PROF MARIA BRYANT ET AL, PUBLIC HEALTH NUTRITION GROUP AT UNIVERSITY OF YORK - SUPPLEMENTARY WRITTEN EVIDENCE (FDO0139)

House of Lords - Select committee evidence in support of Session: 13th March 2024

Prepared by Prof Maria Bryant (speaker), Dr Kath Roberts, Dr Behnam Tajik, Dr Sundus Mahdi, Dr Dea Neilson, Rob Oxley, Patience Gansallo, Georgia Irving, Dr Giorgia Previdoli, Dr Wendy Burton and Nicola Nixon on behalf of the Public Health Nutrition group, University of York.

Q1. How does the prevalence of poor diet and obesity differ across population and demographic groups, and what are the reasons for disparities?

OBESITY PREVALENCE:

●        60% of adults / 30% of children live with overweight or obesity

●        20% of children already live with overweight or obesity when they start primary school (10% obesity)

●        25% of children have overweight or obesity when they leave aged 10-11 (NHS Digital, 2023). Figures are worse in boys (NICE, 2023) (draft for consultation)

●        UK rates are the worst in western europe (WHO, 2022)

DEPRIVATION AND OBESITY:

●        Children living in the most deprived neighbourhoods have over twice the prevalence of obesity than those in the least deprived (obesity: 30.2% vs 13.1%).

●        For severe obesity, rates are more than 4 times higher for those children being raised in our most deprived neighbourhoods (>99.6 centile).

●        The difference in childhood obesity rates between most and least deprived in the UK is larger than for any EU country (26 points compared to the EU average of 8 percentage points) (Holmes, 2021).

●        Health Survey for England- Gaps are getting bigger, especially for women.

ETHNICITY AND OBESITY: People who identify as Black have the highest obesity rates than the national average, though how this is presented depends on the way we look at the data.

In year 6 children (2022/2023) the highest rates of overweight/obesity are children of Bangladeshi, Pakistani and any Black heritage.

DISABILITIES AND OBESITY: 41% of adults classified as living with obesity are disabled compared with 22% who are not (Office for Health Improvement & Disparities, 2023).

Obesity rates are very high for adults with severe mental health disabilities living in in-patient facilities (50%).

GEOGRAPHY AND OBESITY: The highest rates of obesity are clustered around economically deprived areas of urban areas in the north, coastal towns and parts of London (highest in North East and West Midlands regions).

DIETARY INEQUALITIES

Most of the UK population, including children, adolescents and adults are not eating a healthy diet, a pattern that is more pronounced in disadvantaged areas and populations.

We have evidence from national surveys and research studies. Specific values vary depending on when and how they were collected - but all tell the same story.

NATIONAL SURVEYS

Young children 1-5 (SACN, 2023) and Years 1-9 (Public Health England, 2020).

●        Intake of salt, free sugars and saturated fat are above recommended amounts, and fibre is below recommended levels.

●        Children from lower income households are

●        less likely to consume adequate portions of fruit and vegetables

●        Less likely to consume oily fish

●        more likely to consume sugar-sweetened beverages

●        less likely to consume sufficient fibre

●        Adults consistently fail to meet recommendations, particularly in low income households

COHORT STUDY RESEARCH ALSPAC (Buckland et al., 2023)

●        Most school-aged children (7-13) did not meet UK dietary recommendations, particularly children from lower socio-economic backgrounds.

●        A lower socioeconomic status and maternal educational attainment and higher maternal BMI were associated with meeting fewer recommendations.

Born in Bradford

●        Poor diets start very early in life, with early introduction of solids and foods high in salt, sugar and fat (cakes, biscuits, potato shapes, processed meat etc. consumed at 12 months) (Sahota et al., 2016)

●        Food insecure mums and children have poor diet quality: fewer vegetables and higher sugar-sweetened drinks (Yang et al., 2018)

●        The association between food security, body weight and dietary intakes differed by ethnicity

Breastfeeding

●        UK rates of breastfeeding are lower than many European counterparts and the US (Victora et al., 2016)

●        Breastfeeding is lowest among women from the most deprived backgrounds, white women, younger mothers, and women with lower levels of education (Oakley et al., 2014)

Ultra-processed foods (UPF)

●        56.8% of total energy intake and 64.7% of total free sugars in the UK diet comes from UPFs (Rauber et al., 2019).

●        The UK has the highest UPF purchase rate in Europe at 51%, compared to only 14% by French families (Monteiro et al., 2017).

●        For illustration, if we were to remove ultra-processed foods from our diets, we could potentially reduce the prevalence of free sugar intake by 47%.

●        In the UK, adolescents have the highest percentage of their diet comprised of UPF (compared to other age groups) (Rauber et al., 2019).

●        UPF make up 73% of primary school lunch calories (Parnham, Millett and Vamos, 2023).

●        In the UK, adolescents from higher socio-economic backgrounds consume lower overall levels of UPF (62% of daily energy intake) than those from lower socio-economic backgrounds (69% of total energy intake) (Parnham, Millett and Vamos, 2023).

WHY DISPARITIES ARISE

Structural and social factors are at play: Wider determinants of health – the conditions in which we live and work and are raised as children all interact with biological influences on our appetite regulation to greatly influence the how, what and when we eat and, therefore, the type of health we can expect across our lifetime.

There are multiple overlapping and interacting factors – which are not evenly distributed. People don't experience adverse conditions or inequalities in isolation. Many people face a combination of inequalities - ethnicity, deprivation, environmental

There are intersectional inequalities - cumulative effects of experiencing multiple adversities that all add up to increasingly poor dietary quality and poor health outcomes.

Q1 REFERENCES

Buckland, Genevieve, Kate Northstone, Pauline M. Emmett, and Caroline M. Taylor. “Adherence to UK Dietary Guidelines in School-Aged Children from the Avon Longitudinal Study of Parents and Children (ALSPAC) Cohort.” The British Journal of Nutrition 130, no. 3 (August 2023): 454-64. https://doi.org/10.1017/S0007114522003336.

Conway, R., L. Heggie, Natalie Lowry, H. Hallen, G. Heuchan, and Clare Llewellyn. “Ultra-Processed Food Intake of Young Children in the UK: Findings from the Gemini Twin Cohort.” Proceedings of the Nutrition Society 82 (March 8, 2023). https://doi.org/10.1017/S0029665123000101.

