Impact of Measures Aiming to Reduce Sugars Intake in the General Population and Their Implementation in Europe: A Scoping Review

Abstract

Objectives: Implementing public health measures is necessary to decrease sugars intake, which is associated with increased risk of noncommunicable diseases. Our scoping review aimed to identify the types of measures implemented and evaluated to decrease sugars intake in the population and to assess their impact.

Methods: Following a review of systematic reviews (SRs) published in 2018, we systematically searched new SR (May 2017–October 2020) in electronic databases. We also searched the measures implemented in Europe in the NOURISHING database. Two researchers selected the reviews, extracted and analysed the data.

Results: We included 15 SRs assessing economic tools (n = 5), product reformulation and labels/claims (n = 5), and educational/environmental interventions (n = 7). Economic tools, product reformulation and environmental measures were effective to reduce sugar intake or weight outcomes, while labels, education and interventions combining educational and environmental measures found mixed effects. The most frequently implemented measures in Europe were public awareness, nutritional education, and labels.

Conclusion: Among measures to reduce sugar intake in the population, economic tools, product reformulation, and environmental interventions were the most effective, but not the more frequently implemented in Europe.

Introduction

The frequent consumption of excessive dietary sugars, especially sugar-sweetened beverages (SSBs) is a risk factor for unbalanced diet, weight gain, and an increased risk of noncommunicable diseases including type 2 diabetes [1, 2], cardiovascular disease mortality [3], and dental caries [4, 5]. A causal link between a high-sugar diet and obesity has been found and explained by free sugars, especially in liquid form [5, 6]. According to the World Health Organization (WHO), the term “free sugars” includes all “monosaccharides and disaccharides added to foods by the manufacturer, cook or consumer, and sugars naturally present in honey, syrups, fruit juices and fruit juice concentrates” [5].

The WHO strongly recommend that intake of free sugars should not exceed 10% of total energy intake, and a conditional recommendation states that it should not exceed 5% [5]. This represents a maximum intake of 50 g/day, ideally 25 g/day, for a person consuming 2,000 calories. In a review comparing total sugars (naturally present and added in food and drink) in several European countries, the mean intake ranged from 76 g/day in Spain to 117 g/day in the Netherlands [7]. In a Swiss survey, the mean intake of total sugars reached 107 g/day (11% of total energy intake), and only 8% of the population followed the WHO recommendation of less than 5% of total energy intake [8].

Many scientific organizations and authorities at international, national and local levels have issued policy recommendations that aim to reduce sugars intake, with a focus on children given their inclination to have higher sugar intake [9]. These include a range of public health measures, such as consumer education, food and nutrition labelling, regulation of the marketing, fiscal policies, population intake monitoring and product reformulation [2]. Governments around the world have already adopted different measures to reduce sugar intake, and their level of implementation differs among the countries, as shown by the NOURISHING database, a tool developed by the World Cancer Research Fund International that indexes by country the measures designed to tackle unhealthy diets [10, 11].

In 2018, a review of reviews published by Kirkpatrick et al. assessed both the impact of measures aiming to decrease sugars intake among populations and the gaps in the available evidence [12]. Based on 12 systematic reviews (SRs) published between 2006 and 2016, the authors concluded that some interventions had the potential to reduce the intake of SSBs including taxes, modification of food environments, and, lastly health promotion and education. However, the limited available evidence and a high heterogeneity of methods and measures in included studies prevented the authors from drawing firm conclusions about the effectiveness of the interventions. Since 2016, numerous studies and reviews have significantly grown the body of evidence on this topic.

Considering the recent literature and the different approaches implemented by countries to reduce sugar intake in the population, it was important to conduct a scoping review that aimed to gather and analyse evidence on this topic, by assessing which measures have been scientifically evaluated, what were their impact, and which measured have already been implemented in Europe. This would help the decision-makers of European countries to identify which measures are preferable. The primary objective of our scoping review was to determine the types of measures studied to decrease sugars intake in the population and their impact. The secondary objective was to identify the measures implemented in Europe.

