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

Dietary data sources

8.1. The principal sources of government collected data on food purchasing and consumption for the UK are the National Diet and Nutrition Survey (NDNS) and the Family Food component of the Living Costs and Food survey. The NDNS rolling programme is a continuous, cross-sectional survey of food consumption, nutrient intake and nutritional status of the UK population.[1] The Family Food survey provides household data on the expenditure on, and purchased quantities of, food and drink both for the household and that consumed outside the home.[2]

8.2. Government also uses commercial market data, collected by Kantar Worldpanel, which provides information on the volume (kilos or litres) and value (£) sales, and nutrient content of, food and drink purchased for consumption both in and out of the home.[3]

8.3. UK government nutrition advice is underpinned by the best available scientific evidence and independent advice from the Scientific Advisory Committee on Nutrition (SACN). SACN advises the 4 UK governments and is supported by an OHID secretariat. SACN has submitted written evidence separately in relation to questions 4 and 5 of the call for evidence. SACN does not have a policy making (risk management) role.

Key trends in dietary intakes

9.1. The most recent data from the NDNS reports that on average, the UK population is exceeding the recommendations for saturated fat, salt and sugar, and not meeting recommended intakes for fibre, fruit and vegetables and oily fish. People in lower income groups generally have a lower consumption of fruit, vegetables, oily fish, fibre and some vitamins and minerals than higher income groups, and a higher consumption of sugar sweetened beverages. Analysis of NDNS data by equivalised household income shows that those on higher incomes typically were closer to meeting some of the dietary recommendations. However, all income groups fail to meet dietary recommendations.[4]

9.2. Intakes of some vitamins and minerals are also below recommended intakes in some population groups. For example, the NDNS data indicates low blood levels for folate and vitamin D in most age groups, and for folate there has been a fall in blood levels over time. Low iron intakes, and to a lesser extent low haemoglobin and iron stores, were seen in girls aged 11 to 18 years and women aged 19 to 64 years.4,[5]

9.3. NDNS data indicates that overall, dietary intakes, of both food and nutrients, have been relatively stable since initiation of the NDNS rolling programme in 2008. The biggest positive change is the downward trend in free sugars intake, driven at least in part by the reduction in sugar-sweetened soft drinks consumption in most age groups. Mean intakes of free sugars for children (all age groups), adults aged 19-64 years and men aged 65-74 years were significantly lower in 2016-2019 compared to 2014-2016. However, there is little evidence of change for other foods or nutrients.

9.4. Trend analysis in the latest NDNS urinary sodium survey (2020) showed a statistically significant downward step-change in estimated salt intake between 2005/06 and 2008/09, with no significant step changes since.[6] Despite this reduction, intakes of salt remain above recommendations. A high intake of salt increases the risk of hypertension, which itself increases the risk of heart disease or a stroke.

9.5. The most recent Family Food Survey includes household food expenditure from 1974, where data is available, up to the year ending 2022.[7] Changes in the purchasing of a selection of food and drink groups have been provided in the table below for illustrative purposes.

Quantity of food and drink purchased for UK households - average per person per week

Food or drink product	1992 (g/ml)	2021/22 (g/ml)
Semi skimmed milk	767	801
Pork sausages	39	49
Meat based ready meals	89	175
Fresh and processed vegetables (excluding potatoes)	1205	1079
Fresh and processed fruit	1000	1026
Breakfast cereals	124	117
Biscuits	198	162
Solid chocolate bars	27	47
Pizza (all)	28	62
Takeaway pizza	8	14

Average energy (calorie) intakes reported in NDNS are below average requirements due to underreporting of food consumption which is a universal issue in dietary surveys. However, modelling data, based on calculated calorie consumption using height and weight data from the Health Survey for England (HSE), estimates that children who are living with overweight or obesity consume anywhere between 180-560 additional calories each day, depending on their age and sex. Adults who are living with overweight or obesity consume between 250-450 excess calories each day.[8] Previous modelling data, published in 2018, gave lower estimates (140-500 excess calories for children, 200-300 excess calories for adults).[9] At the higher levels, this is equivalent to an extra meal per day. However, the excess calories may come from a range of sources (eg slightly larger portions, or an additional drink or snack), not necessarily from one individual item or a whole meal.
There is some evidence suggesting that portion sizes may have increased over time.[10],[11]
Alcohol is a significant contributor to energy intake for some people. Alcohol contains almost as many calories as fat (7kcal/g) and many alcoholic drinks (or the mixers drunk with them) also contain free sugars. The latest data from the NDNS shows that alcohol provides on average 3.9% of energy intake for adults aged 19 to 64 years as a group.[12] 52% of this age group consumed alcohol during the 4 survey days. For those that drank alcohol it provided 7.4% of energy intake (this is likely to be an underestimate as underreporting of alcohol is known to be a common issue, particularly among heavier drinkers).[13]
Key trends in overweight and obesity

14.1. Data from the HSE (2019) indicates that two-thirds of adults (64%) are classified as living with overweight or obesity. Of these, 28% are living with obesity. Obesity prevalence was lowest among adults living in the least deprived areas (22%) and highest in the most deprived areas (35%).[14] In 2011, 22% of men and 19% of women in the least deprived areas were living with obesity, rising to 25% and 30% respectively in the most deprived areas.[15] In 2019, 22% of men and 22% of women in the least deprived areas were living with obesity and this rose to 30% and 39% in men and women in the most deprived areas, respectively.[16]

14.2. Adult overweight and obesity prevalence in England has consistently increased over time. In 1993, 58% of men and 49% of women were living with overweight or obesity, compared to 68% of men and 60% of women in 2019. Of these, 13% of men and 16% of women were living with obesity in 1993, compared to 27% of men and 29% of women in 2019. These increases occurred largely between 1993 and 2001, and since that time have been more gradual. Prevalence of obesity is predicted to continue to increase, albeit at a slower rate.

14.3. The UK has one of the highest adult obesity rates, both within Europe and across the world. From the late 1980s, the prevalence of adults living with obesity has risen faster in the UK than the Europe average.[17]

14.4. Overweight and obesity prevalence varies across ethnic groups. Of women, Chinese women (22%) were least likely to be overweight or obese. Women from black Caribbean (74%), Pakistani (74%) and black African (73%) backgrounds were most likely to be overweight or obese. Of men, Chinese men (36%) were least likely to be overweight or obese. The proportions of men from other backgrounds who were overweight or obese are similar.[18] Chinese adults were also less likely to be obese than those in other groups: 5% of Chinese men and 2% of Chinese women were obese. Among other groups, the proportions who were obese varied between 13% and 31% of men and 18% and 44% of women.

14.5. Data from the National Child Measurement Programme (NCMP) (2022/23) indicates that 21.3% of children start primary school living with overweight or obesity, and this rises to 36.6% by the time children leave primary school.[19]

14.6. The prevalence of obesity among reception children (age 4 to 5 years) had been relatively stable, ranging from 9.1% to 9.9% between 2006/07 to 2019/20. In 2020/21 there was a large increase in obesity prevalence (14.4%) during the Covid-19 pandemic. Prevalence then decreased but remained above pre-pandemic levels at 10.1% in 2021/22. The decrease to 9.2% in 2022/23 is a return to pre-pandemic levels for this age group and is one of the lowest levels since 2006/07.

14.7. For children in year 6 (age 10 to 11 years), the prevalence of obesity was increasing slowly over time from 18.7% in 2009/10 up to 21.0% in 2019/20. In 2020/21 prevalence increased by 4.5 percentage points (pp) to 25.5%, and in 2021/22 decreased to 23.4% which was still well above pre Covid-19 pandemic levels. The decrease to 22.7% in 2022/23 is still above the pre-pandemic levels and reflects the long-term trend of increasing obesity prevalence which was evident before the Covid-19 pandemic.

14.8. The prevalence of obesity in children in England is more than twice as high among children living in the most deprived areas than those living in the least deprived areas, both in reception and year 6.[20]

14.9. Between 2006/07 and 2019/20 there were small annual increases in the disparities gap in child obesity among reception children driven by decreases in prevalence in the least deprived areas and increases in the most deprived areas. The gap increased to 12.4 pp in 2020/21 and returned to 7.4pp in 2021/22, which was similar to the gap seen in pre Covid-19 pandemic years. The data for 2022/23 for reception children shows a gap of 6.6pp for obesity prevalence between the most and least deprived areas. This is the smallest disparities gap seen since 2014/15 and has been driven by a greater drop in prevalence in the most deprived areas which is at its lowest level since 2015/16.

14.10. Among children in year 6 the gap in obesity prevalence between the most and least deprived areas in 2022/23 has reduced to 17.1pp, but is still much larger than that seen in pre Covid-19 pandemic years. Between 2007/08 and 2019/20 the disparities gap in child obesity among year 6 children was widening each year from 9.6 to 15.5pp, mostly driven by increases in prevalence in the most deprived areas and a relatively stable prevalence among the least deprived children. The disparities gap saw an increase in 2020/21 to 19.5pp and was 17.7pp in 2021/22.

