SUSTAIN - WRITTEN EVIDENCE (FDO0041)

1. Sustain is the alliance for better food and farming. We represent over 110 food and farming organisations.
2. This briefing sets out our response to your call for evidence. We answer questions 1, 3, 5, 6, 9, 10, 11 and 12.

Summary

3. We consider multiple policy tools, in the UK and abroad, that could have a transformative impact on improving health and preventing food-related ill health.
4. We argue that the Government should introduce further fiscal measures that incentivize industry to sell healthier food and drink options, building on the highly successful model of the Soft Drinks Industry Levy (SDIL).
5. We call for expansion and stronger oversight of healthy, sustainable school food as a powerful lever for improving child health. We urge the Government to learn from examples set elsewhere, including in the devolved nations and internationally.
6. We consider the Government’s School Fruit and Vegetable Scheme and Healthy Start programme as powerful tools to increase fruit and vegetable consumption among children, which should be expanded.
7. We urge Government to expand unhealthy food and drink advertising restrictions on reducing levels of obesity, including implementation of the online ban, 9pm watershed, and further measures to address loopholes and extend to outdoor advertising learning from the 12 local authorities who have adopted such restrictions.
8. We acknowledge that sustainability and climate change must be integral to dietary and public health policy. Climate change represents an existential threat to public health and nutritional security.
9. We call for stronger statements in the National Planning Policy Framework to require healthy weight environments to be delivered through new development
10. We urge the Government to invest in public health and restore the public-health grant to at least 2015/16 levels.

Key trends in food, diet and obesity, and the evidential base for identifying these trends.

11. Obesity rates in the UK:
1. The UK has the third highest rate of people being classed as overweight or obese in Europe, behind only Malta and Turkey. Rates are highest in Scotland (67%), and similar in Wales (62%) and England (64%).[1]
2. The latest data on weight shows two in five children in England are facing ill health as a result of the food they eat.[2] Those children are five times more likely to go on to develop serious and life-limiting diet-related conditions in adulthood, including type 2 diabetes, cardiovascular and liver disease, multiple types of cancer, and poorer mental health.[3]
12. Consumption of food high in saturated fat, salt and/or sugar (HFSS):
1. A staggering 85% of the salt we consume is already present in our purchased food, with just three categories—biscuits, confectionery, and desserts—accounting for nearly 60% of the added sugar intake at home.[4]
2. In the UK, 66% of children exceed salt intake recommendations and 95% exceed sugar recommendations.[5]
13. Fruit and Vegetable consumption:
1. 89% of primary school aged children and 94% of secondary school aged children are not getting their 5-a-day.[6]

14. School Children:
1. The prevalence of obesity in school children rises from 9.2% at Reception to 22.7% by Year 6.[7] Although 2022/23 showed a small decline, this remains higher than before the pandemic.
2. There is evidence that most packed lunches do not meet school food standards and are likely to replicate existing HFSS and ultra-processed dietary pattern. Recent studies show that only 2% of packed lunches meet School Food Standards. Packed lunches remain low quality with few meeting standards set for school meals.[8]
15. Local Authority and regional trends:
1. Local Government data analysis projections indicate that no local authority is on target to meet the Government’s aims to halve child obesity by 2030.[9]
2. There is also evidence that people living in more deprived areas being more exposed to unhealthy food advertising.[10]

Nutritional security and the climate and nature emergency

16. Between 2021 and 2023, the cost of healthier foods increased by £1.76 per 1000kcal compared with £0.76 for less healthy foods
17. Unseasonal weather accounted for one-third of food price inflation in 2023, adding £361 to food costs for the average UK household.
18. Environmentally damaging forms of farming are receiving millions of pounds in government subsidies, while horticulture (fruit, veg, pulses, legumes and beans) receive hardly any.

The impacts of obesity on health, including on children and adolescent health outcomes.

