17
Examination of witnesses
Shirley Cramer, Louise Marshall, Professor Susan Jebb and Susan Lloyd.
Q61 The Chair: I welcome our four witnesses and members of the public to this evidence session of our inquiry into poverty, food, health and the environment. The interests of Members have been declared and are available for the audience. The meeting is being broadcast live via the parliamentary website. A transcript of the meeting will be taken and published on the Committee’s website. Our witnesses will have an opportunity to make corrections before the final transcript is agreed if you find any points that you wish to correct.
I will proceed to the questions. We have about an hour. I hope that the members of the Committee who are asking questions and the witnesses who are responding will keep the questions and answers brisk, so that we can get through all the questions in the time we have allotted.
I will kick off by asking about reformulation. How effective have reformulation initiatives such as salt reduction targets and the sugary drinks industry levy been in encouraging or mandating reformulation of products? Supplementary to that, were we to recommend some mechanism to encourage or mandate reformulation of products, what nutrients or food groups would you suggest targeting? Perhaps you could introduce yourselves before answering the question.
Professor Susan Jebb: I am professor of diet and population health at the University of Oxford. Most of my research focuses on obesity and diet-related disease, but there is also a programme on environmental sustainability, with a focus on meat.
Reformulation has been a huge success story, in which the UK has had real leadership. It started with the salt reduction programme, which continues today and has been extraordinarily effective. We have seen salt intakes come down from 9 grams in 2000 to 8 grams in the last urinary survey report, which dates from 2014 when the data was collected. We expect the next iteration of that later this year, probably. The salt reduction programme has been tremendously effective. Salt is effectively an additive. You can take it out quite easily, with a bit of thought.
Likewise, with sugary drinks, we have seen great progress. Recently, we published a paper looking at the change from 2015 to 2018. Sugars sold in sugary drinks have gone down by 30%. That is overwhelmingly due to reformulation. You might imagine that people were more aware that there was harm in sugary drinks and were choosing to buy fewer of them, but if you look at what would have happened if there had been no reformulation, there would have been a reduction of just 4%. Overwhelmingly, the impact in sugary drinks has been down to reformulation. We should not attribute that entirely to the soft drinks industry levy. Clearly, that has been part of it, but there was a lot of pressure from government for companies to reformulate.
Those are the success stories. Sugary drinks are relatively easy. You can replace the sugar with artificial sweeteners or just make the drinks less sweet. That is where the success largely stops. Unfortunately, the Government have decided that reformulation is the answer, and it is the main plank of the PHE strategy in relation to obesity. They have set reformulation targets for sugars in 10 categories and for calories in eight. The progress in those food categories for sugar reduction is woeful. It was down by 2.9% after two years. That is against a target of 20% to be achieved by 2020. There is no way we are going to achieve that.
That is partly because it is very difficult to reformulate. You cannot take the sugar out of a sweet and still have a sweet. Reformulation is not going to be the answer. Although it is a part of the mix, we need to look at other policy levers if we want to change other aspects of the diet. If we are fundamentally to address the very big issues this Committee is focused on, we have to make bigger changes in the way people eat. We cannot do it just by fiddling around when changing the composition of the things that people currently eat. We have to eat fewer biscuits and cakes, less chocolate and confectionery, and more fruit and vegetables. You are not going to achieve that through reformulation.
Louise Marshall: I am a senior public health fellow at the Health Foundation, working on our healthy lives programme, which focuses on the wider determinants of health and health inequalities.
Susan has outlined where the successes and otherwise lie in salt and sugar, as well as some of the difficulties. Your supplementary question was about further targeting and which nutrients or food groups should be targeted. I will speak to some of that. As Susan said, reformulation is very difficult in some foods and is not the only solution, but there is the potential, as is being considered, to extend the soft drinks industry levy to milk-based sweet drinks and coffees. It is potentially harder to encourage reformulation in certain other food groups. Other health-related food taxes are rarer than those on soft drinks, and the introduction of anything would need to be very carefully evaluated.
With the introduction of any sort of mechanism to encourage or mandate reformulation, you need to think through what the potential response from industry would be as regards marketing and the prices of the targeted foods and other foods. The introduction of anything would need to be carefully monitored, with the potential to change the approach if undesirable or unintended effects were seen. For example, the NIHR-funded evaluation of the soft drinks industry levy takes a systems approach. It is very important to think through the broad potential impacts of any moves to encourage reformulation or to tax foods. Do people substitute with foods that you would not necessarily expect or that may be detrimental to health or the environment? Very importantly, what are the potential impacts on inequalities?
