WORLD CANCER RESEARCH FUND INTERNATIONAL - WRITTEN EVIDENCE (FDO0030)

 

World Cancer Research Fund (WCRF) International is the leading authority on cancer research related to diet, weight and physical activity and collaborates with organisations around the world to encourage governments to design and implement policies to prevent cancer. WCRF International has been in official relations with the World Health Organization since 2016. Our response focuses on our research and policy expertise areas.

 

Co-authors: Kate Oldridge-Turner, Rebecca Taylor, Jennifer O’Mara, Kendra Chow, Dr Helen Croker, Dr Giota Mitrou.

 

Question 3: The impacts of obesity on health, including on children and adolescent health outcomes

  1. Obesity is an established major risk factor for 13 different types of cancer including common cancers like breast and colorectal cancer. However, recent research indicates that obesity may be a risk factor in up to 18 types of cancer including leukaemia and non-Hodgkin lymphoma. The evidence shows that those living with obesity in childhood will continue to live with obesity in adolescence and adulthood, underlining the importance of early intervention in childhood. Interventions to reduce the number of adults living with obesity need a life course approach as the evidence further suggests there are also adults living with obesity who had a normal weight in childhood.

 

  1. Estimates show that the cost of obesity inaction on the healthcare system is around £800m with a cost to society of £ 8.7billion. This has financial implications for the economy in addition to reduced productivity, lower educational attainment, and reduced quality of life.

 

Question 4: The influence of pre- and post-natal nutrition on the risk of subsequent obesity, and the specific influences on the diet of children and adolescents that contribute to the risk of becoming obese

  1. The evidence shows that breastfeeding helps protect children against excess weight gain, overweight and obesity, and may benefit the mother’s health by helping her maintain or reach a healthy weight and help protect the mother against breast cancer. The benefits for mothers and babies are greater the longer the cumulative duration of breastfeeding. WCRF International encourages mothers to breastfeed their baby if they can.

 

  1. The World Health Organization (WHO) advises that infants are exclusively breastfed for the first 6 months of life, and then breastfed up to age 2 or beyond, alongside nutritionally adequate and safe complementary (solid) foods.

 

  1. To protect breastfeeding, the marketing of breastmilk substitutes (infant formula) is regulated by an internationally agreed marketing code, incorporated in to UK legislation. The UK legislation only covers first infant formula marketed to babies up to six months old.  Products marketed for older babies are exempt which allows companies to advertise similarly branded products to their first infant formula across many channels including television, print and online media and social media. 

 

  1. There is heavy marketing of unhealthy food products such as those high in fat, salt and sugar (HFSS) aimed at babies, children and young people. The Food Foundation Broken Plate report found in 2023 that 97% of snacks marketed at babies and toddlers contained a nutritional or health claim, despite many containing unsuitably high levels of sugar for that age group. High sugar breakfast cereals often use imagery appealing to children as detailed in a 2020 report from the charity Action On Sugar. HFSS products are a strong feature of digital marketing aimed at teenagers and young people, which youth charity BiteBack2030 has found to be highly effective in enticing young people to buy those products. 
     
  2. This marketing onslaught, combined with multi-buy price promotions on HFSS products, pushes parents and young people towards more unhealthy products influencing the nutritional make-up of their diets, and increasing the risk of overweight and obesity in childhood or later life. The UK government promised to ban HFSS multi-buy offers, but the measure, originally scheduled for April 2022, has been repeatedly delayed and is now due to be implemented in 2025.

 

Question 5: The definition of a) ultra-processed food (UPF) and b) foods high in fat, sugar and salt (HFSS) and their usefulness as terminologies for describing and assessing such products.

  1. a) The term “ultra-processed food” comes from the NOVA food classification system, developed in 2010 by researchers at the University of Sao Paulo, Brazil. It categorizes foods based on the degree of industrial food processing it has undergone. The four groups in the NOVA system are: 1. Unprocessed and minimally processed foods; 2. Processed culinary ingredients; 3. Processed foods; and 4. Ultra-processed foods. Ultra-processed foods (UPFs) are typically made using industrial equipment and involves breaking down original food or a recombination of ingredients. Other ingredients, such as additives and/or emulsifiers, can be added through commercial processing. The NOVA system classifies foods based on degree of processing, not nutritional quality.

