24
Examination of witnesses
Professor Wendy Wills, Professor Amelia Lake and Professor Maria Bryant.
Q90 The Chair: Good morning, everyone. It is just morning; it is before noon. Welcome back to this public meeting of the House of Lords Food, Diet and Obesity Committee. We continue our meeting this morning, and into the afternoon, with the eighth evidence session of the committee’s inquiry exploring the role of foods, such as ultra-processed food and foods high in fat, salt and sugar, in a healthy diet and in tackling obesity.
We are now hearing from Professor Amelia Lake, professor of public health nutrition at Teesside University, and Professor Maria Bryant, professor of public health nutrition at the University of York. They are both joining us in person. We are also joined by Professor Wendy Wills, pro-vice-chancellor and professor of food and public health at the University of Hertfordshire, who is joining us remotely. You are all very welcome. We are looking forward to your evidence. I will ask you to introduce yourselves briefly just before you answer the first question.
Today’s meeting is being broadcast and a written transcript will be taken for subsequent publication. It will be sent to the witnesses to check for accuracy.
I refer to the list of members’ interests, including my own, which is published on the committee’s website. We set them all out in the committee’s first evidence session on 8 February.
I also repeat very briefly what I said at the beginning of the earlier evidence session: that although it would be inconsistent with Lords committee procedure to compel our witnesses to do so, we will, for the sake of transparency, be giving our witnesses the opportunity voluntarily to declare any interests that they deem relevant to the work of the inquiry the first time they speak.
Having done that, I will ask the first question, and I remind you to give a brief introduction, if you would, before you answer it. How does the prevalence of poor diet and obesity differ across populations and demographic groups? What are the reasons for the disparities?
Professor Amelia Lake: Good morning. I am a dietitian and a public health nutritionist. I have spent most of my career in academia. As well as being a professor of public health nutrition at Teesside, I am also associate director for Fuse, the Centre for Translational Research in Public Health—so working closely across policy, practice and with the public. My research ranges from topics as broad as food environments through to food insecurity, obesogenic environments, which I know you talked about in the session earlier, healthy planning, workplace health, energy drinks and food taxes.
You have set out for us a very big challenge, because that is a very big question. I know you have had lots of evidence from a range of people over the past couple of weeks. Obesity is now population-wide, but there are population groups that are particularly affected by obesity, food insecurity and wider deprivation. I know that the three of us will talk about different groups. Related to the research that we are doing in Teesside, we are looking particularly at people who are living with severe mental illness and the fact that they are disproportionately likely to be living with obesity or affected by food insecurity.
Professor Maria Bryant: Good afternoon, everybody. I am from the University of York, where I am a professor in public health nutrition. For the most part, my research focuses on early life, childhood and families, so predominantly through prevention research. I am also the outgoing chair of the UK Association for the Study of Obesity. Thank you for inviting me today to give evidence.
Extending what Professor Lake has said about the rate of obesity—let us make this very clear—there are more people who live with overweight and obesity in the population than those who do not. It is a substantial issue. We know there are huge disparities, with greater levels in those living in the most deprived neighbourhoods. In particular —this is my area of interest—children. One in five children now start school already experiencing overweight or living with obesity. Something happens in primary schools—as rates increase to one in four. This is not equally distributed; if you are a child living in a more deprived area, you are twice as likely to become somebody living with obesity. As a child with severe obesity, you are four times likelier to live in a deprived neighbourhood. It is certainly not an equal condition.
I will let Professor Wills talk to you about other areas, but I am very happy to come back on anything specifically in those.
Professor Wendy Wills: Good afternoon. I am a registered nutritionist in public health and a sociologist. I work as professor of food and public health at the University of Hertfordshire. I am also the director for the east of England of the National Institute for Health and Care Research’s Applied Research Collaboration—ARC. The east of England has a very vibrant regional food and nutrition group, some of whose work I will draw on today. I am quite happy to declare that I have no financial or other industry conflicts that are relevant to this committee.
I have been involved in research on the wider determinants of food, diet and obesity for the last 25 years. My focus has been on the lived experiences of socioeconomic status, social class or life position, particularly in relation to families with children. A lot of the qualitative research that I have led or been involved with is about secondary school-age children and their families, but some of it is about younger children. I also do a lot of work with older people where the patterning is a little different. Today I will focus mostly on children and families.
I will draw on the same statistics that Professor Bryant has just talked about, which come from the national child measurement programme, about the difference in prevalence in children starting primary school versus when they leave. The rate changes to such an extent that, by the time children in England leave primary school, 30% of those from a deprived background are living with obesity compared to 13% from the least deprived areas. It is quite stark.
There is something quite worrying about the socioeconomic factors that change and accumulate throughout the time that a child is at primary school. As you ask your other questions, I will draw on some of our research that tries to help understanding of what factors might be driving those prevalence rates.
Q91 The Chair: Does it accumulate as the child gets older because they have more choice themselves over what they eat?
Professor Wendy Wills: That is certainly the case when children get to secondary school, where they suddenly find themselves in a whole new social and economic world. They often have a lot more autonomy as they get older. A lot of our research has looked at the young people who start to go outside school at lunchtime, for example. We see some patterning there around the food outlets that are available near schools in more deprived neighbourhoods and the number of young people who go outside of school to purchase food and drinks.
In one of our studies of several hundred young people, around 40% of young people in more affluent areas were leaving school regularly, more than twice a week, to purchase food or drink outside at lunchtime. This was more than 90% for the young people at schools in deprived neighbourhoods. Not only were there more outlets, but young people were more likely to go and visit those outlets at lunchtime.
We found a stark pattern in schools in deprived neighbourhoods where there were not a great many food outlets outside. The typical pattern was that a young person would have a hot drink before going to school, drink water at the mid-morning break and have an energy drink or another high-sugar drink at lunchtime, but no food whatsoever during that part of the school day. If food was not available at home, they were not coming to school with money or they were not eligible for or taking up free school meals, they were not consuming a lot of food, which has huge implications for education attainment and concentration, let alone health, well-being, obesity and malnutrition.
