Areas.for.policy.development—product,.price,.promotion.and.place

Policy Area Recent developments EHN Recommendations Reformulation of food products to reduce the

salt, saturated fat, and added sugar content of foods.

Increasingly, attention is focusing on the im-portance of changing mainstream food and drink products to reduce their contribution to salt, fat and sugar intakes.

It is interesting to note the potential synergy between other measures—such as improved nutrition labelling, advertising restrictions or calorie posting—and product reformu-lation. In the UK, for example, restrictions on advertising to children and colour-coded nutrition labelling appear to have acted as an incentive for food manufacturers to refor-mulate some products.⁵⁴¹ Similarly, part of the rationale for introducing a law requiring fast food chains to post calorie counts on menus in New York City was to encourage fast food outlets to modify the products on their menus or reduce portion size.⁵⁹² Changing the nutrient content of foods-tuffs is also appropriate further back down the food chain. Agricultural production techniques can affect, for example, the fat content and the fatty acid profile of meat and dairy products. Extensive livestock pro-duction (grass-fed) has a positive effect on saturated fat content in both red meat and dairy products.

The EU strategy on nutrition, overweight and obesity (the nutrition White Paper) signalled the Commission’s intention to facilitate more pro-duct reformulation.

Initially, efforts at the EU level—as elsewhere—

focused on salt. The EU Framework for National Salt Reduction Initiatives (the salt reduction ini-tiative) was published in 2008. Salt reduction has been the first priority of the new High Level Group on nutrition and physical activity. The fra-mework aims to support national plans, to enable progress to be compared, to ensure consistent messages to the food industry and to help gene-rate momentum and action. The EU Council gave its backing to salt reduction measures, with an emphasis on reformulation, by adopting a series of conclusions in relation to actions to reduce population salt intake for better health in May 2010.⁵⁹³

There are now salt reduction strategies in many countries and several countries have initially focused on efforts to reduce the salt content of bread. Some countries are pursuing a voluntary approach while others have introduced legisla-tion. A voluntary agreement with the bakery in-dustry in Spain, for example, succeeded in re-ducing the salt content of bread by more than 18% in four years.⁵⁹⁴ The UK and Belgium have also adopted a voluntary approach. Finland intro-duced legislation many years ago and Portugal, which has particularly high stroke mortality rates, has launched a multi-sectoral initiative and suc-ceeded in passing legislation to limit the sodium content of bread (having found that Portuguese bread contains almost half as much salt again as bread from six other European countries) and other processed foods, as well as a requirement to list the salt content of foods. So far, only the UK and Finland have been able to show a clear impact on population salt intakes.

Attention is now turning to the need to reformu-late products to reduce the fat and sugar content and to reduce portion sizes (see below). So far, the preferred approach appears to be voluntary, based on working with industry.

A discussion paper presented to the High Le-vel Group on Nutrition and Physical Activity in December 2009 made the point that although the reformulation efforts started with a focus on single nutrients (eg trans fats in Denmark, salt in UK), countries are now more likely to consider a whole product approach.

European Commission

Efforts to reduce the fat, sugar and salt content of mainstream food and drink products should be a key priority for Europe.

The European Heart Network has supported the European Commission’s efforts in this area, but questions whether the proposed voluntary approach will be adequate to secure the full public health gains. EHN is also concerned that some sectors of the population may miss out on the benefits if reformulation is limited to voluntary private sector efforts.

The Commission should set firm targets for progress in product reformulation and should set a priority list of products for reformulation (e.g. bread and bakery, ready prepared meals, breakfast cereals) and target levels. If the col-laborative voluntary approach does not deliver results within that timescale, the Commission should not hesitate to adopt a regulatory ap-proach and introduce rules setting maximum levels of these nutrients/ingredients for diffe-rent foodstuffs.

Efforts to reformulate products should be ac-companied by government information cam-paigns that help to create consumer demand for lower salt/fat/sugar products with a higher fibre (non-starch polysaccharide) content.

Agricultural production methods that improve the nutritional quality of foods should also be promoted with specific measures being taken to increase the production of vegetables and fruit and their ease of access to publicly-fun-ded facilities.

National governments

In addition to pan-European efforts, national governments should work with the manufactu-ring, catering and retail sectors to bring about reductions in fat, sugar and salt contents.