14.11. There is variation in obesity prevalence in children across ethnic groups. Obesity prevalence in reception children is highest among children from black African and black other ethnic groups. Children in year 6 from most minority ethnic groups (with the exception of white Irish, mixed white and Asian, and Chinese) are more likely to be living with obesity than white British children. As in previous years, in both reception and year 6, the prevalence of obesity in 2022/23 was highest for black children (13.6% and 31.6% respectively) and lowest for Chinese children (4.2% and 15.2% respectively). Obesity prevalence in boys and girls in many ethnic groups, in both school years, remain higher than pre Covid-19 pandemic levels, though Chinese boys in year 6 had lower obesity prevalence in 2021/22 than the previous two years.[21]

14.12. Some of these differences may be due to the influence of other factors such as area deprivation and physiological differences such as height.[22] Analysis published in 2019, using data gathered through the NCMP, showed that ethnicity has an independent effect on obesity prevalence in both year 6 and reception boys and girls after pupil age in months, quarter of measurement, national deprivation quintile, height, government office region and the urban/rural status of the low super output area of the child residence are taken into account.[23]

14.13. In 2019, Public Health England published an analysis of the Maternity Services Data Set (MSDS) on the ‘Health of women before and during pregnancy: health behaviours, risk factors and inequalities’. The report found that for women with a known BMI (n=264,790):

14.14. 27.4% were living with overweight, 18.3% were living with obesity and 3.3% were living with severe obesity, when they attended their first booking appointment

14.15. the proportion of women who were living with overweight or obesity during pregnancy increases with age, with the highest proportion being among those aged 40 years or over (55.4%)

14.16. 15.1% of women in the least deprived decile were living with obesity in early pregnancy; 28.5% of women in the most deprived decile were living with obesity in early pregnancy. Two-thirds (66.6%) of black women were living with overweight or obesity, compared with 22.8% of women with Chinese ethnicity. Women of Asian (51.8%), mixed (51.2%) and white (48.6%) ethnicities also had high rates of living with overweight and obesity.

The primary drivers of obesity both amongst the general population and amongst distinct population and demographic groups

Obesity is caused by a combination of complex genetic and physiological factors, mediated through environmental and socioeconomic factors impacting over a life course.[24] It is subject to influences ranging from the individual level (eg individual choices, calorie requirements, access to facilities and knowledge about cooking) to the system level (eg advertising, pricing).[25] However, weight is gained when energy from food and drinks consumed is greater than that expended to maintain our bodies and through physical activity. Excess calories are stored in the body mainly as fat.[26] There are many reasons why people overconsume calories.
Food environment

16.1. Evidence shows that dietary choices and behaviours are influenced by the food environment. [27],[28] How and where we buy food and drink, as well as the types of food available, has changed substantially in the last 30 years. This includes changes in the equipment we have in the home to store and cook food (eg freezers and microwave ovens) as well as growth in the places where we can buy food, including in non-food retail outlets such as clothes shops, and substantial change and increase in the numbers, types, production, availability and marketing of processed food such as ready meals, savoury snacks, pizza, ice cream and desserts, many of which are calorie dense or high in salt, saturated fat, and sugar.

16.2. Advertising and marketing of food and drink is ubiquitous with evidence showing that high calorie foods tend to be heavily advertised in all formats (eg TV, radio, posters and billboards, online and on social media including YouTube, via apps ), increasing the preference, choice, purchase and consumption of these foods.[29] Data shows that HFSS food and drink are marketed and promoted more via price reductions and multibuys than healthier products.[30] Data also shows that 5.5% of all sugar purchased on promotion in supermarkets is an incremental consequence of price promotions with 4.0% coming from higher sugar categories – this is sugar that would not have been purchased if the promotions were not in place. [31] We also know that people living in areas of higher deprivation are subject to more advertising, thus encouraging purchasing of foods higher in fat, salt and sugar. [32]

Cost of food and inequalities

17.1. Cost of food, and money available to buy food, are both major drivers of people’s diets and the incidence of obesity. Information is provided in section 7 of this document.

Eating out

18.1. There has been huge growth in the number of out of home outlets together with the evolution of meal delivery apps, where food and drink can be delivered at the click of a button. Evidence suggests that increased access to takeaway food outlets in home, work and commuting environments was associated with higher consumption of takeaway food, greater body mass index and greater odds of obesity.[33] Data from Lumina Intelligence suggested that the UK restaurant market was forecast to grow in 2023 by 5.2% to a value of £18.7bn, with further value growth to £19.5bn predicted for 2026.[34] Data from the Family Food module of the Living Costs and Food Survey showed that before the Covid-19 pandemic, expenditure on out of home food and drink across 2018/19/20 was relatively static.[35]

18.2. Eating out is no longer a one-off event. Data from the Food Standards Agency shows that 52% of respondents were likely to eat out or buy takeaway for lunch about 2-3 times a month, while 23% of respondents were likely to do this about once a week or more often. The same data shows that 59% of respondents were likely to eat out or buy takeaway for dinner about 2-3 times a month, while 24% of respondents were likely to do this about once a week or more often.[36] It is estimated that 20-25% of an adult’s energy intake comes from eating food out of the home.[37] In addition, the portion sizes of food purchased out of the home are estimated to be double that of food bought through supermarkets.[38],[39]

18.3. Data from the Institute of Fiscal Studies shows that while purchasing of out of home food and drink fell dramatically during the pandemic period, by the end of 2021 this had virtually returned to where it had been before the pandemic. However, the report also shows that in the first quarter of 2022, daily out of home consumption was around 5% higher than it had been in 2019. Data suggests that this change has been caused by a substantial shift in the places people are buying their food from; by the second half of 2021, fast food and takeaways accounted for nearly half (47%) of out of home calories, compared to 31% at the start of the pandemic, with the main losses being seen in coffee shops (a fall from 19% to 11% of out of home calories) and pubs and restaurants (a 15% reduction). It is not known if this change has been sustained, but the share of takeaways was increasing gradually before the pandemic.[40]

Hot food takeaways

19.1. For those living in more deprived communities it can be more difficult to eat healthily out of the home. The density of fast food outlets is almost twice as high in the most deprived local authorities when compared with the least deprived.[41] Not only are there more outlets but these tend to be less healthy in more deprived areas;[42] and eating out of home is frequently associated with a greater risk of weight gain, and becoming overweight and obese.[43] Individuals who consume more foods away from home tend to have higher intakes of energy, saturated fat, sugars and sodium, and lower intakes of micronutrients.[44],[45] Additionally, online food outlet access is greatest in the most deprived areas and easier access to neighbourhood takeaways has been shown to increase consumption of takeaways, and is associated with higher weight. [46] Given the cost of living context, this type of food can be seen as providing value for money per calorie for people who are struggling financially as it is cheap, easily accessible and doesn’t require any time, knowledge or resources for cooking.

Covid

20.1. The Covid-19 pandemic resulted in disruption of the food system and people’s usual eating habits with more food being purchased for consumption in the home. Some food categories saw increased consumption including snacks and alcoholic drinks.[47] A report from the Institute of Fiscal Studies [48] shows the magnitude of the change with an additional purchase of 280 calories per equivalent adult per day during the second quarter of 2020, compared to 2019. While this had halved during the second half of 2020, the first quarter of 2021 saw similar increases with the average household purchasing an additional 295 calories per day, per adult equivalent, compared to 2019. By the start of 2022 at home purchasing remained slightly increased, compared to before the pandemic; the data suggests that the bulk of the increase seen at the start of the pandemic was transient.

20.2. The IFS report also shows that that not only did the number of calories purchased increase, the contribution from “less healthy” calories (ie from products scoring 4 or more judged against the nutrient profile model (NPM)[49]) also increased, making up 54% of total calories purchased, compared to 52.6% in the same period of 2019. By the second half of 2021, these differences had almost completely disappeared.

20.3. The report also details the changes in purchasing of food from the out of home sector during and since the pandemic. This shows the sharp drop-off in purchasing from this sector during the second and fourth quarters of 2020 and the first quarter of 2021. However, during the times when restrictions had eased during 2020, purchases remained well below their pre-pandemic levels. By the end of 2021 purchasing from the out of home sector had returned to virtually where it had been before the pandemic.

20.4. Data also shows that the Covid-19 pandemic was linked with significant decreases in mobility, walking and physical activity;[50] and data from the NCMP shows that levels of obesity increased sharply during the Covid-19 pandemic. For children, therefore, the usual school structure clearly provides a protective factor around usual habits relating to food consumption and levels of physical activity.

