Measures to reduce dietary sodium and sugar

• Dietary sodium and sugar intakes are closely related to health: excessive dietary sodium intake is associated with hypertension, cardiovascular diseases, stroke and coronary heart attack, while excessive consumption of sugar would increase the risk of obesity, diabetes and tooth decay. In Hong Kong, the Government has been strengthening its measures to reduce excessive sodium and sugar intake of the public over the years through encouraging food and meal producers to participate in voluntary sodium and/or sugar reduction schemes and raising public awareness of less-salt-and-sugar diet and food options.
• Although a new round of the Population Health Survey has already commenced back in November 2020, it would take more time before the full impacts of measures on sodium and sugar intake of the public can be ascertained given the main fieldwork of the said Survey would last for 15 months.^{1Legend symbol denoting The Population Health Survey 2020 will provide latest information on the health status, health related lifestyles and other health parameters of the local population and help track changes in parameters such as salt intake level of the Hong Kong people.} Nevertheless, some available data suggests that more and more people are suffering from hypertension and diabetes mellitus, which are diseases often linked to sodium and/or sugar intake. Some stakeholders, therefore, expressed concern about the adequacy and effectiveness of the current measures,^{2Legend symbol denoting See Panel on Food Safety and Environmental Hygiene (2019, 2020).} calling for the Government to strengthen the voluntary sodium and sugar reduction measures with reference to overseas experience and consider legislative or fiscal measures such as: (a) requiring food manufacturers to adopt a mandatory labelling system^{3Legend symbol denoting Many overseas places have required food manufacturers to follow a voluntary or mandatory front-of-pack labelling scheme. The scheme is to help consumers make healthier food choices by providing simplified and easy-to-understand information on the key nutritional features of prepackaged foods. The traffic light food labelling system is one of the front-of-pack labelling approaches under which a food product's levels of specified nutrients are colour-coded on the label with red for high level, amber for medium level and green for low level.} for prepackaged food products (specifically recommending a "traffic light" labelling system); (b) taxing high-sugar content food and beverage products; and (c) outright regulating the sodium and/or sugar content in food.^{4Legend symbol denoting See Panel on Food Safety and Environmental Hygiene (2019, 2020), 香港01 (2017, 2018) and 東網(2020).}
• Many overseas places have implemented measures to reduce sodium and/or sugar in food, albeit with different policy tools and approaches. For example, South Korea is noteworthy for its success in significantly reducing dietary sodium intake through a close collaboration (including research and development ("R&D") support and accreditation schemes) between the government and the food trade in the implementation of various voluntary sodium (salt) reduction schemes. The United Kingdom ("UK"), on the other hand, provides experience on effectiveness of "sugar tax" on specified drinks to complement voluntary sugar-reduction measures. This issue of Essentials highlights the measures adopted by Hong Kong in reducing intake of dietary sodium and sugar, followed by a discussion of the observations on initiatives implemented by South Korea and the UK.

