The Journal of the American Heart Association recently published an article assessing the benefits of following the World Health Organization (WHO) recommendations for salt consumption. In Australia alone – where the study was conducted – a 30% reduction in sodium intake over the next two years could prevent 1,700 premature deaths a year and 7,000 diagnoses of heart disease, kidney disease and stomach cancer.
Another 2021 analysis — published by the scientific journal Circulation — calculated that by meeting the goals of America’s National Salt and Sugar Reduction Initiative, which include a 20 percent reduction in packaged food consumption and a 40 percent reduction in Sugary drinks claims could prevent about 490,000 deaths from cardiovascular disease, as well as 750,000 new cases of diabetes over several decades.
The benefits of reducing sugar, salt, fat and highly processed foods would lead to positive social change. Smart public policies are key. For example, public awareness campaigns – like those that encouraged seat belts in cars to drastically reduce accidents – are very effective. If the negative consequences of poor nutrition are clear, wouldn’t it be possible to make progress through nutrition by forcing people to eat healthily?
Manuel Franco, a professor of epidemiology at Johns Hopkins University, points out how he believes there can be remarkable reductions in salt or sugar consumption: “[These habits] must be produced in the social environment so that I don’t have to choose between a food with a lot and one with little salt every time I go out to eat. It will not work. People, especially those with fewer resources, have little time to cook and choose healthy options. It is necessary to have a policy that has already made the decision,” he explains.
Franco and other researchers have examined dramatic historical experiences that led to such decisions. For example, after the collapse of the Soviet Union in 1991, the US tightened its embargo on Cuba, which was heavily dependent on the USSR for subsidies. This combination of misfortunes caused a severe economic crisis on the island known as the “special period”.
Cubans went from 3,000 calories a day to about 2,200 calories a day while fuel shortages forced them to walk or use their bicycles everywhere. In a study published by the British Medical Journal, Franco showed that a radical lifestyle change – which islanders remember as a miserable time – had benefits for their health.
The combination of diet and exercise resulted in a widespread loss of ten pounds per person nationwide and improved many key health indicators. An analysis of the health of Cubans between 1980 and 2010 showed that this weight loss helped halve deaths from diabetes and reduced deaths from coronary disease by a third. It also reduced the number of hits.
Despite the positive results of this involuntary experiment, it is unlikely that any society would support a government that rationed its population, regardless of the improvements in health. In addition, according to nutritionist Juan Revenga, “there is a very powerful industry [unhealthy] Foods harmful to our health. Many jobs depend on it. They exist because the products are bought and they are bought because we like them.”
In recent years, driven by a growing social and political awareness of the effects of diet on health, some measures have been taken that have reduced the consumption of salt and sugar, making them attractive as processed foods when combined with fat. In Spain, the Association of Soft Drinks (ANFABRA) has promised a 53% cumulative reduction in the sugar content of its products between 2020 and 2025.
Last year, the Spanish government limited the amount of salt allowed in bread. It is estimated that this single measure will reduce the average Spaniard’s salt consumption – around nine grams per day – by around 20%. But even with this reduction, the remaining amount will still be above the WHO recommended two to five grams of salt per day.
To reduce sugar consumption, the Spanish government increased the sales tax on sugar and sweetened drinks from 10% to 21% in 2021. An analysis of this policy by the Center for Economic Policy at ESADE Business School in Barcelona found that while this tax increase had no impact on beverage consumption in middle- and high-income households, it reduced the consumption of sugary beverages by 13% – or 11 litres per household – among the poorest third of Spaniards. This also resulted in a 10.5% decrease in the consumption of high-sugar snacks among this low-income demographic.
The value of sales taxes in changing behavior has also proven useful for harmful non-food products like tobacco. In Colombia, a government mandated tripling of the price of a pack of cigarettes led to an overall drop in consumption of 34%.