The Chair: In your study, did you find any schools that closed the gates and said, “You will not go out during the school day”?
Professor Wendy Wills: We did not. It was a large number of young people but a smallish number of schools in our research. We know that some schools do that. That does not necessarily mean those young people are eating better or eating anything in school. It just limits where they can go outside of school.
Children are very canny. In all our research, they always find a way. If they are allowed out only at mid-morning break, say, but not at lunchtime, or if their parents do not want them to go outside at lunchtime, for example, they will buy food and drink on the way to school to consume while they are there. It is not always a simple matter of not letting them outside.
Q92 Baroness Browning: Good morning. Following on from what you have just said, has there been any research into grazing between meals? It seems that socially, particularly in certain areas, fixed mealtimes have been lost. That may be set in the school day, but in the home environment it all blends in. With hard-working parents sometimes holding down more than one job, children are very often left to help themselves from the fridge and the cupboard.
We are very focused on the nutritional value of the set meals and how it contributes to obesity. All that grazing in between is quite new for the current generations. It certainly was not available in my generation, immediately post-war when rationing was still on. What happened between meals was usually supervised as a treat. How much does between-meals grazing contribute to the obesity problem?
Professor Wendy Wills: We have not looked specifically at snacking. From our studies in schools, we know the vast majority of young people tend to eat something at the mid-morning break. I do not have data on whether that impacts on overall energy intake, whether it differs or whether they eat less at lunchtime because they have had something to eat at mid-morning break.
In terms of parents overseeing what young people eat, we have seen very clear social patterning in our qualitative studies. More middle-class families have almost a different expectation about what young people will eat when they are in or out of the home. We found that they expect children to prioritise healthy eating and control their weight more than families from poorer socioeconomic backgrounds do, where the emphasis is on eating and making sure that you are full enough to get through the day, because those families have many other priorities.
In some of our work we have called that the hierarchy of worry. There are many things that worry families from lower socioeconomic groups: whether they are holding down employment, whether they are holding down multiple low-paid insecure jobs, whether they are managing multiple health conditions or whether their children are in trouble at school. There are a lot of different factors. They are therefore less able and less likely to prioritise exactly what children are eating because of that hierarchy of uncertain things going on in their lives.
It is quite different in families from more affluent middle-class backgrounds. Because there is more security and stability, it is somewhat easier to spend time thinking about how to prioritise healthier eating, how to instil that in your children and how to set the expectations about being mindful of current and future health.
The Chair: I can see that Amelia and Maria are nodding. Do you have anything to add on snacking?
Professor Maria Bryant: Certainly, our dietary patterns have changed immensely over recent years. That is true. I agree that we do not have much data specifically looking at grazing and those outcomes. We have done some research where we explored what happens across a typical school day for a child. We have spoken to children, parents, school leaders, governors, et cetera, about this.
How a child experiences that journey very much depends on how they start and the circumstances that they are in. It is not about just the food that they are provided and offered, but all the other things that happen to them from the start of the day. If you are lucky enough to live in a more rural environment, you are less likely to experience some of the exposures to marketing, advertising and the selling of cheap and attractive foods to children than if you live in a more deprived urban environment, on the whole.
‘Time’ comes up again and again, regardless of who we speak to about this. It is not just the parents. The schools want to do their best, but they have competing priorities. They have a limited amount of time to provide the food, let alone to educate children about this. Parents living in, sometimes quite hectic environments, also tell us a lot that ‘time’ is a key factor as well as the environments they are living in.
Professor Amelia Lake: Just to add to what both my colleagues have said, we should also consider those wider environments and the ability for a pupil from secondary school very quickly, on the way to or from school, to buy high-fat, high-salt and high-sugar food and to access drinks that might be banned in the school, like energy drinks. That broader environment is patterned by deprivation. Children attending schools in different areas will have a very different exposure through the day.
Q93 Baroness Jenkin of Kennington: I refer you to my interests, which are on the website. What is the relationship between food insecurity, poor diet and obesity?
Professor Maria Bryant: I want to start by making it clear that food insecurity, although it includes hunger as a key domain, is not just about hunger. It is about having access to safe and nutritious food. That is really important to this question, and it gives us a better understanding of why some people who experience food insecurity are also at greater risk for health inequalities, including obesity.
Most of the evidence in this area comes from Professor Lake’s brilliant systematic review, so I will let her talk about that. There are other pieces of research going on in this country at the moment, exploring this very issue and the mechanisms through which food insecurity is linked to obesity and other diet-related diseases.
We have the brilliant UKRI-funded Transforming UK Food Systems programme , which is funding a number of programmes, including one about food insecurity in people living with obesity, which has recently provided the results of a survey of 600 adults living with obesity who were asked about the strategies they employed throughout their day-to-day lives. The study found that adults with obesity who also had food insecurity spent a lot of their time budgeting, thinking about supermarket offers and thinking through cooking resourcefully, but the most important one was budgeting, and that was linked to having a poorer-quality diet.
Professor Amelia Lake: Maria just referred to a systematic review that we published quite recently, which looked at international evidence. Basically, the findings are that if you are experiencing food insecurity, you are one and a half times more likely to be affected by obesity. The evidence is now at a point where food insecurity is a well-established driver of obesity. That is the academic assumption: it is a driver. We now need to address it.
Insecurity is a complex problem. When you are food insecure, you are not just food insecure but fuel insecure, you are probably living in poor housing, you probably do not have much of an ability to cook food, you do not have the fuel to cook the food. It is a wider systems problem. That is where Wendy’s expertise comes in. It is an issue that needs further attention. We need to be more aware of this link between the two. We might be aware of it academically, but that needs to translate into thought about how we address that.
Professor Wendy Wills: I think we are all in agreement. Food insecurity, obesity and poor diet are all outcomes of the same underlying causes. We almost do not need to look for separate links or the exact relationship. The Food Standards Agency, for example, runs a monthly consumer tracker survey. I was checking up on it this morning. The three things that still concern people in this country are food prices, food poverty and inequalities, and ultra-processed food.
