Food Active is a healthy weight programme delivered by the public health charity Health Equalities Group (registered number: 1110067) and commissioned by local authority public health teams and NHS organisations at both regional and national level.
Acknowledgements: With thanks to members of our local authority network who have provided evidence to support this response.
1. This submission represents the views of Food Active, a healthier weight programme of work delivered by the charity the Health Equalities Group. This submission also includes evidence submitted by the programme’s local authority network members, to share their local experience of the key themes explored in this inquiry.
2. We welcome the committee facilitating this timely inquiry as this provides an important opportunity to shine a light on the current issues facing families’ ability to access a healthy diet and the current government’s lack of action and commitment to this agenda.
3. As part of this submission, we indicate our support for continuing to use the Nutrient Profiling Model to define less healthy food and drink over the ultra-processed food definition, with scope to adapt and improve. However, we strongly urge the government to regularly review the emerging evidence base on the harms of processing on health and consider the implications on existing policy as it develops.
4. We raise concerns about the amount of lobbying that is happening both at a national and local level from the food and drink industry; and, how this is undermining progress on policies designed to promote healthy weight and a healthier food environment.
5. We highlight examples of where the government has made progress on obesity policy; specifically presenting the findings and recommendations of our recent snapshot research with the Obesity Health Alliance to examine the implementation of the legislation to restrict the promotion of less healthy food and drink by place (implemented in October 2022), and the successful fiscal and legislative approach of the Soft Drinks Industry Levy compared to voluntary schemes.
6. Finally, we present our immediate and long-term priorities for the government. This is followed by a range of actions and priorities from our local authority network.
7. The causes of obesity are complex, as highlighted by the Obesity Foresight map[1]. Whilst this report is now over 10 years old, it illustrates that weight status is determined by a myriad of factors. Yet, for too long, policymakers have focused on individual responsibility, suggesting that the primary drivers of obesity are simply influenced by what an individual choses to eat and how active they chose to be. Through this submission of evidence, we would like to highlight the range of complex factors that are often beyond an individual’s control and significantly impact on lifestyle choices and life chances.
8. There are number of other myths associated with the primary drivers of obesity. Physical activity is one of the most effective ways to promote health and wellbeing, specifically musculoskeletal and mental health[2]. However, evidence shows that physical activity does not have a significant impact on the ability of people to lose weight overall and cannot overcome the impacts of poor diets even for the most active people[3],[4].
9. There is also a strong narrative amongst some policymakers, media outlets and the general public that obesity is caused by simply a lack of willpower, specifically having the willpower to restrain from consuming less healthy food and drink. As Alice Wiseman, Director of Public Health at Gateshead Council was recently quoted at an oral evidence session (14th March 2024), “it is not possible for a whole generation of people to lose willpower at the same time” and with the majority of adults in the UK overweight or living with obesity, it is imperative we start to eradicate this false narrative and focus on the wider drivers of obesity. This narrative, commonly portrayed through the media, also perpetuates weight stigma within society, which can have multiple negative consequences on health including long lasting psychological, social and behavioural implications, such as: depression, anxiety, low self-esteem, binge eating, potential denial of jobs and creates a barrier to accessing healthcare services[5]. For more information on weight stigma, visit the Food Active weight stigma resource hub: https://foodactive.org.uk/weight-stigma-resource-hub/
10. There is some that view obesity as a parenting failure. Yet, it should be easy for everyone to eat healthily, especially children, but it isn’t. Every parent wants their child to be healthy, but efforts to provide a healthy diet for their children are undermined by pervasive marketing of less healthy food and drink to children, which can influence their preference of the advertised foods and result in them requesting said foods and pricing of less healthy food compared to healthier options. Healthy foods are nearly three times more expensive calorie-for-calorie than less healthy foods. The poorest fifth of UK households would therefore need to spend 50% of their disposable income on food to follow the Government recommended healthy diet, compared to 11% for the richest fifth[6]. It is challenging for parents to ensure their child has access to a healthy diet, and the sole cause cannot be simply attributed to poor parenting.
11. Finally, there is some evidence to suggest that obesity is associated with poor education, and poor cooking skills[7]. Whilst education has a role to play, there is an unhelpful narrative that simply teaching children and families how to cook can treat obesity. This approach reinforces the individual responsibility narrative and ignores the challenges households face in their local food environment, such as the cost to source fresh food to cook a meal with the poor access some areas have to healthy food options (also known as food deserts) and the marketing and promotion of less healthy food and drink across several media platforms.