 

The Scientific Advisory Committee on Nutrition (SACN) has considered the definition of ultra-processed foods in a 2023 statement.
 

  1. b) HFSS foods contain high amounts of fat (saturated or trans), added sugar, and/or sodium. They are often highly processed, energy dense foods that are affordable, readily available, highly palatable, and lack nutritional value. Many HFSS foods are also UPFs, such as sugary drinks, packaged snacks (crisps and others), processed meats (sausages, burgers, chicken nuggets, etc.), ready meals (pizza and others), and desserts (biscuits, pastries, cakes, etc.). There is substantial evidence HFSS foods are detrimental to health and can increase the risk of developing several non-communicable diseases, including cancer.

 

  1.         There is a group of UPFs not considered HFSS including, but not limited to: vegetable-based pasta sauces, sliced wholemeal bread, low sugar wholegrain cereals, and unsweetened fruit yoghurts. These foods can make up a substantial proportion of people’s diets and can offer some nutritional value, as they contain fibre, as well as macro- and micro-nutrients. Foods for medical or nutritional purposes are also in this category, such as gluten-free foods or unsweetened, fortified plant-based milk alternatives (e.g. soy, oat).

 

  1.         The term “ultra-processed” can be useful in describing the degree of processing of a food, but is not necessarily indicative of nutritional value. Studies have indicated that processing may influence health outcomes; more research is needed to explore and better understand how and why food processing may be a health concern, and determine any underlying mechanisms.

 

  1.         A pragmatic approach may be needed to regulate UPF products especially as HFSS products defined using the Nutrient Profiling Model (NPM) currently have the best evidence of harm. The NOVA and NPM classifications should not be viewed as competing against one another, but as tools to understand the content of our food better. Whilst we support exploring a policy response to UPFs, we urge no delay in enacting policies and measures that support and increase accessibility to more healthy and seasonal foods and diets.  We also urge Government to support urgent further research to determine the exact mechanisms in ultra-processing that could explain the adverse health outcomes.

 

  1.         We have concerns that some non-HFSS UPF products are being stigmatised, such as wholemeal sliced bread and unsweetened yoghurts. During a cost of living crisis, low income households already struggle to access and afford non-HFSS products. There is no evidence these non HFSS UPFs cause harm.

 

  1.         UK diets are on average 57% UPF and many UPFs are viewed as convenient, affordable and accessible. Policy responses should consider the quantity and type of UPF being consumed as well as individual products, alongside the need to re-balance diets with affordable, accessible nutrient-dense foods.

 

Question 6: How consumers can recognise UPF and HFSS foods, including the role of labelling, packaging and advertising

  1.         Presently, consumers can identify whether a food is UPF and/or HFSS by reviewing its ingredients list. This requires consumers to assess and interpret an often long list of ingredients; identify additives, sweeteners, and/or emulsifiers; and understand percent daily values of sugar, salt and fat, and assumes consumers have the nutritional education/knowledge to conduct such an assessment at the point-of-purchase. However, this requires individuals to be able to quickly and easily understand and interpret back of pack nutritional information, often at the point of purchase. This places a high burden on the individual and is likely to be unrealistic for most people.

 

  1.         While there is some evidence that the health impacts of UPFs may go above and beyond their nutritional composition, it is not yet conclusive, nor have underlying mechanisms been identified.

 

  1.         However, there is a strong evidence-base that supports policy interventions on HFSS foods which includes many UPFs. Improving front of package labelling (FOPL) can assist consumers to more easily recognise foods that are HFSS, improve their understanding of the nutritional content of food, and assist them to make healthy diet choices.