19. Health impact:
1. High salt consumption is strongly linked to high blood pressure, elevating the risk of major conditions like stroke (by 23%) and cardiovascular disease (by 14%).[11]
2. Sugar consumption is similarly associated with chronic health conditions such as type 2 diabetes, musculoskeletal ill-health, cardiovascular disease, and various cancers.[12]
20. Economic impact:
1. Poor population health is increasingly detrimental to our economy, leading to decreased workforce participation and productivity, and escalating demands for medical attention, social care, and welfare support.
2. For instance, in the UK, the economic impact of obesity and overweight alone is estimated at £98 billion annually. Four of the top five risk factors are diet-related.[13]

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.

21. HFSS products are foods and drinks that are identified by the Department of Health's Nutrient Profiling Model (NPM) as being high in (saturated) fat, salt and/or sugar.[14]
22. This definition is used effectively in healthier food advertising policies nationally since 2007 to regulate what food and drinks industry are allowed to advertise. It has also been used for the Government’s in-store location promotions regulations, in relation to a selected number of product categories. It is a valuable definition which we recommend could be used in future policies to incentivise healthier food and drink production. 
23. The term "ultra-processed food" is not formally or legally defined in the UK. It was first coined in 2009 by researchers at the University of Sao Paulo, to describe a the socio-political trend, ie the increasing industrialisation and corporatisation of the global food system. This was exemplified by growing levels of industrial processing of food, with the aim of maximising profits through extending shelf life, reducing ingredient costs and making products hyper-palatable to increase sales. They developed their NOVA classification of food and drink into four categories:

1. Cat 1. Minimally processed foods (eg whole fresh, dried or frozen fruit and vegetables, unprocessed meat and fish, whole grains and pulses, dried pasta, couscous, milk)
2. Cat 2. food ingredients (eg butter, sugar, honey, salt, vegetable oils)
3. Cat 3. processed foods (eg canned/bottled vegetables in brine or fruit in syrup, dried/cured/smoked meat or fish, bread, cheese, salty/sugared nuts,
4. Cat 4. ultra-processed foods (eg soft drinks, crisps, biscuits, cakes, chocolate, sweets, ready meals, sausages and hotdogs, burgers, meat or fish nuggets or fingers, powdered soup, infant formula, sweet yoghurts and desserts, energy bars, pre-prepared reheatable pies/pasties, pizza or pasta dishes).

24. Unlike the Nutrient Profiling Model which is widely used for determining whether specific products should/should not be advertised or promoted the NOVA classification is best understood as a description of the forces and trends in the wider food system – from both an economic, social, health and an environmental/sustainability perspective. It is not designed as an individual product assessment. The growing body of evidence regarding the association between high consumption of UPFs and poor health outcomes should be seen as complementary and additional to the very strong basis of causative evidence regarding high consumption of HFSS food and drink. It calls for an approach that builds on existing health interventions and policies, rather than diverting attention away from these measures.
25. Given the wide (although not total) overlap between HFSS products and ultra-processed food and drink, measures that seek to reduce marketing, sales and consumption of HFSS foods and drinks can continue to play an important role in shifting back towards healthier, more sustainable and less processed food and drink.
26. Recent studies have recognised the problematic heterogeneity of the “UPF” category with regards to nutrition. In an 11 year cohort study with 267,000 participants[15], when the “UPF” category was subdivided, associations between poor health and processing were most notable for animal-based products, and artificially and sugar-sweetened beverages. Other subgroups such as ultra-processed  cereals or plant-based alternatives were not associated with increased disease risk
27. Across a number of studies[16][17], plant-based meat has been found to have a better nutrient profile than meat equivalents, though is sometimes higher in salt. Defining these products as UPFs may therefore prevent policy and dietary changes that would improve health outcomes.

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

Exposure to unhealthy food and drink products influences their food choices.[18] HFSS marketing is linked to a strong preference for HFSS products,[19] more snacking,[20] eating more calories[21] and HFSS products replacing healthier foods.[22] The links between child obesity are sufficiently strong to have been defined as a causal relationship.[23]The cost and availability of a) UPF and b) HFSS foods and their impact on health outcomes.