12. Greater emphasis should be placed on the environmental, societal, economic and legislative factors that affect people’s health and wellbeing, as illustrated in the Foresight report1 and Public Health England’s (now Office for Health Improvement and Disparities) Whole Systems Approach to Obesity[8].
13. We are particularly concerned about the current issues around household food insecurity in the UK, and how this may be contributing to poor diet quality and subsequently, obesity. Affordability is a key factor in determining food purchases; however, the ability to afford a healthy and sustainable diet is affected by a range of factors including household income and cost of other household bills. The ongoing issues relating to the cost of living, coupled with rising food prices is creating more and more barriers for households. A report published by the Food Foundation in 2023 found that the most deprived fifth of the population would need to spend 50% of their disposable income on food to meet the cost of the Government recommended healthy diet. This compares to just 11% for the least deprived fifth. The report also found that more healthy foods are over twice as expensive per calorie as less healthy foods[9]. This is perpetuating the diet-related inequalities in health we have seen across different population groups, and this should be a key consideration for the government in seeking to reduce the prevalence of obesity.
14. Reducing the prevalence of overweight and obesity across the life course is in the government’s interest for a number of reasons. Firstly, a healthy population is the foundation of a strong economy. A recent OECD analysis found that the average UK tax bill is £500 per person per year more than if everyone was a healthy weight[10]. Frontier Economics estimates in 2023 that the total economic impact of obesity in the UK is £98 billion, accounting for the costs to the NHS and social care, lost productivity, workforce inactivity and welfare payments[11].
15. Reducing the prevalence of obesity will also put our health service on a firmer footing. Currently, the NHS spends at least £5.1 billion a year dealing with ill health caused by overweight and obesity in England, with Government analysis in 2017 projecting this to reach £9.7bn by 2050[12]. IPPR predict that excess weight amongst the current cohort of children will cost the NHS £74 billion over their lifespan[13]. Reducing these costs will reduce the current significant pressures and long waiting times being faced by the NHS. Studies suggest that if levels of obesity could be reduced by 1% every year from the predicted trend between 2015 and 2035, £300 million could be saved in direct health and social care costs in the year 2035 alone[14].
16. Reducing the prevalence of obesity will also go some way to tackling inequalities in diet related co-morbidities and longer-term health outcomes. According to NHS data, levels of obesity in reception-aged children living in the most deprived areas (12.4%) were more than double those in the least deprived areas (5.8%). Similarly, the prevalence of obesity among year 6 children was 30.2% in the most deprived areas, compared with 13.1% in the least deprived areas[15].
17. The impacts of obesity on health are also well-documented. Alongside the impact on physical health, children and young people with obesity may experience poorer mental health outcomes due to weight stigmatisation from their peers, as well as teachers, family members, healthcare practitioners and the general public. This can result in school absences which can affect academic attainment, and avoidance of healthcare settings and support[16].
18. This inquiry is timely given the growing discussions around UPFs, and we thank the committee for the opportunity to share our thoughts through this important inquiry.
19. Feedback from our local authority network has suggested that there are concerns about the use of the term UPF, specifically the risk of demonising foods labelled as such. UPFs may represent a significant food source for many households, furthermore, certain groups will need to rely on categories of UPF’s such as those with allergies, special diets, those recovering from illness and those on low incomes. With regards to low-income households, there is some evidence to suggest that UPF are more frequently consumed compared to more affluent households. An NIHR funded study highlighted that when looking at choices for snacking, fresh fruit was out of reach for parents on low incomes, with UP snacks (such as chocolate and sweets) being a more viable choice due to their price point, a longer shelf life, and the likelihood of them refusing the food is reduced compared to fresh fruit. In addition, the multi-buy deals and placement promotions of UP snacks means they are perceived to be better value, which is an important consideration when money is limited[17]. Furthermore, a US study indicated that more severe food insecurity was associated with higher intakes of UPF[18].
20. This needs careful balancing to avoid individuals reliant on UPF’s from feeling guilty and creating anxiety, when there may be no other alternatives and these foods present the most feasible option with the limited resources available. There are also concerns that this ongoing debate and current focus on UPF’s could pose a distraction to addressing the complex wider drivers of obesity, that would improve population health. Some local authorities in the north of England have however started to consider local approaches and application of the term UPF, for example reducing the availability and promotion of UPFs served on council-owned sites and through local authority caterers and developing guidance and communications to encourage local residents to identify UPFs whilst shopping.