 

  1.         Identifying food as HFSS would be useful in differentiating products likely to be detrimental to health when consumed frequently and/or in high quantities. Packaging, advertising and promotions also play a critical role in influencing patterns of consumption including high intakes of HFSS foods. Restrictions on junk food marketing can have positive impacts on household food and drink purchases, and children particularly need to be protected from the harmful impacts of food marketing.

 

  1.         FOPL and marketing restrictions, are listed among others, as best-practice policies to tackle unhealthy diets, and decrease chronic disease incidence in the evidence-based and cost effective WHO ‘Best Buy’ policies.

 

Question 8: The role of the food and drink industry in driving food and diet trends and on the policymaking process.

 

Policymaking process:

  1.         We strongly believe the food and drink industry should not be involved in policymaking processes. The UK is not unique in experiencing high level lobbying to promote industry interests which do not align with public health goals. This is a phenomenon we have researched around the world in our Building Momentum reports, which document industry tactics to derail and disrupt policymaking processes.

 

  1.         In the UK, industry has sought to challenge food policymaking, such as Kellogg’s legal challenge against promotion restrictions on sugary cereals. Kellogg’s undermined the rigorous Nutrient Profiling Model (NPM) by arguing that the model did not consider the nutrient profile of cereal when eaten with milk. Kellogg’s also challenged whether Parliament was correctly consulted. The High Court rejected these claims.

 

  1.         Another industry tactic is to position companies as partners through the development of voluntary measures such as the voluntary target to reduce by 20% the sugar content in food categories most commonly eaten by children under 18. Evaluation of progress against these targets reveals a mere 3.5% voluntary reduction in sugar between 2015-2020. Progress is slow, and voluntary measures are ineffective to drive the change needed to address obesity in the UK.

 

  1.         The food industry has also opposed the introduction of regulation; such as pushing back against the introduction of the Soft Drinks Industry Levy (SDIL) by arguing it would cause economic harm and negatively affect profits. However, following implementation, the soft drinks industry did not suffer the economic harm previously claimed. 

 

  1.         It is important to consider other industries with an interest in food policy. For example, the Departments of Culture, Media and Sport as well as the Department of Health and Social Care were intensively lobbied “by business sectors that – in financial terms – had the most to lose when faced with potential restrictions on advertising, namely media groups, advertising companies and the food and drink industry”.  Lobbying disclosure is only required at the highest levels, and lots of conversations between lobbyists and parliamentarians, civil servants or public agencies can take place without records.

 

  1.         Given the scale of action needed to address the rising prevalence of people living with obesity in the UK, we believe the food industry’s role should be limited to being a delivery partner. This will ensure that conflict of interest is minimised, and policy development is not watered down.

 

Driving food and diet trends

  1.         We believe the food and drink industry has a role in developing healthy and nutritious products and reducing the number of HFSS products sold.

 

  1.         UPFs are often cheaper to produce than less processed healthier food products making them financially attractive to many food companies seeking to increase profits (see study on the financialisation of UPF). As they are cheaper to produce, they can be sold more cheaply, making them attractive to consumers, especially those on lower incomes during a cost-of-living crisis.  At the same time, a recent Food Foundation study identified significant barriers to accessing affordable fruit and vegetables for people on lower incomes.

 

Question 9: Lessons learned from international policy and practice, and from the devolved administrations, on diet-related obesity prevention.

  1.         While it is encouraging that the UK Government has taken steps to develop diet and obesity-related policies, like many other countries, policy implementation remains problematic. Some policies have been repeatedly delayed e.g. HFSS multibuy offer ban, and others have suffered from poor policy design making their aims more difficult to achieve.  A 2021 Cambridge University study outlines some of these problems.

 

  1.         Our series of reports that investigate how to implement robust labelling schemes; HFSS marketing restrictions and sugary drink taxes all identified similar challenges in implementing effective policy. Political will and leadership to steward policies are important catalysts to enacting policy and overcoming industry interference. The reports also reference a wealth of diet-related policies from around the world listed in our NOURISHING nutrition policy database.

