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reformulation in Saudi Arabia
TABLE 7.4 Mandatory and voluntary regulations of food and beverage product reformulation in Saudi Arabia
MANDATORY
Ban the use of added sugar or its sources (glucose syrup) and switch energy drinks to fresh juices and mixed juices in all food establishments in Saudi Arabia.
DATE OF IMPLEMENTATION VOLUNTARY
July 2020 Replace saturated fat with unsaturated fat.
Set the maximum amount of salt in domestically produced bread at 1 gram (400 milligrams of sodium) per 100 grams of produced bread. Ban the use of partially hydrogenated oils. May 2019 Reduce portion sizes for packaged food products.
January 2020 Reduce the amount of salt in 21 food products other than bread.
Source: Original table for this publication based on the Healthy Food Strategy (SFDA 2018a). DATE OF IMPLEMENTATION
June 2018
June 2018
January 2019
(Downs, Thow, and Leeder 2013). The companies are required to submit an annual report on the progress of their commitments to the SFDA (personal communication with SFDA). However, no evaluation studies exist yet.
Foods and drinks are promoted to children more than any other product type and in a far greater proportion than they are to adults (Singh et al. 2008). Children are exposed through television, at school and sports practice, in stores, at the movies, on mobile devices, and online (Institute of Medicine 2005). A 2019 study of television advertising in 22 countries around the world found, on average, four times more ads for unhealthy foods and drinks than for healthy ones during all television air time, and 35 percent more unhealthy food ads during children’s peak viewing times (Kelly et al. 2019). While television has historically been the medium of choice to reach children, marketing via newer online, mobile, viral, and social media has increased considerably in recent years (Institute of Medicine 2005; Montgomery and Chester 2009).
Children are extremely vulnerable to food marketing, which can begin to affect them as early as preschool (Smith et al. 2019). Developmentally, they are highly impressionable, cannot yet recognize advertising intent, lack nutritional knowledge, and are motivated by immediate gratification rather than long-term consequences (Harris, Brownell, and Bargh 2009; Institute of Medicine 2005; PAHO 2011; Swinburn et al. 2011). These are reasons why the World Health Organization, the World Cancer Research Fund, and UNICEF, among others unequivocally recommend protecting children from exposure to unhealthy food marketing by restricting or banning the various forms of marketing targeting or viewed by children, by improving the nutritional profile of promoted products, or both (Institute of Medicine 2005; PAHO 2011).
Existing statutory regulations on unhealthy food marketing to children vary in what foods to include, how they define children, and which communication channels and marketing techniques are covered. However, the most common strategy is to restrict television advertising, primarily during children’s programming (Taillie et al. 2019). Schools are also a common setting for restrictions. However, regulations on media such as cinema, mobile phone
applications, print, packaging, and the internet are infrequent. Additionally, most policies focus on limiting child-directed marketing strategies such as licensed characters, with little attention paid to other marketing strategies such as health and nutrition claims (Taillie et al. 2019).
Emerging evaluation evidence from Chile’s food labeling and marketing law is promising. Phase one of the law was applied only to children’s broadcast media; it prohibited marketing to children under 14 years of age using themes or promotional strategies that appeal to children in any form of marketing, regardless of audience, media, or location (for example, interactive games, children’s music, or apps). Evaluation from the first year shows that the percentage of television ads promoting unhealthy foods and drinks (that is, products that failed to meet the policies’ nutrition criteria) decreased significantly—from 42 percent preregulation to 15 percent postregulation (Correa et al. 2020). Additionally, preschoolers’ and adolescents’ exposure to television advertising for regulated foods decreased significantly, by an average of 44 percent and 58 percent, respectively. Their exposure to regulated food advertising that featured child-directed appeals (for example, cartoon characters) also dropped by 35 percent and 52 percent, respectively (Carpentier et al. 2020).
In Saudi Arabia, the SFDA issued voluntary guidelines to restrict the marketing of unhealthy food and drink targeting children under 12 years of age. These guidelines target all media outlets (including social media). The criteria for unhealthy food are defined as all packaged food products or meals served in food establishments (restaurants, cafés, and other establishments) whose content exceeds either 30 percent of total energy from fat or 10 percent of total energy from saturated fat, or more than 400 milligrams of sodium per serving, or more than 10 percent of total energy from added sugar (SFDA n.d.).
