CANCER RESEARCH UK - WRITTEN EVIDENCE (FDO0029)
Cancer Research UK is the world‘s leading cancer charity dedicated to saving and improving lives through research. We fund research into the prevention, detection and treatment of more than 200 types of cancer through the work of over 4,000 scientists, doctors and nurses. In the last 50 years, we’ve helped double cancer survival in the UK and our research has played a role in around half of the world’s essential cancer drugs. Our vision is a world where everybody lives longer, better lives, free from the fear of cancer.
As well as working towards a smokefree generation to end cancers caused by smoking, our prevention priorities include significantly reducing the number of children who are overweight or obese. For the past decade, we have conducted research and policy development on the need for, and implementation, of TV and online advertising restrictions to reduce the exposure of less healthy food and drink products to children. To this end, Cancer Research UK welcomes the opportunity to continue to engage with government action on obesity.
Cancer Research UK is a registered charity England and Wales (1089464), Scotland (SC041666), the Isle of Man (1103) and Jersey (247).
One page summary of Cancer Research UK’s submission
1. Key trends in food, diet and obesity, and the evidential base for identifying these trends.
3. The impacts of obesity on health, including on children and adolescent health outcomes.
7. The cost and availability of a) UPF and b) HFSS foods and their impact on health outcomes.
11. The impact of recent policy tools and legislative measures intended to prevent obesity.
Overweight and obesity is the second biggest cause of cancer in the UK, after smoking and is linked to 13 types of cancer: more than 1 in 20 cancer cases are caused by excess weight [1]. CRUK analysis estimates over 21 million UK adults will be obese by 2040 [2]. Excess weight does not show the full picture as diet can also directly affect cancer risk. Eating plenty of foods high in fibre, such as wholegrains, fruit and vegetables, can reduce the risk of bowel cancer; whereas eating too much processed and red meat can increase the risk of bowel cancer. For excess weight, the data show that not only are more people in the UK living with obesity and overweight, but the gap between obesity rates in less and more deprived groups is also currently widening [3]. Often intersecting with areas of deprivation, there are also diet and weight-linked inequalities across age, geographical areas, genders, ethnic groups and for those living with mental and/or physical disabilities [4]. We project that around 8,000 total cancer cases in England could be avoided by 2040 – around £249m in economic benefits – if adult overweight and obesity rates were reduced by 2030 [5]. Tackling obesity is therefore central to levelling up health for everyone across the UK.
A child who is obese is around five times more likely to be obese in adulthood [6] and the likelihood is greater for children from more disadvantaged groups [6], [7] ; acting early is critical. The greater availability of fast food in deprived areas [8] and higher density of advertising and promotions of foods high in fat, salt and sugar (HFSS) are likely to be a contributing factor to the socio-economic inequalities seen across obesity levels.
For the past decade, Cancer Research UK has conducted research and policy development on the need for, and implementation, of TV and online advertising restrictions to reduce the exposure of less healthy food and drink products to children[9]. We have two priority policy calls for UK Government action:
We know there is no silver bullet to reduce obesity, and there are many things that need to change in the food environment so that healthy habits are easier to maintain. We strongly support measures to restrict HFSS price promotions and protect our young people from junk food advertising to help address the unhealthy environmental factors that lead to poor diets and excessive weight.
Cancer Research UK is a member of the Obesity Health Alliance (OHA), a coalition of over 50 health organisations who have joined together to advocate for policies to improve population health and address obesity across the UK. We endorse the recommendations in the OHA's response, which echo the calls across the public health community to ensure comprehensive action to improve health outcomes related to weight and diet.
Overweight and obesity is the second biggest cause of cancer in the UK, after smoking, and is linked to 13 types of cancer, including common cancers like bowel and breast cancer [1]. More than 1 in 20 cancer cases are caused by excess weight (22,800 cases a year in the UK) and cancer risk increases with the amount of excess weight. Eating a healthy diet can help people keep a healthy weight, and diet can also directly affect cancer risk. Eating plenty of foods high in fibre, such as wholegrains, fruit and vegetables, can reduce the risk of bowel cancer. Eating too much processed and red meat can increase the risk of bowel cancer.
CRUK analysis estimates over 21 million UK adults will be obese by 2040 [2]. We know that overweight and obesity prevalence is high across the UK population and increasing, but obesity rates also differ across the country, contributing to health inequalities such as cancer risk and cancer treatment outcomes. There are inequalities across age, geographical areas, genders, ethnic groups and for those living with mental and/or physical disabilities [4]. Taking the example of health disparities that impact more deprived groups, rates of children with obesity are increasing significantly faster in communities with high deprivation levels, compared to those living in areas experiencing less deprivation [10]. The gap between obesity rates in less and more disadvantaged groups is widening [3].