Alcohol

21.1. High alcohol intake is likely to contribute to excess energy intake and risk of overweight and obesity for some people, though the evidence is mixed.[51],[52] Health risks tend to cluster; around 17% of people both heavily drink and are living with overweight or obesity (and the clustering is likely to be higher with increasing deprivation).[53]

Physical activity

22.1. Though the issues relating to the incidence and impact of overweight and obesity and weight loss are much more related to diet, physical activity can play an important role in helping people to maintain a healthy weight. Data shows being active can help prevent and manage chronic conditions and diseases, including coronary heart disease, stroke, type 2 diabetes, obesity, cancer, depression and musculoskeletal conditions.[54]

22.2. Increasing levels of physical activity throughout childhood and adolescence encourages children and young people to benefit from a better, healthier start to life by building healthy habits and a strong health foundation, which reduces the risk of obesity and other inactivity-aligned conditions later in life.[55]

22.3. Despite the evidence, as a nation we are not achieving the levels of physical activity set out by the UK CMOs. The latest Active Lives Survey results show that between November 2021 and November 2022, the number of people classed as inactive - averaging fewer than 30 minutes of moderate intensity physical activity a week - was over a quarter of the population at 25.8%.[56] For children and young people this is 30.2%.[57]

Recent declines in obesity prevalence in reception aged children

23.1. In 2022/23, in England, obesity prevalence rates in 4-5 year olds reduced with the largest reduction seen for those in the most deprived areas where prevalence was similar to the prevalence rate of 2015/16. There have been a number of suggested potential drivers that may be contributing to the decline in prevalence of obesity in reception aged children including:

23.1.1. introduction of, and increases in, the provision of paid parental leave. Evidence from California suggests that the introduction of six weeks’ paid parental leave in 2002 was associated with a 4.1% relative reduction in childhood overweight at school entry, with a larger reduction (14.7%) seen in children of mothers with low educational attainment. The reduction in overweight and obesity may be related to increased breastfeeding, prompt infant health check ups, lower prenatal stress and less non-parental infant care.[58]

23.1.2. substantial reduction in the prevalence of maternal smoking which in England, for numbers recorded as smoking at the end of pregnancy, reduced from 15.8% to 9.1% between 2006-07 and 2021-22.[59] Maternal smoking is associated with a 1.50 higher risk of obesity at age 4 years.[60]

23.1.3. improved diet and nutrition at this young age. Breastfeeding and longer duration of breast feeding, nutrition standards for pre-school settings reducing portion sizes of snacks, reformulation and reduced intake of sweetened beverages.[61]

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

Excess weight and poor diet increase the risk of a range of health conditions including cardiovascular disease, type 2 diabetes, some cancers, non-alcoholic fatty liver disease and musculoskeletal issues such as osteoarthritis, through multiple different and complex mechanisms.[62] Those who are living with obesity are more likely to suffer from poor mental health.[63] Due to the associated co-morbidities, excess weight impacts workforce and economic productivity.[64],[65]
Children living with obesity are approximately five times more likely to be living with obesity in adulthood, and more likely in turn to be parents living with obesity.[66] There is evidence showing that excess weight in childhood or adolescence is associated with increased risk of type 2 diabetes, coronary heart disease, high blood pressure and some cancers.[67],[68] Children and adolescents living with obesity are at risk of poor mental health and low self-esteem.[69] There is also evidence to show that excess weight in these age groups can impact educational outcomes and cognitive performance [70],[71] and later in life their employment opportunities and lifetime earnings.[72]

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

Please see the submitted evidence from SACN in relation to their consideration on the diets of pre and postnatal women, and children.
The influences on the diet of children and adolescents that contribute to the risk of becoming obese

27.1. Most children and adolescents do not meet population dietary recommendations as illustrated by the Eatwell Guide. Specifically, they consume free sugars in excess of government recommendations and it is estimated that those who are living with overweight or obesity consume anywhere between 180-560 additional calories each day, depending on their age and sex.[73]

27.2. Consideration is also needed of specific influences on the diet of children and adolescents that contribute to the risk of them becoming obese. Many of these factors are the same for children as they are for adults – eg marketing, advertising, promotions and easy accessibility to HFSS food and drink, including the density and accessibility of takeaways in the local environment and near schools – and details on these topics are included below.

27.3. It is worth noting separately that exposure to advertising has been shown to increase intake and affect food choice and preference in children and adolescents.[74] Some studies suggest advertising can have a greater impact on those who are overweight – for example, children who are overweight or living with obesity appeared to be more vulnerable to the influence of advertising, consuming an average of 46 kcal more than children with healthy weight when exposed to food advertising.[75]

27.4. What may be particularly relevant to children in terms of advertising are the social-cognitive theories that suggest that the effects of food advertising are subtle yet have impacts on eating behaviours that may be outside the participants’ awareness through ‘priming’.[76] Priming studies have demonstrated that complex social and physical behaviours can be subconsciously activated through external stimuli. This is to say, many of the messages delivered through advertisements may not affect conscious decision-making behaviour but will act in the subconscious. The implication of this is that if advertising were to act on the subconscious through ‘priming’, then children may not even be aware of the effect advertising is having on their food preferences.

27.5. Advergames are a form of content marketing in which a marketer commissions a video game featuring its brand and/or products and distributes this game for free, and are likely to be particularly relevant to children. The available evidence indicates that advergames are persuasive in promoting unhealthy foods and are likely to induce unhealthy eating behaviour among children.[77],[78],[79],[80],[81] Children and young adults may not recognise advergames as advertising.[82]

27.6. While recognising that there are a range of factors influencing children's food requests, there are multiple studies showing food advertising increases children’s requests for advertised foods.[83] Studies also suggest that each additional hour of TV watched by children was associated with a 22% increased likelihood of pestering their parents.[84]

27.7. Many products and adverts aimed at children feature cartoon characters or “spokescharacters”. These are used to increase the attractiveness of the product to children and increase the likelihood that children will choose it; and evidence suggests that this type of advertising may increase children’s taste preference for HFSS products.[85]

27.8. A systematic review on the impact of hot food takeaways near schools in the UK on childhood obesity found that there was good evidence of more hot food takeaways in deprived areas; and that children who spend time in deprived neighbourhoods tend to eat more fast food and have higher BMIs. While few studies were able to quantify the correlation between a school’s environment and obesity amongst pupils, the review concluded that this was likely to be a factor of the studies’ ability to identify the correlation rather than lack of a correlation between the two variables.[86]

27.9. The Mayor of London announced in 2017 that fast food takeaways would be banned from opening within 400 metres of schools; and that all new chicken, fish and chip and pizza outlets would have to sign up to minimum healthy food standards before getting planning permission.[87] A study that reviewed the presence of planning policies for the purpose of takeaway food outlet regulation with a health focus, found that such policies were more likely in areas with greater numbers of takeaway food outlets and higher proportions of children with excess weight. The paper also found that other characteristics, including Labour political control and greater deprivation and urbanisation, were associated with planning policy adoption, as were the actions of similar and nearby local government areas.[88]

27.10. Evidence of the impact of planning policies of this kind are mixed. One study found that, in the short term (3 years), planning guidance to limit the number of new fast foodfast food outlets in a school exclusion zone did not have a statistically significant impact on the food environment when compared with a control zone.[89] A different study looking at the impact of a general, rather than school focused, ban on fast food outlets found a reduction in density of fast food outlets by 12.45 per 100,000 of the population and a 13.9% decrease in the proportion of fast food outlets in Gateshead compared to other similar local authorities in the North East. While there was a marginally significant reduction in the number of restaurants this became insignificant after controlling for population density.[90]

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

Please see the submitted evidence from SACN.
Ultra-processed foods

29.1. While there is currently no universally agreed definition of ‘ultra-processed foods’ (UPF), NOVA is the most widely used classification system. This defines UPF as “formulations of ingredients, mostly of exclusive industrial use, typically created by series of industrial techniques and processes”.

29.2. The UPF definition is controversial because it captures a wide range of foods, including many which are typically considered ‘less healthy’, such as sugary drinks, salty snacks and confectionery. However, UPF also captures products that are generally considered ‘healthier’ such as some fortified foods, sliced wholemeal bread, baked beans, low fat yogurts, vegetable sauces and higher fibre breakfast cereals.

29.3. It is estimated that foods that would be classified as UPF contribute 51-68% of calorie intake in the UK, with the higher estimates for children and young adults. Home cooking has declined in the UK since the 1980s, concurrent with an increase in processed foods.[91] There is limited information on trends in UPF consumption, but assessment of NDNS data suggests intakes were largely unchanged between 2008 and 2019.[92]

29.4. In autumn 2022, OHID asked SACN to expedite an assessment of processed foods and the Committee published a position statement on ‘Processed foods and health’[93] in July 2023. The statement identified that systematic reviews consistently reported that increased consumption of UPF was associated with increased risks of adverse health outcomes including obesity type 2 diabetes, cardiovascular disease, depression, mortality and a range of maternal and child health outcomes.

29.5. SACN concluded that the association between higher consumption of UPF and adverse health outcomes is concerning but limitations in the available evidence on processed foods and health means it is unclear whether these foods are inherently unhealthy due to processing or because a large majority of processed foods are high in calories, saturated fat, salt and sugar. The evidence may also be confounded by other factors associated with both poor dietary patterns and health, such as socioeconomic status. This is because the available evidence is almost exclusively observational and unable to show causation. See SACN’s response to the call for written evidence for further details.

29.6. Further research is needed however before any firm conclusions can be drawn about the extent to which processing itself is the problem and therefore before any significant updates to the Eatwell Guide and government dietary recommendations would be considered. Given the broadness of the current classification, a blanket statement to limit all UPF foods is unlikely to be helpful and may be particularly difficult to achieve for those on lower incomes or less able to find time to cook at home.

29.7. The Eatwell Guide already shows that many foods classified as UPF are not part of a healthy, balanced diet. The Eatwell Guide also emphasises that our diets should include plenty of fruit and vegetables and wholegrain or higher fibre foods and processed meats should be limited.[94] Most people are likely to benefit from reducing their consumption of many foods classed as UPFs.