De Amicis, Ramona, Sara Paola Mambrini, Marta Pellizzari, Andrea Foppiani, Simona Bertoli, Alberto Battezzati, and Alessandro Leone. “Ultra-Processed Foods and Obesity and Adiposity Parameters among Children and Adolescents: A Systematic Review.” European Journal of Nutrition 61, no. 5 (2022): 2297-2311. https://doi.org/10.1007/s00394-022-02873-4.

Emerson, Eric, and Janet Robertson. “Obesity in Young Children with Intellectual Disabilities or Borderline Intellectual Functioning.” International Journal of Pediatric Obesity: IJPO: An Official Journal of the International Association for the Study of Obesity 5, no. 4 (August 2010): 320-26. https://doi.org/10.3109/17477160903473713.

Holmes, Jonathon. “Tackling Obesity: The Role of the NHS in a Whole-System Approach,” July 2021. https://assets.kingsfund.org.uk/f/256914/x/cead3911f6/tackling_obesity_role_nhs_who le_system_approach_2021.pdf.

Monteiro, Carlos Augusto, Jean-Claude Moubarac, Renata Bertazzi Levy, Daniela Silva Canella, Maria Laura da Costa Louzada, and Geoffrey Cannon. “Household Availability of Ultra-Processed Foods and Obesity in Nineteen European Countries.” Public Health Nutrition 21, no. 1 (July 2017): 18-26. https://doi.org/10.1017/S1368980017001379.

NHS Digital. “National Child Measurement Programme (2022/23 School Year),” October 19, 2023.

https://digital.nhs.uk/data-and-information/publications/statistical/national-child-meas    urement-programme/2022-23-school-year.

NICE. “Health Inequalities Briefing: Obesity and Weight Management: A Briefing for NICE Guideline Developers and Committee Members (Draft).” National Institute for Health and Care Excellence, February 2023.

Oakley, Laura L., Jennifer J. Kurinczuk, Mary J. Renfrew, and Maria A. Quigley. “Breastfeeding in England: Time Trends 2005-2006 to 2012-2013 and Inequalities by Area Profile.” Maternal & Child Nutrition 12, no. 3 (November 2014): 440-50. https://doi.org/10.1111/mcn.12159.

Office for Health Improvement & Disparities. “Obesity Profile - OHID,” 2023. https://fingertips.phe.org.uk/profile/national-child-measurement-programme.

Parnham, Jennie C., Christopher Millett, and Eszter P. Vamos. “School Meals in the UK: Ultra-Processed, Unequal and Inadequate.” Public Health Nutrition 26, no. 1 (January 2023): 297-99. https://doi.org/10.1017/S1368980022002336.

Public Health England. “National Diet and Nutrition Survey: Rolling Programme Years 9 to 11 (2016/2017 to 2018/2019),” December 2020. https://assets.publishing.service.gov.uk/media/5fd23324e90e07662b09d91a/NDNS_U K_Y9-11_report.pdf.

Public Health England. “Obesity in Mental Health Secure Units.” GOV.UK, February 2017.

https://www.gov.uk/government/publications/obesity-in-mental-health-secure-units.

Rauber, Fernanda, Maria Laura da Costa Louzada, Euridice Martinez Steele, Leandro F.

M. de Rezende, Christopher Millett, Carlos A. Monteiro, and Renata B. Levy. “Ultra-Processed Foods and Excessive Free Sugar Intake in the UK: A Nationally

Representative Cross-Sectional Study.” BMJ Open 9, no. 10 (October 28, 2019): 1-10. https://doi.org/10.1136/bmjopen-2018-027546.

SACN. “Summary of Draft Report: Feeding Young Children Aged 1 to 5 Years.” GOV.UK, July 2023.

https://www.gov.uk/government/consultations/feeding-young-children-aged-1-to-5-y ears-draft-sacn-report/summary-of-draft-report-feeding-young-children-aged-1-to-5

-years.

Sahota, Pinki, Lisa A. Gatenby, Darren C. Greenwood, Maria Bryant, Sian Robinson, and John Wright. “Ethnic Differences in Dietary Intake at Age 12 and 18 Months: The Born in Bradford 1000 Study.” Public Health Nutrition 19, no. 1 (January 2016): 114-22. https://doi.org/10.1017/S1368980015000932.

Victora, Cesar G., Rajiv Bahl, Aluísio J. D. Barros, Giovanny V. A. França, Susan Horton, Julia Krasevec, Simon Murch, et al. “Breastfeeding in the 21st Century: Epidemiology, Mechanisms, and Lifelong Effect.” Lancet (London, England) 387, no. 10017 (January 2016): 475-88. https://doi.org/10.1016/S0140-6736(15)01024-7.

WHO. “World Health Organization European Regional Obesity Report (2022),” May 2, 2022. https://www.who.int/europe/publications/i/item/9789289057738.

Yang, T. C., P. Sahota, K. E. Pickett, and M. Bryant. “Association of Food Security Status with Overweight and Dietary Intake: Exploration of White British and Pakistani-Origin Families in the Born in Bradford Cohort.” Nutrition Journal 17, no. 1 (April 2018): 1-10. https://doi.org/10.1186/s12937-018-0349-7.

Yau, Amy, Jean Adams, Emma J. Boyland, Thomas Burgoine, Laura Cornelsen, Frank de Vocht, Matt Egan, et al. “Sociodemographic Differences in Self-Reported Exposure to High Fat, Salt and Sugar Food and Drink Advertising: A Cross-Sectional Analysis of 2019 UK Panel Data.” BMJ Open 11, no. 4 (April 1, 2021): 1-11. https://doi.org/10.1136/bmjopen-2020-048139.

Q2. What is the relationship between food insecurity, poor diet and obesity? DEFINITION Food insecurity - not having access to safe, nutritious food.

Hunger is a key part of food insecurity, but many people experiencing food insecurity lack access to foods with vital nutrients for health. It is often as much about what foods are NOT eaten as what ARE eaten - this is why it links to diet related disease.

PREVALENCE Food insecurity is not a marginalised issue - a quarter of the population (depends on data source)

EVIDENCE of relationship with diet and obesity

-Systematic review evidence from Teesside University- global evidence -36,113 adults and children (Eskandari et al., 2022)

●       Obesogenic food environments and food insecurity significantly contribute to obesity.