28. Research undertaken by the Imperial College shows children in the UK have the highest rates of ultra-processed food (UPF) consumption in Europe. While schools are often seen as influential environments for shaping dietary habits, the extent of UPF consumption within school settings remains unclear.[24]

Energy Drinks

29. An evidence review of the health impacts of consumption of high caffeine energy drinks indicates a high association with a wide range of both physical (heart palpitations, tooth decay, weight gain, sleep deprivation) and mental health (anxiety, depression, panic attacks) impacts, as well knock-on effects on children’s ability to concentrate, manage their behaviour and maintain energy levels in school.[25]
30. All soft drinks with 150mg caffeine per litre or higher are required under EU law to carry a warning label saying ‘not suitable for children or pregnant and breastfeeding women’. Yet they are still sold to children by a wide range of shops, with no age restriction.
31. The Government consulted on potential ban on sales of energy drinks to under-16s, and following 93% support, pledged to introduce a ban in the 2019 “Advancing our Health: Prevention in the 2020s” green paper. The government response to the consultion has still not been published. In January 2024, 40 health bodies called again on the Government to act on this evidence[26].

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

32. School Food:
1. Scotland: Scotland has provided a total of 231,957 children with free school meals in 2023. The Scottish Government broadened the eligibility for free school meals to encompass all children in P1 to P5. The 2024/25 Budget affirmed the continuation of free school meals for P6 and P7 students who qualify for the Scottish Child Payment. No more than 230g red and red processed meat can be served per week in schools in Scotland, in line with dietary guidance[27]
2. Wales: By 2024, all primary school children in Wales and over 6,000 nursery-age pupils attending maintained schools will qualify for free school meals.
3. India: Since 1995, India’s mid-day meal programme has been providing lunch for 125 million children aged 6 – 14. Costing the government $2.8 billion, it ensures that every child is able to access a hot meal, and has been found to improve nutritional health, educational outcomes and has even been found to have an intergenerational impact[28], with fewer shorter children born to women who had benefitted from the school food program, which is a common sign of malnutrition.[29]
4. Brazil: In 2009, Brazil expanded free school meals for all children following growing evidence that free school meals helped tackle obesity and increase nutritional education. The scheme uses a network of 8,000 nutritionists to design the school meals.[30]
5. Sweden: Sweden serves 260 million hot meals a year to students aged 7-16 and to most 16-19 year olds. Research into the scheme has found that children who eat these meals not only improved their attainment but also improved their long term health outcomes[31]
6. USA: During the Covid-19 pandemic, schools across the USA provided free school meals to ensure every child had access to food. While national support has ended, several states, including New York City, Vermont, Nevada, California, Maine, and Colorado, continue to offer state-wide meals for all students. Other states have also improved their meal programs to benefit more children.
33. Food industry lobbying:
1. The food industry in international settings is lobbying to undermine international governments’ implementation of food policies.
2. For example, Nestlé tried to undermine Mexico’s anti-obesity policy by leveraging in the Swiss Government to challenge a Mexican regulation on the display of product nutritional quality. Nestlé is currently taking the Mexican Government to the Mexican Supreme Court.[32] There is also industry lobbying in Colombia[33] and in Uruguay[34] aimed at undermining anti-obesity laws.
3. In 2022, Kellogg’s challenged the Government promotion restrictions by challenging the application of the Nutrient Profiling Model to breakfast cereal, but in the High Court Mr Justice Linden dismissed their case, saying “the public health case for the approach under the 2021 Regulations is compelling and I am quite satisfied that it is both proportionate and rational”.[35]
4. In 2018, lobbying from the soft drinks industry led to California passing a measure preventing new taxes on soft drinks for twelve years.[36]

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

1. There should be closer links between spatial planning (DLUHC) and health.

1. Jointly produced evidence so that there is greater trust between departments eg. on issues such as obesity & Mental health.
2. Acceptance of public health evidence by the planning inspectorate. (context of fast food).
3. Education: design of schools with kitchens to prepare and cook meals and dining rooms with space for shared mealtimes. Outdoor space with capacity for growing food.