Methods

Type of Research Conducted

We conducted a scoping review in two steps. Firstly, we searched the SRs that assessed the impact of the measures implemented to reduce sugar intake in the population. The review of reviews of Kirkpatrick et al. also addressed this research question, based on SRs published until 2016. Thus, we focused on SRs published after this date and used a similar research methodology. The main findings of Kirkpatrick et al. were included in our analysis and compared to the more recent data. In addition, we searched the NOURISHING database in order to compile the measures that have been implemented by European countries [11].

Initially, our research group was commissioned by the Swiss Federal Food Safety and Veterinary Office FSVO to write a scientific report providing an overview of the strategic options for reducing sugar consumption in Switzerland at the population level [13]. This previous report used international scientific data, but focused on Switzerland. Therefore, the scoping of the current review was expanded to Europe.

A research protocol was developed before this scoping review was conducted, but it was not published. We planned initially to search SRs published until the end of 2019, however as new SRs were published, we extended the publication data and updated the search in October 2020. The PRISMA checklists can be found in Supplementary File S1.

Search of SRs on the Impact of the Measures Implemented to Reduce Sugar Intake

Research Question

Our research question was as follows: “What is the impact of public health measures to reduce sugar consumption on sugar intake and health outcomes in the population?”.

Inclusion/Exclusion Criteria

Publications were eligible for inclusion in this review if they were SRs published in English, French, German, or Spanish. Kirkpatrick et al. searched SRs published in English from January 2005 to May 2017 [12]. Therefore, we searched for SRs published between May 2017 and October 2020. Reviews that did not report a systematic search strategy to identify the literature were excluded, but SRs that did not include a meta-analysis were eligible.

We considered the pediatric and adult populations. The interventions included all type of interventions that aimed to support reductions in sugar consumptions among populations, at various levels (e.g., regional, national, and global). These include different study designs such as randomized control trials, nonrandomized controlled trials, pre-post studies, modelling studies, laboratory studies, etc. When the intervention did not aim to decrease specifically sugar intake, i.e., a program to prevent obesity, the SR was excluded. The outcomes could be either sugar intake, SSB consumption and/or any health outcomes.

Search Strategies and Identification of SRs

The search strategy for Medline PubMed used by Kirkpatrick et al. was used to identify recent studies. The full search strategy, checked by an experienced librarian, including all identified keywords and MeSH terms, is presented in Supplementary File S2. In the Cochrane Database of Systematic Reviews, we used the general term “Sugar” and restricted the search to May 2017–October 2020.

To identify eligible studies in the electronic databases, two independent reviewers (SBDT/CJC) screened the titles and abstracts. They assessed the full text of selected citations in detail against the inclusion criteria and recorded the reasons for exclusion. Disagreements that arose between the reviewers were resolved through discussion with a third reviewer (CM). Additional eligible studies were searched for in the references of retrieved articles. The results of the search and the study inclusion process were reported in a Prisma flowchart [14].

Extraction of Data and Presentation of Findings

The reviewers developed a data extraction tool to extract data of included SRs including goal, context, study methods, methodological quality appraisal, and key findings relevant to the review question. They were summarized in a table and described narratively.

To categorize the measures used to reduce sugar consumption, we employed categories based on those of Kirkpatrick et al. (“interventions influencing price,” “interventions influencing changes to the food environment,” and “health promotion and education interventions”), and the NOURISHING framework. This latter formalizes possible policies to promote a healthy diet across three domains (food environment, food system, and behavior change communication), and 10 sub-policies areas represented by the letters of the word NOURISHING [10], shown in Supplementary File S3.