29.8. Many foods classified as UPF are captured by existing government regulations which restrict the placement of HFSS products in store and online (as identified by our nutrient profile model (2004/5)), as well as regulations on advertising and price promotions due to come into force in October 2025. They are also likely to be the focus of our efforts to reformulate products high in calories, sugar and salt, the SDIL, and calorie labelling regulations for food sold in large out of home businesses.

Foods high in saturated fat, sugar or salt

30.1. There is good evidence to show that high intakes of sugar, fat - particularly saturated fat - and salt are associated with poorer health outcomes such as the risk of excess weight, tooth decay and cardiovascular disease.[95],[96],[97]

30.2. The definition of foods high in saturated fat, sugar or salt (HFSS) is determined by the UK Nutrient Profiling Model (NPM) 2004/5.[98]

30.3. The UK NPM 2004/5 is based on a simple scoring system where points are allocated on the basis of the nutrient content of 100g of a food or drink. Points are awarded for ‘A’ nutrients (energy, saturated fat, total sugar and sodium) and for ‘C’ nutrients (fruit, vegetables or nut content, fibre and protein). The score for ‘C’ nutrients is then subtracted from the score for ‘A’ nutrients to give the final nutrient profile score. This determines whether the product passes and is considered ‘healthier’ or non-HFSS, or fails and is considered ‘less healthy’ or ‘high in saturated fat, sugar or salt’, ie ‘HFSS’. An updated NPM model was consulted on in 2018 but has not yet been finalised. Both the current and updated NPM models have been shown to be aligned with the Eatwell Guide.[99]

30.4. The UK NPM 2004/5 was developed as a tool to enable the Office of Communications (Ofcom), the UK broadcast regulator, to identify ‘less healthy’ foods and drinks that are subject to restrictions during children’s television programming. Ofcom has been using this model for broadcast media since the restrictions came into force in April 2007 and for non-broadcast media since July 2017.

30.5. Therefore, there is already an established method of identifying and defining HFSS foods and drinks that is used by government, businesses and academia. A number of foods that are considered as UPF are also HFSS, which means there is some overlap between the two definitions.[100] There is currently no objective, universally agreed method to determine UPF products in the same way there is for HFSS products. Any method for determining UPF products would need to be robust enough to apply to policy decision making.

30.6. Since February 2019, Transport for London have adapted the UK NPM 2004/5 to restrict the advertising of HFSS products across its whole estate.

30.7. The UK NPM 2004/05 is the technical basis to determine HFSS foods and drinks in government policies including volume price and location promotions and further advertising restrictions. In October 2022, the restriction of HFSS promotions in medium and large retailers being sold in key locations, such as checkouts, aisle ends, store entrances came into force, with price promotion restrictions planned to come into force in October 2025. Further advertising restrictions online and imposing a 9pm watershed are also planned to come into force in 2025.

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

Nutrition labelling helps to support the consumer to make informed choices about their food and non-alcoholic drinks by providing information on the nutrient content of products.[101]
Mandatory nutrition declaration on the back of pack provides information for consumers on the amount of energy (in both kilojoules and kilocalories) and the amount of sugar, saturated fat and salt (in grams), fat, protein and carbohydrates. Alcoholic drinks are not currently subject to mandatory nutrition labelling.[102]
Front of Pack Nutrition Labelling (FOPNL) is intended to support healthier choices and reduce obesity rates by communicating complex nutritional information via colour coding to help consumers identify whether a product is high in saturated fat, salt or sugar. This provides information to shoppers in a way that is easy and quick to understand.[103]
Our current voluntary traffic light labelling scheme is hugely popular, with 9 out of 10 shoppers saying that the current label helps them make informed choices when shopping. A review of the evidence, using experimental and 'real-life' studies, indicate that front of pack labelling encourages healthier food purchasing.[104]
The Food Standards Agency’s Consumer Insights Tracker shows that 75% of people are concerned about ‘ultra-processed or over processing of food’.[105] However, UK consumer research into the understanding and perceptions of UPFs suggests that people are confused about which products are UPFs, they are unable to accurately identify most UPF products, and processing is not the main driver behind their food choices.[106]
There is currently no objective, universally agreed method in the UK or internationally to help consumers identify whether foods are considered as UPF.
In France the voluntary FOPNL system, Nutri-Score, was introduced in 2017 for prepacked foods. It ranks the healthiness of foods according to a scoring system; it ranges from -15 for the healthiest of products to +50 for those that are ‘less healthy’. The scores are represented by a letter with a colour code showing dark green (A) for the most healthy to dark red (F) for the least healthy. Nutri-Score has been introduced in multiple European countries including Spain, Belgium, Netherlands, Luxembourg and Switzerland.
The impact of Nutri-Score on purchasing behaviours has been assessed using randomised controlled trials where participants have been assigned to different groups according to whether products are labelled with Nutri-Score, the Reference Nutrient intake or no label. These found that the Nutri-Score label seemed to increase the nutritional quality of purchasing intentions, support healthier choices [107],[108] and reduce purchases of processed and ultra processed foods.[109]
The Health Star Rating (HSR) is a voluntary FOPNL system used in Australia and New Zealand which applies a star graphic ranging from half to 5 stars. The greater the number of stars, the healthier the product. It is underpinned by an NPM to determine the healthiness of foods according to their nutritional content. The formal review of the system stated that it is well used, recognised, reliable and is helping consumers to make healthier choices when purchasing packaged foods and beverages. Generally Australian and New Zealand consumers view the HSR as easy to understand, easy to use therefore making it easier to decide which packaged foods are healthier. The review, together with a study published in 2020, also cited that there is evidence suggesting that the HSR is encouraging some reformulation.[110],[111]

The cost and availability of a) UPF and b) HFSS foods and their impact on health outcomes

In relative terms, food is cheaper now than it used to be. Data from the Family Food module of the Living Costs and Food Survey shows that the proportion of expenditure that was allocated to food by households more than halved between 1957 (33%) and 2017 (16%). The same dataset shows that between the financial year ending (FYE) 2019 (1st April 2018 to 31 March 2019), and FYE 2022, expenditure on all food and non-alcoholic drinks in real terms, per person per week, fell by 16.4%, from £41.90 to £35.02. However, the data also shows that the lowest 20% of households by equivalised disposable income spent 14.8% of their expenditure on household food and non-alcoholic drink, compared to 11.8% on average per household.[112] Alcohol was also 72% more affordable in 2020 than it was in 1987 (and 14% more affordable since 2010).[113]
Lower household income has been consistently associated with poorer diet quality and poorer dietary health outcomes. Households experiencing poverty find themselves unable to afford enough food, and the food that they can afford is often poor quality, energy dense and low in nutrients.[114]
Prices of food and non-alcoholic drink started rising in the second half of 2021 and were 19.1% higher in the 12 months to March 2023, compared to the previous year, the highest since 1977. In July 2023 food inflation had dropped to 14.8% and it has fallen further since. The Department for Work and Pensions (DWP) publishes data on the numbers of households experiencing food poverty, or ‘household food insecurity’, defined as being unable (or uncertain about whether they can) acquire an adequate quality of sufficient quantity of food in socially acceptable ways. This showed that in 2021/22 there were 4.7 million people, or 7% of the UK population, in food poverty, including 12% of children; and among the 11m people found to be in relative poverty (income less than 60% of median income) 15% were in food insecure households, including 21% of children. DWP data on use of food banks shows that in 2021/22, 2.1m (3%) people in the UK lived in a household which had used a food bank in the previous 12 months, including 6% of children and 3% of working age adults. The Trussell Trust said that 760,000 people used one of their food banks for the first time in 2022/23, a 38% increase from 2021/22.[115]
The Food Standards Agency’s Consumer Insights Tracker gives monthly insights on behaviours and attitudes towards food insecurity, food availability, consumer concerns and confidence in the food chain.[116] The most recent data, published in February 2024, showed that 22% of those questioned for the survey were worried about their household not being able to afford food in the next month; and that 20% are worried about there not being enough food available for their household in the next month. Both these figures are lower than when these questions were first asked in July 2023. The survey also includes details of the coping mechanisms used to save money including buying discounted food close to its use by date (39%), shopping in multiple supermarkets (33%) and buying less fresh and more long life food (19%). People also reported eating food past its use by date because they couldn’t afford to buy more food (10%) or cutting the size of meals or skipping meals because there wasn’t enough money for food (9%), with 8% reporting they couldn’t afford to eat a healthy balanced diet and 4% reporting they couldn’t afford their essential food shopping.[117]
Researchers at the University of Oxford have modelled the cost of consuming a healthy diet in line with the Eatwell Guide compared to the cost of current diets. In 2016, they estimated that a healthy diet would cost £5.99 per adult, per day compared to a current diet of £6.02. The authors noted that achieving the UK dietary recommendations would require large changes to the current average diet and others working in the field have indicated that the results may be an underestimate.[118] The researchers used the same methodology to update the figures in 2019 and 2022 and found the cost of a healthy diet rose to £6.82 and £7.48 per adult per day, respectively.[119],[120]
In 2022, the Food Standards Agency Northern Ireland published data showing the cost of a minimal essential food basket for four lower income household types in 2022. This work updated previous estimates, the last of which was published in 2020. The analysis shows that between 2020 and 2022 minimum weekly food costs increased by an average of 4.6% (range 4.3% to 4.9%). Food costs, as a percentage of net income, for the minimal essential food basket ranged from 23% to 45%, varying according to household size, age of children and source of income. Temporary cost of living supports significantly increased household income between 2020 and 2022 and without these supports food costs would have risen by more than the increase in net household income for working-age families reliant on state benefits.[121]
Food Standards Scotland undertook some exploratory research to provide an estimate of the cost of a healthy balanced diet for a week using information from a single supermarket. This resulted in a wide range of estimates for the cost of a healthy basket – for example, the cost of a basket of food needed to create a specific set of meals for a week for a couple cost £67.56 at its lowest price and £166.11 at its highest price, a difference of £98.55 (146%). This suggests that making use of budget and lower cost options can be a successful way to cut the cost of a weekly shop.[122] Modelling work undertaken by OHID for the House of Lords Select Committee on Food, Poverty, Health and the Environment broadly aligns to the research undertaken by Scotland and Northern Ireland.
The Priority Places for Food index measures food insecurity against 7 domains: proximity to supermarket retail facilities, accessibility to supermarket retail facilities, proximity to supermarket food provision, access to online deliveries, fuel poverty, socio-economic barriers (income deprivation and car access) and need for family food support. This index indicates that there are areas spread around the country where people struggle to access food, often where there is economic deprivation. This can be for a variety of reasons but in some areas poor online delivery access and proximity to supermarkets were identified as contributing factors.[123],[124] The Social Market Foundation investigated the presence of food deserts, which they defined according to the number of supermarkets or convenience stores within an area. They identified areas across Great Britain that are poorly served by food stores and that this may be one barrier some people face in being able to eat healthily. In the survey that was commissioned as part of the research, 12% of individuals stated that “not being near a supermarket offering healthy food at low prices” was a barrier to being able to eat more healthily and 7% said not having access to a car to travel to the supermarket was an issue.[125]