Susan Lloyd: I am the executive lead for the Faculty of Public Health. I lead on policy. Our view at the faculty is that, as Susan said, the salt and sugar levies have been effective. However, they have now stalled, primarily because they were voluntary agreements.
The Chair: The salt reduction was voluntary. The sugar levy is mandated.
Susan Lloyd: It is a levy, a sugar tax.
The Chair: But both have stalled, in your view.
Susan Lloyd: The salt reduction process has stalled, certainly, when it comes to reductions in formulated salt in products. Susan alluded to that. The sugar levy has been effective; Susan’s research attests to that.
We support a voluntary approach but we also support regulation, particularly around salt and sugar. However, we recognise that that puts the onus on individuals and that individuals are not the only ones who have a responsibility. There is also a societal responsibility, which is why we are here. Like Louise, we suggest that we require a whole-systems approach, which will address a cultural view of obesity and diet. We therefore suggest not only the current approach to salt and sugar reduction, but regulation. We support a whole-systems cultural approach to changing diet within communities.
The Chair: What sort of regulation do you envisage?
Susan Lloyd: We would support any proposed regulation on salt reduction that saw a further reduction in the amounts in food. Obviously, we are very supportive of the sugar tax.
The Chair: I will come back to the salt question in a moment, but let me ask Shirley to come in.
Shirley Cramer: I am the chief executive at the Royal Society for Public Health. A lot of our work is related to health inequalities and environments related to health and well-being. We often talk about the public’s health and well-being.
On the subject of reformulation, Susan could not have articulated it better. In our view, the soft drinks industry levy has been successful. We have seen over 90 million grams of sugar come out of the system, which is exceptional. I know from working in other countries that people look to what we have done in the UK as something different and innovative, but we feel, with others, that it is part of the mix of the things we need to do to tackle obesity and promote healthy eating. It is for the researchers to look at how big a part it is, but we cannot see it as the main plank of what the UK needs to do to solve the obesity crisis. That would be a mainstay for us.
If you look at the broader piece, which I am sure you will ask questions about, there are areas where we need to engage with industry. Many agribusinesses are global, so this is something we need to tackle with others. The increasing health inequalities that lead to poorer health are mostly to do with the environments in which people live, work and play, and their opportunities in life. We know that children are more than twice as likely to be obese if they are in a poor family. Reformulation tackles the level playing field to some degree, but there need to be many more policy levers in place to make it a level playing field for children and their families.
The Chair: I have a couple of short follow-up questions. One concerns salt reduction. Susan Lloyd said that it had stalled. Susan Jebb referred to the success up to 2014. Susan Jebb, is there any evidence about what has happened since 2014?
Professor Susan Jebb: I do not know of any. This comes mostly from the urinary sodium survey. You can look at individual products, but I am not aware that we have any evidence that tells us what has happened since 2014. I hear public health campaigners saying that salt reduction has stalled, but between 2011 and when the 2014 survey came out we were also told that it had stalled, and clearly it had not. My suggestion is that we wait for the evidence.
The question of mandatory targets comes up a lot. Voluntary is working. It would be great if it were better, but are we absolutely sure that mandatory would make it better? I know of no other example in the world that has achieved as much as we have. In South Africa, they have mandatory targets, but very few categories—10 or 12—and the targets they have set are much weaker than our voluntary targets. I do not know how successful their system has been, because I do not think that they have published on that. It is very easy to call for mandating it, but before we do, we should have the evidence that it will actually deliver greater change than we are getting with voluntary targets.
Susan Lloyd: I have several references that I can share with the Committee. There is a 2019 article by Caraher and Hughes entitled “Tackling salt consumption outside the home” in the BMJ. I can give you the reference number later, if you like. There is also an article by Caraher and Perry entitled “Sugar, salt, and the limits of self regulation in the food industry”. Again, it is in the British Medical Journal. There is some evidence of an approach that is stalling.
The Chair: I have a short question before I move on about the efficacy of the sugar levy, which is often called the sugar tax. The Food and Drink Federation opposes the soft drinks industry levy, perhaps not surprisingly. It says two things against it: first, that it is wrong in principle to single out individual product categories for punitive treatment; and, secondly, that the impact of the soft drinks levy is very small. In Mexico, it showed an initial reduction of only 6 calories per day in a diet of over 3,000 calories a day. Susan Jebb, you introduced this. Would you like to comment?