●       People with food insecurity were 50% more likely to be affected by obesity (OR 1.5)

●       There is a relationship between food insecurity, poor diet quality, (incl. lack of access to fruits and veg), reliance on fast foods and food insecurity

●       Qualitative evidence from 19 studies in this review demonstrate a reliance on energy-dense, nutrient-poor foods due to their affordability, accessibility, and purchase of foods with extended shelf life

●       Cost was a barrier to purchasing fresh fruit

-This is consistent with other data/reports (e.g. Diet Related Health inequalities - [UK Parliament Post, 2022]):

●       Over half (58%) of food insecure households reported buying fewer fruits and vegetables between Sept-Oct 2022

-FIO Foods: Food Insecurity in people living with obesity (Johnstone et al., 2022): Aiming to co-design of supermarket-based interventions that support people living with obesity and food insecurity to acquire healthy and sustainable food

Recently surveyed approx 600 adults living with obesity

●       Higher food insecurity was associated with greater use of budgeting, supermarket offers, energy-saving appliances, and cooking resourcefully

●       Budgeting - linked to poorer food quality

Q2. REFERENCES

Eskandari, Fatemeh, Amelia A. Lake, Kelly Rose, Mark Butler, and Claire O’Malley. “A Mixed-Method Systematic Review and Meta-Analysis of the Influences of Food Environments and Food Insecurity on Obesity in High-Income Countries.” Food Science & Nutrition 10, no. 11 (November 2022): 3689-3723. https://doi.org/10.1002/fsn3.2969.

Johnstone, Alexandra, Charlotte Hardman, Adrian Brown, Flora Douglas, Michelle Morris, Mark Gilthorpe, Mark Green, Paul Gately, Claire Griffiths, and Nilani Siratharan. “Food Insecurity in People Living with Obesity (FIO Food),” November 2022. https://www.abdn.ac.uk/rowett/research/fio-food/index.php#panel1744.

UK Parliament Post. “Diet-Related Health Inequalities,” December 2022. https://researchbriefings.files.parliament.uk/documents/POST-PN-0686/POST-PN-06 86.pdf.

Q3.How do inequalities in diet and obesity affect health outcomes? What role does the food environment play in these inequalities?

HIGHER PREVALENCE OF OBESITY IN SOME POPULATIONS PUTS THEM AT GREATER RISK OF MANY SERIOUS HEALTH OUTCOMES (16 Billion / year cost to NHS;

far greater social economical impact):

●       Type-2 diabetes, cardiovascular disease (CVD), liver disease, some cancers, musculoskeletal conditions, and poor mental health

●       Adverse pregnancy and fertility outcomes, - gestational hypertension , gestational diabetes, infertility, and miscarriage (Seif, Diamond and Nickkho-Amiry, 2015)

●       8 times more at risk of Gestational diabetes - 23% compared to 3.4% - Meta Analysis 2021 -European 133 papers (n=15.5M) (Paulo et al., 2021)

●       Higher proportion of maternal deaths, especially women from Black family backgrounds (fourfold difference compared with women from White family backgrounds (NICE, 2023))

●       Maternal obesity is associated with a 264% increase in childhood obesity in offspring (Heslehurst et al., 2019)

●       Lower life expectancy: From age 40 years, life expectancy is 4.2 years shorter in men with obesity and 3.5 years shorter in women (Bhaskaran et al., 2018). This is worse in those with learning disabilities, who die 16 years earlier (Raleigh, 2022)

HEALTH INEQUALITIES MEAN THAT: People living in England's MOST DEPRIVED AREAS are:

●       almost 4 times more likely to die prematurely of CVD than those in the least deprived areas (OHID, 2022).

●       30% more likely to have high blood pressure, the biggest single modifiable risk factor for heart attack and stroke (OHID, 2022).

●       24% of people with Type 2 diabetes in England come from the most deprived areas, compared to 15% from the least deprived (UKHSA, 2019).

POOR HEALTH STARTS IN CHILDHOOD: Obesity is no longer an issue solely because of its persistence into adulthood.

Meta-analysis of global data showed increased risk of liver disease and diabetes indicators (Sharma et al., 2017). Our NHS data shows a worrying increasing prevalence of type II diabetes in children - something that was unheard of 10 years ago.

ALSPAC DATA: Obesogenic dietary patterns in childhood (7-10 years) are related to increased arterial stiffness, while Mediterranean-style and anti-inflammatory diets are related to decreased arterial stiffness in adolescence (Buckland et al., 2024).

Mental health concerns - Food insecurity and free school meal eligibility is negatively associated with self-esteem, academic performance and future earnings potential in children.

>3,300 DAILY OBESITY RELATED HOSPITAL ADMISSIONS in 2022-23. Twenty three

were under 16s, a 323% increase in 10 years (NHS Digital, 2023).

ENVIRONMENTAL CONTRIBUTION

The environment Interacts with many other factors - including our drive to eat AND, for many, the biological drivers that impact appetite regulation (Agurs-Collins et al., 2024).

The neighbourhood-built environment, including the nutrition environment contributes to CVD risk through its impact on diet quality and obesity risk (Kris‐Etherton et al., 2020).

Areas of high deprivation have:

Relatively affordable, high availability of less healthy food and drink products.

More fast-food outlets - up to 5x as many unhealthy food outlets as those that are less deprived (Public Health England, 2017).

Disproportionate exposure to unhealthy food advertising (Boyland et al., 2022)

We have too many unhealthy places:

Unhealthy food is promoted in almost all of our settings… our workplaces, our schools, our leisure centres and our highstreets

●       Schools are faced with multiple challenges, particularly related to cost, that mean that they are often unable to prioritise food and our secondary schools still have vending machines.

●       Fast food outlets still surround our schools and places of work

●       Systematic review evidence shows positive correlations between ethnicity, obesity and fast food presence (mostly USA data [Matsuzaki et al., 2020]).

●       Adolescents attending schools near fast food outlets are more likely to skip lunch and buy a more affordable and preferred meal at neighbouring takeaways (Caraher, Lloyd and Madelin, 2014).

●       In a survey of 2,500 children in the London Borough of Brent, students from schools with no nearby takeaways were less likely to visit a hot food takeaway than students from schools with nearby takeaways (43% vs 62%) (London Borough of Brent, 2014).