We defined the following categories: 1) economic tools including taxes, 2) product reformulation and labels, and 3) education/healthy food environment [12]. The first category corresponds to the “intervention influencing price” of Kirkpatrick et al. and to the letter U of NOURISHING. For the second category, we have combined the different measures from the food environment domain of NOURISHING (letters I and N) other than economic tools, and that we consider applicable at a macro-level (regional or national level). No findings were available for letters R and S. Our last category combines the measures that aim to offer healthy food in specific settings (letter O of “the food environment” domain) and information and education measures (letters I and G of the “behavior change communication” domain). This combination, from two different domains, may seem counter-intuitive as these interventions are expected to impact sugar intake via different pathways. However, as widely recommended, these two types of measures were combined in the large majority of SRs that we included in our scoping review. When feasible, the findings of the SRs were further separated depending on the type of measure.

Search of Measures Implemented in European Countries in the NOURISHING Database

We searched all measures implemented in European countries that aimed to decrease sugars intake among populations in the NOURISHING database (last search conducted in October 2020) [11]. We focused on Europe in order to provide a clear overview of the measures implemented in this world region instead of providing unmanageable data for all countries across the world. We synthesized the results in a table using the NOURISHING framework [10].

Results

Characteristics of Included Studies

After screening 292 titles and abstracts, and reading 53 full texts, we have included a total of 15 SRs in the current review, as described in Figure 1.

FIGURE 1

The authors of the included SRs assessed the quality of the primary studies using different tools, mainly the Cochrane risk-of-bias tools [28, 29]. Two studies did not provide information on quality assessment [24, 30]. Table 1 shows the characteristics of the 15 SRs included.

Impact of the Use of Economic Tools Mainly Health Taxes

Table 2 details the findings of the five SRs that assessed the impact of economic tools on sugar consumption. Pfinder et al. showed that taxing foods exceeding a specific sugar threshold value impacted the consumption of sugar-added foods based on one study [16]: after implementation of the Hungarian public health product tax, the mean consumption of taxed sugar-added foods decreased by 4.0% [95% Confidence interval (CI): −0.07 to −0.01; very low-certainty evidence]. Teng et al., who made comparison between pre–post tax (n = 11) or taxed and untaxed jurisdiction(s) (n = 6), found that a 10% SSB tax was associated with an average decline in beverage purchases and dietary intake of 10.0% (95% CI: −5.0% to −14.7%), with considerable heterogeneity between results between jurisdictions [15]. Meta‐analysis results varied by study design and tax type, but not significantly. No significant difference was observed by study quality, consumption measure, age group (all ages, adults or children), or funding source.

Von Philipsborn et al. demonstrated, based on three studies, that an increased SSB price was associated with a reduction in SSBs sales by −19% (95% CI: −33 to −6%) at 4–12 months [6]. Roberts et al. found in 10/11 studies a decrease in purchases of SSBs and high sugar foods, at least in the short term, following an increase in prices [17]. Wright et al. observed in 18/26 studies a positive impact of SSB taxes on the reduction of their consumption. The observed effect may be proportionate to the level of the tax. Tax on SSBs higher than 20% of the initial price appeared more likely to have a positive impact [30].

Impact of the Use of Product Reformulation or Labels/Claims

The two SRs of Hashem et al. and Grieger et al. assessing the impact of reformulation essentially included modelling and simulation studies (Table 2) [18, 19]. They showed a theoretical reduction in sugar consumption and an estimated improvement in health outcomes. In addition, Hashem et al. observed, based on four randomized controlled trials assessing the effect of sugar-reformulated products over a period of 8–10 weeks, a reduction of −11% (95% CI, −20 to 2) in sugar intake and −1.0 kg (95% CI, −2.2 to −0.08) in body weight [18]. In the SR of von Philipsborn et al., very low-certainty evidence from three studies suggested that voluntary industry initiatives to improve the nutritional quality of the whole food supply may affect SSB sales and purchases, but the direction of reported effects varied [6].