Governments should consider taking a manda-tory approach to reformulation if a voluntary approach does not work.

Food industry

The food manufacturing, retail and catering in-dustries should build on the progress that has already been made, and collaborate fully with national and European authorities to reduce the fat, sugar and salt content of foods.

Initiatives to reduce portion size.

The.growing.understanding.that.people.who.

are. served. more. food. eat. more. (regardless.

of.other.factors).has.focused.some.attention.

on. reducing. portion. size.. Research. shows.

that.average.portion.sizes.have.increased.in.

the.last.10-15.years.and.people’s.energy.in-take. increases. when. they. are. offered. larger.

portions,. as. people. tend. not. to. compensate.

between.meals.⁵⁹⁵.Bigger.portion.sizes.appeal.

to.consumers.because.they.imply.better.value.

for.money.and.also.because,.over.time,.expo-sure.to.larger.portions.affects.perceptions.of.

what.is.an.appropriate.portion.for.one’s.size.

and.level.of.physical.activity.

Linked to the recent efforts on product refor-mulation, there has also been attention on the need to reduce portion sizes. The European Par-liament has called on industry to review single-service portion sizes, providing a broader range of smaller portion options. More than 10 companies in Europe have made commitments to the EU Platform for Action on Diet, Physical Activity and Health that they will reduce portion size.

In parallel with initiatives to reformulate food products, the European Commission, national and local governments, along with the food industry and the voluntary sector, should fa-cilitate, and encourage initiatives to reduce portion size.

Legislation to ban industrially produced trans fatty acids

Trans fatty acids are found in commercial baked foods, fried foods, frozen foods, mar-garines, red meat and dairy products. Al-though trans fatty acids occur naturally in dairy and meat products, they are also in-dustrially produced and added to processed foodstuffs.

Given the strong evidence that consumption of trans fatty acids is a risk factor for car-diovascular disease, some national and local governments have taken the lead in regula-ting to restrict the amount of industrially-produced trans fats in foods.

In 2003, Denmark introduced legislation to li-mit the amount of partially hydrogenated oils in foods.

Some local administrations were quite quick to take a lead from the Danish example, and cities such as New York and Calgary introduced legisla-tion to limit trans fats in foods from restaurants and fast food outlets.

National governments, however, have been re-latively slow to follow the Danish example. In recent years, Switzerland, Austria and Iceland are among those countries that have introduced legislation to limit the trans fat content of foods and Spain has been considering a proposal. In the UK and the Netherlands, food authorities have worked with food manufacturers to agree a voluntary approach to reduce trans fats. The US and Canada have introduced mandatory labelling to warn consumers that foods contain trans fatty acids.

A study for the European Parliament⁵⁹⁶ found that the Danish ban on industrial trans fatty acids has been more effective in limiting trans fats in-takes than the voluntary action or the mandatory labelling requirements. The study, commissioned for the Parliament’s ENVI committee, called for a ban on industrially produced trans fats to be considered at EU level. The study was followed up by an initative by five MEPs to adopt a writ-ten declearation. However, The initiative did not achieve the required amount of signatures and fell in September 2010.

A legislative approach to reducing industrially-produced trans fatty acids has been shown to be effective. Given that trans fat intakes can vary dramatically between and within Euro-pean countries, policy in this area should be guided by actual intake data of vulnerable groups and not on population averages. Mea-sures are also needed to ensure that trans fats are not replaced with saturated fat.

European Commission

The European Commission should bring forward a proposal for an EU-wide regulation to eliminate industrially produced trans fats in foodstuffs marketed in the EU. Action at the EU level will support the functioning of the in-ternal market while at the same time ensuring a high level of health protection for all.

National governments

In the absence of proposed EU legislation, or for countries outside the EU, national legisla-tion to limit the presence of industrially-pro-duced trans fatty acids in foodstuffs is recom-mended.

Local governments

In many countries, food sold in catering outlets is regulated at the local level (with an existing local inspection infrastructure). In the ab-sence of national legislation, this presents the opportunity for local authorities to ban trans fats from foods served in restaurants, fast food chains, pub, cafés and other catering outlets.