Tackling obesity is therefore central to levelling up health for all people in England and across the UK. Because obesity prevalence is higher amongst people from lower socioeconomic groups [11] [12], it is people on the lowest incomes and people who live in deprived areas who stand to gain proportionally the most from public health interventions [5].
We know there is no silver bullet to reduce obesity, and there are many things that need to change in the food environment so healthy habits are easier to maintain. Over the last ten years, Cancer Research UK has conducted research and policy development on the need for, and implementation, of TV and online advertising restrictions to reduce the exposure of less healthy food and drink products to children [9]. Even a one-off exposure to food advertising can potentially increase children’s food intake by around 30 calories during or shortly after the exposure [13]. Research has also suggested that an energy gap of only 69–77 kcal per day over a number of years can make the difference between normal weight and overweight in young children [14]. Therefore, Cancer Research UK strongly supports measures to restrict price promotions on less healthy food and drink and measures to protect our young people from junk food advertising. These are two essential measures to address the unhealthy environmental factors that lead to poor diets and excessive weight that effect the most deprived parts of the UK the greatest.
HFSS product advertising
Our research has shown that exposure to junk food marketing can influence young people’s food choices [15]. These findings align with evidence from systematic reviews and wider research, which show advertising increases food intake in children [16][17]. There is also a strong link between advertising and health inequalities, with children and families from more deprived backgrounds being more exposed to junk food advertising than their less deprived peers [18]. Even a one-off exposure to food advertising can potentially increase children’s food intake by around 30 calories during or shortly after the exposure [13]. As stated previously, research also suggests that an energy gap of only 69–77 kcal per day over several years can make the difference between normal weight and overweight in young children [14].
We strongly urge the UK Government to implement the UK-wide TV and online advertising restrictions on HFSS foods, which were passed into law in 2022 but which the UK Government delayed coming into force until October 2025. The implementation of these restrictions requires minimal effort and no further legislation. The UK Government’s own figures suggest that implementing the HFSS advertising restrictions could reduce the number of children living with obesity by around 20,000 over the coming years [19]. The policy also garners consistently high public support, with 8 out of 10 UK adults supporting the government banning advertising of unhealthy food on TV and online to children [20].
Price promotions on HFSS products
Implementing restrictions on volume-based price promotions would positively influence food purchasing choices in England [21]. As HFSS products are more commonly on offer than healthier products [22], volume-based promotions can normalise the purchasing of unhealthy food and drink categories, contributing to an obesogenic environment for consumers [23].
There is strong evidence that promotions lead families to spend more money overall, not less, increase the consumption of unhealthy foods, decrease the consumption of fruit and vegetables and are associated with higher rates of overweight and obesity, regardless of demographics factors such as age and income [24]. Our 2023 report, Trolley Trends: Shifting the nation towards healthier shopping [25], used anonymised Tesco Clubcard data to show that people intend to make healthier choices when they shop, but they struggle in practice. Price promotions lead to higher consumption of unhealthy food and drink and are associated with higher rates of overweight and obesity [25].
In 2022, regulations came into force to restrict the placement of HFSS food and drinks in stores. Thanks to this and the expectation of (the delayed) restrictions to volume-based promotions on HFSS foods, industry has already started to reformulate some of its unhealthier products or bring in new products [26]. Companies have a choice as to which products they advertise and/or place on promotion. These regulations would incentivise industry to rebalance their product ranges and offers in favour of healthier options.
Inequalities in the food environment
Eating a healthy diet (as defined by the UK Government’s Eatwell Guide) can be expensive and there is a disparity in how much it costs people to follow a healthy diet. According to one study, the most deprived fifth of the UK’s population would need to spend 50% of their disposable income on food to meet the cost of the UK Government’s recommended healthy diet [8]. This compares to just 11% for the least deprived fifth. Junk food outlets are also more prevalent in more deprived areas [8]. This means it is harder for some people to eat a healthy diet than others.
When a healthy balanced diet isn’t an option, the alternative is high-calorie, highly processed, less nutritious food that makes it much harder to keep a healthy weight. Addressing deep-seated inequalities in health outcomes needs action to reduce poverty and increase household incomes. But efforts to support people to maintain a healthy weight would make a genuine contribution. Government action to directly reduce poverty and increase household incomes might make it easier for people to afford to eat a healthy diet [8], as well as separately help speed up the pace of becoming smokefree.