The people in the UK who are most likely to have these worries are people with a limiting disability or health condition, households with children and households on low incomes, which in the FSA survey tends to be less than £20,000. Many people who are on a low income may also have health conditions and disabilities; they may also have children. All these things become compounded. It is a vicious circle of factors influencing their food insecurity, their diet and their obesity outcomes.
We need to move beyond that now, as Amelia has just said, to look at what might work, what is driving it and how we overcome these complex factors. They are part of everyday life, but they are socially patterned. That is the key thing, really: there is a socioeconomic gradient in these things.
Q94 The Chair: Among the organisations that try very hard to address food insecurity are food banks. To what extent are they able to provide nutritious food to the people who need to come to them? When I pass the donation box in my local supermarket, I notice that there is mainly processed food in it. You can understand why, since people do not know how long it will be before it gets to the recipients, but is that an issue?
Professor Amelia Lake: Again, we have done some systematic reviewing of the quality of food in food parcels. On the whole, it was quite poor. There was a limited ability to deal with people who have special dietary requirements, such as people living with diabetes or a whole host of other diet-related conditions.
We have food banks, but food aid is much broader than food banks. We are doing a lot of work on social supermarkets, and I know Maria is doing the same. That is a different environment, which usually uses surplus food. Again, the kind of food that comes into that tends to have a longer shelf life. At least those are the more popular types of food that go out. In Middlesbrough, the social supermarkets are called eco shops to destigmatise them and make it about reusing surplus food. In those supermarkets, when you provide free fruit and vegetables, they are not taken up. Our research shows that there are multiple reasons for that. When you are cooking with just a kettle, what are you going to do with a potato? That is the harsh reality.
Our research means that I am privileged to be able to go into those environments. It is heart-wrenching to see the queue of people waiting outside those shops, which might only open a few days a week. Our work says that people want these shops to be open more often. They tend to be pop-up shops. This is a whole different food system, which we know very little about. It is feeding the people we are talking about today. We need to understand more. It is run by volunteers, who are amazing. When we talk about food systems, we think about supermarkets, but this is a whole different food system that is happening.
The Chair: One of our members knows a fair bit about this. Baroness Boycott, did you have a point to make?
Baroness Boycott: Yes, I am the chair of Feeding Britain. When I was in London, we opened the first social supermarket at the back of a cemetery in West Norwood. We now have 273 of them. You are absolutely right: they are pop-ups. They are not all run by volunteers because the notion is to make them sustainable. Some of the ones that are brilliant have bakeries attached and they have staff. We manage to balance it out. I would slightly dispute with you the thing about fruit and vegetables not going. In most of the ones I stay in regular touch with, we find that fruit and vegetables and fresh produce go quickly. If you can put the right stuff in front of people at the right price, they will go there.
Professor Amelia Lake: I agree.
Baroness Boycott: They will go there. All our social supermarkets say that it is a middle ground. We teach cooking. It is part of the deal when you join the club that you learn how to cook, even if you only have a kettle, which is depressing. You are right: it is a different and more respectful model. They all have good names. They all have cafés. For anyone who is here, I went to one 100 yards from here yesterday. I was going to propose that we all went there for tea.
The Chair: I think we should.
Baroness Boycott: It is completely amazing. It is in the Abbey Centre, which is the old public baths in Westminster. It is next to the Cinnamon Club. It is absolutely extraordinary.
Professor Amelia Lake: Are you going to take us too?
Baroness Boycott: I will take everybody.
The Chair: Perhaps we should arrange a little visit.
Baroness Boycott: I did not know it existed. Anyway, it is a social supermarket. Thank you for bringing them up.
The Chair: We may not be able to manage a formal visit for the whole committee together, but individually we may very well accept your invitation. Thank you.
Q95 Baroness Pitkeathley: I want to come to Professor Wills first on this. Can you expand more on what you have said about health? I want us to focus on how food, diet and obesity affect health outcomes. I would appreciate it if all three of you could talk about health outcomes in the very widest sense, the role the food environment plays in those health outcomes and how they are disparate for different groups in society.
Professor Wendy Wills: I can try to. I can probably say more about the second part of that question than the first part.
The socioeconomic differences in diet, which are well acknowledged and evidenced, also show that it is linked to high levels of obesity, as we have already said, to type 2 diabetes and to cardiovascular disease. Of course, poor diet does not lead only to obesity; it can also lead to malnutrition, sometimes at the same time as obesity. Malnutrition does not always present itself as being underweight; you can be overweight as well as malnourished. We can send you links to a lot of epidemiological and other research so you can look at that, because there is a lot there about those health outcomes.
What is less clear is the impact on multiple health outcomes and people living with multiple conditions. This is a complex area and slightly aside from my own expertise and background in research. Looking at those complexities, you might be living with type 2 diabetes, cardiovascular disease, arthritis and other conditions. It is about that cumulative effect and how those conditions are managed in combination.
In terms of how the food environment impacts on people, I wanted to draw your attention to a study from Stevenage in Hertfordshire that we did through ARC East of England. We wanted to get young people to think about the immediate factors that might influence their own and their family’s diet, weight, well-being and wider health. We spent a lot of time talking to them and asking, “What is it like growing up in your town? Tell us about your everyday life”. We had great fun talking to them about that. When we went back on a different occasion, we said, “Let’s try to think through how some of those factors that you’ve raised could influence whether somebody is overweight or impact on their health more broadly”.
Once they got their heads around linking those things together, it was so informative. They brought to life what their lives were like. For example, they might want to go swimming with their friends after school, but if they had younger siblings or others in the family who also wanted to do that, their parents could not afford for all of them to do that. Access to those things had to be rationed. They wanted to access basketball courts, football pitches and gyms where teenagers might be welcome rather than turned away.