Food industry

EHN favours the regulatory approach in this case, as it has been shown to be more effec-tive. Nonetheless, the voluntary approaches in the UK and Netherlands have yielded some progress and—pending any national or Eu-ropean legislation—the food industry should work collaboratively with national or local food authorities to reduce the presence of trans fat-ty acids in foods. In particular, multi-national companies have a responsibility to ensure and demonstrate that the low levels of trans fats that they can achieve in countries where there is regulatory or policy pressure are applied uni-formly across the countries where they operate.

Ensuring that consumers have easy access to meaningful information about the nutritional quality of foods.

For a food and nutrition strategy to be ef-fective it is essential that consumers can understand at-a-glance what is in their food.

Clear, nutritional labelling is a crucial part of educating people about a healthy diet and how different foods contribute to it.

For over 20 years public health advocates and consumer groups have been calling for rules to ensure consistent access to clear, understandable nutrition information.

Consumer research shows that colour co-ding is an effective way to ensure this rapid understanding.⁵⁹⁷

Nutrient profiles that enable the classifica-tion of foods that are high in fat, salt and sugar are an essential element for effective controls on food labelling and advertising.

In relation to nutrition labelling, the Commission adopted a proposal for a regulation on provision of food information to consumers in January 2008.

The Commission has tried to establish nutrient profiles as required by the regulation on health and nutritional claims.

The Commission’s approach to nutrient profiling has come in for a great deal of criticism from public health advocates (including EHN) and consumer groups.⁵⁹⁸

European Commission

Mandatory, legible, back-of-pack and front-of-pack labelling should receive first priority at the European level.

EHN continues to call for a simplified front of pack scheme. This should be a “sign pos-ting” scheme that would enable consumers to identify healthier choices at a glance. It should only contain key elements: energy, fat, saturated fat, sugars and salt. The front-of-pack scheme should be colour coded with red, yellow and green indicating high, medium and low levels of the four elements (based on percentage GDAs).

National governments

Urgent action is needed to improve the pro-vision of nutrition information in restaurants, cafés and other catering outlets. Authorities should consider a mandatory requirement to provide nutrition information (in the form of a traffic light labelling scheme covering key nutrients) for all chains with more than 10 outlets.

Ensuring availability of fresh drinking water Policies that promote access to free, safe drinking water could contribute to reducing consumption of sugary drinks. Schools, workplaces, public institutions, local autho-rities and private caterers could all play a role.

In France, public health advocates have been calling for legislation to introduce a requirement for water foundations in all public places (scho-ols, higher and further education establishments, swimming pools and sports facilities, ministries, town halls, public institutions) and transport fa-cilities, as well as in private companies.

Policies to ensure the provision of safe unswee-tened drinking water, particularly in schools, workplaces, public places and public institu-tions should be introduced.

2.4.2.2 Promotion

The. food. and. soft. drinks. industry. use. a. variety. of.

techniques. to. grab. our. attention.. Market. research—

including. techniques. such. as. focus. groups. to. identify.

words.and.images.that.provoke.a.positive.reaction.and.

studies.of.shoppers’.eye.movements—shows.that.choices.

about.what.to.eat.and.what.to.buy.can.be.influenced.by.

the.way.those.choices.are.presented.

Contemporary. food. marketing. techniques. have. been.

called. the. “modern sirens, leading us inexorably to chronic diseases and sometimes to early death.”^599.There.

is. growing. recognition. that. children,. at. the. very. least,.

should.be.protected.from.these.sirens..

Food.and.nutrition.policy.also.needs.to.promote.healthier.

eating.options..As.well.as.appropriate.use.of.mass.media.

educational.campaigns,.policy.makers.need.to.consider.

how.modern.food.marketing.techniques.can.be.used.to.

better.effect.to.promote.healthy.choices.

.

This. section. covers. both. policy. issues. that. seek. to.

mitigate. the. potential. negative. impact. of. modern.

marketing.techniques.on.food.choices.and.those.that.aim.

to.use.marketing.and.promotional.techniques.to.promote.

healthier. diets. and. more. active. living.. It. is. important.

to. recognise,. however,. the. vastly. different. amounts. of.

resources. to. these. different. types. of. promotion.. The.

communication. budget. of. France’s. national. nutrition.

programme. (PNNS),. for. example,. is. equivalent. to. only.

0.5%.of.the.budget.that.food.and.agriculture.companies.

allocate.to.television.advertising.in.France.⁶⁰⁰...