Healthy food costs more

●       Weekly food basket gone up by 25% since 2022 (The Food Foundation, 2023)

●       Healthy food twice as expensive per calorie (The Food Foundation, 2022b)

●       Servings of healthy food are also more expensive (Rao et al., 2013)

●       To follow Government’s guidelines on healthy eating:

-          The poorest 20% of UK households would spend 50% of disposable income on food

-          The most well off 20% would need to spend 11% of their disposable income

(Public Health England, 2018; Scott, Sutherland and Taylor, 2018)

Q3 REFERENCES

Adab, Peymane, Timothy Barrett, Raj Bhopal, Janet E. Cade, Alastair Canaway, Kar Keung Cheng, Joanne Clarke, et al. “The West Midlands ActiVe Lifestyle and Healthy Eating in School Children (WAVES) Study: A Cluster Randomised Controlled Trial Testing the Clinical Effectiveness and Cost-Effectiveness of a Multifaceted Obesity Prevention Intervention Programme Targeted at Children Aged 6-7 Years.” Health Technology Assessment 22, no. 8 (February 2018): 1-608. https://doi.org/10.3310/hta22080.

Agurs-Collins, Tanya, Jennifer Alvidrez, Sanae ElShourbagy Ferreira, Mary Evans, Kimberlea Gibbs, Bramaramba Kowtha, Charlotte Pratt, Jill Reedy, Marissa Shams-White, and Alison GM Brown. “Perspective: Nutrition Health Disparities

Framework: A Model to Advance Health Equity.” Advances in Nutrition 0, no. 0 (March 2024): 1-9. https://doi.org/10.1016/j.advnut.2024.100194.

Atanasova, Petya, Dian Kusuma, Elisa Pineda, Gary Frost, Franco Sassi, and Marisa Miraldo. “The Impact of the Consumer and Neighbourhood Food Environment on Dietary Intake and Obesity-Related Outcomes: A Systematic Review of Causal Impact Studies.” Social Science & Medicine 299 (April 1, 2022): 1-13. https://doi.org/10.1016/j.socscimed.2022.114879.

Bhaskaran, Krishnan, Isabel dos-Santos-Silva, David A Leon, Ian J Douglas, and Liam Smeeth. “Association of BMI with Overall and Cause-Specific Mortality: A

Population-Based Cohort Study of 3·6 Million Adults in the UK.” The Lancet Diabetes & Endocrinology 6, no. 12 (December 2018): 944-53.

https://doi.org/10.1016/S2213-8587(18)30288-2.

Brennan, Sarah F., Fiona Lavelle, Sarah E. Moore, Moira Dean, Michelle C. McKinley, Patrick McCole, Ruth F. Hunter, et al. “Food Environment Intervention Improves Food Knowledge, Wellbeing and Dietary Habits in Primary School Children: Project Daire, a Randomised-Controlled, Factorial Design Cluster Trial.” International Journal of Behavioral Nutrition and Physical Activity 18, no. 1 (February 4, 2021): 1-17. https://doi.org/10.1186/s12966-021-01086-y.

Buckland, Genevieve, Kate Northstone, Pauline M. Emmett, and Caroline M. Taylor. “Associations of Childhood Diet Quality Scores with Arterial Stiffness and Carotid Artery Intima-Media Thickness in Adolescence/Early Adulthood: Findings from the ALSPAC Cohort.” The British Journal of Nutrition 131, no. 4 (February 2024): 720-35. https://doi.org/10.1017/S0007114523002763.

Caraher, M., S. Lloyd, and T. Madelin. “The ‘School Foodshed’: Schools and Fast-Food Outlets in a London Borough.” British Food Journal 116, no. 3 (January 2014): 472-93. https://doi.org/10.1108/BFJ-02-2012-0042.

Chang, Kiara, Neha Khandpur, Daniela Neri, Mathilde Touvier, Inge Huybrechts, Christopher Millett, and Eszter P. Vamos. “Association Between Childhood Consumption of Ultraprocessed Food and Adiposity Trajectories in the Avon Longitudinal Study of Parents and Children Birth Cohort.” JAMA Pediatrics 175, no. 9 (September 2021): e211573. https://doi.org/10.1001/jamapediatrics.2021.1573.

Conolly, Anne, and Byron Davies. “Health Survey for England 2017 Adult and Child Overweight and Obesity,” December 4, 2018. http://healthsurvey.hscic.gov.uk/media/78619/HSE17-Adult-Child-BMI-rep.pdf.

Guy’s and St Thomas’ Charity. “Serving up Children’s Health: Opportunities and Barriers in the School Food System to Prioritise Nutritious Food for Our Young People,” October 2020.

https://urbanhealth.org.uk/wp-content/uploads/2020/12/Serving-up-childrens-health. pdf.

Healthcare Quality Improvement Partnership. “National Maternity and Perinatal Audit – NHS Maternity Care for Women with a Body Mass Index (BMI) of 30 or Above,” May 2021.

https://www.hqip.org.uk/resource/nmpa-maternity-care-women-bmi-30-plus/#.Y1cex 3bMI2w.

Heslehurst, Nicola, Rute Vieira, Zainab Akhter, Hayley Bailey, Emma Slack, Lem Ngongalah, Augustina Pemu, and Judith Rankin. “The Association between Maternal Body Mass Index and Child Obesity: A Systematic Review and Meta-Analysis.” PLOS Medicine 16, no. 6 (June 2019): 7. https://doi.org/10.1371/journal.pmed.1002817.

Kris‐Etherton, Penny M., Kristina S. Petersen, Gladys Velarde, Neal D. Barnard, Michael Miller, Emilio Ros, James H. O’Keefe, et al. “Barriers, Opportunities, and Challenges in Addressing Disparities in Diet‐Related Cardiovascular Disease in the United States.” Journal of the American Heart Association: Cardiovascular and Cerebrovascular Disease 9, no. 7 (March 2020): 1-13. https://doi.org/10.1161/JAHA.119.014433.

London Borough of Brent. “Takeaway Use among Brent’s School Students,” June 2014. https://legacy.brent.gov.uk/media/16403699/d26-takeaway-use-brent-school-student    s.pdf.

Matsuzaki, Mika, Brisa N. Sánchez, Maria Elena Acosta, Jillian Botkin, and Emma V. Sanchez-Vaznaugh. “Food Environment near Schools and Body Weight — a Systematic Review of Associations by Race/Ethnicity, Gender, Grade, and Socioeconomic Factors.” Obesity Reviews : An Official Journal of the International Association for the Study of Obesity 21, no. 4 (April 2020): 2-10. https://doi.org/10.1111/obr.12997.