 

  1.         Furthermore, our analysis shows the real variation in the quality of policy design in diet related policies across 30 European countries, and England rates fairly well on design. However, there is further work to understand the level of implementation of policies across European countries and the impact of these policies. Many policies fail to include monitoring and evaluation measures in their design.

 

  1.         The aforementioned WHO ‘Best Buy’ policies are important best-practice policies to tackle unhealthy diets, and decrease chronic disease incidence. Furthermore, WHO guidance on marketing restrictions and digital platforms and the 2022 WHO Euro report on Obesity provide technical guidance to support policy development and implementation.

 

Question 10: The effectiveness of Government planning and policymaking processes in relation to food and drink policy and tackling obesity.

  1.         The current delays in implementing online, on demand and TV marketing and advertising restrictions on unhealthy food between 05:30am-09:30pm, and multibuy promotions in retail stores call into question the government’s commitment to addressing obesity. We call on the government to renew its promises on tackling obesity and immediately implement several elements of the Childhood Obesity Strategy and “Tackling obesity: empowering adults and children to live healthier lives” strategy which have been repeatedly delayed. These policies are well designed and important levers to improve healthy diets.

 

  1.         We believe these policies are important tools to improve the food environment, and have already been developed considering similar policies from around the world, including best practice examples. The government’s consultations on these policy areas have already sourced high quality research and evidence. For example, the 2021 Health and Care bill highlighted that protection from unhealthy food adverts (for UK children aged 4-15) “could remove up to 7.2 billion calories from children’s diets per year in the UK”. Therefore, a key barrier to tackling obesity is lack of government implementation.

 

  1.         Furthermore, an analysis of obesity policy in England shows that none of the 14 obesity strategies published between 1992-2020 have reduced obesity prevalence. This is largely due to lack of implementation and evaluation, as well as weak policy design. Adequate policy implementation is paramount to truly address obesity and other associated non-communicable diseases.

 

Question 11: The impact of recent policy tools and legislative measures intended to prevent obesity.

  1.         Well designed, mandatory measures can deliver impactful changes. For example, the Soft Drinks Industry Levy (SDIL) demonstrated great success one year after implementation with a reduction of 2.6% per household per week on the volume of all soft drinks purchased. Since 2015, there has been a 46% reduction in the sales weighted average of sugar.

 

  1.         However voluntary sugar reduction measures have been less effective and impactful. In October 2020, Public Health England published its third-year report on progress against voluntary targets to reduce sugar in everyday foods that contribute most to children’s sugar intake by 20% by 2020. This has resulted in an overall 3% reduction (sales weighted average sugar per 100g) since 2015.

 

Question 12: Policy tools that could prove effective in preventing obesity amongst the general population, including those focussed on the role of the food and drink industry in tackling obesity

  1.         WCRF International developed a series of tools to help hold governments accountable for the design of policies to reduce child and adolescent obesity. Our nutrition policy index compares 30 European countries, including all 4 UK nations, for their policy design across a range of areas. This is an effective tool to see how one country compares against another in or across nutrition policy areas. The index also highlights where greater action is needed by governments and in what specific areas.

 

  1.         WCRF International also published a series of country snapshots on what and how the 30 European countries were scored for different diet-related policy actions and policy areas. This is an effective tool to highlight what aspects of policy design a country may need to improve on.

 

  1.         Furthermore, conflict of interest must be minimised and the food and drink industry should only be involved as a delivery partner. UK experience e.g. voluntary sugar reduction targets, and that of other countries shows that self-regulation fails to achieve its objectives and is a food industry delaying tactic to avoid regulation, at least in the short term. This contrasts with the success of SIDL, whereby soft drinks companies contributed to reduced sugar consumption once required to do so by legislation.

 

  1.         The Access To Nutrition Initiative is an example of working with the food industry on the delivery of food policy. ATNI develops accountability tools and strategies to accelerate access to healthy nutritious food, including through benchmarking the progress individual companies are making. ATNI does not accept food industry funding.

 

 

4 April 2024