There was sometimes an issue of funding and being able to get to those things, but one thing that surprised me was how often they brought up antisocial behaviour and crime, both their perceptions of those things and their experiences of people around them. For example, they would say, “I’ve got a bike. I could cycle to the football pitch, but I don’t have a lock for my bike and I don’t want my bike to be stolen”, because they know that that is what happens. Or, “To get to the basketball court I have to go through the underpass. It’s not a safe place to go at night. The street lighting is inadequate”. They were worried about going there, getting their bike stolen or encountering others they did not feel safe around. Many of them said, sometimes for them and their families, both their siblings and their parents, “Why would we go out? It’s easier to stay at home. We want to be physically active and to support our own health, but there are all these barriers in the way”.
They talked about fast food outlets. We asked them a lot about that. Someone in one of your earlier sessions—it might have been Henry Dimbleby or Chris van Tulleken—talked about the vouchers on bus tickets. We found exactly the same thing in Stevenage. Young people said that they would use the bus if they had the money for it, but they were quite outraged that their bus ticket had a voucher on the back so they could get a burger from a particular fast food chain at a discounted price. They were almost saying, “How dare they? We’re young people. Other people who use the buses do not have much money. It makes them more likely to buy that food”. They were quite rightly asking, “Why isn’t it a voucher to get free fruit or free vegetables at a local shop?” Of course, it never is.
They also wanted to point out that their use of fast food places was often not just about the food. In fact, it was rarely about the food. It was a warm safe space where they could hang out and chat with other friends and teenagers, and where they would not be hurried on. As they pointed out, the places that sell healthier food do not open late as fast food outlets do, and they are not welcome to stay there, to spend only 99p on a burger or a milkshake, and to just hang out and chat with their friends. It was quite eye-opening to hear about those social rituals around where young people went as well as their fear of crime and antisocial behaviour. They came on to lots of solutions too, which I can come on to later.
I want to outline one more thing that was quite stark in our studies in schools. In the schools that were in lower socioeconomic areas, the staff in food outlets around schools built up a good relationship with young people. Young people were an important part of the lunchtime economy—before, during and after school, actually. They knew young people’s families. They had seen the children grow up. They were part of that area and that neighbourhood. It was about more than just buying the food.
We did not see that at all in areas where it was more affluent. The shops around those schools were much more business-like. They did not have a personalised relationship that they built up with young people, who would go in, make a transaction and leave.
The food environment was almost pulling young people out of schools because they knew the people in the shops that they went to. How the food environment plays into inequalities if you are from a lower socioeconomic group was eye-opening.
Baroness Pitkeathley: Amelia, can you comment on health and the food environment? Is there any evidence about the effect of obesity and food on mental health as well as physical health?
Professor Amelia Lake: I was just going to say that we know that people who are living with mental illness are more likely to be obese. There is also evidence on the mental health impacts of obesity. At the moment, children and young people are living through a mental health epidemic post Covid. So we need to be mindful not just of physical health but of mental health.
Wendy listed the comorbidities associated with obesity, but there is another one, which used to be called NAFLD, non-alcoholic fatty liver disease, but is now called MASLD, metabolic dysfunction-associated steatotic liver disease. That is the most common liver disease worldwide and is associated with obesity. In the UK, particularly in our deprived areas—again, it is patterned with deprivation; it is in Chris Whitty’s report—this will be an additional burden on the health services. It can be avoided by addressing many factors, including lifestyle. We could have a whole session on the health outcomes and obesity, but I will stop there.
We have been looking at how the food environment affects behaviour and therefore health outcomes. Building on what Wendy has said, the food environment is very much patterned by socioeconomic deprivation. People living in more deprived areas are subject to more unhealthy food environments. We know that; we have the data. It was last collected by Public Health England before it became OHID. We also know that, as well as the actual food environment, they are more likely to see advertising for unhealthy outlets, whether it is outdoor advertising or in bus stops. We have done a nice piece of work in Middlesbrough and Redcar on what is being advertised in bus stops.
It is about this broader environment. We have some bits of legislation on advertising that are not yet in force, but we need to think more broadly about the wider advertising environment that impacts the food environment. That includes bus tickets, which Wendy just talked about.
Professor Maria Bryant: Starting with the first part of your question—I will start at the beginning—I want to mention something that we have not talked about so far, which is the impact it can have during pregnancy. If you are a woman who experiences food insecurity and/or obesity, you are more likely to experience adverse pregnancy and fertility outcomes. In particular, you are more likely to experience hypertension and gestational diabetes. In fact, you are eight times more at risk of getting gestational diabetes if you are a woman living with obesity. This is particularly bad in the UK compared to other European countries.
Unfortunately, we also see higher numbers of maternal deaths in particular populations. In particular, women from black backgrounds are at the greatest risk of this.
Obesity during childhood used to be something we thought of as a risk for adult obesity. We now know that not to be the case. In fact, we did a systematic review and a meta-analysis a few years ago.[1] Again, liver disease came up most prominently in relation to children being at greater risk. We also now see children with type 2 diabetes. We did not see that before. Some of our daily admissions to hospital for diet-related diseases, of which there are over 300,000, are children. Proportionally there are fewer, but there should be none.
The environment is important. It interacts with many other factors, including our biological drive to eat. It influences not just what we eat but how we eat, when we eat, how much we eat and when we can stop eating. As others have said, in the most deprived areas the sale of cheap food with no nutrients is much more prevalent.
It is important to acknowledge that it is also hard to access affordable healthy food in those environments. It is both sides of the coin. Healthy food costs more, regardless of how you look at it. Whether you look at it by calorie or per portion, it costs more.
This is getting worse. The weekly food basket has gone up 25% since 2022. Other indices of food insecurity have increased alarmingly over recent years. Free school meals entitlement has gone up from 19% to 24% since 2019. This is a significant rising issue.
Quite frankly, though, our settings are unhealthy. Our public settings are super unhealthy: our schools, our workplaces and even our leisure centres. We still see vending machines in schools. This is unnecessary and is driven by profit. We face multiple challenges in these areas. That is where I would like to leave it.