NHS Digital. “Statistics on Public Health.” NHS England Digital, 2023. https://digital.nhs.uk/data-and-information/publications/statistical/statistics-on-public

-health/2023.

NICE. “Health Inequalities Briefing: Obesity and Weight Management: A Briefing for NICE Guideline Developers and Committee Members (Draft).” National Institute for Health and Care Excellence, February 2023.

OHID. “Analysis of 2020 CVD Mortality Data,” 2022. https://fingertips.phe.org.uk/.

Paulo, Marília Silva, Noor Motea Abdo, Rita Bettencourt-Silva, and Rami H. Al-Rifai. “Gestational Diabetes Mellitus in Europe: A Systematic Review and Meta-Analysis of Prevalence Studies.” Frontiers in Endocrinology 12 (December 2021): 1-14. https://doi.org/10.3389/fendo.2021.691033.

Pineda, Elisa, Josefina Bascunan, and Franco Sassi. “Improving the School Food Environment for the Prevention of Childhood Obesity: What Works and What Doesn’t.” Obesity Reviews 22, no. 2 (2021): 1-24. https://doi.org/10.1111/obr.13176.

Public Health England. “Obesity and the Environment,” December 2017. https://assets.publishing.service.gov.uk/media/5ba11e77ed915d2bb50f9eb0/Fast_Foo d_map.pdf.

Public Health England. “Promoting Healthy Weight in Children, Young People and Families: A Resource to Support Local Authorities,” 2018. https://assets.publishing.service.gov.uk/media/5bcf0ab540f0b644210d72f9/promotin  g_healthy_weight_in_children_young_people_and_families_resource.pdf.

Raleigh, Veena. “What Is Happening To Life Expectancy In England?” The King’s Fund, August 2022.

https://www.kingsfund.org.uk/insight-and-analysis/long-reads/whats-happening-life-e    xpectancy-england.

Rao, Mayuree, Ashkan Afshin, Gitanjali Singh, and Dariush Mozaffarian. “Do Healthier Foods and Diet Patterns Cost More than Less Healthy Options? A Systematic Review and Meta-Analysis.” BMJ Open 3, no. 12 (December 2013): 1-15. https://doi.org/10.1136/bmjopen-2013-004277.

Roberts, Katie. “How We Estimated When Obesity Might Catch Smoking as the Top Cause of Cancer.” Cancer Research UK - Cancer News, September 23, 2018. https://news.cancerresearchuk.org/2018/09/24/how-we-estimated-when-obesity-mig  ht-catch-smoking-as-the-top-cause-of-cancer/.

Rogers, Nina T., Steven Cummins, Hannah Forde, Catrin P. Jones, Oliver Mytton, Harry Rutter, Stephen J. Sharp, Dolly Theis, Martin White, and Jean Adams. “Associations between Trajectories of Obesity Prevalence in English Primary School Children and the UK Soft Drinks Industry Levy: An Interrupted Time Series Analysis of Surveillance Data.” PLOS Medicine 20, no. 1 (January 26, 2023): 1-14. https://doi.org/10.1371/journal.pmed.1004160.

Scott, Courtney, Jennifer Sutherland, and Anna Taylor. “Affordability of the UK’s Eatwell Guide,” September 2018.

https://foodfoundation.org.uk/sites/default/files/2021-10/Affordability-of-the-Eatwell- Guide_Final_Web-Version.pdf.

Seif, Mourad W., Kathryn Diamond, and Mahshid Nickkho-Amiry. “Obesity and Menstrual Disorders.” Best Practice & Research Clinical Obstetrics & Gynaecology, Obesity in Gynaecology, 29, no. 4 (May 2015): 516-27. https://doi.org/10.1016/j.bpobgyn.2014.10.010.

The Food Foundation. “Food Prices Tracker: April 2023 | Food Foundation,” April 2023. https://foodfoundation.org.uk/news/food-prices-tracker-april-2023.

The Food Foundation. “The Broken Plate 2022,” July 2022. https://foodfoundation.org.uk/sites/default/files/2023-01/FF_Broken_Plate_Report%20 2022_DIGITAL_UPDATED_2023.pdf.

UKHSA. “Health Matters: Ambitions to Tackle Persisting Inequalities in Cardiovascular Disease – UK Health Security Agency,” March 2019. https://ukhsa.blog.gov.uk/2019/03/04/health-matters-ambitions-to-tackle-persisting-i  nequalities-in-cardiovascular-disease/.

Q4 What are the main drivers of food poverty and inequalities in diet?

FOOD POVERTY IS NOT A MARGINALISED ISSUE. Food insecurity impacts 20-25% of the population depending on data (Food Standards Agency, 2024)

Free School Meal eligibility increased from 15% in 2019 to 24% in 2023 (GOV.UK, 2023)

Families must be in receipt of welfare and must have an annual household income of less than £4,700 to be eligible for free school meals.

There are 2472 Food banks and other CFAs in the UK - more than the total number of Sainsbury’s, Morrisons and Asda put together (Doherty and Hadley, 2023).

MOST VULNERABLE: One particularly affected population is families (especially those with young children - (The Food Foundation, 2022). Food insecurity is also high in single parent households, people with disabilities and people without stable homes

Food insecurity affects working people too, many of whom don't meet eligibility criteria for means tested benefits, including Free School Meals. Even people who work

full-time on the National Living Wage cannot necessarily achieve the Minimum Income Standard (Yau et al., 2020).

Food insecurity is worse in some geographical areas - including poorer urban areas and some rural, coastal areas.

A higher proportion of available budget is spent on food in the most deprived. The poorest fifth of UK households would need to spend 50% of their disposable income on food to follow the Government recommended healthy diet, compared to 10% for the richest fifth.

Food insecurity disproportionately affects households on Universal credit: In a January 2024 survey, almost half of households in receipt of Universal credit reported

experience food insecurity (45.4% compared to 11.7% among non recipients - [The Food Foundation, 2024a]).