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

34. The Soft Drinks Industry Levy (SDIL):
1. The Soft Drinks Industry Levy to date has reduced the sales weighted average sugar in soft drinks by 46% from 2015-2020, whilst raising £300-350 million every year in revenues for the Exchequer.[37]
2. These revenues have supported investment in child health programmes including the National School Breakfast Programme, support the Holiday Activities and Food Programme and the doubling of the Primary School Sports & PE Premium.
3. By contrast, the voluntary sugar reduction programme has only achieved a 3.5% overall reduction, and mixed results across different categories.[38]
4. An industry wide levy on salt and sugar could help prevent up to two million cases of disease over 25 years, with potential gains of around 3.7 million quality adjusted life years (QALYs), worth £77.9 billion in overall economic value over 25 years.[39]
5. Even a targeted application of this model to biscuits, cakes, confectionery and desserts could prevent up to 800,000 cases of diet-related disease, with overall gains of up to one million QALYs, with an economic value of £23 billion over 25 years.[40]
6. SDIL has not been adjusted for inflation since its introduction in April 2018, potentially limiting its effectiveness. Many drinks have been reformulated to hover just below the 5g sugar per 100ml threshold.[41] Nonetheless, drinks with 4.5g sugar per 100ml still fail to meet the Nutrient Profiling Model criteria, indicating they are high in fat, salt, and/or sugar (HFSS) according to government regulations.
7. Additionally, a substantial portion of revenues comes from drinks in the higher charging tier, with estimated revenues for 2022/23 reaching £355 million, the highest recorded income to date. This suggests that the SDIL may not have reached its maximum potential to drive reformulation or revenue for children's health.[42]
35. School Food:
1. School food procurement represents a tremendous lever of positive change for both human and planetary health, if focussed on the right nutritional and sustainability principles. Schools across the country are already demonstrating how it might be done, and experience from other countries also provide evidence that universal healthy school food is not just a vision but can be a powerful tool for boosting child health and overall progress, with a multiplication benefit into families, wider communities, and a healthier catering sector.[43]
2. 2024 is the 10th anniversary of the introduction of Universal Infant Free School Meals, following the School Food Plan. The plan led to strengthening of school food standards and commitments to food education and cooking skills in the curriculum. 
3. This was intended to be a first step in transforming school food towards healthy, nutritious meals available for all children. The recent Covid pandemic and subsequent cost of living crisis – including rocketing food and fuel prices, new pressures to increase wages – have once again put our school food system under incredible strain.
4. Without stronger intervention in updating School Food Standards and enforcing a proper monitoring and compliance system, there is also a risk – especially at secondary schools– that food does not always meet the healthy guidelines and nutritional balance needed by growing children. 
5. Studies by University of Essex of universal school meals programmes in London boroughs, showed obesity prevalence was reduced by 7-11% for children in Reception, and 2-5% for children in Year 6. The effect rose to 5-% reduction in prevalence for those who received universal school meals throughout all 6 years of primary school.[44]
6. Pupils who take up school meals are more likely to have higher fruit and vegetable consumption. The Universalism Multiplier, research showing physical and mental health benefits and changes to eating habits associated with expansion of meals in London[45]

36. Healthier food advertising policies:
1. There are now 12 local authorities as well as Transport for London that have worked with Sustain to successfully implement restrictions on advertising unhealthy food. One fifth of all London councils now have a healthier food advertising policy.[46]
2. The independent evaluation of the Transport for London policy showed the policy led to a 20% reduction in high sugar products (e.g. confectionery) being purchased, and that households are consuming 1000 calories less per week from unhealthy foods and drinks.[47]
3. Academic modelling indicates that the policy on London’s transport is expected to lead to 100,000 fewer cases of obesity, 3000 fewer cases of diabetes and 2000 fewer cases of heart disease as well as a saving of £218 million for the NHS.[48]
4. Advertising revenues have been maintained under the healthier food advertising policy because companies are simply switching the spotlight from unhealthy food to healthier food. Therefore, they are still spending money to advertise. Transport for London’s advertising revenues increased by £2.3million in the first year of the healthier food advertising policy.[49]
37. Restricting Hot Food Takeaways
1. Hot food takeaways are associated with diet-related diseases such as obesity, and there are higher rates of hot food takeaways in areas of higher deprivation, worsening the UK’s health inequalities.[50] The space dedicated to Hot food takeaways is increasing at a pace with an increase of 10% over 4 years.[51] Analysis by The Times shows that almost 200 schools in England and Wales have ten or more takeaways within 400 metres of the site.[52]
2. Gateshead Council uses planning policy to improve health and tackle childhood obesity by taking a zero-tolerance approach to new applications for fast food takeaways. An external evaluation[53] looked at how Gateshead Council had been able to reduce the proportion of fast-food outlets in the borough by 14%. The density of takeaway outlets per capita was also reduced.[54]
    