The role of the food and drink industry in driving food and diet trends and on the policymaking process

The role of the food and drink industry in driving food and diet trends

48.1. Unhealthy commodity industries, which includes elements of the food industry, are responsible for producing and promoting the unhealthy consumption of products which play a major role in driving the growing burden of non-communicable diseases.[126] Therefore, all businesses and sectors within the food industry – supermarkets and more specialist retailers, manufacturers, the out of home sector (high street restaurants, pubs, cafes, catering at the places people spend their leisure time etc), takeaway and food delivery businesses – whether large or small, all have role to play in driving food and diet trends and in the decisions people make about what they eat and drink, where and when.

Advertising and marketing

49.1. One of the common ways in which all sectors of the food industry – retailers, manufacturers and the out of home sector – drive food trends, and consumption of HFSS food and drink, is through advertising and marketing. One-third of advertising spend by the food industry (2022/23) is spent on marketing confectionery, snacks, desserts and soft drinks, while only around 1% of advertising budgets are spent on marketing fruit and vegetables.[127] Data also shows that around 40% of businesses budgets are spent on advertising brands, with no specific product included.[128] Advertising of unhealthy, high calorie food has been identified as a contributory factor to the increasing prevalence of obesity around the world.[129]

49.2. Children are thought to be particularly vulnerable to marketing techniques, with academic evidence showing their food preferences, purchasing and consumption can be influenced by advertising.[130] One study showed that short-term exposure to unhealthy food advertising on TV and advergames increases immediate calorie consumption in children;[131] while an additional study estimated that 6.4% of UK childhood obesity and 5.0% of overweight is attributable to HFSS TV advertising.[132] Evidence shows that adults are also susceptible to advertising, increasing the choice, purchase and consumption of high sugar food and drink.[133]

49.3. A report from OfCom [134] showed that while 85% of children aged 3-17 years viewed television programmes or films via a TV set, a similar majority (80%) watched this type of content via other devices eg via a tablet or mobile phone. All devices were also used to watch other forms of video content, such as live streams and user-generated content. On average, children aged 4 to 15 years watched 253 minutes of broadcast TV per week (BBC, ITV, Channel 4 etc) and 265 minutes of subscription video on demand (eg Netflix, Amazon Prime, Disney+) and advertising-based video on demand (where viewers access content free in return for watching advertising eg YouTube). The report also shows that 64% of children aged 3-17 years used apps for social media purposes (eg following friends, reading, liking or sharing photos, comments, links); and that YouTube is the most used site or app among children, visited by 88% of 3-13 year olds who go online.

49.4. Data from the Advertising Standards Authority (ASA) shows that children were exposed to around 83 TV ads per week in 2021, a fall of almost two-thirds from 2010 (227 ads per week).[135] ASA data also shows that, on average, children aged 11 to 17 were exposed to 118 ads a week via websites and four social media platforms (in alphabetical order: Facebook, Instagram, Twitter and YouTube) in 2022.[136]

49.5. Data shows that the UK’s digital ad market attracted £13.8bn of spend in the first six months of 2023, a year on year increase of 5%.[137] The same analysis shows that spend on video ads saw the strongest growth, which is in line with data from OfCom that shows the popularity of short-form video content with over one-third of UK adults, and 68% of 15-24 year olds, watching short-form online videos daily.

49.6. Data on the spend and degree of advertising by the out of home sector brings this to life. A report by Bite Back showed that digital and social media advertising expenditure by the top ten biggest spending fast food outlets and delivery platforms increased by £37.5m between 2021 and 2022 - an increase of 75% - rising from £50m in 2021 to £87.5m in 2022. This was driven by big increases in spend by McDonald’s (equivalent to just under 300%) and KFC (equivalent to 225%).[138] And in 2022 the top 10 spending businesses accounted for more than two thirds (67%) of the total combined digital and social media advertising spend by restaurants and food delivery platforms.137

Other research from Bite Back [139] shows the following:

50.1. young people (aged 13-19) are regularly exposed to adverts for less healthy food and drink across a range of media platforms and recalled seeing these adverts at least twice per day on average, although the amount of exposure is likely to be higher (under-reporting may be due to differences in perceptions of what food and drink is considered less healthy). Out-of-home food (eg pizza, burgers and other fast food) advertising dominates the advertising seen by young people.

50.2. brands target young people across a range of media channels. Social media platforms together are where less healthy adverts were encountered the most, followed by TV. 35% of survey participants reported seeing adverts on YouTube at least once a day, 27% on TikTok and 24% on Instagram, with TikTok emerging as a particularly influential channel for advertising.

50.3. the food advertising young people see is highly effective in influencing them, with young people reporting feeling hungry, getting cravings for, and wanting to purchase less healthy products after exposure. Advertising featuring price promotions and new product launches were the most compelling in influencing young people to want to buy from the brand advertised.

There has been substantial growth in personalised digital advertising in recent years. Coca-Cola has used this device in producing bottles with names on (eg Sarah, Paul) rather than the name or brand of the product; Sainsbury’s has used it to provide personalised coupons to encourage repeat purchasing; and Cadbury used a person’s Facebook profile to offer them a personalised flavour of Dairy Milk, which resulted in a 65% click through rate and a 33% conversion rate (ie the individual purchased the chocolate).[140],[141] In 2022, 58% of companies surveyed by Deloitte Digital said they were planning to increase their spend on this in 2022, with 69% of consumers surveyed saying that they are more likely to purchase from a brand if it personalises experiences.[142]
Volume price promotions

52.1. One of the other mechanisms businesses use to increase the volumes of food we buy are volume price promotions. These kinds of promotions have generally been applied to products in the form of a temporary price reduction (eg a product being offered at half its usual price, so 50p instead of £1) or a multibuy offer (eg buying 2 products, that usually cost £2 each, for £3).

52.2. Data and analysis of data from Kantar WorldPanel [143], for a 2 year period spanning 2017 and 2018, shows that, in the supermarket environment:

52.2.1. over the two years of this analysis (2017- 2018) the proportion of product bought on promotion was 34%

52.2.2. promotions frequently lead people to buy more of the promoted category than expected; on average, about 18% of promoted food and drink volumes bought are calculated to be additional to expected purchasing levels

52.2.3. promotions not only get people to buy more of a specific category, the evidence shows that people buy more overall. This is because increased purchasing of one high sugar category does not lead buyers to make a significant compensatory reduction in their purchasing of other higher sugar categories.

52.2.4. higher sugar food and drink items are more likely to be promoted and the depth of the discount applied is also slightly higher on these items. Some higher sugar food and drink categories represent more discretionary products that generally have a longer shelf life and promotions in these areas will more easily get shoppers to buy more than normal. This means promotions in some higher sugar categories can more readily drive up take-home food and drink volume. This also explains why the high sugar categories account for a bigger proportion of the amount of extra sugar purchased.

52.2.5. promotions are more common on products where sugar is added (particularly discretionary products such as carbonated drinks, biscuits and cakes), than on table sugar and products where sugar is naturally present such as milk and fruit and vegetables, with the exception of fruit juice

52.2.6. price promotions are a common feature of grocery shopping and therefore all shoppers are regularly exposed to promotions on products they want to buy. However, although differences are small, shoppers from lower socio-economic groups, on lower incomes, and in the youngest and oldest age groups are slightly less likely to buy into promotions

52.3. The form of volume price promotions used in supermarkets is shifting with retailers now offering specific price deals if you have a loyalty card; and the use of “everyday low pricing” strategies, to match the generally lower pricing offered in discount stores.

