Impact of a health marketing campaign on sugars intake by children aged 5–11 years and parental views on reducing children’s consumption

The association between Free Sugars intake and non-communicable diseases (NCDs) such as obesity and dental caries has been well documented [1‐4] and there is a wealth of evidence suggesting current sugars intakes are exceeding recommendations in many countries [5‐7]. Free Sugars include all mono- and di-saccharides added to foods by manufacturer, cook or consumer, plus those sugars naturally present in honey, syrups, fruit juices and fruit juice concentrates¹ [8].

In 2015 the World Health Organisation issued a strong recommendation that Free Sugars intakes by individuals should not exceed 10% of total energy intake, with a conditional recommendation to reduce Free Sugars intake to below 5% of total energy intakes [9]. Following this, the Scientific Advisory Committee on Nutrition (SACN) recommended that at a population level, the intake of Free Sugars should not exceed 5% of total energy intake in the UK [10]. Likewise, in the US Department of Agriculture recommend that Americans should consume less than 10% of calories as added sugars [11] (which includes syrups and honey, but excludes those Free Sugars in fruit juices and fruit juice concentrates).

Data from the UK National Diet and Nutrition Survey (NDNS) indicate that intake of Free Sugars by all age groups exceeds the recommendation [12]. Boys and girls aged 4–10 years received an average of 13.6 and 13.4% (respectively) of their food energy from Free Sugars. Only 3% of boys and 1% of girls had intakes below or equal to 5% total energy. In the US more than 13% of energy is provided by added sugars [11], and only 33% of children aged 2–19 years meet the dietary guideline recommendation [6].

Considerable action, including upstream and downstream preventive measures is therefore required to bring sugars intake in line with current recommendations. Following a review of the evidence for action on sugar reduction, including what drives excessive sugars intake, PHE proposed a broad range of measures to reduce sugars intake [13]. Actions included upstream approaches, such as the introduction of a structured, transparent programme of sugar reduction and a wider reformulation programme. With all sectors of the food industry challenged to reduce the overall sugars content of key foods that contribute to intakes of children by around 20% by 2020 through product reformulation to cut the sugars levels in products; a reduction in portion size; and/or a shift in consumer purchasing towards lower/no-added sugars products and introducing a levy on sugar-sweetened beverages [13]. However, if instigated without first building public support such measures can attract criticism for interfering unduly with personal choice [14‐16].

Downstream approaches aim to inform the public, change opinion and build support for change. PHE proposed to reduce sugars intake by raising awareness of the amount of sugars in children’s diets in England in comparison with government recommendations, problems around high amounts of sugars in the diet and to encourage families to take action to reduce intakes [13]. In 2016, PHE launched the Change4Life Sugar Smart Campaign [17]. This health marketing campaign used TV, radio, a digital product and advertising to: raise awareness of the high levels of sugar consumed by children and the associated health harms; raise awareness of the amount of added sugars in everyday foods and drinks; and to encourage parents to cut down the amount of such sugars their children consumed.

Sugar Smart packs were distributed to primary age children via schools, which provided families with information about guidelines for sugars intake and practical information to help them reduce sugars in their children’s diet. A free Sugar Smart app was available to download, which enabled parents to see how much sugars was contained in everyday foods and drinks (depicted in sugar cubes) by scanning the barcode on pack.

The main purpose of health marketing campaigns such as the Change4Life Sugar Smart Campaign is to raise awareness, change attitudes and ultimately help shift the behaviour of the population. Information on the impact on attitudes and on dietary behaviour is therefore important in determining if health marketing is an effective means of helping to reduce a populations sugars consumption.

The aim of the present study was to assess any impact of the Change4Life Sugar Smart Campaign on the dietary behaviour of children aged 5–11 years whose parents had shown an interest in previous Change4Life campaigns. A second aim was to explore any impact in awareness around sugars and to identify any potential barriers and facilitators to reducing sugars intake.

The objectives were:

In total, 837 participants were invited to take part in the first three time points. For the long-term follow-up, the 539 participants who completed two baseline dietary recalls, were invited to take part. The completion rates and sample demographics for each time point of the study are shown in Table 1.

A small number of invalid recalls were eliminated from the final dataset at each time point. Reasons included, the inclusion of alcohol (possibility that the parent completed the recall for themselves instead of their child), or a recall time of less than 2 min (suggesting the recall had not been completed accordingly).

To the authors knowledge this is the first study to measure the impact of a health marketing campaign aimed at reducing sugars consumption on the detailed dietary behaviour of a national sample of children. The final sample was balanced for gender split, however, despite weighting the sampling procedure, the final sample included a relatively higher proportion of families from the ABC1 group. The study has shown that the health marketing campaign was successful in reducing the mean intake of total sugars by approximately 2% of total energy intake in a group of children whose families had shown an interest in previous Change4Life campaigns, however reductions were not sustained at the 12-month follow up. The qualitative findings indicate that parents want to reduce their child’s sugars intake but societal barriers and confusion over types of sugars hamper efforts to change. The unintentional increase in the mean amount and percentage of energy derived from dietary fat of between 1 and 2.4%, may have resulted from an increase in consumption of milk or of higher fat savoury snacks as replacements for sugars-containing items. This finding highlights the importance of giving any nutrient specific advice in the wider context of a healthy diet; indeed the PHE’s 2017 campaign focused on all elements of a healthier diet under the banner of Change4Life ‘Be Food Smart’ [26].