ANFABRA Director-General Beatriz Blasco Marzal believes the self-regulation “shows that progress can be made” without limiting the change to the “sub-measures” that include taxes on soft drinks. She assures EL PAÍS that in her sector – which accounts for 2.1% of the total calorie intake of Spaniards – professionals “are committed to reducing sugar consumption”.
She notes that drinks with little or no sugar already account for 60% of the drinks industry in Spain. In addition, she mentions other measures taken by the industry, in partial acknowledgment of the notion that many of the products being sold are not entirely healthy. “We are committed to not promoting our products to children under the age of 13 … and to selling no soft drinks of any kind in elementary schools and only low-calorie or no-calorie drinks in secondary schools.”
Ramón Ortega, professor of bioethics at the University of Nebrija in Madrid, has studied other techniques to influence the behavior of groups of people around food without restricting their freedom. “Paternalism is very present in our lives. One case is the seat belt, that [authorities] forcing us to use for our own good, without giving us the freedom to choose…or the banning of certain substances like heroin.”
Ortega’s concept of “libertarian paternalism” would fall somewhere in the middle of this policy. It would consist of exploiting popular prejudices to make people more likely to make healthy choices without directly enforcing them.
“An example is what was done in the cafeterias at Google headquarters. To reduce consumption of soft drinks, they placed the vending machines in less visible places than the water dispensers,” explains Ortega. “With this measure, Google has managed to increase water consumption by 47%. [among its employees].”
Other examples of these positive nudges, described by Ortega — who recently wrote an article on the subject in The Conversation — are offering meat and fish with salad in school cafeterias while students continue to have the option to buy chips. Or, as has been the case in some Argentinian cities, restaurants have had to remove salt shakes from tables. If customers want extra salt, they must request it.
Ortega acknowledges that these policies “involve a degree of manipulation without seeking rational acceptance of the measures.” However, he thinks this is a positive alternative compared to more restrictive public health measures. He also notes that the food processing industry also uses these cognitive biases to guide our behavior, “for example, when staple foods — including meat or fish — are placed at the back of the supermarket to let us pass other products, like candy or French fries.”
When it comes to the ability to remove temptation (in the form of unhealthy food) from citizens, a common appeal is freedom of choice: consumers and businesses can choose what they buy and produce. However, this freedom is already conditional. The large amounts of sugar, salt, and fat in processed foods often result in combinations not found in nature that have powerful effects on our brains. This is why we find water, for example, boring compared to sugar-flavored drinks.
Some researchers, such as Ashley Gearhardt from the University of Michigan and Johannes Hebebrand from the University of Duisburg-Essen in Germany, have analyzed the addictive potential of some foods.
Gearhardt suggests that certain products — like pizza, french fries, or hamburgers — share some characteristics with addictive substances. This makes it difficult for us to control their uptake, even though we know they are not good for us. Many foods have been modified to induce more intense sensations of pleasure…much like what happens with coca leaf when it’s made into cocaine.
On the other hand, Hebebrand, who disagrees with the term “food addiction,” believes that the overconsumption of certain products is mainly due to their ubiquity in places like supermarkets, as well as their wide variety that keeps consumers interested.
dr Johns Hopkins’ Franco believes that going back to enjoying less-processed foods that contain less salt and sugar will go a long way for today’s consumers.
“We will not all become flexitarians overnight, nor will we suddenly enjoy salt-free bread. We will not be able to shop and cook three hours a day because that would require brutal economic and social change.”
Also, the food industry “is not only very powerful, it also feeds us,” notes Franco. “We can live without tobacco… but not without the food industry. We must live together as we drive change.”
Revenga – which questions the value of measures like reducing salt in processed foods “because they can provide a feeling that it’s safe to consume a product that’s still unhealthy” – believes one of the important ones Steps Forward is, within schools, “they’re beginning to teach what our mothers knew so well: to buy groceries and to cook. Nobody knows how to do that anymore.”
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