• The latest Report of Population Health Survey published by the Department of Health (covering data for 2014-2015) indicated that people aged 15-84 had an average daily sodium intake of about 3 500 milligrams (or 8.8 grams of salt), which was higher than the level recommended for adults by the World Health Organization ("WHO") (i.e. less than 2 000 milligrams daily, equivalent to 5 grams of salt or slightly less than one level teaspoon of salt). Meanwhile, the mean daily intake of total sugar among local adults was 53 grams per day,^{5Legend symbol denoting See Food and Health Bureau and Centre for Food Safety, Food and Environmental Hygiene Department (2020).} as estimated by the Centre for Food Safety. WHO recommends that a healthy adult with a daily energy intake requirement of 2 000 Kcal should limit intake of no more than 50 grams of free sugars,^{6Legend symbol denoting Free sugars refer to monosaccharides (e.g. glucose) and disaccharides (e.g. table sugar) added to food by the manufacturers, cooks or consumers, as well as sugars naturally present in honey, syrups and unsweetened fruit juices. See World Health Organization (2017).} representing about 10 sugar cubes per day.
• Against the above, the Government has strengthened its efforts on promoting sodium and sugar reduction in recent years, with the launch of a series of voluntary measures under five directions based on the advice of experts^{7Legend symbol denoting An international advisory panel was set up in 2014 to provide professional advice on reducing salt and sugar intake by the local population. The panel comprises five renowned public health experts from the Mainland and overseas.} and the Committee on Reduction of Salt and Sugar in Food ("CRSS") which was established in 2015.^{8Legend symbol denoting CRSS was set up in March 2015 to advise the Secretary for Food and Health on the formulation of policy directions and work plans to reduce the intake of salt and sugar by the public. It comprises representatives from various sectors, including food trade, healthcare professionals, academia and the education sector.} These measures seek to attain the targets of (a) achieving a 30% relative reduction in mean population daily intake of sodium/salt; (b) halting the rise in diabetes and obesity; and (c) containing the prevalence of raised blood pressure by 2025.^{9Legend symbol denoting These three targets are among those laid down in the "Towards 2025: Strategy and Action Plan to Prevent and Control Non-communicable Diseases in Hong Kong". The document, which was issued jointly by the Food and Health Bureau and the Department of Health in 2018, sets out nine targets to be achieved by 2025 for the prevention and control of non-communicable diseases.} The major voluntary measures/schemes implemented under the five directions for reducing salt and sugar intake by the public comprise:
  • (a)
    nurturing healthy dietary habits from an early age – the Government launched the Salt Reduction Scheme for School Lunches in 2017-2018 with a view to reducing the average sodium level of primary school lunches to not more than 500 milligrams in 10 years. A total of 13 lunch suppliers had participated in the Scheme to provide sodium-reduced lunch options in 2019-2020, covering over 80% of all primary schools in Hong Kong. The Government also implemented the "Healthy Drinks at School" Charter in 2018-2019 to reduce the intake of excessive sugar from drinks for preschool students. As at April 2021, about 45% of all kindergartens and child care centres had participated in the programme, committing to encouraging children to drink water and making healthy drinks available for them;
  • (b)
    encouraging restaurants to reduce salt and sugar in food provided – the Government introduced the Less-salt-and-sugar Restaurants Scheme in early 2019 to encourage restaurants to provide customers with food options of reduced salt and/or sugar or tailor-made less-salt-and-sugar dishes.^{10Legend symbol denoting According to information provided by the Centre for Food Safety to the Research Office, restaurants which offer less salt/sugar options to customers are committed to reducing (a) the salt content by at least half a teaspoon and/or (b) the sugar content by at least one teaspoon when preparing the dishes. For restaurants offering tailor-made less-salt-and-sugar dishes, they are required to provide at least three tailor-made less-salt and/or less-sugar dishes, as well as reducing the salt and/or sugar contents through reformulation of the original recipes (though there is no specific reduction target imposed).} Some 1 100 restaurants have so far joined the Scheme;
  • (c)
    reformulation of food products to reduce sodium content – Salt Reduction Scheme for bread was launched in September 2019 with the Centre for Food Safety setting voluntary sodium reduction targets (average and maximum) for bread,^{11Legend symbol denoting The average sodium reduction target set by the Centre for Food Safety for both white bread and wholemeal bread is 380 milligrams sodium/100 grams, with the maximum target for selected bread product set at 490 milligrams sodium/100 grams.} one of the major sources of sodium intake of the local population. As at May 2021, the seven major chained bakery shops and 16 non-prepackaged bread manufacturers that joined the scheme had all met the maximum reduction targets.^{12Legend symbol denoting As at May 2021, the participating chained bakery shops had achieved a 6% to 7% reduction in the overall average sodium content of their prepackaged white bread and wholemeal bread products. Meanwhile, participating non-prepackaged bread manufacturers had reduced the overall average sodium content of their non-prepackaged white bread and wholemeal bread products by 11% and 13% respectively. See Food and Health Bureau and Centre for Food Safety, Food and Environmental Hygiene Department (2021).} The Centre for Food Safety will further extend the Scheme to cover other prepackaged food products which are also among the major contributors of sodium intake of the local population such as soup products;
  • (d)
    enhancing transparency of information to facilitate informed product choices by consumers – the "Salt/Sugar" Label Scheme for Prepackaged Food Products was launched in October 2017 to help consumers easily identify prepackaged food products that meet the legal definitions of "low salt", "no salt", "low sugar" and/or "no sugar" by label display. So far, over 240 prepackaged food products have participated in the Scheme; and
  • (e)
    strengthening publicity and education efforts – the Government has promoted the importance of a less-salt-and-sugar diet through various conventional channels such as organizing large-scale publicity events, sponsoring radio and television programmes, promoting low-salt-low-sugar diet through posts on social media and performing online cooking demonstrations with less salt and sugar.
• Notwithstanding the various voluntary sodium and sugar reduction measures mentioned above, the full impacts of those measures on the sodium and sugar intake levels of the public have yet to be ascertained, probably until the completion of the 2020 Population Health Survey. The survey will provide latest information on the health parameters of local population such as, among other things, changes in sodium intake level of the Hong Kong people.^{13Legend symbol denoting Regarding sugar intake level of the population, the results of the 2014-2015 Population Health Survey did not include this indicator and there is currently no information on whether the 2020 survey will conduct such measurement.} Meanwhile, the Thematic Household Survey conducted by the Census and Statistics Department revealed a rising trend in the rate of persons who had chronic health conditions as diagnosed by practitioners of Western medicine. In particular, the rate of persons suffering from hypertension increased from 10.3% in 2009-2010 to 12.6% in 2014 and further to 14.6% in 2020-2021, and that of diabetes mellitus increased from 4.1% to 4.8% and then to a noticeably higher level of 6.8% over the same period.^{14Legend symbol denoting See Census and Statistics Department (various years).}