Q96 Baroness Boycott: Professor Amelia Lake, can I ask you a bit more about this liver disease? I do not know much about it. What foods specifically are causing it? How young do children get it? How prevalent is it?
Professor Amelia Lake: As a condition, I am not an expert in it. I am assisting colleagues in the area. It was new to me. I remember reading that review. These children are getting it in adulthood, are they not? We are not seeing liver disease in—
Professor Maria Bryant: We are seeing increased risk during childhood.
Professor Amelia Lake: Yes. It is often misdiagnosed or not diagnosed correctly. There is a lot of misunderstanding around it, because liver disease is associated with alcohol intake. It is one of those new frontiers in public health. There will be experts in this who say that it has been around for ever and it is related to a range of other metabolic conditions. As somebody who works primarily in public health, it is a new frontier for me. There will be a massive wave of people, primarily from an obesity perspective, who will end up being admitted to hospital as a result of this liver disease.
Baroness Boycott: Could you point us towards the people who are doing the cutting-edge research on this? It does not seem to be that well known.
Professor Amelia Lake: Yes.
Q97 Baroness Boycott: I have a very quick question to Wendy. Sustain ran a campaign in London to make healthy takeaways because of all the things you said. Another thing we found was that it was safer for women. They got you from a streetlight to a streetlight when you were coming home. You want them to stay, but you want them to be healthy. It was not fantastically successful. Have you tried anything similar and had better success?
Professor Wendy Wills: No, but I know of other attempts at the healthier takeaway model, as it were. Where they are positioned is important. What drives people to eat at a takeaway overrides whether they are looking for healthy food, because quite often they are not.
Baroness Boycott: That always makes you think that, because they go for other reasons, you could in fact sell healthy food there.
Professor Wendy Wills: It is worth trying. There are chains like Leon that have done exactly that. Again, I suspect it is very socially patterned as to who is accessing those chains versus McDonald’s or KFC, et cetera. Driving people to go to a healthier outlet, even if they are available, is a difficult one to tackle.
Professor Amelia Lake: We need to think about what we do. Those outlets are everywhere. Most of the time they are run by local people. These are local businesses.
We did some work—it is called the Foodscape study—looking at the alternatives. We worked with people who supplied the packaging to provide a lighter-bite box for fish and chips in order to reduce calories. Lots of people like that. We looked at the number of holes in the saltshaker. Changing the number of holes significantly reduced the salt. We had what we called masterclass courses that were being run by Kirklees Council. We copied the model and took it up to the north-east.
Businesses can change behaviour. It is very much local authority-run, but you work with what you have. Those businesses are there and people like a takeaway, but will they notice how many holes are in their saltshaker? I do every time I go in, but other people do not.
Baroness Boycott: I completely agree with you. We got the main chip supplier into London to change the designations of its boxes because everybody bought “medium”. It agreed to turn “small” into “medium”, which led to a reduction. Anyway, it is about whether you can legislate. That was very interesting. Thank you.
The Chair: I imagine that it is pressure, rather than legislation.
Q98 The Earl of Caithness: I have a quick question for Professor Bryant on her opening statement. Would it make any material difference to the statistics whether you measure children on BMI or waist-to-height?
Professor Maria Bryant: You have been listening to the news today.
The Earl of Caithness: Yes.
Professor Maria Bryant: Yes, it would. How we measure all these things has a very big impact on what the data look like. I need to make it clear that what we do in one circumstance does not always work for another. At an individual clinical level, for example, you probably would not want to use BMI. BMI is literally your weight adjusted for your height. It is a proxy, but very much a proxy, for obesity. It does not measure adiposity. So, yes, it would make a difference.
On a population basis, which is what we are talking about today, it is a well-established and perfectly suitable measure. For children, it would be quite challenging to use other measures in a school setting, quite frankly. There are some discussions about the national child measurement programme. Without that data, we would not have a good handle on what we are talking about today.
Q99 The Earl of Caithness: Thank you. That is very helpful. For my next question, I will start with you, Maria. We have slightly covered a lot of this ground. What are the main drivers of food poverty and inequality in diet? Can you say a little more about our welfare system?
Professor Maria Bryant: Certainly, I can. I was going to do that anyway. As we have already said, this is no longer marginalised. Again, it depends on when and how you are collecting the data. Between 20% and 25% of our population are experiencing food insecurity at the moment. It is substantial. I have already told you about the figures for free school meal entitlements. To be entitled to free school meals, you have to earn less than £7,400 a year. We are talking about people on extremely low incomes.
Coming back to food banks, it is estimated that there are now more food banks in England than Asda, Sainsbury’s and Morrisons supermarkets put together. Those are the ones that we know about, by the way. It is a substantial wider system.
We also know that some groups are more vulnerable, particularly families with children. Particularly families with very young children tend to be quite vulnerable. There are wider economic and social drivers to this: poverty, low income, unpredictable income, et cetera.
Specifically related to food, the cost of food, particularly healthy food, has risen considerably for a number of reasons that are partly related to the cost of living crisis.
You asked me to talk specifically about welfare. In my research, we do quite a lot of work on free school meals, but what I am going to say applies to other areas. There are two things here. First, the cut-offs for eligibility are far too low. We have evidence showing that children, who quite frankly are often more shielded than their parents, are experiencing a high degree of food insecurity.[2] These are children who do not qualify for free school meals. The £7,400 is a ridiculously low amount. That is something that we can work on.
Secondly, we know there are barriers in accessing welfare. Again, this is about free school meals, but not solely. On the whole, people have to apply for their welfare. From data that is now quite dated, we know that about 11% of families who are entitled to free school meals do not apply. That is about 250,000 families. We have been working with one local authority in Sheffield, which has created a system that uses the data that it already has on those families’ circumstances to register them automatically to receive free school meals. This is low-hanging fruit. This is something that we do not need to invest too much time thinking about.
