aggregated weekly. The predominant socioeconomic position (SEP) of the store population was provided by the retailer. The primary analyses used interrupted time series and multivariable hierarchical mixed-effects models. Results: Sales of both promotion-targeted and overall NAS plant-based milks during the promotional period increased (targeted food: +126 units, 95% CI: 105, 148; overall: +307 units, 95% CI: 264, 349). The increase was greater in stores with predominately low SEP shoppers. During Veganuary, sales increased for plant-based foods on promotion (+60 units, 95% CI: 37, 84), but not for the sales of plant-based foods overall (dairy alternatives: −1131 units, 95% CI: −5821, 3559; meat alternatives: 1403 units, 95% CI: −749, 3554). There was no evidence of a change in the weekly sales of promoted seasonal fruit products (assessed via ratio change in units sold: 0.01, 95% CI: 0.00–0.01), and overall fruit category sales slightly decreased in intervention stores relative to the control (ratio change in units sold: −0.01, 95% CI: −0.01, –0.00). None of the promotional activities resulted in the continued purchase of promoted products after the intervention period was over. Conclusion: Promotional activity (including prominent positioning and price promotions) related to healthier or more sustainable food products can have a short-term impact on what food consumers purchase. But interventions are short-lived and effects on behaviour are not sustained, suggesting these have limited value in the long-term goal to achieve healthier and more sustainable purchasing patterns. Keywords: sustainable diet; promotions; supermarkets; purchases