• Similar to the case of Hong Kong, South Korea has adopted a voluntary approach for its sodium (salt) reduction strategy. It introduced the National Plan to Reduce Sodium Intake ("National Plan") as early as in 2012, featuring a series of voluntary programmes and measures targeting at reducing the average population sodium consumption by 20% to 3 900 milligrams per day by 2020. The South Korean government has overachieved its salt reduction target, with the average population sodium intake level down to 3 274 milligrams per day in 2018. While this intake level remains more than 60% higher than the maximum daily value recommended by WHO,^{15Legend symbol denoting See Ministry of Food and Drug Safety (2020).} it represents a reduction of 32% from the baseline level of 4 831 milligrams per day in 2011. The distinctive features of the sodium reduction measures that have contributed to remarkable progress in reducing dietary sodium intake are summarized in the paragraphs below.

• According to an analysis conducted by the Korea Health Industry Development Institute^{16Legend symbol denoting The Korea Health Industry Development Institute is a government-affiliated institution under the Ministry of Health and Welfare tasked to provide professional support for enhancing the development of the healthcare industry of South Korea.} at the early stage of implementation of the National Plan, reduced sodium content in processed food made possible by various product reformulation initiatives of food manufacturers has played an important role in lowering the sodium intake level of the population.^{17Legend symbol denoting See Korea Health Industry Development Institute (2015) and Park, H. K. et al. (2020).} The active involvement of food manufacturers could be attributed to the proactive efforts of the government in enlisting their collaboration via (a) inviting representatives from the food manufacturing industry to sit on a subcommittee formed under the National Movement to Reduce Sodium Intake ("NMRSI") programme tasked to drive the product reformulation initiatives;^{18Legend symbol denoting The NMRSI programme was launched in 2012 to raise awareness of the sodium reduction initiatives among the key stakeholder groups. Subcommittees had subsequently been formed under NMRSI to drive the implementation of initiatives targeting at specific sectors (e.g. the processed food and catering sectors). See Park, H. K. et al. (2020).} (b) providing R&D support for manufacturers' product reformulation efforts; and (c) funding the Korea Food Industry Association to develop and disseminate implementation guidelines^{19Legend symbol denoting During the initial stage of the National Plan, the South Korean government spent 965 million won (HK$6.9 million) between 2012 and 2014 on developing sodium reduction guidelines for selected categories of high-sodium processed food. See Korea Health Industry Development Institute (2015).} for reformulating selected high-sodium processed food categories such as kimchi,^{20Legend symbol denoting The government has funded research on the reformulation of kimchi, which is a major contributor of sodium intake of the South Koreans, for reducing its sodium content. The high penetration of "kimchi refrigerators" among the South Korean households from round 2000s has helped facilitate the acceptance of reformulated lower-sodium kimchi: these refrigerators are specially designed to meet the storage and fermentation requirements of kimchi, and their lower storage temperature allows for a reduced sodium content of packaged or homemade kimchi.} instant noodle and soy sauce to reduce their sodium content. The product reformulation programme in South Korea covers a wide range of product categories, involving a total of 582 product items in over nine categories of prepackaged food as at end-2019. Moreover, the average sodium level of these reformulated products was reduced by 24%, which was well above the 10% sodium reduction target set by the government for high-sodium food categories.