MAIN DRIVERS OF FOOD INSECURITY:

●       Food insecurity is linked to wider economical factors: Poverty, low income, unemployment, falling wages, income variability/unpredictability

●       There has been an unprecedented rise in food insecurity since the cost of living crisis, and Ukraine war

●       Rates of inflation have been highest with food, especially healthy foods, which are twice as expensive than unhealthy foods (The Food Foundation, 2024b)

●       Eligibility criteria for welfare support, including Free School Meals are too stringent and not aligned with actual needs

●       Food choices are influenced by unhealthy food environments, which are worse in areas of deprivation (more fast-food outlets, cheaper, energy dense, easy to access and highly marketed)

●       Access and affordability of healthy options is low in more deprived areas (Eskandari et al., 2022). Nanny state arguments miss the point. People living in areas of high deprivation don't have a choice. They can't choose healthy food within their budgets

MECHANISM LINKING FOOD INSECURITY AND OBESITY - There are a number of

different hypotheses to help explain this relationship and these have been nicely described in a recent PhD thesis by Dr Zoe Bell at Newcastle University:

●       Meeting energy needs at a lower cost - compromise food choice and linked to environment = Energy density framework

●       Overeating to compensating/preparing for when money will be short = Cyclical framework - based on variation in income over a week or month

●       Physiological adaptation to increase fat storage when food is scarce

●       Chronic stress caused by food insecurity increasing drive to eat

●       Programming during pregnancy - malnutrition in pregnancy linked to low birth weight is associated with increased risk of childhood obesity - and rapid excess weight gain

Q4 REFERENCES

Eskandari, Fatemeh, Amelia A. Lake, Kelly Rose, Mark Butler, and Claire O’Malley. “A Mixed‐method Systematic Review and Meta‐analysis of the Influences of Food Environments and Food Insecurity on Obesity in High‐income Countries.” Food Science & Nutrition 10, no. 11 (August 2022): 3689-3723. https://doi.org/10.1002/fsn3.2969.

Doherty B & Hadley P. New approach needed to feed regions children. Yorkshire Post. 21st June. 2023

Food Standards Agency. “Food and You | Food Standards Agency,” 2024. https://www.food.gov.uk/research/food-and-you.

GOV.UK. “Schools, Pupils and Their Characteristics, Academic Year 2022/23,” June 2023.

https://explore-education-statistics.service.gov.uk/find-statistics/school-pupils-and-t heir-characteristics.

The Food Foundation. “Families Cutting Back on Healthy Food Risks Widening Health Inequalities | Food Foundation,” February 2024a. https://foodfoundation.org.uk/news/families-cutting-back-healthy-food-risks-widenin  g-health-inequalities#:~:text=Healthy%20food%20is%20simply%20not%20affordable

%20for%20many%20families&text=With%20healthy%20food%20on%20average,stretc h%20budgets%20to%20the%20limit.

The Food Foundation. “Food Insecurity Tracking | Food Foundation,” 2024b. https://foodfoundation.org.uk/initiatives/food-insecurity-tracking.

The Food Foundation. “New Data Show 4 Million Children in Households Affected by Food Insecurity | Food Foundation,” 2022. https://foodfoundation.org.uk/publication/new-data-show-4-million-children-househol  ds-affected-food-insecurity.

Yau, Amy, Martin White, David Hammond, Christine White, and Jean Adams.

“Socio-Demographic Characteristics, Diet and Health among Food Insecure UK Adults: Cross-Sectional Analysis of the International Food Policy Study.” Public Health Nutrition 23, no. 14 (October 2020): 2602-12. https://doi.org/10.1017/S1368980020000087.

Q5. How effective are current local and national approaches to reducing inequalities in diet and obesity and preventing associated health outcomes?

Focusing only on individual behaviour change is unlikely to be successful at reducing inequalities. Systematic, strategic change is required to address the complex economic, social and commercial factors that make healthy eating harder.

However, in evidence of behaviour change interventions: multicomponent interventions (diet and physical activity) are more effective than those that focus on single behaviours (Brown et al., 2019).

Modelling of these smaller effects indicates cost savings, but LONG TERM DATA ARE NEEDED.

We have less evidence that individual behaviour change interventions reduce inequalities (all evidence points towards the most wealthy benefiting the most). Modelling methods for longer-term forecasts are also uncertain (Dötsch-Klerk et al., 2023).

Population based interventions that tackle the wider determinants indicate the strongest impact is on populations of lowest deprivation - who face the great environmental issues.

Systematic review of socioeconomic inequalities in the impact of interventions that promote healthy eating (McGill et al., 2015).

●       Interventions that reduce inequalities most were those focused on “Price” (especially those those combined taxes and subsidies)

●       These were more effective in groups with lower SES (10 of 18 studies)

●       Four of six “Place/Environment” interventions were likely to reduce inequalities

●       Interventions that widened inequalities: “Person” interventions (e.g. dietary counselling) were more effective in higher SES groups (8 of 18 studies)

Umbrella review undertaken to explore if food environment policies reduced inequalities (including taxation) (Løvhaug et al., 2022) - Norway

●       Explored policies on: food composition, food labelling, food promotion, food provision, food retail and food pricing.

●       Results - food taxation may reduce inequalities, but the evidence base was poor for all other policies.

Sugary Drinks Industry Levy

●       Tiered levy on sugary drinks to encourage reformulation. Announced 2016. Launched 2018

●       Reduced sugar in drinks, some reduction in sugar intake, improved rates of admission to hospital for dental caries (especially most deprived), especially very young; and obesity in Year 6 girls (Rogers et al., 2023)

Ban on Junk Food Advertisements

Consistent benefits based on studies for Transport for London, restricting TV advertising etc. For example:

Review of reviews (Coleman et al., 2022) - children’s TV and online advertisement restrictions

●       Statutory regulation is potentially cost-effective (resulting in healthcare savings outweighing implementation costs) according

●       Voluntary restrictions are not effective based on before/after studies.

Transport for London ban (Natural experiment), on junk food advertising (Yau et al., 2022)

●       Average weekly household purchases of energy were 7% lower than predicted without the ban. Reductions were seen in fat, saturated fat, and sugar content. The largest reductions were seen for energy content from chocolate and sweets

●       94,867 (4.8%) fewer individuals with obesity, a reduction in incidence of diabetes by 2857 cases, and cardiovascular disease by 1,915 within three years

●       16,394 additional quality adjusted life-years and saving £218m in NHS and social care costs over the lifetime - with the most deprived seeing greatest benefits (37% higher gain in QALYs, and additional £1m in NHS and PSS cost savings per 100,000, than those least deprived (Thomas et al., 2022).