38. School Fruit and Veg Scheme:
1. Increasing consumption of fresh, minimally processed food including fruit and vegetables, should be a key objective of any policy to address prevalence of HFSS and UPF in overall diets. The independent National Food Strategy called for an increase in fruit and veg consumption by 30% over the next decade to meet health, climate and nature targets.[55]
2. The Government’s School Fruit and Veg scheme (SFVS) increases fruit and vegetable consumption.[56] The SFVS initially increased fruit intake after three months. However, by seven months, although the effect remained significant, it diminished. Ultimately, by year 2, when pupils were no longer part of the scheme, fruit intake returned to baseline levels.
3. A Freedom of Information request from Sustain revealed that a significant portion of the scheme's produce is imported. Shockingly, only half of the apples come from the UK, and none of the pears nor tomatoes are homegrown. According to a report by the Soil Association[57] it leads to produce that is not just cheaper but often of lower quality and lacking in flavour and texture. The potential health risks associated with sourcing fruits and vegetables abroad further intensify the concern around whether the scheme is fit for purpose, with a previous report revealing that pesticide residues in SFVS fruits exceed those found in the UK's supermarkets.[58]
    
39. Healthy Start Scheme:
1. From January 2023 to March 2024, the number of infants and children eligible for Healthy Start payments has dropped by 22,537, amounting to a 3.9% drop in eligibility. Uptake numbers have dropped by 1.1% in Wales, and by 1.8% in Northern Ireland, although they have risen in England by 1.2%, due at least in part by Local Authorities investing in community promotion of the scheme. However, the overall shrinking of the pool of eligible children is concerning as child food insecurity and healthy food and formula prices remain high. The downward trend is likely affected by the upper earnings threshold for eligibility remaining unchanged over the past decade.
2. Healthy Start payments have been proven to increase both vitamin intake and fruit and vegetable consumption among pregnant women, and maintain nutrient intake levels (such as iron and vitamin D) among infants and children on the scheme (compared with the general population. [59] There is currently no body of research comparing nutrition outcomes of children on the scheme and children in comparable socio-economic circumstances not on the scheme.
3. The weekly value of the payments is no longer sufficient to cover the cost of infant formula. Between March 2021 and April 2023, the seven standard, powdered, first infant formulas sold by the market leaders increased in cost by an average of 24% - and the only ‘own brand’ infant formula increased by 45%.[60]
4. Research by IGD commissioned by Sainsbury’s found that a supermarket £2 Healthy Start top up coupon scheme led to Healthy Start recipients’ shopping baskets shifting positively towards the Eatwell Guide even when Healthy Start payments weren’t utilised.[61]
5. Government should increase the Healthy Start allowance from £8.50 to £10.47 a week for infants and from £4.25 to £5.24 a week for pregnant women and children aged 1-4 years old and keep this value under close review given the levels of inflation.
6. Government needs to increase overall funding to support expansion of Healthy Start programme to five-year-olds in order to close the gap between eligibility to Healthy Start (up to age four) and Free School Meals (from age 5), to families on No Recourse To Public Funds and to all families on Universal Credit or equivalent benefits.
    
40. Public Health Funding:
1. Public health services are critical for improving the population’s health and reducing health inequalities. Investment by the Government in public health can relieve pressure on other services such as the NHS by helping to prevent or delay disease.
2. This funding enables local authorities to deliver vital preventative and treatment services, including many that contribute to healthy weight, such as early-years interventions and weight-management services.
3. Analysis from the Health Foundation has shown that public-health grant allocations have fallen in real terms from £4.2 billion in 2015–16 to £3.3 billion in 2021–22.[62]
4. Government should restore the public-health grant to at least 2015/16 levels and increase public health investment by £1 billion per year and commit to ensuring the grant keeps pace with growth in NHS England’s spending in the longer term.

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.