Given.this.huge.imbalance.in.resources,.along.with.the.

fact. that. promotional. techniques. can. be. used. to. have.

either.a.positive.or.a.negative.impact,.is.it.is.clear.that.

policy. action. to. promote. healthier. choices. will. only. be.

successful.if.it.is.combined.with.efforts.to.neutralise.the.

marketing.power.directed.at.children.

Policy Area Recent developments EHN Recommendations Controlling advertising of unhealthy foods

aimed at children

There is now widespread recognition that children should be protected from commercial influences that may influence their eating patterns. Throughout the last decade there have been growing calls for action to limit marketing of unhealthy foods to children in print, broadcast and electronic media. As well as advertising openly directed at children, there is also the issue of product placement—where food or drink products are portrayed in films or television programmes. A study in the US found that most brand placements in the movies are for energy-dense, nutrient poor foods. Six companies—PepsiCo, Coca-Cola, Nestle USA, McDonald’s, Dr Pepper/Snapple Group and Burger King—account for 45%

of 1,180 product placements in 138 films between 1996 and 2005.⁶⁰¹

There is also concern about sponsorship of sporting events—both spectator and participation sports—by foods or soft drinks high in fat, salt or sugar. Coca Cola, for example, is a major sponsor of events such as the Olympic Games and the FIFA World Cup. In the UK, for example, confectionery manufacturer Mars has sponsorship deals with football’s governing bodies in England and Scotland to encourage participation in the sport.

Given the global nature of many food and drink brands (and as national borders become less relevant for modern media) it is clear that international cooperation is needed to have any effect on international commercial media communications. There is, in fact, a precedent for international regulatory action to control marketing, in the form of the International Code on the Marketing of Breast Milk Substitutes. This is a useful precedent for international action on the marketing of foods and drinks to children.

A resolution by the World Health Assembly (Resolution WHA 60.23) requested that the Director General, among other things, takes action

“to promote responsible marketing including the development of a set of recommendations on the marketing of foods and non-alcoholic beverages to children.” In May 2006 in Oslo, WHO convened a Forum and Technical meeting on marketing of food and non-alcoholic drinks to children. At the World Health Assembly in 2010, a new resolution (WHA63.14) was adopted, urging member states to implement the recommendations proposed by the WHO Director General to reduce the impact on children of marketing of foods high in saturated fats, trans fatty acids, free sugars or salt. The Director General is to report back on progress in implementing these recommendations to the World Health Assembly in 2012.

The Directive on Audiovisual Media Services obliges EU member states and the Commission to encourage media service providers to develop codes of conduct regarding inappropriate audiovisual commercial communication relating to unhealthy foods accompanying, or included in, children’s programmes.

The review process that led to this new Directive is seen by many as a missed opportunity to restrict the advertising of unhealthy foods to children. The European Parliament has called on the Commission to bring forward stricter proposals if the voluntary approach is found not to be working.

The Commission organised workshops on codes of conduct on advertising unhealthy foods to children in December 2009 and in October 2010 encouraging the development of national codes.

In 2010 the UK took action to prohibit product placement (where items are portrayed in films or television programmes) of foods high in fat, sugar or salt in UK-made programmes.⁶⁰²

There should be no audiovisual commercial communication for foods high in fat, sugar or salt broadcast between 06h00 and 21h00.

Nutrient profiling schemes can be used to identify affected food products. Audiovisual commercial communication includes surreptitious advertising, sponsorship and product placement.

Restrictions on marketing of unhealthy foods to children should also encompass non-broadcast marketing techniques (eg online media etc) and the use of toy promotions to promote unhealthy foods. Controls should be introduced to prevent the promotion of links between sports or celebrities and unhealthy foods.

WHO

An international code should be developed—

under the auspices of WHO—to reduce substantially the extent and impact of marketing of unhealthy foods and beverages, particularly to children.

European Commission

Measures to protect children from audiovisual commercial communication concerning unhealthy food and drinks should be a priority at European level.

National governments

Pending the introduction of an international code or EU legislation in the long-term, national governments should introduce their own restrictions to protect children from advertising for unhealthy foods.

Local government

Local authorities—including, for example, health, education and recreation departments—can also take action to protect children from commercial messages about unhealthy foods in or near schools, play areas and other places where children gather.