Regarding the use of food labels, the SR of von Philipsborn et al. found moderate-certainty evidence that traffic-light labelling was associated with decreasing sales of SSBs, and low-certainty evidence that nutritional rating score labelling was associated with decreasing sales of SSBs [6]. Anastasiou et al. found a positive association between food labels and healthier diet quality in 12/13 studies, and one study found a negative association. In addition, the authors observed a positive association between the use of nutrition fact panels and a healthier diet in 10/12 studies. Research on the effect of the use of ingredient lists, serving size information and front-of-pack labels was insufficient to draw conclusions [20].

In the two SRs of Oostenbach et al. and Anastasiou et al., it remains unclear whether the impact of food health-related claims was beneficial or detrimental [20, 21].

Impact of the Educational and Healthy Food Environmental Interventions

As stated previously, the seven SRs assessing the impact of educational/healthy food environmental interventions included very heterogenous study designs, interventions, settings, and populations. Except the SR of Micha et al. focusing on SSB and snacks, the other SRs evaluated only SSB intake, as illustrated in Table 2.

The majority of those reviews observed a reduction in sugar intake, mostly assessed by a reduction in SSB consumption. The SRs of Micha et al. [27] and von Philipsborn al et. [6], which studied the impact of healthy food environmental interventions only, and not education, showed beneficial impact on SSB intake, and unhealthy snacks intake or weight. More specifically, in a meta-analysis including 5/11 studies, von Philipsborn et al. reported a decrease in SSB consumption of −413 ml/day (95% CI: −684 to −143) after 4–12 months, when improving access to low-calorie beverages in the home environment among high consumers of SSBs at baseline. The same SR also concluded that a reduced availability of SSBs in schools was associated with decreased SSB consumption. Based on low evidence, these authors showed that improved availability of drinking water in schools and school fruit programs were associated with decreased SSB consumption [6]. Micha et al. reviewed the impact of school food environmental policies and observed a reduction of 0.18 servings of SSB/day (95% CI: −0.31 to −0.05) compared to habitual intake [27].

The five other included SRs examined the effect of educational and healthy food environmental interventions. In 2020, Dibay Moghadam et al. found a statistically significant decrease in SSB consumption/purchase in 7/17 (41%) studies promoting water consumption [22]. Based on 36 studies, Vézina-Im et al. concluded that over 70% of all interventions targeting individuals, their environment, or both were effective in decreasing SSB intake. The success rates (defined as the proportion of studies showing a significant reduction in SSB consumption) were 90% for legislative/environmental approaches, 65% for educational/behavioral interventions, and 67% for a combination of educational/behavioral and legislative/environmental approaches [26]. These authors found that more than half of the interventions were based on a psychosocial theory. The most frequent behavior-change techniques were: providing information about health consequences, restructuring the physical environment, behavioral goal setting, self-monitoring of behavior, threats to health, and providing general social support [26].

Some SRs provided findings for specific age groups. Abdel Rahman et al. assessed the impact of educational and behavioral interventions among children aged 4–16 years and found a trend toward reduction, with a mean reduction of 284 ml/day (95% CI, −643 to 76) [23]. Vargas-Garcia et al. evaluated the impact of educational and/or environmental changes on different age groups. A significant decrease in SSB intake was observed in children, with a mean reduction of 76 ml/day (95% CI: −105 to −46; 23 studies), and in adolescents, with a mean reduction of 66 ml/day (95% CI: −130 to −2; 5 studies). The reduction in adults was not statistically significant [25].

Comparison With the Previous Findings

A total of 12 SRs were included in the review of Kirkpatrick et al. [12], assessing the effect of price changes (n = 6) [31–36] and food environment interventions (n = 7) [34, 37–42], and health promotion and education (n = 7). The seven SRs that assessed the effect of food environmental interventions were the same that studied the impact of health promotion/education. The Supplementary File S4 details the characteristics and main findings of the studies included in the review of Kirkpatrick et al., as presented by these authors.