41. Build on the success of the Soft Drinks Industry Levy:

Sustain is a founder of Recipe for Change, and we support the detailed submission on all our behalf made by the Obesity Health Alliance.

1. HM Treasury and the Department for Health and Social Care should issue a call for evidence on measures to incentivise healthier food and drink production, including use of further financial levers.
2. In the meantime, maintain and extend the Soft Drinks Industry Levy to incentivise product reformulation and raise revenues for investment in children’s health. For example, uprate company liabilities under the SDIL, as duty rates have not been increased since its introduction in 2018. The current tiered approach to the SDIL could also be reviewed to incentivise further sugar reduction.
3. Signal intent to initiate a process to bring sugary milk and alternative milk-based drinks into scope of the SDIL
4. Maintain a commitment to ensuring revenues from SDIL and any further healthy food and drink levies support government investment in programmes to support children’s health.
1. Improve access to nutritious school food:
1. As an immediate first step, the government should commit to increasing funding for school meals to enable all children in state-funded schools in England from families in receipt of Universal Credit or equivalent benefits to become eligible for a Free School Meal immediately.
2. The government should state a long-term goal for the Government to provide comprehensively funded, nutritious school food for all children. This would bring England in line with developments in Scotland and Wales, as well as reflect the original vision of the Government when it announced Universal Infant School Meals in 2013.
3. We need stronger intervention in updating School Food Standards and enforcing a proper monitoring and compliance system. This will ensure that school food meets healthy guidelines and nutritional balance needed by growing children. 
   
    
2. Expand the School Fruit and Veg Scheme:
1. We are calling on the government to expand the scheme to all 4.7 million state-funded primary school children and prioritise seasonal, home-grown, and environmentally friendly produce.
3. Restrict Energy Drinks sales to under-16s
1. The Government should implement the proposal to restrict sales of all high caffeine energy drinks to children under 16 – both those high in sugar, and those containing sweeteners and advertised as ‘sugar free’. All products with 150mg caffeine per litre are already required to carry a warning label saying ‘not suitable for children’ and with some major retailers already implementing voluntary restrictions, regulation would create a consistent message to children and teenagers and a level playing field for the industry. 
4. Tighten regulations regarding labelling and packaging on food and drink
1. We support the introduction of mandatory colour-coded front-of-pack labelling (FoPL) for all pre-packaged food and drink. The Government should build on the previous consultation on different label options, and bring forward a process to achieve ‘best in class’ labelling, as promised in the 2019 Prevention green paper.
2. The Government should legislate that no product designated as HFSS through the Nutrient Profiling Model should be allowed to carry other health claims or ‘health halos’.
3. The Government should restrict the use of child-friendly cartoons, characters, high profile figures or influencers on the packaging of any product classed as HFSS under the Nutrient Profiling Model.
5. Restore the public health grant:
1. Government should restore the public-health grant to at least 2015/16 levels and increase public health investment by £1 billion per year and commit to ensuring the grant keeps pace with growth in NHS England’s spending in the longer term.
6. Revise National planning policy:
1. To date, national planning policy and guidance has failed to acknowledge the influence of the built environment on obesity in children. National policy and guidance does not focus on the food system and how the built environment affects health and lifestyle of children with long lasting effects on their lives.
2. Designing places which enable access to good food helps to create healthy and vibrant places and avoid the creation of even more obesogenic environments.[63]
7. Introduce a Dietary policy for ‘less and better’ meat and dairy consumption
1. regular meat consumption is linked to a range of common diseases[64].Replacing half of UK meat and dairy with fruit, vegetables and cereals would avoid or delay an estimated 37,000 deals per year[65]
2. Revise UK dietary health guidelines to reflect a planetary health diet
3. Adopt mandatory standards to ensure all public sector meals reflect a planetary health diet, including removing the requirement to serve meat 3 times per week in schools and introducing a limit on the amount of meat that can be served in public sector settings across the week (as adopted already for schools in Scotland).
4. Mandatory ‘scope 3’ emissions reductions targets for all large retailers
5. Introduce a UK horticulture strategy to increase production of, and support for, fruit, vegetables, pulses, legumes and high-protein grains

5 April 2024