• The government has introduced the "Samsam (low-sodium) Food Service Center" and the "Sodium Reduction Practice Restaurant" schemes to accredit food service centres and restaurants respectively as low-sodium food providers for providing low-sodium meal options. Participating food service centres are required to provide one lunch meal containing less than 1 300 milligrams of sodium for at least five days a week and employ at least one nutritionist for joining the "Samsam Food Service Centre" scheme. Meanwhile, restaurants joining the "Sodium Reduction Practice Restaurant" scheme are required to reduce the sodium content of at least 10% of the menu items and meet the specific reduction targets i.e. reduction to less than 1 300 milligrams per serving or by more than 30% of the sodium content if the menu item has more than 2 000 milligrams of sodium per serving. The sodium reduction menu should be operated in place for at least one month before designation. The government has provided clear guidelines and procedures to guide the participating food providers to meet the sodium reduction targets.
• To promote participation in the above schemes, the local government allows participating food providers to display a signboard designating it as "Samsam Food Service Centre" or "Sodium Reduction Practice Restaurant" and attach a menu board with information regarding the sodium-reduced menu items. The local governments conduct on-site inspections of the food service centres and restaurants before and after accreditation in order to ensure the sodium reduction targets are achieved and sustained. As at end-2019, some 230 food service centres and 600 restaurants had joined the accreditation schemes.

• South Korea has complemented the voluntary sodium reduction programmes for meals and food suppliers with educational initiatives at schools. For instance, under a "nutrition teacher" system,^{21Legend symbol denoting South Korea has implemented the "nutrition teacher" system since 2007 under which each school has to recruit a "nutrition teacher" to replace the then dietitian in administering the school meal operation and take up the additional role on nutrition education. As at end-2020, about two-thirds of the schools had recruited a "nutrition teacher". The rest had still been deploying a dietitian in managing the school meal operation.} "nutrition teachers" who have training as a teacher as well as a dietitian are deployed in individual kindergartens, primary schools and secondary schools to administer the school meal operation (to ensure quality and nutritional standards) and provide nutrition education to students. They have played an important role in helping reduce the sodium content in school meals by overseeing the introduction of low-sodium recipes in schools^{22Legend symbol denoting Low-sodium recipes have been shared to "nutrition teachers" through the Korean Dietetic Association.} and monitoring the sodium content of meals provided under the school lunch programme.

• In order to help reduce sodium content of home-made meals, the South Korean government, as another educational initiative at home, has developed and disseminated low-sodium recipes for homemakers^{23Legend symbol denoting The South Korean government spent 86 million won (HK$0.6 million) on developing low-sodium recipes and cookbooks, including analysis on the nutritional content of the recipes, during the first two years of the National Plan. See Korea Health Industry Development Institute (2015).} through channels such as cooking classes and social media. The low-sodium recipes focus on home-made kimchi and dishes which are popular among the South Koreans and are designed to keep the taste and nutritional value of the dishes so prepared despite reduction of sodium content. The government has also promoted the take-up of low-sodium food products by setting up dedicated areas in large retailers to sell such products.

• The South Korean government has regularly reviewed the impacts and effectiveness of the National Plan and revised the plan where necessary using data collected from the Korea National Health and Nutrition Examination Survey ("KNHANES"). Being an ongoing surveillance and monitoring system, KNHANES is conducted every year on a national basis to assess the health and nutritional status of South Koreans,^{24Legend symbol denoting Being a nationwide survey, KNHANES covers a representative sample of 10 000 South Koreans annually.} including the sodium intake level and sources of dietary sodium of the population.