21. As an organisation, we are supportive of continuing the use of the Nutrient Profiling Model (NPM) as a reference for government policy to define ‘less healthy’ food and drink and would prefer to evolve and strengthen this model rather than create a new or additional definition. As an organisation we lobby for dietary policies that will have greatest impact based on the current evidence available; at present the best evidence of harm we have is to define foods as ‘less healthy’ through the NPM. This definition is already in use in existing policy frameworks whilst industry is very familiar with this model and for consistency, we believe at present this is still the most suitable definition to refer to base on the current evidence base. We are also concerned that starting to develop a new definition or model for classifying foods could delay future policy progress.
22. This is not to say that we do not consider the processing of food, the extent of the processing and the potential impact on public health as a concern. However, there is already a significant amount of crossover of HFSS and UPFs; the NPM categorisation of ‘less healthy’ foods encapsulates a large (est.~75-80%) proportion of NOVA-defined UPFs, therefore by continuing to use the NPM to categorise ‘less healthy’ foods this already covers a substantial number of UPFs[19].
23. We will continue to review the emerging evidence base on UPFs and consider how this may affect Food Active’s policy calls when considering the impact of food and dietary quality on health. However, we recommend that the government should start to consider what options could be available to incorporate markers of harmful processing into the existing NPM model to inform policies to limit exposure or intake of less healthy food and drink.
24. Driving food and diet trends: One significant way the food industry plays a role in shaping diet and food trends is the marketing and advertising of products and placing certain products in the spotlight. The Food Foundation’s Broken Plate report last year found that a third (33%) of food and soft drink advertising spend goes towards confectionery, snacks, desserts and soft drinks compared to just 1% for fruit and vegetables[20]. This does not align with the quantities of food and drinks recommended to contribute towards a healthy diet, as outlined in the government’s Eat Well Guide.
25. Food Active has also published a number of research reports which highlight the ways in which the food industry places less healthy food and drink in the spotlight, including:
26. Influencing the policy making process: We are concerned about the influence the food industry currently has on the policy making process, and how much industry lobbying has played in derailing the implementation of the 9pm watershed marketing legislation. A recent example is the Advertising Standards Authority consultation on the legislation on less healthy food and drink marketing on TV and online media. Alongside other national charities, Food Active raised concerns that the proposed guidance was significantly weaker than the original level of guidance stipulated by government. Evidence has revealed that a pre-consultation workshop was held with the food industry, and we are concerned about the lack of transparency as meeting notes have not been circulated, nor were other groups invited to be part of similar discussions before the consultation went live.
27. There are also examples of the food and drink industry challenging the policy making process at a local level. Many of the local authorities we work with across the North of England and more widely across the country are struggling to combat the powerful influence of the food and drink industry. This includes lobbying and local policy measures to restrict new takeaways opening in areas with high levels of children living with obesity and councils implementing a healthier advertising policy across council-owned advertising estate. A recent investigation by the Times revealed that the fast-food company KFC have challenged at least 43 councils in England over their planning policies to restrict new hot food takeaways from opening and have successfully overturned decisions in more than half of cases[25]. Other examples of industry marketing include hosting pop up events in areas of high footfall with free giveaways and offering in-kind support in exchange for advertising space at events.
28. Another example of the food and drink industry undermining local healthy weight policy concerns a local authority that had implemented a policy to restrict the density of hot food takeaways (HFT). This led to a new HFT application being rejected by the planning department as it would have breached the concentration of HFT’s as permitted as part of the policy. This resulted in the business then changing its application to become a restaurant by including seating, which was then deemed out of scope of the HFT policy and subsequently granted planning permission. The restaurant is now offering takeaway food, and this has resulted in an unlevel playing field. National policy frameworks must support implementation of local policy that consistently promotes health over economic benefit and avoids loopholes in their implementation.
29. We strongly believe local authorities must be protected against industry lobbying and commercial influences, with a particular focus on action (including legal challenges) that deliberately undermines mechanisms to promote health and protect the well-being of local communities.