As illustrated in Table 3, Kirkpatrick et al. found positive impact of taxes on SSB demand and consumption in four SRs [12]. The findings on taxes and weight changes were less consistent; two reviews found positive outcomes, two found mixed results, and one showed no effect. No SR on the impact of labels/reformulation were included by Kirkpatrick el al. [12]. The five SRs that assessed the impact of environmental interventions alone showed reduction in SSB consumption. The impact of educational measures on SSB consumption was positive in three SRs, mixed in one SR, and no impact was observed in one SR. The impact of the educational/environmental measures on weight was more contrasted (beneficial effects: n = 3; mixed effects: n = 4; and no effect: n = 2).

As shown in Figure 2, considering all types of measures, a beneficial impact on SSB consumption was observed in 15/21 SRs included in the review of Kirkpatrick et al. and published since 2017 [12]. Beneficial effects on SSB consumption were observed for economic tools and interventions focusing on environment alone whereas SRs on education and those combining educational and environmental interventions found mixed results. Regarding the impact on weight outcomes, the results were less concordant. In the most recent SRs, economic tools, reformulation, and environmental interventions showed beneficial effects.

FIGURE 2

Synthesis of NOURISHING Database

Several European countries have implemented measures aimed at reducing sugar consumption in the population. In the “Behaviour change communication” domain, information (I) and nutritional education (G) are the most widely implemented measures, as described in Table 4. In the “Food environment” domain, the most frequently implemented measures are labels (N), followed by environmental measures aiming to offer healthy food and set standards in public institutions and other specific settings (O), restricting food advertising and other forms of commercial promotion (R), and health-related food taxes (U). In contrast, only a few countries have implemented environmental measures in the following areas: improving the nutritional quality of the whole food supply, including reformulation (I) and setting incentives and rules to create a healthy retail and food service environment (S). In the “Food system” domain, only a few countries have implemented measures aiming at decreasing sugar intake in the population.

Discussion

The aim of this scoping review was to identify the types of measures implemented and evaluated to decrease sugars intake in the population and to assess their impact. We included 15 SRs published since 2017 and that assessed economic tools (n = 5), product reformulation and labels (n = 5), environmental interventions (n = 2), and educational/environmental interventions (n = 5). Despite high heterogeneity in the 15 SRs included, we observed a beneficial impact of economic tools and interventions focusing on environment alone on sugar intake, mostly with respect to SSB consumption whereas SRs combining educational and environmental interventions found mixed results. The impact on weight outcomes was less frequently studied but still showed a beneficial trend, especially in the most recent SRs evaluating economic tools, product reformulation, and environmental interventions. According to the NOURISHING database, the most frequently implemented measures in Europe were information through public awareness, nutritional education, and labels.

Among the three types of measures that have been studied in the SRs, economic tools, focusing mostly on health taxes, were studied by five SRs. The implementation of taxes has shown to be effective in reducing SSB purchases and consumption. The SR of Roberts et al. has shown that the reduction in SSB purchases may be proportionate to the level of price increase imposed [17]. Wright el al. concluded that a tax on SSBs higher than 20% of the initial price was more likely to have a positive impact on health behaviors and outcomes [30]. According to the NOURISHING database, economic tools have been implemented in several European countries, including Belgium, Estonia, Finland, France, Hungary, Ireland, Latvia, Norway, Portugal, Spain, and the United Kingdom. The level of the tax and the ways it has been implemented (e.g., definition of the foods and drinks subject to the tax) differs widely between countries. The majority of available evidence has shown a beneficial impact on short-term outcomes, mainly on SSB sales/consumption; however, other positive and long-term impacts should not be underestimated. The implementation of taxes on sugar may provide an incentive for the food industry to develop and promote healthier products. Some studies have extrapolated the long-term effects of a tax on SSB and concluded that they could reduce rates of illness, including obesity [31], mortality rates, health costs and increase quality of life [43–45].