Modelled potential health impact of restricting less-healthy food and drink advertising on UK television between (Mytton et al., 2020).

●       With 1.5 fewer HFSS adverts seen by children per day = 9kcal decrease per day; 3.6- 4.6% reduction in obesity in some children; 40,000 fewer cases of obesity

Restrictions to Fast Food outlets near schools

50% of local authorities in England use planning guidance to restrict new fast-food outlets, though few have been evaluated.

Local planning policies can reduce the number of fast food outlets. Brown et al. (2022) compared Gateshead (area in the North East that implemented 3 new planning policies) with another similar area in the North East that did not implement planning guidance.

13.9% reduction in proportion of fast-food outlets in Gateshead compared to comparator local authority.

NB: Early evidence - need more longer time studies.

Nutritional labelling

Recent study = reduction in obesity, reduction in CVD (Colombet et al., 2024) - but greatest effects when labelling policy included all out-of-home food businesses - not just the current policy of those with >250 employees.

Systematic review and meta-analysis (Croker et al., 2020) - UCL - Significant decrease in sugar and salt content of purchases with traffic lights labelling.

Another study in the UK (Fichera and von Hinke, 2020) - explored impact of nutrition labelling in-store bought products (brought in by the UK Food Standards Agency in 2006).

Labelling increased quantity and nutritional quality of purchases of store-brand foods. Monthly calories reduced by 588 kcal, saturated fats by 14 g, sugars by 7 g, and sodium by 0.8 mg.

The effect was larger for lower social class households.

School interventions

Very important environment - 30% intake in children - but under pressure AND funding constraints = Food not prioritised.

The UK lacks consistent policies regarding school food environments, leading to variability in food environment quality and dietary intake (Lalli et al., 2024).

The school food offer is based on affordability and (in some cases) profit. There are still vending machines in secondary schools.

A ‘whole school approach to food’ has been advocated by the WHO and in the UK Levelling Up White paper - creating a culture of healthy eating; supportive food environments, consistent messages and policies, stakeholder engagement. However, this is not well implemented or monitored. Head teachers tell us that they will only do it if it is mandated (FixOurFood, 2024).

We understand school food systems (Bryant et al., 2023) and have developed free resources for schools to develop policies (CONNECTS-Food, 2022). We worked with DfE but this has yet to be integrated into policy.

Multi-component interventions could reduce BMI in children. Southampton research highlights the importance of engaging with key stakeholders (Jacob et al., 2021).

Why provide universal free school meals:

●       Essential, -and often ONLY- hot meal for many children.

●       Universal provision - level playing field AND reduces stigma.

●       School meals are better quality than packed lunches (Evans et al., 2020).

●       Modelling suggests that, for every £1 invested, there would be up to £1.71 return on investment (Impact on Urban Health, 2022).

Reduce low eligibility for means tested FSM- means that many families with food insecurity are missing out (Yang et al., 2022).

Centralise automated systems to register FSM -

250,000 children (11%) are missing out every day and schools miss out on funding because free school meals are only awarded to parents/carers who submit an application. Through FixOurFood and Bremner&Co, we are supporting local authorities to implement auto-award approaches. Early evidence shows that this is identifying thousands of additional children who were entitled by not being registered; also bringing in millions of pounds of funding to schools (via pupil premium).

Breastfeeding interventions

●       dose-response effect in breastfeeding, with the greatest protective effect against obesity for children who are breastfed for longer (Qiao et al., 2020).

●       The Lancet’s series on breastfeeding last year provides insights into areas of intervention AND argued that the formula industry exploits parental concerns and uses unfounded product claims in advertising, in violation of the International Code for Marketing of Breast-milk substitutes (Pérez-Escamilla et al., 2023).

Q5 REFERENCES

Brown, Heather, Huasheng Xiang, Viviana Albani, Louis Goffe, Nasima Akhter, Amelia Lake, Stewart Sorrell, Emma Gibson, and John Wildman. “No New Fast-Food Outlets Allowed! Evaluating the Effect of Planning Policy on the Local Food Environment in the North East of England.” Social Science & Medicine (1982) 306 (August 2022): 1-7. https://doi.org/10.1016/j.socscimed.2022.115126.

Brown, Tamara, Theresa Hm Moore, Lee Hooper, Yang Gao, Amir Zayegh, Sharea Ijaz, Martha Elwenspoek, et al. “Interventions for Preventing Obesity in Children.” The Cochrane Database of Systematic Reviews 7, no. 7 (July 23, 2019). https://doi.org/10.1002/14651858.CD001871.pub4.

Bryant, Maria, Wendy Burton, Niamh O’Kane, Jayne V. Woodside, Sara Ahern, Phillip Garnett, Suzanne Spence, et al. “Understanding School Food Systems to Support the Development and Implementation of Food Based Policies and Interventions.” International Journal of Behavioral Nutrition and Physical Activity 20, no. 1 (March 13, 2023): 1-11. https://doi.org/10.1186/s12966-023-01432-2.

Coleman, Paul C., Petra Hanson, Thijs van Rens, and Oyinlola Oyebode. “A Rapid Review of the Evidence for Children’s TV and Online Advertisement Restrictions to Fight Obesity.” Preventive Medicine Reports 26 (April 1, 2022): 1-6. https://doi.org/10.1016/j.pmedr.2022.101717.

Colombet, Zoé, Eric Robinson, Chris Kypridemos, Andrew Jones, and Martin O’Flaherty. “Effect of Calorie Labelling in the Out-of-Home Food Sector on Adult Obesity Prevalence, Cardiovascular Mortality, and Social Inequalities in England: A Modelling Study.” The Lancet Public Health 9, no. 3 (March 1, 2024): e178-85. https://doi.org/10.1016/S2468-2667(23)00326-2.

CONNECTS-Food. “School Food Policy | Connects-Food.” Connects Food, 2022. https://www.connects-food.com.

Croker, H., J. Packer, Simon J. Russell, C. Stansfield, and R. M. Viner. “Front of Pack Nutritional Labelling Schemes: A Systematic Review and Meta-Analysis of Recent Evidence Relating to Objectively Measured Consumption and Purchasing.” Journal of Human Nutrition and Dietetics 33, no. 4 (2020): 518-34. https://doi.org/10.1111/jhn.12758.