Professor Susan Jebb: Martin is doing a full evaluation of this. I give credit to the UK Government for investing in a very big and comprehensive evaluation. As I mentioned, we published some data that looked at the change from 2015 to 2018. There was a 30% reduction in sugars sold in drinks in the UK. That is very comparable to the PHE analysis, which, interestingly, used a completely different dataset. Two different ways of looking at it got exactly the same answer, so I feel pretty confident about that.
The important thing to remember is that the soft drinks industry levy in the UK works very differently from the tax in Mexico. The tax in Mexico is a sales tax, so you are getting the effect of price on consumer behaviour. In the UK, we have put the levy on industry as an incentive to reformulation. As I indicated earlier, that has been the principal way we have got sugars down. They are very different. Price is an effective lever, but we should not think of the soft drinks industry levy as purely a price mechanism. It operates in a raft of other ways. There is a bit of consumer awareness as well.
The Chair: Do other members of the panel wish to add anything? Are you happy with the way it is being represented?
Louise Marshall: Yes. The population-level effects of small differences in individuals can be significant. There have been criticisms that, although mostly they are not passed on to the consumer, taxes on foods can be regressive. There can be a progressive effect on health, because the most deprived in society, who have the poorest health, are impacted. It therefore has the potential to reduce inequalities.
Q62 Baroness Sanderson of Welton: In the different approaches to the issue, how effective are initiatives that aim to change people’s behaviour, especially public health campaigns? We have been told that they are least effective at reaching those who most need them and that they do not reach the poorest in our society. Last week, we heard from somebody who said that public health campaigns are very middle class. Should they, and can they, be more carefully targeted so that they reach every sector of society?
As a supplementary, how do the Government assess or measure the effect of such behavioural change interventions? What are the metrics? How would they feed into new campaigns? How effective do you find front-of-pack labelling? Again, there is some evidence that it is not that effective for the people who might need it most.
Shirley Cramer: What a question. I will do my best with it.
In our view, public information campaigns are great for public awareness, which is a very important part of the picture. They are about direction of travel. We believe that seat belts should be mandatory. All of those things are really important. We can point to many examples in public health that have been successful. Have they led to behaviour change directly? There are some questions related to that. Reformulation is an important part of the mix, but would we expect people to change their behaviour totally?
I understand the allusion to the middle class, because the low-hanging fruit in the “Stop smoking” campaign and others are those who are closest to stopping smoking or who are more motivated. For example, the people who smoke now are those who were furthest away from those information campaigns and hardest to reach, because of mental health or other issues. If you were to take that as an example, you would say, “Should we be targeting campaigns at the poorest in society?”
At RSPH, we would say that targeting information is probably not the best use of resources. One thing that is very clear is that we should be targeting, but the issues that are raised most with us are around poverty. If we look at food in the environment and at food insecurity, the issue is that people do not have enough money to buy the kinds of things they might need. If we were targeting, we would want to widen access to healthier food, but you have to have the money to buy it.
Last week, the Joseph Rowntree Foundation research showed that people in working poverty cannot afford to buy certain things. Healthy food is one of them. For example, if you are on a low income and want to do the Eatwell guide, it would be 42% of the money that you have left after you have paid your rent. If you eat what Public Health England says we should all eat, that will be 42% of your income after rent. Clearly, that is not a viable proposition for many people. If we want to target things, it should be about more income equality and resources that would support people to buy healthier foods in healthier environments.
Another example is the Healthy Start voucher scheme. It is a good scheme, but it has a 64% take-up rate. We could do more to train professionals to know about it. If we were going to do an information campaign, we could promote the Healthy Start vouchers in communities. It has been the same amount of money—£3.10—for the last 10 years. That is a tiny amount. It has not gone up with inflation and is the same as it was 10 years ago. We need to do something about that.
In the research around why people are going to food banks more, you find that a lot of it is about universal credit. Many of us here would look to those wider determinants of health around the food environment and poverty. People who are struggling are going to food banks. The Trussell Trust tells us that there is a correlation between when universal credit is rolled out and when it sees more people going to food banks. There are lots of things we could do in that area that would be much more targeted on funding and the environment. I am sure that we will get on to local authorities and other things later.
The Chair: Thank you. That is fine. Do the other witnesses have anything to add?
Susan Lloyd: From our point of view, campaigns do not always reach the individuals they are targeting. Particularly when individuals have lower income, it is very much the inverse. Individuals need the skills, knowledge and capability to utilise the information that is targeted at them in a campaign. Individuals with less money available have penalties on them as regards fuel and travel. That means that they are less able to utilise information that comes down to them.
There is also a suggestion that individuals need some pre-existing skills in order to apply the knowledge that comes through campaigns such as the five-a-day campaign. We are talking about not only income but knowledge. We are also talking about risk. Individuals stick to foods they feel safe with and that they know their family will eat. They will not try other foods, such as fruit and vegetables, that may be riskier and therefore more expensive. Overall, we are supportive of campaigns, but there are better ways of targeting information. Shirley outlined those.
Louise Marshall: I agree. As behaviour is driven more strongly by the environments we live in than by the information we have, we need to target the wider determinants of what we eat. As has been said, those are income and access, as well as time and skills. Unless those factors are addressed, information campaigns put into that context will continue to fail. They need to be part of a wider approach.
Professor Susan Jebb: Is it necessary to have these campaigns? Yes. Are they sufficient? No. The good thing about Change4Life, which is the Government’s main effort, is that it has created a lot of trust in the brand. It has relayed some consistent messaging. If we did not have it, we would probably be saying that we should do it. It may have the indirect effect of raising people’s awareness such that they understand that other policies are necessary. That is fine.
The inequality issue is interesting. One of the things that Change4Life has done well is to target most of its resources on areas with the lowest income. When I am doing talks at fancy science festivals, people tell me that they have never heard of Change4Life. That is because it has not been targeted at them. In so far as information campaigns can, Change4Life has tried hard.
I want to push back a little against the across-the-board assumption that advice does not work for low-income groups. Clearly, some interventions that require high levels of cognitive processing can be more demanding and difficult, but we have evidence that basic information is more effective in low-income, more deprived groups.
There are two studies, one of which was published, where doctors encouraged people who were overweight to lose weight. We saw a bigger effect of that brief advice in the low-income groups than in the high-income groups. In a study that is under review at the moment, where practice nurses gave patients very brief advice, in a 10-minute appointment, about reducing saturated fat, we saw bigger reductions in the low-income groups than in the high-income groups. You can speculate about why that is, but it is possible that for them it was new information and that some of the high-income groups had already acted on it. I share the concerns but let us be careful that we do not throw out babies with bathwater. Some people benefit from basic information. I have seen no evidence that Change4Life, for example, is increasing inequalities.
Labelling requires more cognitive effort to interpret, so there are greater concerns about that. However, the overarching evidence from a Cochrane review that we did shows that nutritional labelling in cafés and restaurants leads to a small but significant reduction in calories purchased. In a meta-analysis of three trials, it was 47 calories. If you assume that the meal was about 600 calories, that is an effect of about 8%, which is not to be sniffed at. The evidence from grocery stores is much more limited and of poorer quality; it is hard to do those kinds of studies. The trend is towards a small effect, but we cannot be so confident of that.
The case for labelling, beyond consumer behaviour, is twofold. First, if we are asking people to make healthier choices, they need the information to be able to do that. Secondly, there is good evidence that it has quite a marked impact on businesses. When businesses have to start labelling, we know that they start building those thresholds and values into their product development and the requirements for their menu portfolios. There is good data showing that, when companies label in restaurants and cafeterias, the number of calories on offer goes down. Effectively, you get a population-level impact over and above individuals making better choices.
Yes, I think that labelling works. Like many of the things we are going to discuss this morning, it has a small effect, but we cannot afford to turn our back on small effects.
Baroness Sanderson of Welton: Thank you. That is really helpful.
The Chair: Very briefly, in a sentence or two, could you address the supplementary question that Baroness Sanderson asked about how the Government measure the effect of interventions? Is that the sort of thing you were just talking about?
Professor Susan Jebb: There are two main ways. One is the National Diet and Nutrition Survey, which is our continuous rolling survey of what people eat and is a nationally representative sample. It provides tremendously rich and valuable data. It has its limitations, of course. People do not always report accurately, but it gives us a good sense of trends.
Increasingly, they use sales data, mostly from Kantar, which provides data on household purchases in grocery stores. That is used in the monitoring and evaluation of the reformulation activities, because one can calculate the changes in sales.
Those are the two main things. They are used mostly for monitoring. Data for developing new interventions comes mostly from outside government, from academic and other research, consumer insights and so on, which starts to build the case for something. A whole battery of academic evidence and consumer insights from civil society groups encouraged government to look at and to introduce the soft drinks industry levy, for example.
Q63 Baroness Ritchie of Downpatrick: Could you outline some examples of other public health levers that could encourage or mandate healthy food environments? How can these levers encourage consumption of healthy food rather than simply reducing unhealthy food?
Professor Susan Jebb: I personally would not put a huge amount of effort into getting people to eat more healthy food, perhaps with the exception of vegetables. Vegetables are a special case because there are specific health benefits from them.
I am cautious about actively encouraging other healthy food because the biggest diet-related problem we face is overconsumption and obesity. People can get a lot of calories from pretty healthy food. We should focus on restricting the unhealthy, and the healthy will largely look after itself. As I say, that is with the exception of vegetables. I do not know what intervention would increase vegetable consumption; that is proving hard to shift.
What levers are there? We have to recognise that we are in this position as a consequence of huge social changes. After the war, we asked industry to produce more food more cheaply and to distribute it as widely as possible. We developed very efficient distribution systems, and that has worked fabulously, but it now works against us.
People have busy lives. They work longer hours, and more people are in work. There is a demand for convenient, easy food. Those two things have come together and that is a huge social change. It is difficult to think of the one thing that government could do that will suddenly change that around.
What we can do is recognise that we are now in a position where there is market failure. It is not a failure economically, perhaps; the food industry is doing very well, but there is certainly a failure in food delivering for health, food delivering for social justice and food delivering for the environment. What that does is to make the case for some substantive intervention by government in the system, but it is very hard to know what it is.
My personal bias at the moment, although I could not give you absolutely objective evidence that it was the best thing to do, would be towards controlling the sheer availability and extreme marketing of food. It is absolutely everywhere. It is in shops that do not even sell food. There are vending machines everywhere. The advertising promotion is phenomenal, and we know that all those things encourage people to eat at times when they would not eat, and they shape their choices. Most of the advertising is for unhealthy foods. We are, effectively, actively encouraging people to eat things that are not good for their health. That seems to me an area where the Government legitimately ought to step in with a duty of care.
Louise Marshall: There is not much to expand from that. The levers fall within the economic and the fiscal. We have heard about the soft drinks industry levy. There is good evidence for some of the fiscal and economic interventions, not least because currently there is an issue that profit motives for producers and retailers are not aligned with the health of the population or of the planet.
There are marketing approaches and availability levers. That availability has to be across all the places where we access food. Potentially within the readiest control—I do not know about the easiest—is some of the public sector procurement and buying of what is provided in public sector outlets such as hospitals, schools and prisons.
Susan Lloyd: It is important for us to recognise that obesity is associated not only with food but with physical activity. From a food point of view, food access is vitally important. The Government can alter the fiscal and regulatory environment in which people can exercise and make their choices. Some very specific changes can be made from a regulatory point of view, such as: reducing speed limits around housing estates so that people feel more comfortable when walking and accessing shops; transport planning that puts people before vehicles; the 400-metre zone for hot food around schools; and numerous other similar interventions that can make an impact. It is important to consider not only the price of food but the environment—the regulatory and fiscal environment—around food production.
Shirley Cramer: One lever with real potential, although we cannot quantify it at the moment, would be having human health in the Agriculture Bill, which is coming up for discussion again. I served as a commissioner on the Food, Farming and Countryside Commission. We clearly need to do more to make the default option the healthy option and to have more food production, certainly post Brexit, of the fruit and vegetables we need.
Human health is not in the Agriculture Bill, although animal health is, and many of us feel that that would be a good idea. Today or later in the week, there is a piece of research coming out from Imperial that has looked at the production of fruit and veg in the UK and what could happen. At the moment, 1.9% of our land is given over to fruit and vegetables. If we took the 20% that we could use for fruit and vegetables, we could by 2030 have 18,000 fewer deaths from cardiovascular disease. It is quite a complicated study; I will share it with you. People are beginning to look at this and if we want to transform the system, we need to think about the healthy outputs in agriculture and production.
Baroness Janke: You have said quite a lot about what the Government could do. What about the very pervasive and strong advertising and marketing campaigns? What specifically do you feel could be done about that? I have something from the British Dietetic Association that talks about the nine o’clock watershed. How effective is that? What do you think could be done to restrict these things?
Not just through television, but online, children are being relentlessly targeted. We saw the other day that they are being targeted for e-cigarettes. The scale of money that is spent on advertising is incredible. I wonder whether we are up against something that needs to be looked into and have something done about it, although I am not sure what.
Professor Susan Jebb: I am sure that something needs to be done about it. I was very clear that advertising and marketing was where I would put my efforts. On the nine o’clock watershed, yes, fine; that is clearly one of the things, but we absolutely must not get so obsessed with that that we think we have done it. Of course, we have not. It has to be much broader. It has to include social media, billboards and all those other things.
When you really concentrate as you walk down the high street and look for food adverts, there are even more than you thought. They have subliminal effects on people’s desire to eat and on their food choices. We have to take a very bold and comprehensive approach. We have seen some good action in London with restrictions on advertising. I would like those kinds of interventions done nationally. If we leave it for local authorities to do, first, we will get a patchy response and, secondly, we will waste a huge amount of time and effort as every local authority goes through the process for itself. For heaven’s sake, if we think this is important let us do it once, do it properly and do it nationally.
We absolutely need strong action. I support the nine o’clock watershed but it is not nearly enough. It has to go much further than that. What I do not want is for the nine o’clock watershed to become a huge fig leaf that stops anything else.
The Earl of Caithness: When is the Imperial report coming out?
Shirley Cramer: This week, and I will send a copy to the Committee.
The Earl of Caithness: Is there anything we can learn from the Amsterdam Healthy Weight project, which seems to be a success?
Shirley Cramer: I had a presentation on that a couple of weeks ago with the people who started it. The first thing is leadership. They had elected officials in Amsterdam who took leadership of it. It was not just left to the people who were the chief execs and others. That was definitely one of the primary things.
It was entirely and utterly comprehensive. It was in every part of their system. They looked at how they could make a difference incrementally in all areas: environment, behaviour change, information campaigns, education campaigns, school food and nursery food. It was all of those areas, backed up by real political capital and sustained over quite a long period. Instead of having short political bits where you get three or four years, it has been sustained over quite a long period, and that seems to have made it a success. It has become mainstream activity and not an additional piece that we do nicely because we want to deal with obesity. It has become “What we do in Amsterdam”, so they are seeing sustained change.
Q64 Baroness Parminter: Shirley, you mentioned earlier that we would come to local authorities. Well, here we are.
What are the Government doing, and what could the Government be doing, to support local authorities in their job of promoting healthier diets, particularly for people at most risk?
Shirley Cramer: The first thing is that they could be giving them more money. Many of us think that the issue is around the social determinants of health, and of course there is individual responsibility, but local government has lost 49% of its income overall in 10 years. The public health grant has gone down. A lot of the local authority grant is statutory, as you know, so that means that there is very little left for any kind of innovation. I have been amazed, in our organisation and others, at some of the innovative and good programmes that many local authorities have managed to put on, despite having very few resources in this area. The first thing would definitely be money.
Some national guidance and framework on business rates retention would be good. It is our view that you could incentivise healthy businesses by lessening their rents and their business rates. There has to be a framework whereby we could incentivise. The healthy towns checks are to do with economics. Why can it not be health and well-being as well? There is a whole range of frameworks. Many organisations have put some of them out. If they were national, we would have less of the patchwork that Susan mentioned.
We need planning guidance. Planning is an important part of how we can make our towns and cities healthier. That requires money, and it requires planning law to be easier for local authorities to manage, take authority for and have responsibility for it.
Susan Lloyd: From the faculty’s point of view, local authorities are key because they deliver public health in communities. Local authorities in some areas have very much taken a lead on health and well-being because it has become a central tenet of their cultural approach. This Committee and the Government could encourage health and well-being as part of the central tenet that local authorities take to many policies. For example, the local development plans are coming up for review in the very near future—next year—and if well-being or health in all policies was a central tenet that was used in developing the local development plans, everything we have talked about today would be embedded within the local environment, similar to the Amsterdam project.
It is a cultural approach. It starts centrally. Local authorities are well placed. They have had a reduction in money, and that is a major problem. However, local authorities that take a well-being approach can make big differences. There are some very good examples; Shropshire Council is one of them. Let us not just focus on money, although money is very important as well.
Louise Marshall: I agree, particularly around the money. I will not add anything on that. As Susan says, there are excellent examples. Local governments are increasingly trying to take whole-systems approaches to childhood obesity and to other areas in addressing the wider determinants of health, but due to the cuts they are limited in their ability to do that. We need to support sharing the learning from places that are doing it well. What are the lessons from those areas and how can they be transferred and spread?
At the Health Foundation, we are working with the Local Government Association in a grant programme for local authorities, leading systems approaches to the wider determinants of health. We have recently closed the applications and long list, and it was very striking how many were applying for, and needing, money to fund exciting and novel approaches to a range of issues. It was very striking how many were on food poverty.
Professor Susan Jebb: I do not have much to add to what others have said, except to say that this is a national problem. There are small regional variations by local authority, but mostly these are pretty similar things. Until our national Government really step up and absolutely make this a priority, they are expecting a lot of local authorities, with all the pressures they are under, to say, “Okay, we’re going to do it or not do it on our own”. Yes, there are things they can do, but they will work best when they are supported and complemented by the things that are better done nationally. We should not push it all down to local authorities because the national Government think it is too hard.