We are now working with over 30 local authorities. They are committed to doing this and are working very hard. In the early findings that we are getting, we are seeing thousands of extra families becoming eligible. All those children are getting a hot meal, and millions of pounds are being invested into the schools in pupil premium. Those schools certainly need it. There is some relatively low-hanging fruit in that area.
The Earl of Caithness: Could you write to us about what the eligibility criterion ought to be, if you reckon it is too low?
Professor Maria Bryant: Quite frankly, it should be universally provided. However, there is a call for those on universal credit to receive free school meals.[3]
Professor Wendy Wills: I agree. The widespread adoption of free school meals would right an injustice, in my view. Children go to school. They have to go to school. We want them to go to school. They ought to be fed when they are at school, irrespective of what their parents’ income is.
Children have a very keen sense of social justice. They see their friends or friends of friends at school. They tell us in interviews and focus groups, “Their mum’s not poor enough. They don’t get free school meals like I do”. They know those children are either going hungry or having to go outside and buy a bag of chips.
Recent research has been reported from my colleagues at the University of Essex which shows that the universal free infant school meal system has a modest impact on obesity and BMI outcomes, particularly for children who would not meet that threshold, the criterion that Maria just referred to. Those children are what we might call moderately deprived; they are not deprived enough to get free school meals. Under the universal infant free school meals scheme, they are getting fed, and there is a small but significant impact on their obesity levels.
The authors of that research hypothecate that that could be because they are not bringing in packed lunches. Packed lunches tend to be higher in calories than the food they would get through free school meals. It is about having that control and making sure that they eat. They are not having a packed lunch. They are getting a universal infant free school meal. It is having an impact on BMI.
The more we go in that direction and the more children we make eligible to be fed for free at the point of being at school, the better, in my view.
Professor Amelia Lake: We also need to consider people who are considered as in-work poor. Lots of people are working but in poverty. There is a stigma attached to using food banks or even social supermarkets, which has an impact on the wider family.
Q100 Lord Brooke of Alverthorpe: You referred there to school meals and you said “hot meals”. Are they in fact all getting hot meals, or are some schools providing packed meals?
Professor Maria Bryant: On the whole, they are all offering hot meals. Whether they are taken up is another thing. What tends to happen is that some very well-meaning people recognise that some children may not want the hot food and then provide them with a sandwich or something like that. But hot meals are being offered.[4]
Q101 Lord McColl of Dulwich: What are the scientific parameters that distinguish poor obese people from obese people who are not poor? How easy is it to correct the deficiencies that such an investigation would reveal in poor obese people?
Professor Maria Bryant: I am not sure I understand your question.
Professor Amelia Lake: By “poor”, do you mean socioeconomically poor?
Lord McColl of Dulwich: You were saying that poor people who are obese can be malnourished. What scientific parameters distinguish the two groups? Is there any way of correcting them?
Professor Wendy Wills: It is quite hard to give you an answer on how many might be obese as well as malnourished. I am not sure I can, I am afraid.
Professor Maria Bryant: We know a bit about food intake in those circumstances. People who have obesity tend to have diets that are lacking in the nutrients that they need. We certainly know they are less likely to eat their five a day. Not that many people do, quite frankly. They are less likely to consume oily fish and more likely to consume sugar-sweetened beverages. Again, that is mixed up in the wider social and environmental determinants.
Q102 Baroness Boycott: I will concentrate more on national approaches than local ones. We have done quite well so far on local. You can bring in the local if it applies, but the question is about national approaches to developing healthier food environments. Maria, I completely agree with you about FSM. It should extend at least to people on universal credit. What other things do you want to see the Government doing?
Professor Maria Bryant: Thinking back to that question in particular, I want to be quite clear about the evidence. There has been a large focus on trying to change people’s behaviours, including at a population basis through education. On the whole, that has been fruitless or has increased inequalities, because it tends to be those people in a more privileged situation who take them up.
However, we can still do something within behaviour change if we think about multicomponent interventions in that space. One way forward is to support people to interact and manage the system they are living in. However, population-based approaches that tackle the wider determinants have the strongest impact on health inequalities. We have some relatively good evidence on some of those. The tax on sugary drinks is a good one. There are also some systematic reviews coming out in this area. One came out of Liverpool, in which they looked at different types of policies.[5] They looked at policies that addressed price and at taxes and subsidies for that. They looked at place and environment policies as well as personal dietary counselling and advice.
Universally, the things that came through as most beneficial were those that tackled price both in terms of taxes and subsidies. This comes back to the two sides of the coin. This is not just about targeting the unhealthy foods, which I still think we should; it is also about promoting the purchase of healthier foods.
There is lots that we can do to move policies forward in schools. We have WHO guidance. Our levelling-up priorities state that whole-school approaches to food need to be adopted. We do not see this. This is not the fault of very busy schools, by the way. They cannot prioritise whole-school approaches to food. Whole school approaches to food are about the universal messages being sent throughout the day, in addition to the food that is being offered. It is about food education, learning where food comes from and learning how to cook. We need to send consistent messages so that we are not using food as a reward. Schools have other things to do. They are trying to deal with English and maths, quite frankly. There is something that we can do about UK school food policies as well.
Q103 Baroness Boycott: How would you promote healthier food in the current system that we have? Should the Government spend a certain amount of money advertising or subsidising it?
Professor Maria Bryant: The marketing of food is a very persuasive thing. Quite frankly, we would need to invest resources for that. Certainly, in the industries that do, there are substantial benefits. We have to go back to the evidence that says that price is key. We should be taxing unhealthy foods as well as subsidising healthier foods.
Professor Amelia Lake: In addition to Maria’s comments, we are running one of a group of three studies looking at new ways to think about food tax. [6] That work is currently under way. Our research is working with stakeholders at a national level on what would be acceptable. That is now moving forward into economic modelling. There will be more to think about.