Dötsch-Klerk, Mariska, Maaike J. Bruins, Patrick Detzel, Janne Martikainen, Reyhan Nergiz-Unal, Annet J. C. Roodenburg, and Ayla Gulden Pekcan. “Modelling Health and Economic Impact of Nutrition Interventions: A Systematic Review.” European Journal of Clinical Nutrition 77, no. 4 (April 2023): 413-26.

https://doi.org/10.1038/s41430-022-01199-y.

Evans, Charlotte Elizabeth Louise, Kathryn Elizabeth Melia, Holly L. Rippin, Neil Hancock, and Janet Cade. “A Repeated Cross-Sectional Survey Assessing Changes in Diet and Nutrient Quality of English Primary School Children’s Packed Lunches between 2006 and 2016.” BMJ Open 10, no. 1 (January 1, 2020): 1-9. https://doi.org/10.1136/bmjopen-2019-029688.

Fichera, Eleonora, and Stephanie von Hinke. “The Response to Nutritional Labels: Evidence from a Quasi-Experiment.” Journal of Health Economics 72 (July 1, 2020): 1-16. https://doi.org/10.1016/j.jhealeco.2020.102326.

FixOurFood. “FixOurFood in Schools.” Fix Our Food (blog), 2024. https://fixourfood.org/what-we-do/our-activities/schools-and-nurseries/.

Impact on Urban Health. “Investing in Children’s Future: A Cost Benefit Analysis of Free School Meal Provision Expansion,” October 2022.

Jacob, Chandni Maria, Polly Louise Hardy-Johnson, Hazel M. Inskip, Taylor Morris, Camille M. Parsons, Millie Barrett, Mark Hanson, Kathryn Woods-Townsend, and Janis Baird. “A Systematic Review and Meta-Analysis of School-Based Interventions with Health Education to Reduce Body Mass Index in Adolescents Aged 10 to 19 Years.” International Journal of Behavioral Nutrition and Physical Activity 18, no. 1 (2-19): 1. https://doi.org/10.1186/s12966-020-01065-9.

Lalli, Gurpinder, Kim Smith, Jayne Woodside, Greta Defeyter, Valeria Skafida, Kelly Morgan, and Christopher Martin. “A Brief Review of Secondary School Food Policy (SSFP) Approaches in the UK from 2010 to 2022.” Nutrition & Food Science 54, no. 2 (January 1, 2024): 433-44. https://doi.org/10.1108/NFS-11-2023-0259.

Løvhaug, Anne Lene, Sabrina Ionata Granheim, Sanne K. Djojosoeparto, Janas M. Harrington, Carlijn B. M. Kamphuis, Maartje P. Poelman, Gun Roos, et al. “The Potential of Food Environment Policies to Reduce Socioeconomic Inequalities in Diets and to Improve Healthy Diets among Lower Socioeconomic Groups: An Umbrella Review.” BMC Public Health 22, no. 1 (March 4, 2022): 1-12.

https://doi.org/10.1186/s12889-022-12827-4.

McGill, Rory, Elspeth Anwar, Lois Orton, Helen Bromley, Ffion Lloyd-Williams, Martin O’Flaherty, David Taylor-Robinson, et al. “Are Interventions to Promote Healthy Eating Equally Effective for All? Systematic Review of Socioeconomic Inequalities in Impact.” BMC Public Health 15, no. 1 (May 2, 2015): 2-12.

https://doi.org/10.1186/s12889-015-1781-7.

Mytton, Oliver T., Emma Boyland, Jean Adams, Brendan Collins, Martin O’Connell, Simon J. Russell, Kate Smith, Rebekah Stroud, Russell M. Viner, and Linda J. Cobiac. “The Potential Health Impact of Restricting Less-Healthy Food and Beverage Advertising on UK Television between 05.30 and 21.00 Hours: A Modelling Study.” PLOS Medicine 17, no. 10 (October 13, 2020): 1-18. https://doi.org/10.1371/journal.pmed.1003212.

Pérez-Escamilla, Rafael, Cecília Tomori, Sonia Hernández-Cordero, Phillip Baker, Aluisio J. D. Barros, France Bégin, Donna J. Chapman, et al. “Breastfeeding: Crucially Important, but Increasingly Challenged in a Market-Driven World.” The Lancet 401, no. 10375 (February 11, 2023): 472-85. https://doi.org/10.1016/S0140-6736(22)01932-8.

Qiao, Jia, Li-Jing Dai, Qing Zhang, and Yan-Qiong Ouyang. “A Meta-Analysis of the Association Between Breastfeeding and Early Childhood Obesity.” Journal of Pediatric Nursing 53 (2020): 57-66. https://doi.org/10.1016/j.pedn.2020.04.024.

Rogers, Nina Trivedy, David I. Conway, Oliver Mytton, Chrissy H. Roberts, Harry Rutter, Andrea Sherriff, Martin White, and Jean Adams. “Estimated Impact of the UK Soft Drinks Industry Levy on Childhood Hospital Admissions for Carious Tooth Extractions: Interrupted Time Series Analysis.” BMJ Nutrition, Prevention & Health, October 31, 2023, 3-9. https://doi.org/10.1136/bmjnph-2023-000714.

Thomas, Chloe, Penny Breeze, Steven Cummins, Laura Cornelsen, Amy Yau, and Alan Brennan. “The Health, Cost and Equity Impacts of Restrictions on the Advertisement of High Fat, Salt and Sugar Products across the Transport for London Network: A Health Economic Modelling Study.” International Journal of Behavioral Nutrition and Physical Activity 19, no. 1 (July 27, 2022): 1-10. https://doi.org/10.1186/s12966-022-01331-y.

Yang, Tiffany C., Madeleine Power, Rachael H. Moss, Bridget Lockyer, Wendy Burton, Bob Doherty, and Maria Bryant. “Are Free School Meals Failing Families? Exploring the Relationship between Child Food Insecurity, Child Mental Health and Free School Meal Status during COVID-19: National Cross-Sectional Surveys.” BMJ Open 12, no. 6 (June 1, 2022): 1-9. https://doi.org/10.1136/bmjopen-2021-059047.

Yau, Amy, Nicolas Berger, Cherry Law, Laura Cornelsen, Robert Greener, Jean Adams, Emma J. