Can the 'Sheffield’s Sweet Enough' campaign reduce sugar consumption?
On the 4th of February 2020 Sheffield City council and partners (NHS, healthcare professionals, Sheffield Universities, Learn Sheffield, Weight Management Services, colleges, Trading Standards, and the voluntary sector) have launched a campaign to reduce obesity and tooth decay in children over the next five years. This City based initiative that has emerged as a direct result of the new arrangements in public health. It demonstrates how National Public Health initiatives can be used to support a local ‘grassroots’ attempt to improve the health of the City. This is a fascinating interchange because it demonstrates how national programmes can be championed locally through the new arrangements in public health. This campaign is worth following closely for all sorts of reasons – in this post I want to go through the background to the campaign (as I see it) whilst exploring other experiences of campaigns for sugar reduction. This campaign is just starting, but what can we learn from previous campaigns? I feel we have quite a few reasons to be optimistic about this campaign.
Part of the background to this campaign is the Coalition Government’s shift of public health functions in England into local authorities in 2013. This has resulted in Public Health Directors and their teams being located within local government and having to work with elected officials who are directly accountable to the public [1, 2]. The result? Public health is now more directly able to mobilise City-wide resources in order to place health into all policies. You can see evidence of this in this fascinating initiative. Whilst on the face of it we might think the initiative looks like health education, after all the council states that “The campaign aims to provide information to local people on the effects of sugar and to give them the tools they need to make educated choices that support their family’s health.” But behind this is a much wider desire to mobilise communities across Sheffield. The council states, that “the aim is to create a social movement in which everyone can play a part – schools, parents, healthcare professionals, councillors, voluntary organisations, community leaders, businesses and workplaces”. This is clearly something more than health education. The initiative deserves attention because building this kind of movement is certainly going to be a challenge. In truth there are clear examples where sugar consumption has fallen through City-wide action but what were those initiatives?
What is Sheffield’s Sweet Enough?
Sheffield's Sweet Enough seeks to mobilise a range of local actors (NHS, healthcare professionals, Sheffield Universities, Learn Sheffield, Weight Management Services, colleges, Trading Standards, and voluntary bodies) in order to recruit these actors into the movement. The very fact that ‘Sheffield’s Sweet Enough’ has Councillors acting on its behalf indicates that there are already forms of power operating through the initiative. Councillor Mary Lea states that: “Sheffield has high levels of obesity and tooth decay and we see a large variation across the city. Being overweight and having a poor diet impacts on children’s physical and emotional wellbeing and overall life chances. We want better for our children. We want to create lasting change by helping people understand how much sugar is too much and empowering them to make healthy choices. We believe that Sheffield is sweet enough and with a few small changes, we can all reduce our sugar intake, so that eventually these healthy habits become part of daily life.” The fascinating thing for a sociologist looking in on this is the degree to which localised power can challenge the social determinants of health.
Director of Public Health, Greg Fell, already knows that information and therefore health education will not be enough. The 'Sheffield’s Sweet Enough' Team clearly recognise that as well. Greg Fell has stated that “A complex mix of causes lead to people being overweight or obese in Sheffield and we are working hard to tackle these issues… As well limiting the amount of sugar we eat and drink, we must address the wider issues about the availability of high sugar products and the way they are advertised to children, but we’d need to see real changes in legislation to make this happen.” The ‘Sheffield’s Sweet Enough’ team are also clearly aware that this is only going to work if they can mobilise families, schools, work places and community groups and community workers to engage in pledges and activities to limit sugar intake.
So where else has sugar reduction been tried?
On our Masters in Dental Public Health at the University of Sheffield I had the pleasure of supervising a student, Zeyad Alkwaifali, who conducted a detailed scoping review of this area in 2018. He found a range of historical examples, from one-dimensional health education campaigns, to sugar taxes and finally multi-dimensional campaigns .
Health education campaigns and sugar reduction
Health education campaigns have used mass marketing approaches with advertisements on buses, trains and short videos [4-9].