• The UK government stepped up its efforts to reduce the intake of dietary sugar across the population in 2016, consequential to the publication of the report entitled Sugar Reduction: the Evidence for Action by Public Health England, the national public health agency, in October 2015. The report portraits sugar as a health problem as consuming too much of it can lead to weight gain and related health problems. At that time, average daily sugar intake of UK residents was significantly higher than the recommendation level put forward by the UK Scientific Advisory Committee on Nutrition (i.e. not exceeding 5% of total calorie intake per day, equivalent to 30 grams or seven cubes of sugar), being double or even triple of the level recommended.^{25Legend symbol denoting Children and young people consumed three times the recommended amount of sugar on average (ranging from 14.7% to 15.6% of their total calorie intake), with adults consuming more than double (12.1%). The recommendation level is set by the Scientific Advisory Committee on Nutrition, a UK-wide advisory committee advising the government organizations on nutrition and related health matters. The committee comprises experts in the related disciplines and lay members. See Public Health England (2015).}
• In response to the high sugar consumption figure, the UK government has implemented a series of sugar reduction measures comprising both voluntary and mandatory components. The prominent measures so taken have brought positive outcomes to reducing the sugar content of food or inducing changes in consumers' dietary/product purchase habits.

• In 2016, the UK government announced the introduction of the "sugar tax" on locally produced and imported packaged drinks,^{26Legend symbol denoting The "sugar tax" applies to packaged drinks that are ready to drink or to be drunk in a diluted form; and contain at least five grams of sugar per 100 millilitres that is added during production, or exists naturally (except for fruit juice, vegetable juice and milk).} to be enforced two years later.^{27Legend symbol denoting The tax measure was introduced as part of the sugar reduction and reformulation programme which also featured voluntary initiatives for reducing sugar in other categories of high-sugar food such as breakfast cereals and ice-cream. Under the sugar reduction and reformulation programme, the UK government targeted to reduce the amount of sugar coming from key categories of food that contributed to children's sugar intake by 20% by 2020 through product reformulation, reducing portion size and/or shifting consumer choice to lower or no added sugar options.} The new tax had the effect of encouraging manufacturers to reduce the sugar content of their products through reformulation, as sugar-sweetened packaged drinks had been a main source of sugar intake of children and a key contributor to the childhood obesity issue.^{28Legend symbol denoting According to the UK government, a can of sugar-sweetened soft drink with a volume of 330 millilitres may contain as much as 35 grams of sugar, which is over the maximum recommended daily intake of sugar for a child.} The "sugar tax" is payable at two tax rates^{29Legend symbol denoting The two tax rates are: (a) £0.18 (HK$1.9) per litre of drink if it contains between five to less than eight grams of sugar per 100 millilitres; and (b) £0.24 (HK$2.5) per litre of drink if it contains eight grams or higher level of sugar per 100 millilitres.} and the tax revenue so collected has been used to fund programmes that promote physical education activities and balanced diets among school age children. The tax measure succeeded in prompting over half of the manufacturers to reformulate their drinks in the two-year transition period. It also brought positive outcomes in terms of a 43.7% reduction in the total sugar content per 100 millilitres between 2015 and 2019 for drinks potentially subject to the tax and a 35.4% decrease in total sugar sales (in tonnes) from those drinks.^{30Legend symbol denoting See Gov.UK (2018) and Public Health England (2020).}

