Can Sheffield’s Sweet Enough reduce sugar consumption in Sheffield?

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 voluntary sector bodies) have launched a campaign to reduce obesity and tooth decay in
children over the next five years. This is 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 through the
new arrangements in public health locally. This campaign is worth following closely for all sorts of
reason – in this post I want to go through the background to the campaign (as I see it) and explore
what we might expect from this campaign over the next five years. The campaign has a long way to
go but what can we learn from previous campaigns? When we look at previous attempts to do this I
personally feel we have quite a few reasons to be optimistic.

Background

The background to this 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
and links 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 and it
is of course sociologically interesting. In truth there are clear examples where sugar consumption
has fallen through City wide action but what where those initiatives?

What is Sheffield’s Sweet Enough?

The first thing that is apparent about this initiative is that it seeks to mobilise a range of local actors
(NHS, healthcare professionals, Sheffield Universities, Learn Sheffield, Weight Management Services,
colleges, Trading Standards, and voluntary sector 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, stating 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 education will not
be enough. The Sheffield’s Sweet Enough Team clearly recognise that as well. Greg Fell has stated

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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 of one health education campaigns that tend to be one dimensional,
sugar taxes and multi-dimensional campaigns [3].

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 [4]. 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 [4]. The problem with this of course is that stating your intention to change is not
the same thing as changing [3]. [Insert Youtube video here https://www.youtube.com/watch?
v=wKhi8uaoDeo&feature=emb_logo]

‘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]. [Insert
itstartshere image]

‘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 [6]. 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 sugar sweetened drinks fell by around 3.4 %,
largely explained by a 4.1 per cent 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 [6]. This illustrates that
targeted campaigns can produce modest gains in sugar sweetened drinks consumption. (Embed
video https://youtu.be/EzTdqJHUiks). Other campaigns include the “Live Lighter ‘Sugary Drinks’”
campaign in West Australia which also has had modestly positive outcomes [7].

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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, the
involved targeted adults in the city of Nottingham living in deprived locations and sought to increase
knowledge on nutrition, sought to promote skills and confidence in cooking and promoted the ability
to change behaviour in order to eat a balanced diet [10]. 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 [10].

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 is Sweet Enough’ demonstrating fascinating interactions between PHE centrally and the
local team in Sheffield. [Insert video https://youtu.be/zBnLC4ti8cA ]

Sugar taxes

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 [12]
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 the Figure to the right taken 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. Resulting in a significant reduction in the reported consumption of SSBs 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 [11]. 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 multicomponent sugar reduction
strategies. These strategies are both 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 [15]. 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 [15]. It affected almost
3000 beverage vending machines located in the city, the strategy expanded in 2010 to include one-

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third of New York hospitals’ vending machines, patient meals and cafeterias, whilst also making
water available for free [15]. 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 [15]. 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 beverages menus were clear. Although
these initiatives were evaluated through self-report surveys (which clearly does not report actual
behaviour) and demonstrated significant falls in reported consumption [16]. 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 [3] from 2012 to 2015 seeking to influence all levels of sugar
consumption [17]. 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 [3]. 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 [17].
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% Howard County’s supermarkets compared to Pennsylvania (0.6%)in the.

Okay then so what does this mean for “Sheffield is Sweet Enough”?

If we take all of the previous work that has been done we can see that “Sheffield is Sweet Enough”
combines upstream and downstream action [13, 14]. We already have the ongoing sugar tax at a
national level. But “Sheffield is Sweet Enough” would also not be possible without Public Health
England’s “Change4Life - Smart Swaps” initiative. As a consequence it represents an interesting
example of downstream and upstream action working in tandem. BUT 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. This intensification seeks to mobilise community action much in the
same way as that in Howard County. “Sheffield is Sweet Enough”. 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.

Acknowledgement

This post is only possible because of 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. 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. This is just one example of what it
is like to work at the University with such a range of diverse and interesting students.

References

1. Mansfield, C., Healthy Dialogues: Embedding Health in Local Government 2013: London.

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2. Buck, D., The English local government public health reforms: An independent assessment.
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A scoping review, in School of Clinical Dentistry. 2018, University of Sheffield: Sheffield, UK.
4. Barragan, N., et al., The “sugar pack” health marketing campaign in Los Angeles County,
2011-2012. Health Promotion Practice, 2013. 15: p. 208-216.
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