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"Old issues, new promises" - Professor Francesco Cappuccio responds to plans to limit fat, salt and sugar in Children's food

Old issues, new promises

Mr Burnham and the Labour Party, if elected, pledge to set maximum limits on levels of fat, salt and sugar in food marketed to children. Whilst cynics and political commentators will fly the concept that this is purely pre-election campaign to attract attention, it would be good for the public to ponder on the potential of such promises and to welcome them[1].

The majority of the food and drinks we consume globally is produced by 10 large food and non-alcoholic beverage companies. They feed an estimated global population of several hundred million in more than 200 countries generating annual revenues in excess of US$400 billion. Food manufacturing and processing have relied on making food more convenient and fast to prepare and eat, cheap and alluring to the consumer in highly competitive markets. Stimulation of hedonic centres in the brain by the right combination of fat, sugar and salt would create preference and addiction. This explains why food processing has moved more and more towards the production of high fat, sugar and salt foods.

The principle of setting maximum targets is not new and it is central to public health priorities of national and international health organizations, whether governmental or not, based on a wealth of evidence accrued over decades that diets high in fats, sugar and salt are largely responsible for the epidemics of cardiovascular and metabolic diseases we face, with both health and financial burdens.

Obesity and obesity-related diseases (that include diabetes, cardiovascular disease and some forms of cancer) are the plague of the 21st century in the Western world and the prevalence has been rising worldwide, in spite of all attempts to change individual behaviour regarding food intake and exercise.

There is agreement that we need to reduce the consumption of fat, sugar and salt, as well as to continue reducing smoking rates and the proportion of young individuals who take up smoking, and to stop the unhealthy trend of heavy alcohol consumption in our society. However, there is disagreement on how to achieve these objectives. With the past Labour Governments, Britain saw the implementation of successful public health programmes, like population salt reduction, with the important component of engagement with food industry on a ‘voluntary’ basis for the achievements of independently set targets, signalling nevertheless the readiness to regulate, if necessary. This readiness was informed by the knowledge that, whilst a good self-regulatory voluntary system has benefits, it is less effective than regulation or legislation and, often, less cost-effective[2]. In 7 years Britain has seen an average reduction in salt intake of 1.4 g per day, equivalent to 15% reduction.

With the introduction of the Responsibility Deal by the incoming Conservative Government, things have changed. Emphasis has shifted to changing the behaviour of individuals towards food and drink and industry now sits at the centre of health policy making. Since then, the NICE Public Health Guidance for the prevention of cardiovascular disease published in 2010 was virtually shelved, population salt reduction slowed down with less food reformulation from industry, minimum price on alcohol was rejected, consumer-friendly labelling systems ditched, the adoption of plain cigarette packaging delayed and action on reducing sugar halted.


Prof F P Cappuccio MD DSc FRCP FFPH

Professor of Cardiovascular Medicine & Epidemiology

University of Warwick





In randomized controlled clinical trials in adults,

  • reducing dietary sugars (1-14%) was associated with a significant decrease in body weight of -0.80 (95% CI -0.39 to -1.21) kg.

  • increasing dietary sugars was associated with a significant increase in body weight of +075 (+0.30 to +1.19) kg.

In prospective cohort studies in children,

  • Significantly increased risk of being overweight associated with higher intakes of sugar sweetened beverages (one daily serving compared to none or very little) (odds ratio 1.55 [1.32 to 1.82]).


Salt[4] [5] [6]

In randomized controlled clinical trials in adults,

  • A reduction in salt intake reduces blood pressure by 3.39 (2.46 to 4.31) mmHg systolic and 1.54 (0.98 to 2.11) mmHg diastolic.

  • Those with intake below 5g salt per day had a reduced BP by 3.47 (0.76 to 6.18) mmHg and 1.81 (0.54 to 3.08) mmHg compared to those with intake above 5g per day.

In randomized controlled clinical trials in children,

  • A reduction in salt intake significantly reduces BP by 0.84 (0.25 to 1.43) mmHg systolic and 0.87 (0.14 to 1.60) mmHg diastolic.

In prospective cohort studies in adults,

  • Increased salt intake is associated with an increased risk of stroke (risk ratio 1.24 [1.08 to 1.43], stroke death 1.63 [1.27 to 2.10]), CHD death (1.32 [1.13 to 1.53]).

  • From 2003 to 2011, there was a significant decrease in mortality from stroke by 42% (~42 stroke averted per million population) and IHD by 40% (~151 heart attacks averted per million population). In parallel, there was a fall in BP of 3.0±0.33/1.4±0.20 mm Hg, and an increase in body mass index (0.50±0.09 kg/m2). Salt intake, as measured by 24 h urinary sodium, decreased by 1.4 g/ day.

  • Legislation or other measures to reduce dietary salt intake by 3 g/day (current mean intake approximately 8.5 g/day) would prevent approximately 30 000 cardiovascular events, with savings worth at least £40m a year.

Fats 6

  • Reducing mean cholesterol concentrations or blood pressure levels in the population by 5% (as already achieved by similar interventions in some other countries) would result in annual savings worth at least £80m to £100m.

  • Legislation to reduce intake of industrial trans fatty acid by approximately 0.5% of total energy content might gain around 570 000 life years and generate NHS savings worth at least £230m a year.

  • A programme across the entire population of England and Wales (about 50 million people) that reduced cardiovascular events by just 1% would result in savings to the health service worth at least £30m (€34m; $48m) a year compared with no additional intervention.


[1] Cappuccio FP et al. Br Med J 2011; 343: d4995

[2] Cappuccio FP. Br Med J 2007; 334: 859-60

[3] Morenga LT, et al. Br Med J 2012; 345: e7942

[4] Aburto NJ et al. Br Med J 2013; 346: f1326

[5] He FJ et al. BMJ Open 2014; 4: e004549

[6] Barton P et al. Br Med J 2011; 343: d4044