30. There are a number of examples which highlight the government’s current approach to the policy making process and opportunities for how this could be improved. In 2020, there was a focus on tackling the social and environmental drivers of health through the National Obesity Strategy and publication of Public Health England’s (now Office for Health Improvement and Disparities) whole systems approach to obesity. This was welcomed by Food Active and campaigners alike, representing a significant shift from the previous narrative on individual responsibility. The national obesity strategy promised progress, turning the tide of obesity and removing less healthy food and drink from out of the spotlight. Disappointingly, the government has made a very quick U-turn on their vision and priorities to address obesity, with a particular focus over the last 18-24 months on weight-loss drugs such as Wegovy. At the same time, the government has delayed important legislation to tackle the wider drivers of obesity, such as the 9pm watershed on less healthy food and drink marketing. Despite a significant amount of work being undertaken by government departments to prepare this piece of legislation, in addition to food and drink industry preparation this important policy measure has been delayed.
31. Treatment of obesity such as weight loss drugs and weight management services can provide people living with obesity the opportunity to work with healthcare professionals to manage their weight, should they wish to do so, and treatment forms an important component of an approach to reducing the prevalence of obesity, alongside prevention. It was promising to see the government provide an additional £100m in funding in 2021 to expand tier 2 services locally. However, this funding was withdrawn just 12-months later, despite local authorities dedicating a significant amount of time and resource to setting up these services and building expectation within user groups. Whilst some areas have been able to sustain these services through the public health grant, others have had to close these services. These short-term funding cycles do not represent good value for money and ignore the fact many services take time to establish, and the government should commit to longer term funding cycles.
32. It is also important to note the value-for-money of treatment options such as weight loss drugs, when compared to preventative population health measures. A review of international studies suggests that past investments in prevention have had a significant long-term social return on investment[26]. Yet, the cost of treatment can be significant and without ensuring there is a prevention strategy which addresses the wider drivers of obesity, this can impact on their effectiveness and as a result, add more pressure to the NHS. As Sir Michael Marmot was quoted in his book The Health Gap, “What good does it do to treat people and send them back to the conditions that made them sick?”[27].
33. Furthermore, despite the rising tide in the prevalence of overweight and obesity across the life course and demonstrating excellent value for money, the public health grant has been cut by 27% on a real term per person basis since 2015/16. This grant is set by national government but disseminated to local authority public health teams to invest in the health of their residents. Cuts to this grant represent poor foresight and planning from the government and we strongly urge that these cuts are reversed.
34. The Soft Drinks Industry Levy (SDIL) is a strong example of the government taking bold action as part of efforts to reduce the prevalence of obesity. Since it was implemented in 2018, the SDIL has removed 46 million kgs of sugar from the nation’s diet - every year. Also, total soft drinks sales increased by 14.9% between 2015 and 2019, predominantly of drinks that don’t pay the levy. Simply put - they're just selling healthier drinks instead. Researchers from Cambridge University have also reported an 8% relative reduction in obesity levels in 10/11-year-old girls as a result of the policy, especially those from the most deprived areas. The research also found that implementation of the SDIL was associated with a 12% reduction in the number of under-18s admitted to hospital for a tooth extraction due to tooth decay. Now we need Government to do the same for other food and drink categories, to ensure there are incentives for companies to produce tasty, affordable food that doesn’t incur a cost our health. Any funds raised from companies not changing their recipes should be invested into children’s health and access to good food, just as it was with the SDIL.
35. However, not all areas have had as much success and historically, the Public Health Responsibility Deal has shown that self-regulation does not work. The sugar and calorie reduction programmes aimed to challenge the food and drink industry to reformulate a specific set of food categories to contain less sugar and calories with a 10-20% target. The impact of these programmes has been very limited as they are based on voluntary measures. The latest progress report from the calorie reduction programme is a stark example - despite targets being reduced from 20% to 10%, the food industry only managed an average of less than 2% calorie reduction across selected food categories and in some cases, including family meals, calories actually increased by 10%. This was a similar story with the sugar reduction programme a few years ago – when compared to the success of the SDIL, we can conclude that legislative rather than voluntary measures are the ones that have real impact.
