Tackling salt consumption outside the home

In an editorial for The BMJ published this month, and reproduced here in full, Dr Martin Caraher Professor of Food and Health Policy at City University, and Footprint Associate Editor Nick Hughes argue that tougher policies are required to make fast food healthier

Salt has traditionally been used in food for preservation and to enhance taste. Modern processing techniques and cold storage have reduced the importance of salt’s role as a preservative, but it is still used widely as a flavour enhancer and to provide a contrast with a sweet palate experience. High levels of salt in the diet are linked to high blood pressure, which can lead to stroke and coronary heart disease. In the UK, despite reformulation programmes dating back to 2006, the average amount of salt consumed by the population is still too high—8 g/day rather than the recommended 6 g/day for adults. Some communities are also more likely to consume higher levels of salt, especially people living in more deprived localities, where fast food enterprises tend to congregate.

Reformulation programmes to reduce salt in food products have historically relied on voluntary action by businesses. There have been four sets of voluntary agreements for salt reduction targets in the UK, the most recent covering 2014-17. This agreement set out 76 targets for the salt content of different foods, with additional targets covering 11 food categories for the eating “out of home” sector, which Public Health England (PHE) defines as “quick service restaurants, takeaway, and meal delivery businesses.” PHE, which is responsible for administering the salt reduction programme, reported that just over half (52%) of average salt targets were met, with the retail sector judged to be more successful than the out-of-home sector.

Official figures show that £87.6bn is spent on food and drink outside the home in the UK, compared with £113.5bn through retail. The proportion of the population eating out on a regular basis is predicted to rise as the UK continues to adopt a US pattern of eating outside the home. These trends have important implications for future intakes of calories, fat, and salt.

Product reformulation is just one part of a package of policy interventions aimed at reducing consumption of salt. Another is labelling. Prepackaged food must carry mandatory nutrition labelling under EU law, including the amount of salt per 100 g. This is supplemented in the UK by a voluntary front-of-pack traffic light labelling scheme. The same requirements are not in place for food served out of the home, including prepacked food such as pies and sandwiches sold for immediate consumption (although some businesses provide this information voluntarily), meaning the onus is on the customer to seek out the healthiest option.

Unlike the food retail market, where a large proportion of sales is consolidated within a small number of businesses, the out-of-home sector is fragmented, with most establishments being small or medium size.

Focusing policy interventions on larger chain outlets, which account for 30% of outlets but 54% of transactions, makes sense at a population level but risks omitting small, independent outlets that can be hard to reach through voluntary initiatives that require engagement with central government or a trade organisation.

The Department of Health and Social Care has committed to setting out the next steps towards reducing salt consumption by Easter 2019, and this is to be welcomed. We believe that these must address the unique opportunities and challenges presented by the eating out-of-home sector. Extending the voluntary traffic light labelling scheme to prepacked foods sold for consumption out of the home would have the dual benefits of providing consumers with information and acting as an incentive for reformulation, since outlets do not want to display a “red” label on their foods.

Progress on voluntary salt reformulation programmes has stalled since 2008, which implies that further progress will not be made through more voluntary agreements with industry. We therefore recommend that the next moves should follow approaches such as the soft drinks levy, using mandatory and fiscal levers to reduce the salt content in foods purchased for consumption both outside and in the home. Other countries and administrations that have used legislative measures to restrict salt levels in food have often not taken a universal approach. In New York City, for example, chains with fewer than 15 outlets are exempt from the regulations. Such an approach in England would exclude roughly 70% of all outlets, many of which serve low income populations. This would miss the opportunity to help small, independent outlets improve their food. PHE’s plans should therefore consider how public health at the local level can contribute to salt reductions through work with environmental health officers and trading standards officers.

A fully referenced version of this editorial is available on the BMJ website.

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