The reported data for intake of sugars and nutrients are comparable with the recently published UK data from the NDNS [12], which showed the average intake of Free Sugars was 54.5 g and 49.9 g for boys and girls aged 4–10 years respectively, contributing 13.6% (boys) and 13.4% (girls) to daily energy intake. The data are similar to that for added sugars from other industrialised countries including Australia and the US: data from the 2011–12 Australian Health Survey showed children aged 4–8 years obtained 11.9% of energy from added sugars (~ 50 g/ day) [27]. Data from the US NHANES for the 6–11 years age group showed added sugars (including honey and syrups) contributed 16.2% to energy intake [28].

The present study showed a wide range of values for the per capita median contribution of a food group, known to be high in sugars, to total sugars intake. This in part is explained by the wide age range of the study population, as the contribution of different foods to sugars intake will change with age. The sample size was, however, not large enough to allow meaningful sub-group analysis by age. The data show that soft drinks and fruit juice make relatively large contributions; a finding that concurs with data from the aforementioned surveys in the UK, Australia and the US [12, 27, 28]. What is distinct from the current data is that the median contributions from known sources of sugars did not account for total sugars intake. This suggests that children obtain a substantial proportion of sugars from less obvious sources i.e. foods not perceived by parents to be high in sugars. The qualitative data support this and indicate concern amongst parents about the amount of sugars in unsuspected items such as pasta sauces and some breakfast cereals.

The campaign made no notable impact on the contribution of dietary sources of sugars. Trends towards an increased contribution from soft drinks due to a possible shift in the source of sugars from foods to drinks, a trend which warrants further investigation, and a slight reduction in that from fresh fruit are of concern and contrast to the campaign messages. However, the qualitative data indicated confusion over ‘bad’ and ‘good’ sugars, with reference being made to restricting fruit intake because of sugars content. Despite the Sugar Smart app including clear information with respect to which sugars to limit, this sound information competes with misleading misinformation from other sources such as the media and internet. The public need to be made aware of where to look for credible information on food and nutrition, including information on sugars.

The qualitative findings showed that the health marketing campaign raised awareness of sugars in foods and drinks in both parents and children and impacted on foods bought and consumed by families. Data showed that in general, parents supported the messages of the campaign and want to control their child’s sugars intake, but face challenges in putting this into practice, including misleading marketing, less obvious sources of sugars and confusion for which types of sugars to reduce.

The study has several limitations. First, parents were selected from the PHE Change4Life database, therefore it could be argued that they were potentially more motivated to make changes to their children’s diets. Measuring individual exposure to the campaign was not possible. Second, food and drink intake was assessed at weekends only. This was because children were not of an age where they could reliably record their own food intake and parent records of child food intake had to be relied upon. Recording at a weekend, when giving treats may be more likely, may have in part obscured the impact of the campaign. Children under the age of 10–11 years are unlikely to be able to accurately recall their food and drink intakes and estimate portion sizes due to limited cognitive ability [29]. Although conducted in a younger age group, research by Wallace et al. (2018) found that parents of pre-school children were able to report the food and drinks their child consumed using an online 24-h recall tool similar to Intake24 with reasonable accuracy [30]. Thirdly, the PHE Change4Life campaign was scheduled to run immediately in the New Year, following the holiday period as this is a time when people may be more perceptive to making healthy lifestyle changes [31]. This meant that seasonal activities may have impacted upon baseline data and seasonal fluctuation in intake may have contributed to the changes observed at peak campaign. To explore this phenomenon and control for seasonal variation, long-term follow up included data collection exactly 12 months from baseline and data at 10 month post baseline (outside the Christmas season). Although our results suggest a decrease in sugars intake that was not sustained, there were differences between 10 and 12 months data. At 10 months post-campaign there was a statistically significant decrease in percentage energy from Free Sugars, but this was not sustained at the 12 month follow up. Therefore a seasonal influence on sugars intake cannot be ruled out. Finally, the study relied on self-reported dietary data, the limitations of which, including recall bias, are discussed elsewhere [32].

The Sugar Smart health marketing campaign was successful in raising awareness of sugars intake among parents and children who had shown an interest in previous Change4Life campaigns. This study suggests the campaign had a positive impact in reducing sugars intake, however reductions in sugars were not sustained. The findings suggest improved consumer education on different types of sugars and improved food labelling are needed. The health marketing campaign was, however, only one of a broad range of measures being introduced collectively by PHE to reduce sugars intake.