36. In December 2023, Food Active and Obesity Health Alliance published the ‘Location, Location, Location’ report to review the implementation of the less healthy food and drink restrictions by place within retailers’ legislation. This was conducted through fieldwork in-store and online and interviews with trading standards officers and store managers. The report suggests that after the first year of implementation, many retailers have worked hard to remove less healthy food and drink from key locations in store including the checkout, end of aisles and store entrances (and similar equivalents online). Whilst a small number of breaches were found in the fieldwork online and in-store, the legislation has proved itself to be a useful step towards shifting less healthy foods and drinks away from the spotlight in retailers and online. However, the report also highlighted the challenges that are being faced by trading standards officers. Insufficient funding combined with competing priorities mean that enforcement of this important legislation is lacking, and there is a need for, greater funding, addressing current workloads and staffing issues in trading standards and finally, more training and tools to support officers to carry out inspections. This informed a series of recommendations to government to review the legislation, which will help to fully maximise the benefits to public health:
The full report can be accessed here: https://foodactive.org.uk/wp-content/uploads/2023/12/Location_Location_Location_January2024Update.pdf
37. It is worth highlighting that according to the commitments in the national obesity strategy there should in fact be many more government policies implemented by now – including:
These policies should have been implemented as a package of measures designed to address the multiple and wider drivers of obesity; see the response to the following question for further information.
38. Priorities for Food Active: The government have an array of policy tools at their disposal to effectively start to reduce the prevalence of obesity. However, it is imperative that policymakers do not view any one single policy as a silver bullet. It is well understood that the causes of obesity are complex, influenced by over 100 different factors as highlighted by the Foresight report. This ultimately requires a multifaceted response from stakeholders across the system, and the government is ideally positioned to lead the way and highlight their commitment to the health of the population. As an organisation, we would like to see the government prioritise the following with immediate effect:
39. As part of a longer-term strategy, we would like the government to consider the following:
40. Examples of local work: The inquiry may wish to consider some of Food Active’s work with local partners happening at ‘place’ to promote healthier weight, including:
41. Priorities from Food Active’s local authority network: Following a call for evidence across our network of commissioners and stakeholders, encompassing many regions within England, the following feedback was received on how local authorities could be better supported by national government:
5 April 2024
[i] Offers included holidays, cash prizes, free tickets/passes to theme park attractions, sports games, entertainment shows and the cinema
[1] Government Office for Statistics (2007) Tackling obesities: future choices – obesity systems atlas [online] Available at: https://assets.publishing.service.gov.uk/media/5a7b8811ed915d4147620fb2/07-1177-obesity-system-atlas.pdf [Accessed: 28th March 2024]
[2] World Health Organisation (n/d) Physical activity [online] Available at: https://www.who.int/health-topics/physical-activity#tab=tab_1 [Accessed: 28th March 2024]
[3] Pontzer, H., Durazo-Arvizu, R., Dugas, L.R et al. (2016) Constrained Total Energy Expenditure and Metabolic Adaptation to Physical Activity in Adult Humans. Current Biology. V.26 (3) p410-417.
[4] Dimbleby, H. (2023) Ravenous: How to get ourselves and our planet into shape. Profile Books.
[5] Food Active (2021) Evidence briefing: weight stigma [online] Available at: https://foodactive.org.uk/wp-content/uploads/2020/09/Weight-Stigma-Briefing_Food-Active_July-20201.pdf [Accessed: 28th March 2024]
[6] Food Foundation (2023) The Broken Plate [online] Available at: https://foodfoundation.org.uk/publication/broken-plate-2023 [Accessed: 28th March 2024]
[7] Cohen AK, Rai M, Rehkopf DH, Abrams B. Educational attainment and obesity: a systematic review. Obes Rev. 2013 Dec;14(12):989-1005. doi: 10.1111/obr.12062. Epub 2013 Jul 25. PMID: 23889851; PMCID: PMC3902051. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3902051/