Tax is a dirty word, but, like Maria said, we need to think about both sides. The sugar levy has been successful in reformulation. It has influenced the food industry to change what is on offer to consumers. We should not think about this at an individual level. This is not about changing individual-level behaviour. We need to change the environment in which people make their choices.
I know your session this morning was about planning—I have not watched it, so I apologise if this is a repetition—and there are planning levers that can be used to help to shape that environment. We can move away from just thinking about reducing fast food outlets. Alice Wiseman from Gateshead joined you in the first session today. We have published research showing that Gateshead’s three-pronged approach successfully reduced the number of takeaways. That looked at the childhood obesity data. If somebody applied for planning in an area that had a rate of childhood obesity higher than the national average, it would get rejected.
We also need to think about bringing on board the Planning Inspectorate for when these cases go on to appeals. We have done some work in that area as well. We need to be more creative with the levers that are there.
Q104 Baroness Boycott: I know you know a lot about the whole question of sports drinks advertising and the targeting of kids. Can you say something about how that works at the moment in our society? Red Bull sponsors the rugby and it gets very young kids, does it not?
Professor Amelia Lake: Maria also mentioned that marketing and advertising is a very powerful tool. Of course it is, otherwise companies would not use it. One particular interest of me and my colleagues is the marketing, advertising and uptake of energy drinks by ever-increasing numbers of young children. Energy drinks typically contain sugar as well as caffeine, and these are everywhere. They are part of young people’s culture, as you said—sport, music, extreme sports, anything that is cool. We have had a promise to look at how those are sold. The drinks do say on them that they are not to be sold to young people, but that is down to the individual. Children we interviewed in County Durham said, “If it says it’s not for us, why are people selling it to us?”
Baroness Boycott: Why does something like Red Bull have so much sugar? Does it not seem to get through the sugar levy? I am puzzled.
Professor Amelia Lake: All of them have a range of drinks with sugar or low sugar, but, yes, they are still available. Some of them are quite pricey and out of the reach of children, but there are a lot of brands that are cheaper than water.
Baroness Boycott: Have they become part of meal deals?
Professor Amelia Lake: I cannot comment on that.
Professor Maria Bryant: No they have not, to my knowledge, because of the age restrictions.
The Chair: We can check on that. Amelia, you mentioned some research that is ongoing. I realise you cannot give us the results, but it would be interesting if you could give us the remit and the methodology. Would that be in the public domain for us to see?
Professor Amelia Lake: I will forward all the links. There are three studies. That is the food tax work. Yes, that is currently ongoing.
The Chair: That would be very interesting.
Baroness Boycott: Wendy, what would you want to see nationally that could support all the local efforts or make changes?
Professor Wendy Wills: There are a couple of things beyond what my colleagues have already mentioned. The first is looking at minimum income standards. There is research conducted by my colleagues at Hertfordshire and elsewhere looking at what people need to live on—from salaries as well as from welfare benefits—so that they can live at a reasonable level and be more able to afford the food needed to support health. I can send the links on minimal income standards.
I also want to talk about whole-systems approaches, as Maria did, to things like obesity. This is when we look beyond the individualistic level, public health and health. Although it is local, this should be applied nationally to look within the system at what partnerships and what understanding is needed of town planning, public health, education, libraries or the fire service. It is about all these different elements, with people working in partnership, which is in line with the integrated health and care systems that we have across England now, to address what is a complex issue of obesity.
Although it is too early for evaluations of outcomes when whole-systems approaches have been put in place, I have been involved in Scotland, England and now Northern Ireland in some process evaluations looking at the enablers to making a whole-systems approach work, which we hope will lead to better outcomes later. We did a review of existing evidence for the Northern Ireland Executive, which looked at what evidence was available. It showed that whole-systems approaches are starting to be associated with some improvements in body mass index and in supporting better physical activity environments and community well-being. When whole-school approaches were part of those broader whole-systems approaches, they were particularly effective. There are effective schemes in place, with outcome data, in the US, Australia and the Netherlands. In one small part of London, there is one study with some evidence of that.
That is something that we could advocate more that has to happen and be evaluated. We have to see local authorities and other organisations in an area working in partnership and aligning their vision and objectives to that end goal of having an impact on obesity in our communities across the country. We can address it only by having this broad approach across the whole environment where we all live and work, et cetera. We cannot focus only on behaviour, otherwise we will not tackle inequalities at all.
Baroness Boycott: Were you referring to Southwark?
Professor Wendy Wills: No, it was Golborne on that occasion. I will send the links to that study.
Q105 Lord Brooke of Alverthorpe: I declare my interest. I too have an interest in organic alternatives to sugar, in particular Stevia. That takes me to you identifying pricing as being a major factor. You talk about taxation. We have policies developing on taxation. We need more taxation. You mentioned subsidies. What are the areas in which subsidies operate? Have they been looked at extensively, and could they be extended?
Professor Amelia Lake: I do not know an awful lot about the evidence base on subsidies. I am more familiar with taxation.
The Chair: Are you referring to sugar, Lord Brooke?
Lord Brooke of Alverthorpe: I am referring to free fruit, for example, and whether it could be subsidised.
Professor Maria Bryant: It was looked at in the systematic review, which I believe came out of Liverpool in 2015[7]. They noted in particular that it was not just the tax; it was equally about subsidising to improve the uptake of the healthier foods.
Lord Brooke of Alverthorpe: It has not been particularly strongly pursued. I wonder whether there is evidence as to why it was not or whether it should be.
Professor Maria Bryant: I agree that it should be and that there has not been too much in that space.
Professor Wendy Wills: I do not have any evidence to offer there, I am afraid.
Q106 Baroness Browning: The whole-systems approach that you have been talking about this morning is clearly a theme that we are picking up from our various evidence sessions. Without wanting to disparage in any way the choices open to individuals to improve their health and obesity, clearly that is not enough for us to tackle the problem, certainly as a legislature here. Is there anything happening in Scotland, Wales or Northern Ireland that is ahead of the game in this part of the country?