‘Sugar Pack, Los Angeles’ was carried out in 2011-12 using mass marketing techniques in
different blocs . Subsequent evaluation demonstrated that 57% of those surveyed indicated having seen the campaign and of that group 60% ‘reported’ that they would be likely or most likely to change their behaviour . The problem with this of course is that stating your intention to change is not the same thing as changing .
‘It Starts Here’ in Multnomah County, Oregon in 2011 involved media advertisements aimed at adults in order to improve adults’ knowledge. The evaluation demonstrated that of those surveyed by phone, 68% had seen the campaign and 80% reported an intention to decrease soda or sugary drinks they offered to children, and around 50% stated a willingness to reduce their own sugar consumption, but in the end there was little or no change in actual consumption [3, 5].
‘Live Sugar Freed’ campaign was targeted at rural adults in Northeast Tennessee, Southwest Virginia, and Southeast Kentucky from 18 to 45 years old in 2015. This campaign
sought to demonstrate that sugar consumption was as dangerous as cigarette consumption, its core image being a man holding a bottle of soda in one hand and a pack of cigarettes in the other. The campaign was broadcast through multiple channels, advertisements in and through online platforms including Facebook .
The campaign delivered 19 million video ‘impressions’, 2.3 million audio ‘impressions‘ 5.6 million static ‘impressions’. Researchers were interested in exploring if a mass media campaign had any effect on awareness and if this in turn reduced consumption. This was evaluated through a telephone survey of 1,031 adults. Here 54% of the sample reported seeing the advertisements and of these 53% of respondents believed sugar sweetened drinks could be related to heart disease [3, 6]. What they also discovered, however, is that the sales of sugar sweetened drinks fell by around 3.4 %, largely explained by a 4.1% drop in soda sales in the target population compared to comparable cities where the campaign had not happened. The comparable cities were similar to the intervention area in geography, population density, and demographics . This illustrates that targeted campaigns can produce modest gains in sugar sweetened drinks consumption. Other campaigns include the “Live Lighter ‘Sugary Drinks’” campaign in West Australia which also has had modestly positive outcomes .
Campaigns in England
There have been several campaigns in England. The ‘Eatwell for Life’ campaign involved a
community development programme in Nottingham developed by a specialist group
consisting of Registered Public Health Nutritionists and Dietitians in Nottingham City Care Partnership. This involved targeted adults in the city of Nottingham living in deprived locations and sought to increase knowledge on nutrition, promote skills and confidence in cooking and promoted the ability to change behaviour in order to eat a balanced diet . This campaign involved courses in local community centres to enable participants to share their experience, skills and knowledge with other participants. The evaluation showed significant changes in groups who participated in the dietary and cooking program. The problem with this, however, is the relatively small numbers of people the campaign could reach and the challenge of rolling it out to a larger group of people .
Another programme worth mentioning is of course “Change4Life - Smart Swaps” which was conducted in all English cities by Public Health England in January 2014.
This campaign managed to reach more than 400,000 families joining and the goal to get families to make modest changes to their diets. The campaign used local television and radio channels the video can be seen on YouTube. The evaluation demonstrated significant changes for those who took part, for example, of those who had taken part 267 families were compared with 135 families from Wales who had not been exposed to the campaign. The group from England made more swaps to low-sugar drinks (27% in the second week of the campaign and 32% in the third week) compared with the Wales group (14% and 19% respectively). This is significant because this national campaign is being used to help develop ‘Sheffield's Sweet Enough’, demonstrating fascinating interactions between PHE centrally and the local team in Sheffield.
The sugar tax is already in place in England and is under evaluation. There are two pretty famous examples of such initiatives in Mexico and Berkeley, California [11, 12]. In Mexico Colchero et al  were able to demonstrate a clear decrease in sugar sweetened beverage consumption and an increase in water consumption after the introduction of the tax, although this was short-term between January 2012 through December 2014, (See Figure from Colchero et al).