The second type of measures that have been studied in the included SRs are product reformulation and labels/claims. Only three SRs have recently assessed the impact of product reformulation [6, 18, 19], mainly based on simulation and model studies. The results were promising on estimated sugar reduction and health outcomes; however, these results need to be confirmed in the community. This type of measure has the advantage of reducing consumers’ intake of certain nutrients without requiring a conscious effort on their part. The impact of labels and claims is more contrasted. These mixed results may be explained by the large variability in existing labels and their confusing effect on consumers, who may be lost at the time of purchase [46, 47]. The effects of claims were unsure because of potential compensatory behaviors. The NOURISHING database shows that product reformulation has been implemented only in four European countries, i.e., France, Norway, Switzerland, and the United Kingdom. This type of measure may be difficult to implement, as it requires the involvement of several partners, mainly the food industry, and may present challenges in terms of foods technology. In contrast, the majority of European countries have already implemented labels and claims, which are often applied in the form of the nutritional composition available on food and drinks packages.

The third type of measures that have been studied in the included SRs are educational and environmental interventions, mostly implemented in a school setting. High heterogeneity was observed in the interventions that included educational initiatives, especially nutrition education curriculums, and/or environmental measures, such as the provision of healthful foods or beverages and quality standards for competitive foods and beverages. It is therefore difficult to assess the impact of each of these individual interventions, as they are frequently associated as recommended by current guidelines on prevention of overweight and obesity and health promotion. Educational measures place a lot of responsibility on individuals to make the final choice about their diet while the environmental conditions strongly influence food choices and adequate conditions clearly promote healthy choices. In this scoping review, the findings of environmental interventions alone were more striking than education alone or a combination of educational/environmental measures. Educational interventions still remain important tools in order to improve the nutritional knowledge and food literacy of the population, and facilitate the acceptability of environmental measures. Therefore, both types of measures should be combined in a coherent approach in order to avoid nutritional aberrations resulting from the different messages and stakeholders. Monitoring of the measures is also crucial in order to validate and/or adapt these measures according to the results. Targeted evaluations of the measures in terms of the resources invested, the process, and the results obtained are essential. The NOURISHING framework may be useful for the various stakeholders to clarify the types of measures implemented and their coherence, and to structure the intervention in a comprehensive approach.

Our scoping review has some limitations. First, the SRs included in our review included mainly adults and children in a school setting, and some subgroups of the population were not represented, such as preschool children, pregnant women, and the elderly. Moreover, the studies were mostly conducted in the US and Europe, thus affecting the external validity of our findings. Secondly, we only searched for the measures implemented in European countries in the NOURISHING database and not those implemented worldwide. Thirdly, the quality of the original studies included in the SRs was often considered to have high risk of bias by the authors, which may affect the internal validity of the findings. The weaknesses of the studies were often related to data collection related to sugar intake, the definition of sugars, or the duration of interventions. In relation to the SRs included in our review, the study designs of included original studies were heterogenous, the measures to decrease sugar intake were also highly variable, and the outcome most frequently studied was reduction in SSB purchases and consumption. However, this intermediate outcome, widely used as a surrogate for total sugar intake, does not consider substitutions or compensatory behaviors.

In conclusion, this scoping review shows that three types of measures have been studied in SRs, including economic tools, product reformulation and labels, and education/environmental interventions. A high level of heterogeneity was observed in the methodologies, populations, and interventions in the original studies. Economic tools and environmental interventions were effective to reduce sugar intake, as mostly assessed by SSB purchases and consumption. Interventions combining educational and environmental measures found mixed results. The findings on weight outcomes were less concordant but still showed a positive trend, especially for product reformulation. Some of these measures are used in Europe, but the most frequently implemented measures to date are information through public awareness, nutritional education, and labels. To close the large gap between sugar intake recommendations and actual intake, future measures should be implemented based on the available evidence using a global approach and integrating a thorough long-term evaluation.

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