Professor Wendy Wills: I can say a bit on that in relation to whole-systems approaches, because in Scotland—and shortly, I believe, in Northern Ireland—they are putting funding behind helping local systems by working in partnership across local authorities and all the different departments and organisations that work in an area, supporting them to understand more about how a whole-systems approach will work.
Leeds Beckett University worked with what was Public Health England on which components are needed for a whole-systems approach. The resulting Leeds Beckett methodology is about getting senior buy-in, aligning budgets and resources, when you can for that longer-term solution, and making sure that you have a certain number of workshops to work through a meaningful action plan with SMART targets.
Sometimes small pots of funding can go a long way to putting your money where your mouth is, almost, and they are doing that in Scotland. I believe that the plan in Northern Ireland is to make that happen so that they are held to account: “You’ve had some funding. What are you going to make happen? How are you going to monitor your action plan? When are we actually going to see some evidence that this is starting to have an impact on that joined-up picture of how a local area is addressing obesity?”
That needs to involve the community as well, which is the bit that often gets missed out but is vital so that everybody is on the same page about where it is going.
Professor Amelia Lake: Wales is actively consulting at the moment on food environments and energy drinks. Next week we have a workshop that I am attending where they have consulted. I will know more next week, but they have a specific interest in the food environment, which we have talked about today, and energy drinks, which we are also interested in.
The Chair: We are keeping an eye on that. Maria?
Professor Maria Bryant: There are quite a lot of pockets of activity going on. I work quite closely with Bradford Council, and one of the pilots using the Leeds Beckett methodology is instigating something called Living Well, which crosses workplaces, schools and hospitals, including the council’s own workforce.
It is too early on the whole for our local data to show us any impact at this stage, but there are other systematic reviews in this area, which I am happy to share with you, which do find that place-based interventions, and interventions that cover multiple places and settings, are most likely to have an impact.[8]
The WHO’s 2022 European obesity report lists a number of strategies that relate to whole-systems approaches for obesity right from the start, so it covers pre-conception, pregnancy, early years and into older life. For each of those times in your life, it has different recommendations for things that can cover the whole system. I am very happy to share those with you.[9]
Q107 The Chair: Wendy, you mentioned targets a minute ago in relation to small local programmes, and the targets are quite helpful. We have had national targets for reducing obesity for years and none of them have been met. We have had many obesity strategies and hundreds of anti-obesity policies, but they do not seem to have worked. Why have they not worked?
Professor Wendy Wills: It is about whole systems. It is about working in partnership. We cannot tackle obesity and get the rates down by focusing on individuals’ behaviour. We are all grounded in practices that draw on our own histories, backgrounds and socioeconomic situations, as well as the policies and levers around us. As individuals, we are part of complex systems, so it is only by taking that kind of approach that we might start to see a dent in the prevalence of obesity. Partnership working has to be the way forward to drive a reduction in prevalence rates.
Professor Amelia Lake: I absolutely agree with Wendy. According to Dolly Theis’s work, there have been 14 strategies and 700 policies, or the other way round. It is mind-blowing that we are where we are. Yes, there needs to be a way of thinking about those multicomponent ways of working within systems, and public health teams understanding planning.
I am a dietitian, but food environment determines what people eat. We cannot send somebody to a dietitian, give them individualised advice, and then send them out into an environment where they are bombarded with food advertising. We need to think about that system, but in the context of the fact that people are hungry. This morning coming here, we passed mothers outside on hunger strike, protesting at the fact that mothers and children are going hungry in this country.
What is being discussed in this room is so important, but we need action, and we need our local authorities to have the capacity to deliver the action, because what happens locally is so important in tailoring it to those local populations. Those teams are diminishing because of funding and capacity issues, so people are less able to deal with that planning appeal from a hot food takeaway or a national takeaway. Those people are then stepping in and creating holiday food clubs. Foundations run by a well-known hot fried chicken brand provide holiday food activities. That is where we are at.
Professor Maria Bryant: It is clear why those strategies have not made a difference. Hardly any of them have been enacted, as others have said. That is important.
The Chair: What about follow-up and enforcement of those that have?
Professor Maria Bryant: We do not have that many, apart from the sugar tax at the moment, that we know anything about, but we do know through things not just in the UK but elsewhere that these things have to be statutory. I have been in a meeting with the Department for Education and two head teachers from schools who said, “Make us do whole-school approaches to food, otherwise we won’t do it because we can’t prioritise it”.
We have to get away from this notion of the nanny state. People do not live in environments where they have choice. This is not about open choice. We need to make healthy food accessible, and the best way to enact policies is by mandating them.
The Chair: Yes, and by providing the funding for them to do it.
Professor Maria Bryant: Absolutely, yes. Then we need to do something about marketing and to stop the delays in doing something about it. Then there are the low-hanging fruits that I mentioned, such as paperwork not being a barrier to people getting the support and welfare they need.
I agree that local authorities have an important role to play, but they are also in a very difficult situation at the moment. They need supporting financially, but sometimes things can be done centrally. The free school meal auto-enrolment project is one example of something that we are very capable of delivering on now.
Q108 The Chair: Some local authorities are trying to do that auto-enrolment of free school meals. Is it costing them time and money to do it? If it was done nationally, would that save them the time and money, as well as get more children the food they are entitled to?
Professor Maria Bryant: We have been interviewing local authority representatives about this very thing, and we are collecting data about how much time they are spending doing it. First, they are all very happy to do it because they see the benefits, but it is an unnecessary amount of time. It also incurs time spent in schools, because the schools are supporting the letters that go out to parents, et cetera.
We have not finished collecting the data. I am happy to share that when we do, but we have early findings to show that it is considerable. Like I say, they are happy at this stage to do it, but they do not need to do it. It could be delivered centrally.[10]
The Chair: It would be very helpful to see that, even though they are early results. Thank you indeed. Can I thank all three of you very much for all the evidence you have given this morning? It has been very interesting and helpful. There are a number of things you have said you will send on to us, and we look forward to seeing all that as well.