Overweight and obesity is the second biggest cause of cancer in the UK, after smoking and is linked to 13 types of cancer [27]. A child who is obese is around five times more likely to be obese in adulthood [6]– so acting early is critical. Actions that can help reduce childhood obesity are vital.
Ultra-processed foods (UPFs) are not well defined [28]. Most research looking at the links between UPFs and health use the NOVA classification [29]. This was first developed in 2009 by Brazilian researchers and splits food into four categories; unprocessed foods, processed culinary ingredients, processed foods and ultra-processed foods. There is no universally agreed definition on which categories foods fall into and there is much overlap, particularly between processed and ultra-processed foods [30]. Take for example bread: industrial breads made only from wheat flour, water, salt and yeast are processed foods, while those that include emulsifiers or colours are ultra-processed. Therefore, the only way to determine if a food is processed or ultra-processed is to check the individual ingredient list. This is a key limitation in studies of UPF consumption that rely on self-reported food intake measures.
Foods high in fat, sugar and salt (HFSS) are defined based on the Nutrient Profiling Model (NPM): an evidence-based tool that was subjected to rigorous scientific scrutiny, extensive consultation and review when it was first created in 2005 [31]. Research using the NPM as a framework to categorise food has been useful for research into diet and weight and the evidence clearly links overconsumption of HFSS to overweight and obesity [32].
Many foods that are considered UPFs are also HFSS, and research has not yet shown if overconsumption of UPFs can lead to weight gain because of the food processing or if it is their poor nutritional value, high palatability, and the fact that they are HFSS, that leads to weight gain. As such, the term UPF is currently unhelpful when talking about health and weight. Some UPFs are even healthy and can help people keep a healthy weight – such as wholegrain sliced bread, which is high in fibre.
While research continues to explore whether or not processing a food can lead to weight gain, independent of how much fat, salt and sugar it has, policy should continue to focus on HFSS products. More research is also needed into whether eating ultra-processed foods can be linked directly to cancer, independent of weight gain.
Adults and children should be presented with easy-to-understand nutritional information about the products they are buying to help them make an informed healthy decision. Colour coded nutritional labelling including ‘traffic light’ labelling used in the UK, has been shown to nudge consumers’ purchasing behaviour towards more healthful products [33]. Front of pack (FoP) nutrition labels continue to be voluntary [34], despite colour-coded labelling being preferred by consumers, the most effective method of facilitating understanding of nutrition information and that they support the uptake of healthier choices [35].
Colour coded front of pack labelling should be mandatory on all processed food and drinks for all retailers and manufacturers as evidence from reformulation suggests that a voluntary approach to measures is not effective to enact real change [36], [37]. Obesity Health Alliance’s Turning the Tide strategy outlines how pack labelling could be improved and standardised [38]. From our own Trolley Trends Report (more information included in our answer to question 7), nutritional information on food packaging appears to have limited impact on most consumers’ food purchasing decisions: less than half surveyed reported regularly reading the nutritional information on the foods they buy [25]. Consumers reported confusion around what nutritional labelling means across different products and was the main barrier for consumer engagement[25]. This was both in terms of the way in which the content is displayed (particularly when not in the ‘traffic light’ system) and the way serving/portion sizing is communicated [25].
In March 2022, we partnered with British Heart Foundation and Diabetes UK to independently commission YouGov to conduct research to explore attitudes and behaviours around healthy eating and food shopping [25]. As part of the health partnership, Tesco provided an anonymised sample of customer Clubcard data which also allowed YouGov to explore actual purchasing behaviours. This research delivered insights that underpinned a policy discussion that we authored, with recommendations for how supermarkets and the UK Government can positively impact the supermarket environment to make a healthy diet more available, affordable, appealing and accessible to all.
Key Findings - Trolley Trends: Shifting the nation towards healthier shopping.
Conclusions - Trolley Trends: Shifting the nation towards healthier shopping.
The world around us makes it hard for people to be healthy. Consumer-facing messages of ‘everything in moderation’ are overshadowed by an abundance of marketing on alcohol and HFSS food and drink, unhelpfully shaping consumer perceptions and practices. The well-established marketing practices and big budgets of major brands have made less healthy behaviours the social norm. This is hard to counteract. It’s taken concerted government effort over decades to change this for tobacco. And even then, the job is not complete. In 2022, according to Cancer Research UK-funded analysis, the tobacco, alcohol and food industries (and associated intermediaries such as retailers and distributors of each product) derived around £52.7bn of revenue from high-risk consumption [39]. Industry expends significant efforts to maintain these revenues, including trying to influence public policy and limit appropriate regulatory measures via a ‘common playbook’ of tactics. This can even include discrediting evidence, informing opinion through public relations activities and threatening litigation [36]. The UK Government, regulators and civil society have roles to play in redressing this imbalance by protecting public health policymaking from these vested interests, and in protecting consumers.
England is ahead of Wales, Scotland and Northern Ireland in passing legislation to restrict volume-based and location-based promotions. However, lessons can be learnt from London and Transport for London’s (TfL) the HFSS advertising ban. The effect of these restrictions on out-of-home advertisement on in-home food consumption are explored below.
In February 2019 TfL introduced a policy to ban the advertising of HFSS foods on its network. This included underground tubes, bus stops, and railway stations. Research suggests that there’s an association between the implementation of restrictions on outdoor HFSS advertising and relative reductions in energy, sugar, and fat purchased from HFSS products [40]. The researchers used data on nearly two million grocery purchases of HFSS products to estimate the effect of the policy. The main findings were that the policy was associated with:
Improving the nation’s diet is key to levelling up society – thus helping to close the inequalities in the number of children living with obesity and dietary related poor health across the life course. Over the past 30 years governments have attempted to address rising obesity resulting in the publication of 14 different UK Government health strategies, containing 689 policy recommendations [4]. However, many of these policy recommendations were not fully implemented or evaluated. Our two priority calls for the current UK Government are to implement the delayed UK-wide TV and online advertising restrictions on HFSS foods, which were passed into law in 2022, and to also implement the delayed restrictions on volume-based promotions[5].
Progress has been achieved with population-level policies, such as the Soft Drinks Industry Levy (SDIL), that has successfully removed sugar from UK diets [41]. This model directly targets the food system, disrupting the ‘junk food cycle’ which locks the food industry into manufacturing and marketing unhealthy food and drinks due to profitability [42]. Thanks to the 2022 regulations restricting the placement of HFSS food and drinks in stores and the expectation of restrictions to volume-based promotions on HFSS foods, industry has already started to reformulate some of its unhealthier products or bring in new products [26]. Policies that target the food and drink industry directly create a financial incentive to change and remove the burden of behaviour change from the consumer.
Any policy measures should carefully consider how they are mandated. For example, the voluntary sugar reduction programme, which ran initially between 2015 and 2020, achieved just a 3.5% average sugar reduction over the time period [43]. Compared with the 46% reduction achieved by the mandatory SDIL [43]. The voluntary calorie reduction programme, which ran initially between 2017 and 2021, showed only a single product category demonstrated a significant reduction in calorie content [44]. Past voluntary approaches to food reformulation have not produced sufficiently rapid results but the evidence suggests that mandatory measures work [37].
The nutrient profile model (NPM) was originally developed by the Food Standards Agency to categorise food and drinks as ‘healthier’ and ‘less healthy’ and has been an important tool in health and food policy since developed in 2004-2005. However, the NPM is yet to be updated and is now nearly 20 years old [45]. Public Health England (PHE) developed a modified version of the NPM that reflects updated dietary guidance on free sugars intake and on fibre intake which was consulted on in 2018 but is yet to be formally responded to and adopted by the UK Government; partly due to industry lobbying [46]. An outdated NPM, could weaken the impact of policy using this model, such as the restrictions on the advertising on HFSS products. The model should be updated to reflect the changing food environment and new evidence.
The positive impact of population-level measures such as the SDIL and outdoor advertisement restrictions seen across the Transport for London Network have been explored in our answer to question 11.
Cancer Research UK’s two priority calls for the UK Government are to:
In addition to these two policy calls, we endorse the Obesity Health Alliance’s manifesto[47] . Their three main asks for the next UK Government are:
• Give children’s health the priority it deserves – including renewing the commitment to halve childhood obesity by 2030, alongside tangible measures to achieve this.
• Build on the success of the Soft Drinks Industry Levy to design further fiscal measures that incentivise industry to sell healthier food and drink options, and to invest revenue raised in funding policies to improve children’s health, especially for people on lower incomes.
• Empower local communities to make the places they live healthier. Do this by updating planning laws to enable local authorities to increase the number of healthy food and drink options and reduce the prevalence of unhealthy food outlets. And do this by increasing the powers of local authorities to tackle the flood of unhealthy food and drink advertising in outdoor areas, especially near places children congregate.
4 April 2024
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