School-based policies
Schools are ideal vehicles for delivering overweight and obesity interventions to reach children. Children spend half of their waking hours and consume at least one-third of their daily calories in schools. Additionally, a recent systematic review of 50 trials found that school-based interventions are generally effective in reducing excessive weight gain of children, both as single component interventions (for example, physical activity only) and as multicomponent interventions (for example, physical activity and nutrition education). Specifically, physical activity interventions that had curricular sessions and emphasized participants’ enjoyment were significantly more effective than interventions without these components, resulting in a drop in body mass index of 0.3 kilogram per square meter and 0.2 kilogram per square, respectively (Liu et al. 2019). Two systematic reviews found that school-based programs are likely effective in increasing the number of children engaged in in-school physical activity as well as the amount of time they spend engaged in these activities (Dobbins et al. 2013; Salmon et al. 2007).
Setting nutrition standards in schools can be effective in limiting unhealthy foods and promoting the consumption of healthier food options. A recent meta-analysis of 91 studies around the world found that setting nutrition standards increased fruit intake while reducing fat and sodium intake both within and outside of school settings (Micha et al. 2018). In 2012, Massachusetts implemented nutrition standards for foods sold in schools statewide; these standards
have been associated with significant decreases in students’ sugar consumption both during and after school hours (Cohen et al. 2018). In Brazil, an evaluation study seven years after implementation of the first municipal law regulating sales of unhealthy foods in schools found that nearly 70 percent of school vendors have stopped selling these items (Gabriel et al. 2009).
In Saudi Arabia, there are some school-based policies related to obesity prevention. In 2013, the country’s Ministry of Education updated its Regulations of Health Conditions for School Canteens (MOE and MOH 2013), which contains a list of banned food items, namely, confectioneries, chocolates, chips, soda, sport drinks, sweetened beverages, all meat products, and fried food. Most boys’ public high schools in Riyadh fully banned soda and sports drinks but offered highly processed energy-dense snacks for sale, including muffins, sweets, biscuits, cookies, and chips (Aldubayan and Murimi 2019). In 2017, the Ministry of Health and Ministry of Education launched the Rashaka Initiative program (box 7.1), which targets school-age students along with their parents and schoolteachers to increase their awareness about the importance of a healthy lifestyle. The initiative works toward improving the school environment by providing healthy food choices in school cafeterias (fruits, vegetables, whole-grain bread, and so on) and by inhibiting the sales of high-energy (high fat and sugar) snacks and drinks. It also promotes physical activity sessions (Al Eid et al. 2017). It is worth noting that, starting in 2017, girls’ schools are able to hold physical activity classes as part of the King Abdullah Program for Education Development (Tatweer) initiative to increase physical activity in schools (Al-Hazzaa and AlMarzooqi 2018). However, to date there has been no evaluation evidence assessing the effectiveness or cost-effectiveness of this program.
Media campaigns
Media campaigns are commonly used to affect various health behaviors in populations because of their ability to reach a wide audience at a relatively low cost (Wakefield, Loken, and Hornik 2010). A systematic review of overweight and obesity campaigns found that the evidence suggests that campaigns can have an impact on intermediate outcomes, such as knowledge and attitudes. However, evidence is still limited as to whether campaigns can influence behavior change (Kite et al. 2018). One study found that mass media campaigns (television, radio, cinema, online, and social media advertising, as well as stakeholder and community engagement) around the health harms of SSB consumption in victoria resulted in a significant reduction in frequent SSB consumption compared to respondents from a different Australian state not exposed to the campaign (Morley et al. 2018).
As for physical activity promotion, a meta-analysis found that mass media campaigns boosted moderate intensity walking by 53 percent but neither reduced sedentary behavior nor led to achieving recommended levels of overall physical activity (Abioye, Hajifathalian, and Danasei 2013). Some interventions used posters and signs only to promote stair climbing and found that messages that are based on practical information, such as how many calories are lost by using the stairs (Eves et al. 2012), were more effective than motivational messages or signs (Avitsland, Solbraa, and Riiser 2017). Similar interventions were implemented in some workplaces in Saudi Arabia. However, evaluation studies are needed to explore the impact of these physical activity and healthy eating promotion campaigns and/or interventions in workplaces. One longitudinal study