52.4. Price promotions are also used in the eating out of home sector. This includes mechanisms such as the lunchtime sandwich-based meal deals, buying 2 pizzas for £20 etc. Unpublished data shows that these offers and deals also increase the volume of products purchased and the amounts of money spent.

Locations promotions

53.1. The location of products within supermarkets and other stores can significantly affect what we buy.[144] A high-quality observational study in England found that end-of-aisle displays (after controlling for the effect of price, price promotion and number of display locations) increased sales volumes for carbonated drinks by over 50%.[145] Location promotions of HFSS products can lead to excess purchasing and therefore overconsumption of products which are associated with a greater propensity to create impulse purchases [146] and act as a significant contributor to weight gain.[147],[148] This suggests that the intrinsic value of products is not increased by being placed in prominent locations; rather their consumption is stimulated via ease of access or triggered impulsive behaviour.

53.2. A survey, prior to the location restrictions being implemented, showed that 43% of all food and drink products located in prominent areas, such as store entrances, checkouts, and aisle ends were for sugary foods and drinks. 70% of these products in prominent areas were for food and drinks that contribute significantly to children’s sugar and calorie intakes and less than 1% of food and drink products promoted in high profile locations were fruit or vegetables. The survey showed that 86% of food and drink products located at store entrances were for products that contribute significantly to children’s sugar and calorie intake, 67% for checkout areas and 67% for aisle ends.[149]

Other mechanisms used by businesses to shape consumer purchases

54.1. Conversations with food industry businesses over many years have provided additional information and insights on the other mechanisms that are used to shape consumer purchases and increase the probability of food and drink sales. These include, but are not limited to:

54.2. keeping a watch on emerging food trends and tailoring brands and marketing strategies considering these, for example the expansion of products that are high in protein, plant based, positive for gut heath.

54.3. regular review and reformulation of existing products within a business’ portfolio; and relaunching the same product, with some minor changes highlighted as “new and improved” or similar to prompt purchasing; and businesses in the out of home sector regularly reviewing and changing menus (twice per year at least)

54.4. bringing out new products, new brands, new flavours or variations of an existing product to keep the brand relevant and attract additional purchases. This can include seasonal products covering Halloween, Easter, Valentines Day etc, or other limited-edition flavours. For example, in March 2024 there were 14 different flavours and varieties of one chocolate bar available on one retailer online shopping platform, including a breakfast cereal, and the additional availability of 6 Easter eggs and a bunny shaped version. Out of home businesses also provide seasonal flavours and different products, often for a short time to encourage purchase and consumption.

54.5. differently packaged forms of the same product eg, baked beans in large cans, small cans, large plastic containers to keep in the fridge, small "snap pots" of individual portions; and changing the form of product packaging and/or design of the packaging to attracted new customers and sales.

54.6. retailers incorporating a greater variety of food types in store and expanding how they offer them eg, being able to buy hot chicken, cooked pizzas, sushi bars in store and pre-packed.

54.7. changing layouts of stores

54.8. the eating out of home sector selling products in supermarkets eg, Pizza Express pizzas and doughballs; Starbucks coffee.

54.9. the use of health and nutrition claims, while strictly governed by legislation, can attract customers. A systematic review, although based on research mostly conducted in artificial settings, showed that the use of health related claims had a substantial effect on dietary choices with 20 studies showing that claims increased purchase and/or consumption, with 8 showing mixed results and 2 showing reductions. The paper also concluded that natural experiments had yielded smaller effects.[150]

Hot food takeaway and delivery services

55.1. Data on the density of fast food outlets by local authority shows that the poorest areas in England have five times more fast food outlets than the most affluent areas.[151] A specific study in Norfolk found that between 1990 and 2008, takeaway food outlet density increased overall and was significantly higher in more deprived areas at all time points. It also found that socioeconomic disparities in takeaway food outlet density increased across the study period.[152] A separate study found the number of food outlets people can order from on online food delivery platforms, was 50% higher in the most deprived postcode districts in England, compared to the least deprived.[153]

55.2. Studies also show that exposure to more fast food outlets increases the risk of being overweight or living with obesity. For example, one study looking at data for Cambridgeshire Fenland found that those exposed to takeaways were almost twice as likely to be obese than those who encountered the fewest outlets.[154] A study in Leeds found that there was a significant positive correlation between density of fast food outlets and higher deprivation; and that a higher density of fast food outlets was significantly associated with children being overweight or obese.[155]

55.3. Food delivery aggregators are platforms which act as the middleperson between the consumer and the food business which can be a takeaway, café, restaurant or supermarket. The growth of these platforms since Covid-19 has increased with online food delivery considered a post-pandemic norm. Temporary planning regulations introduced during the pandemic to allow more takeaways without the need for planning permission may have lasting health impacts and behaviours.[156] Research also shows that food outlet access through online food delivery services increased in England between 2020 and 2022, in the context of the Covid-19 pandemic and only in the most deprived areas in England.[157]

55.4. Since the pandemic, use of food delivery apps has increased exponentially and is set to continue; the number of users is estimated to reach 55 million by 2027.[158] Data from Lumina Intelligence shows that the UK foodservice delivery market was expected to grow by 7.8% and reach a total value of £14.4bn in 2023. It was suggested that investment in development of delivery company order sites and apps, optimisation of brand sites and prominent marketing activity would contribute to this growth. Branded businesses, such as McDonald’s, KFC and Burger King had seen the largest growth in share across the market, increasing by 12%; while the coffee, sandwich and bakery sector was set for the largest percentage growth in delivery turnover, increasing by 20.7% between 2020 and 2023.[159]

55.5. Food on delivery apps tends to be highly energy dense. Data from Food Standards Scotland shows that the average content of meals is between 1125-1820 kcal per meal, 2 or 3 times higher than the guideline that lunch and dinner should each provide around 600kcals.[160] Eating takeaway food and using food delivery apps are associated with overweight and obesity, with research using UK Biobank data showing that people who reported having more takeaways or delivery meals were more likely to have a higher body mass index (BMI).[161] Evidence from the US over a 15-year period also suggested that people who use delivery apps frequently were more likely to have a poorer diet overall and a higher BMI.[162]

55.6. One study showed that adults in the UK had online access to a median of 85 food outlets and a similar number of unique types of cuisine, with 15.1% reporting online food delivery service use in the previous week. Those with the greatest number of accessible food outlets had 71% greater odds of online food delivery service use compared to those with the least. This pattern was evident amongst adults with a university degree, adults aged between 18 and 29 years, those living with children, and females.[163] However, data from Cancer Research UK shows that the use of food delivery apps is more common among those who are on lower and middle incomes, and young adults aged 25-34 years.[164] These two different findings likely simply reflect the ubiquitous use that is now made of food delivery apps.

55.7. There are a number of ways in which food delivery apps and websites are encouraging people to buy more food. These include:

55.7.1. volume promotions – offering discounts or special deals if you spend a certain amount of money

55.7.2. frequency – offers that encourage you to return within a short period of time

55.7.3. price discounts – these attract you to the app or website in the first place by offering a discount or free delivery on the first order or a limited-time promotion for new users; or offer discounts on specific foods or restaurants

55.7.4. positioning – by having a “featured” section to attract you to specific cuisines or restaurants

55.7.5. marketing – sending push notifications from apps installed on phones, emails offering deals on specific days eg 2 for £20 Tuesdays

55.7.6. personalisation – being able to adapt and customise the food being ordered so it better suits your tastes eg leaving gherkins out of a burger, adding an additional meat, or stuffed cheese crust, to a pepperoni pizza

The role of the food and drink industry in the policy making process

56.1. Policies that are implemented to improve the food people eat, and overall diets, and reduce levels of obesity in adults and children, are based on the best available evidence. This includes evidence of health issues associated with high or low intakes of certain foods, nutrients and substances from SACN; data on intakes from the NDNS; and evidence of the impact of policies from a range of sources including real world examples, academic papers and scenario modelling.

56.2. The government engages with a range of relevant stakeholders including all sectors of the food industry and their representative trade bodies in the development of relevant policies to gain technical insight and views on implementation. However, it is important to note that government retains overall decision making and leadership of the policy design and implementation.

56.3. OHID generally engages with large food industry businesses who contribute to the biggest market sales. Examples of the policies where OHID has engaged with businesses include the voluntary reformulation programme,[165] the Food Data Transparency Partnership,[166] and development of the regulations on promotions,[167] advertising and out of home calorie labelling [168] where all stakeholders including the food industry were consulted.

56.4. Through the voluntary reformulation programme, for example, when working to establish the sugar reduction programme, businesses and relevant trade associations across all sectors of industry were consulted at several points during the process. This included when considering:

56.4.1. what the percentage reduction target for the programme would be

56.4.2. which categories to include in the programme and where to set the specific, numerical guidelines for each category

56.4.3. the types of targets to set eg sales weighted or simple averages, additional maximum targets and the metrics to use to monitor progress.

56.5. Other stakeholders such as non-governmental organisations including health charities and Royal Colleges were all involved at all stages of the process. This is to ensure all views were considered when decisions were being taken by government. Discussions were held in variety of fora including bilaterals and large group meetings by category and by sector as different types and levels of information become available in different settings.

56.6. Interactions with businesses and other stakeholders have adhered to the principles set out by the WHO in “Safeguarding against possible conflicts of interest in nutrition programmes”.[169] This includes, for example, publishing online details of organisations met with and the main points raised during discussions and in consultation responses;[170] and monitoring progress by businesses.

56.7. Through these and other interactions, while providing information that is helpful to government in setting policy, businesses also have the opportunity to argue against the need for such policies. OHID is cognisant of the “playbook” used to undermine public health policies that do not align with commercial objectives, as is often the case with public health policies.[171],[172]

56.8. This highlights the need for health policy being based on robust science and evidence, such as independent advice from SACN and other sources as stated earlier in this paper for obesity policy. Policy making is outside the remit of SACN – this is the responsibility of government. SACN was established in 2000 as part of a wider government approach to separating risk assessment from risk management (policy making) following the BSE crisis and subsequent Philips enquiry. A clear conclusion from the enquiry was that expert scientific committees should be restricted to giving advice and should not be setting policy. Therefore, the development of government food and nutrition policy, while based on advice from SACN, is separate to the scientific assessment.[173] The SACN Code of Practice sets out how the committee puts into practice the guidelines governing government scientific advisory committees.[174],[175]

56.9. Policies also need to be based on sound concepts and to be implementable by those required to do so – one of the issues with current definitions and classifications of ultra processed foods is that they do not adhere to this principle.

56.10. One such policy put under scrutiny in relation to its scientific basis was the NPM, with the case brought by Kellogg’s against the use of the NPM to determine the products that could, and could not, be placed in certain locations in supermarkets through location promotions legislation. Despite the concerns raised by Kellogg’s the judge ruled that the NPM provided the necessary transparency and scientific robustness for the policy.[176]

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

The WHO works in many policy areas such as the Nutrient and Promotion Profile Model of food products for infants and young children aged 6-36 months, advertising and marketing, front of pack nutrition labelling, nutrient profile models and product reformulation. WHO now recommends the taxation of sugar sweetened beverages (SSB),[177] as part of a collection of policy measures to prevent and control NCDs and to address childhood obesity.[178] A number of countries (in addition to the UK) have introduced fiscal policies on SSB’s including Barbados, Mexico, Chile, Peru, Columbia and South Africa.[179] Some countries in Europe (including France, Belgium, Norway and Latvia), South America (including Chile), and some parts of the US and Canada (including British Colombia, San Francisco, Philadelphia and Cook County) also include non-sugar or artificial sweeteners in their SSB tax.[180],[181] Furthermore, some countries including Mexico and Hungary have implemented taxes based on the energy density of foods or foods high in saturated fat, salt or free sugars (HFSS);[182],[183] and Colombia is the first country to introduce fiscal policies stated as being based on ultra-processed food and drink products; however, the foods in scope of the tax are HFSS.[184]
A number of other measures have been implemented in other countries around the world to encourage the provision and consumption of healthier diets. In 2016 Chile implemented a suite of measures to limit the marketing of HFSS food and drink, and sales of these products in schools, and the labelling of products with a highly visible logo if they are high in salt, saturated fat and sugar.[185] The Health Star rating [186] and Nutri-Score [187] scheme are voluntary front of pack labelling measures implemented in Australia and France, respectively. Nutri-Score was based on the UK NPM and has now been implemented in many other countries in Europe. Some countries have implemented mandatory reformulation programmes, such as the legislated salt targets set in South Africa [188] and Argentina.[189]
While not all programmes and policy measures implemented internationally are monitored and evaluated, data shows that some of these have been effective. Evaluation of Chile’s food law shows that intakes of calories, sugar, salt and saturated fat fell following implementation;[190],[191],[192] and that businesses actively used the fact that products didn’t have the warning label as a positive point in marketing and advertising. A study by FAO found that of 1915 products reviewed for nutrient content before and after implementation of the law, 276 products (15 %) were reformulated and changed from being classified as being “high in”, and showed statistically significant changes. What is particularly notable is the significant reductions in sodium in cold meat categories where greater reductions are needed in the UK, and businesses have cited various technical issues with doing so.[193]
In the case of the 8% Mexican excise tax on energy dense snacks, data shows that taxed food items were substituted for cookies marketed as healthy, cereal bars and cereal boxes which were not taxed. Because of these substitutions, while the purchase and sales of taxed items decreased, overall calories and fat purchased did not. However, multiple studies from Mexico have consistently shown the largest decrease in purchase of taxed nonessential energy-dense foods was among consumers of lower socio-economic status or households who showed stronger preferences for taxed foods prior to the implementation.[194],[195],[196]
Data suggests that Argentina’s mandatory salt targets have led to reductions in salt levels in foods, with 85% of products being compliant in 2015, increasing to 90% four years later. As salt content in foods in Argentina remained quite high, some targets have now been reduced to drive greater reductions.[197],[198]
Globally, several countries now include some reference to food processing in their dietary guidelines. For example, Belgium, Brazil, Ecuador, Israel, Maldives, Peru and Uruguay specifically discourage consumption of foods subject to ‘ultra-processing’, and Brazil, Brunei Darussalam, Kenya, Malta, New Zealand explicitly recommend consumption of ‘minimally processed’ or ‘unprocessed’ foods.[199] The 2023 Nordic Nutrition Recommendations include the recommendation for ‘minimal intake of…processed foods containing high amounts of added fats, salt and sugar’.[200] However, we are not aware if this messaging has been consumer tested or of any evaluation of the impact of this messaging on dietary intakes.
OHID is leading the World Health Organization Regional Office for Europe’s (WHO EU) Sugar and Calorie Reduction Network on behalf of the UK. The aim of the network is to promote global action on this agenda through shared learning with other member states across the region. The UK Government is interested to learn from others and co-ordinate cohesive action. Collective action on sugar and calorie reduction will drive the global food industry to make food and drink healthier faster. This network was developed following the success of the European Salt Action Network, established by the UK government and WHO EU in 2007/08, in encouraging and facilitating the establishment of salt reduction programmes in new countries. This network is still running under the leadership of Switzerland, but the UK continues to participate.
Through these networks, and other international fora, OHID has established positive working relationships with a number of other countries working to improve the diets of, and reduce obesity prevalence among, their citizens. To ensure OHID can learn from the experiences of other countries OHID conducts bilateral meetings to discuss policies implemented, what has worked and what hasn’t, what they would consider doing differently next time etc. OHID is also happy to share with other countries its learnings from the policy measures it has implemented.

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

A range of evidence is used to inform government advice and policy interventions around food and diet. This includes evidence evaluated by SACN, monitoring of population intakes via the NDNS, surveillance of weight status through the NCMP and HSE, evidence on the effectiveness of international policies, academic evidence on drivers of poor diet and obesity, responses to consultations, intelligence from stakeholders, reports from other organisations and government commissioned research.
The Government recognises that the food environment has a significant influence on health. Government action is vital in shaping the environment in a way which makes it easier for people to make healthier food choices and prevent overweight and obesity. To date, Government has done this through providing consumer facing advice and information including through product and menu labelling and social marketing campaigns;[201],[202] public sector standards for the procurement, recipes used for, and selling of food and drink;[203] structured voluntary industry product reformulation programmes;[204] legislated restrictions on the foods that can be promoted and marketed;[205] application of taxes to soft drinks;[206] and healthy food schemes, such as Healthy Start,[207] the Nursery Milk Scheme [208] and the School Fruit and Vegetable Scheme,[209] which provide a nutritional safety net to those families who need it the most and encourage the establishment of healthier diets..
As well as policies focused on diet, the government also has several policies aiming to encourage physical activity. These include the PE and Sport Premium which can be used by primary schools to build capacity and capability for physical activity within their schools, and the Better Health social marketing campaign, including the Couch to 5k and Active 10 apps which continue to encourage adults to increase activity levels by promoting easy and fun ways to get active.
The Government undertakes monitoring and evaluation of its policies to establish their effectiveness and impact, and inform future policy design. Information from external modelling and evaluations and learnings from international experience is also considered. For example:

68.1. policy impact assessments which include modelling of the estimated health economic benefits [210],[211]

68.2. monitoring change in products that are subject to the Soft Drinks Industry Levy and the structured voluntary reformulation programme – which challenges businesses to reduce levels of salt, sugar and calories in everyday foods – is undertaken regularly to assess industry progress. These assessments are published on GOV.UK [212]

68.3. monitoring changes in intakes through the NDNS can provide evidence of whether policies may be affecting people’s diet [213]

68.4. Government is required to undertake a post-implementation review of the legislation restricting the promotion of products high in fat, sugar or salt by location and by volume price (eg “buy 2 products for £3”)se regulations, and the advertising restrictions on TV and online for products high in fat, salt and sugar, every 5 years, and publish a report setting out the conclusions of the review.

68.5. evaluations of policy interventions in place in other countries, including their design, impact, and relevance to the UK.

68.6. modelling conducted by academic institutions on the effectiveness of policies

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

Government advice on a healthy, balanced diet is encapsulated in the UK’s national food model, the Eatwell Guide.[214] Modelling indicates that if everyone ate in line with existing UK dietary recommendations as illustrated by the Eatwell Guide, we could increase population life expectancy by eight years.[215] We know that adherence to the Eatwell Guide has also been shown to improve both health and environmental outcomes,[216] with a diet in line with the Eatwell Guide having an appreciably lower environmental impact than the current UK diet according to analysis carried out by the Carbon Trust.[217]
In 2015, it was estimated that if the average population intakes of free sugars over 15 years reduced to 5% of daily energy intake in line with SACN recommendations, over a 25 year period it would prevent around 57,600 premature deaths and over 4m cases of dental caries, and saved the NHS around £10bn.[218]
The Soft Drinks Industry Levy (SDIL) has reduced the sugar content of drinks subject to the levy by 46% between 2015 and 2020, removing over 46,000 tonnes of sugar in retailer and manufacturer branded products. The changes in products have had equal impact across all socio-economic groups. A modelling study showed that SDIL may have prevented up to 5,000 cases of obesity in girls in the last year of primary school. Reductions were greatest (9%) in girls whose schools were in deprived areas.[219]
The most recent NDNS intake data, published in 2019, showed that sugar intakes have fallen for some age groups (children aged 1.5-3, 4-10 and 11-18 years; adults aged 19-64 years). In older children and adolescents, the percentage contribution of soft drinks to overall sugar intakes was 17%, down from 22% in the last survey, likely as a result of the changes made to drinks through SDIL.[220]
The voluntary sugar reduction programme has resulted in reductions in sugar levels in all categories covered by the programme, including a 14.9% reduction in breakfast cereals and 13.5% reduction in yogurts and fromage frais, between 2015 and 2020. Overall, there was a 3.5% reduction in sugar between 2015 and 2020, as the larger reductions achieved in some categories were negated by increased sales of higher sugar products (eg chocolate confectionery). Over the same time, levels of sugar and calories in pre-packed milk-based drinks have been reduced by 29% and 20%, respectively. This is against a sugar reduction target of 20%.[221]
The first progress report for the calorie reduction workstream showed generally little change in calorie levels across all sectors and categories between 2017 and 2021, and increased volume sales in some areas.[222] However, the data period covers some of the Covid-19 pandemic when the food supply was disrupted, and more food was purchased for consumption in the home. Retailers and manufacturers were asked to make reductions of up to 10%, and the out of home sector reductions of up to 20%, by 2024.
The Calorie Labelling (Out of Home Sector) (England) Regulations 2021 came into force on 6th April 2022 implementing mandatory calorie labelling among large food businesses (businesses with 250 or more employees) in the out of home sector. Unpublished data from OHID found that, although calorie labelling was not associated with changes in calories purchased or consumed, it was associated with improved estimation of calories purchased. 80% of outlets complied with the legislation, with the number of outlets including calorie labelling increasing from 21% in 2021. Better enforcement may improve compliance and the impact of this policy.
The locations promotions restrictions came into force in October 2022. They are expected to be the single most impactful obesity policy at reducing children’s calorie consumption, accruing health benefits of over £57 billion and providing NHS savings of over £4 billion, over the next 25 years. The department has a duty under the Regulatory Enforcement and Sanctions Act 2008 (RESA) to review the locations and volume price restrictions. It is also required to undertake a further post-implementation review of the regulations every 5 years and publish a report setting out the conclusions of the review.
Whilst the health benefits from the volume price promotion restrictions, due to come in to force in October 2025, are not expected to be as large as the location restrictions, they are not insignificant. They are expected to accrue health benefits of over £2 billion and provide NHS savings of £180 million, over a 25 year period.
The advertising restrictions are also due to come in to force in October 2025. These are expected to deliver health benefits of £2 billion, provide NHS savings of £50 million and deliver an additional £119 million of economic output, over the next 100 years. Evidence from similar advertising restrictions on the Transport for London estate suggest that the policy was associated with an estimated 1,001 kcal (6.7%) decrease in average weekly household purchases of energy from HFSS products compared with what would have happened without the policy.[223] Modelling data suggests the policy has resulted in 4.8% fewer individuals living with obesity after 3 years.[224]
Local authorities are acting to restrict the over-proliferation of hot food takeaways - particularly focusing on environments where children congregate. In 2019, 50% of local authorities had a policy restricting the over proliferation of hot food takeaways.[225] Amongst these local authorities, the most common approach was to create exclusion zones around places for children and families.[226] These policies can be very effective; an evaluation of the use of planning policy in the North East of England found a reduction in the proportion of fast food outlets by 14%, and the density of takeaway outlets available to 13 fewer outlets for every 100,000 residents.[227]

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

In 2015, Public Health England published a document that set out a number of actions that could be taken to reduce high intakes of sugar, and the evidence available at that time that supported these proposals.[228] This demonstrated that no single action alone would be sufficient to address the health issues associated with high sugar intakes; and that action is needed in all these areas – in the environment around us that influences our food choices; our food supply; and in the areas of knowledge and training, and local action.
While many of the suggested policies included in Sugar reduction: The evidence for action have now been acted on and are in the process of being implemented – including a tax on sugary drinks, a voluntary reformulation programme to reduce levels of sugar in food and drink, reducing the promotion of high sugar products in supermarkets and placing restrictions on the advertising and marketing of high sugar food and drink – there are opportunities to go further. OHID continues to explore these options for additional policy action.
Location Promotion Restrictions

82.1. The location restrictions came into force on 1 October 2022. The restrictions prohibit the placement of less healthy products in key selling locations such as checkouts, aisle ends, store entrances and their online equivalents.

82.2. The location restrictions are expected to be the single most impactful obesity policy at reducing children’s calorie intakes and account for 96% of the health benefits of the overall promotions policy.

82.3. The restrictions are expected to accrue health benefits of £57 billion and NHS savings of £4 billion, over the next 25 years.

Volume Price Promotion Restrictions

83.1. The volume price promotion restrictions will come into force on 1 October 2025. These restrictions will prohibit less healthy foods from being promoted by volume price promotions or offers, such as ‘buy-one-get-one free’ or ‘3 for 2’.

83.2. The volume price promotion restrictions are expected to accrue health benefits of £2 billion and NHS savings of £180 million, over 25 years.

Advertising restrictions

84.1. Further restrictions on advertising less healthy food will come into force on 1 October 2025. These restrictions will prohibit less healthy foods from being advertised before the 9pm TV watershed and restrict paid-for advertising of these products online, UK wide.

84.2. The advertising restrictions are expected to deliver health benefits of £2 billion and NHS savings of £50 million, over the next 100 years.

Food Data Transparency Partnership

85.1. As part of the Government’s Food Strategy, the Food Data Transparency Partnership (FDTP) is a multi-year partnership between government, industry, and civil society to improve access to, and the availability of, data for key health and sustainability objectives.

85.2. The FDTP Health Working Group (HWG) was launched in 2023 to consider health metrics for large food and drink companies that incentivise, and most effectively measure progress towards, improving the healthiness of food.[229] The FDTP will aim to build consistent reporting requirements for businesses that align with existing health initiatives and will work alongside and build off the Government’s structured and closely monitored voluntary reformulation programmes.[230] Health reporting will be voluntary; however, the HWG will also consider the impact reporting requirements will have on businesses, how this data could be publicly reported, and how to streamline existing reporting requirements.

85.3. Transparent, robust data on nutrition composition and sales volumes of food products which is comparable across food sectors (retailers, manufacturers and out of home) is an essential part of driving reformulation.[231] This data will supporting broader efforts from government, industry and elsewhere to create a level playing field between companies and drive a healthier food system.

85.4. Through the HWG, work is already underway with industry, investors and civil society to develop a mutually agreed, consistent and standardised set of recommended metrics for large food and drink companies.[232],[233],[234] Evaluations of the 2015 Public Health Responsibility Deal found that inconsistency between what different businesses were doing and how they reported their progress led to limited engagement and lack of impact.[235]

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[84] Cancer Research UK (2018) See it, Want it, Buy it, Eat it. Available here: https://www.cancerresearchuk.org/sites/default/files/see_it_want_it_buy_it_eat_it_final_report.pdf

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Inquiry theme and questions	Page Number
Summary	2
Key trends in food, diet and obesity, and the evidential base for identifying these trends	4
The primary drivers of obesity both amongst the general population and amongst distinct population and demographic groups	11
The impacts of obesity on health, including on children and adolescent health outcomes	17
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	18
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	22
How consumers can recognise UPF and HFSS foods, including the role of labelling, packaging and advertising	25
The cost and availability of a) UPF and b) HFSS foods and their impact on health outcomes	27
The role of the food and drink industry in driving food and diet trends and on the policymaking process	30
Lessons learned from international policy and practice, and from the devolved administrations, on diet-related obesity prevention.	42
The effectiveness of Government planning and policymaking processes in relation to food and drink policy and tackling obesity	46
The impact of recent policy tools and legislative measures intended to prevent obesity	48
Policy tools that could prove effective in preventing obesity in the general population, including those focussed on the role of the food and drink industry in tackling obesity	51