• In addition to tax measure, provision of clear nutritional information and educational efforts are also considered effective at influencing consumer behavior (e.g. purchases and consumption of healthier food products). The government has made use of its well-accepted voluntary front-of-pack traffic light labelling scheme ("FOP labelling scheme") as a platform to provide clear and easy to understand nutrition information to consumers for promoting their choice of lower-sugar products. The FOP labelling scheme, which was introduced in 2013, uses colour-coding to show whether a packaged food product is high (in red), medium (in amber) or low (in green) in sugars, salt, fat and saturated fat at a glance, and provides the percentage reference intakes^{31Legend symbol denoting Percentage reference intake of a nutrient refers to the value that it contributes to the amount needed by an adult to have a healthy and balanced diet in percentage terms calculated per a portion of the product. If a portion of food states that it provides 50% of an adult's reference sugar intake, this means that the serving contains half of an adult's daily maximum amount of sugar intake, and over the rest of the day, options lower in sugar should be chosen.} as well.
• The FOP labelling scheme has proved to be helpful to consumers in making informed food choices and developing healthier dietary habits.^{32Legend symbol denoting A research study commissioned by the Department of Health and Social Care in 2016 revealed that over 80% of respondents claimed that they looked at the FOP labels and 69% agreed that a FOP label was useful when trying to choose a healthier diet. Respondents who looked at FOP labels had healthier shopping baskets with fewer calories, less sugar, fat and salt content, and higher fibre content. See Department of Health and Social Care et al. (2020).} To support implementation of the scheme and promote wider adoption by the trade and usage by consumers, the government updated the FOP nutrition labelling guidance in 2016 to set out detailed nutrition criteria and step-by-step guidelines for businesses on developing a FOP nutrition label and promoting its usage.^{33Legend symbol denoting See Gov.UK (2016).} Nevertheless, the provision of FOP labels remains voluntary for manufacturers.^{34Legend symbol denoting It is noted that mandatory FOP labelling schemes have been implemented in Thailand, Mexico and a few South American countries (including Chile; meanwhile, Brazil passed the regulation to put in place such a scheme from October 2022).} According to the latest figure available, the FOP labelling scheme covered over two-thirds of packaged food and drink products sold in the UK in 2018.^{35Legend symbol denoting Most recently, the UK government conducted a consultation in 2020 to collect views and evidence to inform the future improvements of the FOP labelling scheme, including the suggestion to update the scheme to reflect the latest dietary advice for sugar intake. The current FOP labelling scheme shows the total sugar content of foods, but the new maximum intake recommendations are based on intake of free sugars, excluding sugars naturally occurring in foods such as fruit, vegetables, cereals and milk products.}

• Another publicity and educational measure launched by the UK government is the national "Change4Life Sugar Smart Campaign"^{36Legend symbol denoting Social marketing campaign under the "Change4Life" brand was first launched in 2009 to encourage parents and their young children to adopt healthy lifestyle and change their dietary habits. Over the years, Change4Life campaigns had been launched under different themes comprising elements such as mass communication programmes, dissemination of healthy eating tips and recipes through a dedicated portal and a membership programme, and partnership with businesses and non-governmental organizations to provide relevant promotion offers and activities for kids.} in 2016 to motivate and support parents to make changes through helping them understand the sugar content of the food and drinks given to their children and providing tips on how to cut down on sugar. The campaign covered television advertisement, publicity on the social media, and distribution of promotion packs sponsored by commercial partners to children through primary schools. The campaign had contributed to raising parents' awareness of the sugar issue and inducing changes in the family's dietary habits.
• Moreover, the free mobile application – the Sugar Smart App – launched under the Change4Life Sugar Smart Campaign had also helped parents visualize the amount of sugar in food products and make product comparison by scanning the barcodes. An evaluation study on the campaign conducted in 2016 indicated that 70% of mothers with children aged 5-11 were aware of the campaign and 75% of these mothers had changed their dietary behaviour as a result. Besides, over 2 million people downloaded the Sugar Smart App and usage was over 14 million times.^{37Legend symbol denoting See International Association for Measurement and Evaluation of Communication (undated) and Public Health England (2017).}

• It is observed that Hong Kong, South Korea and the UK all rolled out measures that successfully encouraged producers to reduce sodium/sugar content of their products. While Hong Kong is able to encourage noticeable sodium reduction for selected products through sector-based collaboration initiatives (more specifically, school lunches and bread products), the South Korean government's multi-facet approach (including providing R&D funding support, establishing accreditation schemes and developing home-cooking recipes) appears to achieve reduced sodium content in more fronts ranging from processed foods and meals supplied by catering establishments to food prepared at home, thereby contributing to attaining its population dietary sodium intake reduction target well ahead of schedule. The UK's "sugar tax" also contributed to reducing the population's sugar intake mostly by incentivizing drink manufacturers to reformulate their products with a view to ensuring their sugar content would be contained at below the taxable thresholds, rather than acting as a significant deterrent for consumers from purchasing such drinks through pushing up prices which could potentially be unwelcomed by both producers and consumers.
• Measures to educate and empower consumers to make better choices are essential to sodium/sugar intake reduction as well. In particular, South Korea's low-sodium recipes for homemakers, as well as the UK's Sugar Smart App and its traffic light style FOP labelling scheme are some examples that demonstrate success in reaching specific groups or recording relatively high degree of penetration among consumers.

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