Q65 Baroness Osamor: What is your assessment of the Government’s action on obesity? In your view, how effective are the initiatives outlined in chapters 1, 2 and 3 of the Government’s obesity plan likely to be, if implemented? Obesity remains a pervasive issue. What is preventing progress on tackling it?
Professor Susan Jebb: I refer you to the evidence I gave to the House of Commons Select Committee when we were talking about obesity, which was basically that the Government are talking really tough on obesity and there is lots of discussion, and that is good, but it is not enough. Action is still far too slow. Most of the childhood obesity plans have said, “We will consult on”, “We will discuss”, “We will consider”, or, “We will think about”. Many of those consultations have been out and closed months and months ago. There is simply no apparent sense of urgency.
The things that have been done are good. It is important that we have Change4Life. It is good that we have set voluntary targets. The sugary drinks industry levy has been helpful. All the things they have done are good, but they are not nearly enough, and they are not being done at a pace and with a sense of urgency that is anywhere near the scale of the challenge.
The question is not what we should do, because we all know. There is a long list. Sally Davies, in her report, when she was CMO, set out a whole catalogue of possible options. The question is: why is it not happening? There is something about the topic. Partly, it is prevention. I am afraid prevention always gets a poor look-in compared with treating an acute issue. When we look at the response to coronavirus, serious as it is, absolutely everything is out for it. Obesity is the biggest cause of diet-related disease. It is the leading cause of morbidity in the UK, yet we say, “Well, there are a few things we might do and we’ll get round to them one day”.
It is partly about prevention. It is partly that the Government are not facing up to the market failure I alluded to earlier in relation to the food industry. It is also that somehow, although in their rational objective moments the public want a healthy diet, because everyone wants their children and families to be healthy, none the less, because of all the pressures in the system, they end up buying less healthy foods and are not wildly keen on interventions that might prevent that. The Government are excessively sensitive to assertions that somehow any intervention will restrict people’s choice. In fact, many of them will not. Actually, advertising affects people’s choice. If we really wanted people to have a free choice, we would have no advertising at all and people would make the decision they wanted to make without being swayed by the company with the biggest marketing budget.
It is a combination: prevention is not valued enough; there is industry pressure; public support is a bit too weak and not quite vocal enough. People care about it, but somehow those voices are not being heard or articulated.
Going back to the previous question about local authorities, there is a real opportunity for local communities to start building demand for healthier environments and healthy foods. That is more likely to happen at local level than it is from some national campaign. I am not going to list all the things that the Government could do. They have been listed in many other places.
Louise Marshall: I agree. There is too much focus on individual behaviour change and reliance on individuals’ agency to be able to change. Some of the approaches taken are promising, but, as Susan said, they need to happen with more urgency. There needs to be a much bigger focus on the system of wider determinants of our diet, and the complex system that determines what we eat and its impacts. That needs to be joined up across government, with a whole-government approach. On some of the specifics, the big gap is in child poverty and food poverty. Unless that is addressed, a lot of the actions being proposed are unlikely to be maximally effective.
To come back to some of the things we have said, there needs to be bolder use of regulation and marketing. There needs to be more joining up across government, making sure that we also focus on the physical environment, transport and all the other things that determine our weight as a population.
Susan Lloyd: The Government’s obesity approach is a very positive step, but I reiterate the important point that it focuses on individual behaviour, rather than the environment and the whole-systems approach. I will not labour that because we have talked about it.
Susan made the very important point about it being a long-term approach. We find in local government that when we are working in political cycles, it can be very disruptive when trying to achieve long-term aims. Ideally, we need a standardised, focused approach where well-being is embedded in the legislative approach as health in all policies. We are very welcoming of the obesity approach, but we think it could be enhanced.
Shirley Cramer: I entirely agree with the other three panellists. There are a lot of very nice words out there, but we have not seen the implementation that we need to see. I have no idea why it has been so slow. We have seen it. It is patchy. In some areas people are trying hard on this but they have not been supported, in our view, by the national Government to make a good fist of it. There are wise words but implementation needs to be clear, robust, and national. It needs to be long term and in all policies. It has to be about the environment much more than about individual behaviour change.
One of the opportunities we have is perhaps to link the issue of our health and well-being in eating with climate change. It is clear from the Lancet papers last year that what we eat and what we grow is related to climate change. The positive way that is taken, particularly by many young people, is around a social movement. If we could link a social movement for health with what we need to eat for a healthy planet and healthy people, that might be a better narrative than coming across as stigmatising people and always looking at the negative end of it. There is something about having a new narrative around this that might re-engage the population in the debate.