[8] Local Government Association, ADPH, Leeds Beckett University and Public Health England (2017) Making obesity everyone’s business: a whole systems approach. https://www.local.gov.uk/sites/default/files/documents/15.6%20Obesity-05.pdf [Accessed: 28th March 2024]
[9] Food Foundation (2023) The Broken Plate [online] Available at: https://foodfoundation.org.uk/publication/broken-plate-2023 [Accessed: 28th March 2024]
[10] OECD (2019) The Heavy Burden of Obesity : The Economics of Prevention https://www.oecd-ilibrary.org/sites/6cc2aacc-en/index.html?itemId=/content/component/6cc2aacc-en
[11] Frontier Economics (2023) Estimating the Full Cost of Obesity https://www.frontier-economics.com/media/5094/the-full-cost-of-obesity-in-the-uk.pdf
[12] PHE (2017) Health matters: obesity and the food environment https://www.gov.uk/government/publications/health-matters-obesity-and-the-food-environment/health-matters-obesity-and-the-food-environment--2
[13] IPPR (2020) The whole society approach: Making a giant leap on childhood health [online] Available at: https://www.ippr.org/articles/the-whole-society-approach [Accessed: 28th March 2024]
[14] Cancer Research UK and UK Health Forum (2016). Tipping the Scales: why preventing obesity makes economic sense [online] Available at: https://www.cancerresearchuk.org/sites/default/files/tipping_the_scales_-_cruk_full_report11.pdf
[15] NHS Digital (2023) NCMP data [online] Available at: https://digital.nhs.uk/news/2023/latest-figures-show-drop-in-obesity-rates-among-primary-school-children-statistical-press-release [Accessed: 28th March 2024]
[16] Office for Health Improvement and Disparities (2022) Childhood obesity: applying all our health [online] Available at: https://www.gov.uk/government/publications/childhood-obesity-applying-all-our-health/childhood-obesity-applying-all-our-health [Accessed: 28th March 2024]
[17] Gallagher-Squires C, Isaacs A, Reynolds C, Coleman PC. Snacking practices from infancy to adolescence: parental perspectives from longitudinal lived experience research in England. Proceedings of the Nutrition Society. Published online 2023:1-9. doi:10.1017/S0029665123003592
[18] Leung CW, Fulay AP, Parnarouskis L, Martinez-Steele E, Gearhardt AN, Wolfson JA. Food insecurity and ultra-processed food consumption: the modifying role of participation in the Supplemental Nutrition Assistance Program (SNAP). Am J Clin Nutr. 2022 Jul 6;116(1):197-205. doi: 10.1093/ajcn/nqac049. PMID: 35199832; PMCID: PMC9257471.
[19] Galan, P., Guyot-Kesse, E., Touvier, M. et at. (2020) Nutri-Score and Ultra-Processing: two dimensions, complementary and not contradictory [online] Available at: https://nutriscore.blog/2020/11/07/nutri-score-and-ultra-processing-two-dimensions-complementary-and-not-contradictory/ [Accessed: 28th March 2024]
[20] Food Foundation (2023) The Broken Plate [online] Available at: https://foodfoundation.org.uk/publication/broken-plate-2023 [Accessed: 28th March 2024]
[21] Food Active and Children’s Food Campaign (2018) Junk food marketing to children: a study of parents perceptions [online] Available at: https://foodactive.org.uk/wp-content/uploads/2018/06/Junk-Food-Marketing-to-Children-a-study-of-parents-perceptions.pdf [Accessed: 26.03.2024]
[22] Food Active and Children’s Food Campaign (2020) Pester Power or Parent Power? Parents views of child friendly characters on food and drink packaging [online] Available at: https://foodactive.org.uk/wp-content/uploads/2020/07/Cartoon-Characters-Report-July-2020.pdf
[23] Food Active and Children’s Food Campaign (2021) Kicking out junk food – sports sponsorship and a better deal for health [online] Available at: https://foodactive.org.uk/wp-content/uploads/2021/11/Kicking-Out-Junk-Food.pdf [Accessed: 26.03.2024]
[24] Food Active (2022) On pack promotions on less healthy food and drink [online] Available at: https://foodactive.org.uk/wp-content/uploads/2022/10/Coupons-Passes-And-Prizes-On-Less-Healthy-Food-And-Drink-Food-Active-FINAL-4th-Oct.pdf [Accessed: 26.03.24]
[25] Sustain (2023) KFC's aggressive tactics to undermine councils' health policies exposed [online] Available at: https://www.sustainweb.org/news/dec23-kfc-undermining-councils-health-planning/ [Accessed: 28th March 2024]
[26] Masters et al., Return on investment of public health interventions: a systematic review, BMJ, 2017 - the
return on investment estimate is a median of a review of published interventions worldwide (and not just
limited to health interventions), and is total social return and is therefore not only healthcare savings.
[27] Marmot, M. (2015) The Health Gap: The Challenge of an Unequal World. Bloomsbury Publishing.