After this period consumption gradually increased. Berkley, California became the first US based city to implement a sugar tax in November 2014. The tax included energy drinks, fizzy drinks, and ice teas, but did not cover milk-based drinks, meal replacement beverages, diet drinks, alcohol and fruit juice. This resulted in a significant reduction in the reported consumption of sugar sweetened beverages after one year of excise tax implementation of 21%, while there was an increase in consumption by 4% in a comparison city. Study results showed an increase in water consumption in Berkeley by 63% as opposed to 19% in comparison cities . Nonetheless this can only really be regarded as a short-term change and of course this is reported behaviour not actual consumption figures.
Multi-component campaigns on sugar
New York City and Howard County have both implemented multi-component sugar reduction strategies. These strategies are crucial because they are quite different, reflecting the various upstream and downstream [13, 14] ‘tools’ you can draw on in a city and in a local community. New York City started its efforts in 2008 by focusing on ‘nutrition standards’, particularly food purchased for meals and snacks served by city agencies including contracted service providers . This meant that drinks in these settings should contain no more than 8oz of sugar. To get a sense of what this means, the rule changed more than 260 million meals served every year . The strategy expanded in 2010 to include one-third of New York hospitals’ vending machines, patient meals and cafeterias, whilst also making water available for free . New York subsequently engaged in two mass media campaigns between 2009-2013 with the people of New York being exposed to campaigns between 6-12 times a month . Finally they engaged in a regulatory policy change between 2006-2012 which focused on childcare facilities, children’s campuses, and food service establishments. These regulations required easy access to drinking water and a ban on all sugar sweetened beverages. The city was also able to enforce rules making sure the calorie values on food and beverage menus were clear. These initiatives were evaluated through self-report surveys (which clearly does not report actual behaviour) and demonstrated significant falls in reported consumption . Clearly however not every city will have the tools available to legislate and regulate to this extent. But perhaps this is what Sheffield needs if it is to be able to more autonomously manage its sugar consumption?
Howard County’s initiative “Howard County Unsweetened” is fascinating because it drew extensively on the social-ecological model  from 2012 to 2015 seeking to influence all levels of sugar consumption . The goal was to influence people’s social networks by finding a way to adjust ‘social norms’, regulations within social organisations by changing internal regulatory systems and policies, adjusting the community engagement through increasing community resources and participation .
This involved getting on board with a range of partners like businesses, faith-based groups, the school system, government agencies, health care providers, and doctors through extensive community outreach. This initiative has been evaluated by comparing sugar sweetened beverage sales in Howard County with comparable stores in another state over a three years . The results demonstrated a reduction of 19.7% in soda sales in Howard County’s 15 supermarkets in comparison to an increase of 0.8% in Pennsylvania (17 supermarkets. Sweetened fruit drink sales also decreased in 15.3% in Howard County’s supermarkets compared to Pennsylvania (0.6%).
So what does this mean for “Sheffield's Sweet Enough”?
If we take all of the previous work that has been completed in this area we can see that “Sheffield's Sweet Enough” combines upstream and downstream action [13, 14]. We already have the ongoing sugar tax at a national level. Indeed “Sheffield's Sweet Enough” would not have been possible without Public Health England’s “Change4Life - Smart Swaps” initiative. As a consequence the campaign represents an interesting example of downstream and upstream action working in tandem. However, like the work of those in Howard County, we can see an intensification of actions that go beyond the mass media campaign associated with “Change4Life - Smart Swaps”. This intensification seeks to mobilise community action much in the same way as that in Howard County. The City Council has also implemented its own sugar tax on beverages on its premises. It is, however, unable to legislate in the way that we have seen in New York City. Will the emergence of the new Sheffield City Region enable more devolved powers to do so?
We will have to wait and see.
This post is supported through the unpublished work of Zeyad Alkwaifali who I had the pleasure to supervise when he was with us at the University of Sheffield in 2018 undertaking a Masters in Dental Public Health. He deserves credit for being able to summarise what was quite a difficult topic to deal with. The post itself draws on his references and adds analysis based on what we know about changes to Public Health in England as well as the work of Michael Marmot and, of course, Richard Watt.
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