Baroness Parminter: I was very struck by what Susan said about politicians not wanting to tackle the issue for fear of upsetting the general public. Whereas in other arenas there is a strong lobby from civil society, particularly on the environment, which you have just been talking about, which can counter some of the pressures from the industry to give the Government a bit of a nudge and support them in doing that, in this area there is not that strong, charitable, civil lobby perspective. There seems to me to be a gap. Do any of you have a view on that?
The Chair: Very briefly.
Professor Susan Jebb: There has been a gap. In the food area, we have been much less organised than, for example, the tobacco control people, who were very clear what policy had to come next and were building public support for it as they went. We now have the Obesity Health Alliance, which brings together a whole collection of charities and other organisations that are focused on obesity. I think we are beginning to get a bit more joined-up action.
What we have also seen is that, when a clear policy is the one next in line, NGOs have been very good at creating public dialogue and public interest. They have been first class on that. We saw it ahead of the soft drinks industry levy, and prior to that ahead of the restrictions on advertising in children’s viewing. Yes, we need to get better at that, but some things are happening.
The Chair: Do the others have anything to add? Do you agree that we need to get better at it?
Professor Susan Jebb: The national food strategy is an opportunity as well. We will see how that plays out.
The Chair: What about the big medical charities such as Cancer Research UK?
Professor Susan Jebb: They are part of the Obesity Health Alliance and have been very instrumental in setting it up. It is interesting that we know that obesity and diet is a big driver of diabetes, heart disease and cancer, yet all of those charities put much more emphasis on treatment. Their prevention stuff is very muted. That is a real shame, but it is human nature; we deal with problems when they happen. We are less good at taking a long-term view, but that is what is needed in this area.
Baroness Janke: Have we learned anything from the Smokefree campaign, where there was quite a lot of social pressure? Restaurants, bars, shops and so on had a requirement to live up to standards or to promote Smokefree. It became socially unacceptable to smoke. I know there are problems with eating disorders, body image and all the rest of it, but I am just wondering whether for restaurants and food providers—although labelling is one thing—there could be campaigns to have healthy providers or retailers awarded with stars, or that kind of thing. That happened very well in my city of Bristol with Smokefree, where we were fighting against years of the tobacco industry. It was very successful.
Shirley Cramer: I am talking about a new narrative because we think that if you have a different version of it, which is more about eating less and better meat and more plants, you are not saying, “You are a bad person because you ate that”. You are encouraging restaurants, out-of-home sales and others in a much more positive way: “Let’s all save the planet”.
Baroness Janke: The rating system could reflect that with stars if we could get the Michelin Guide or whoever to give awards.
The Chair: We heard last week from Blackpool Council that it is doing something along those lines by recognising shops that sell healthy foods.
Baroness Janke: It is a national thing to aspire to.
The Chair: We should move on to the very last question, with a one-word or one-sentence answer from each panellist.
Q66 Lord Empey: To some extent, some of you have already answered bits and pieces of it. What would be your key policy ask to ensure that a healthy and sustainable diet is accessible to everybody? You can finish our report for us.
Professor Susan Jebb: As I said, advertising and marketing are skewing the food system in an unhealthy direction at the moment. That would be where I would start. There is one other thing. It is probably not my top priority, but I am surprised that we have talked so little about price. The soft drinks industry levy is mostly not about price. As we have discussed, it is an incentive to reformulation. Food is astonishingly cheap, and until we start addressing that we are going to have an ongoing problem.
The obvious immediate place you could take action would be on VAT. There are ridiculous anomalies that do not help the health agenda. Why do cakes not have VAT on them? That seems to me very easy to fix. If the price of cakes went up by 20%, you would probably see something of the order of a 15% to 20% reduction in consumption.
Louise Marshall: We need strong political leadership of a long-term, whole-government approach to the complex system of determinants of what we eat and the impact of that on population health and planetary health. All policies related to the food system need to support accessible and sustainable healthy diets for all.
Susan Lloyd: The faculty sees the national food strategy as a real opportunity. There was clearly experience during World War II where the national food strategy was very effective. It was a different environment, but it is important that there has been success in the past.
Shirley Cramer: I agree with all of that. In addition, there needs to be a lot more engagement with the food industry itself and with the shareholders who invest in those industries, in the same way as was done with tobacco.
The Chair: Thank you very much. I would now like to draw the session to a close and thank all of our witnesses very much indeed for their extremely helpful evidence. As I said at the beginning, you will be sent a transcript of this session in order for you to make any corrections that you wish to make. With that, I close this session and we will move on to the next one. Thank you very much.
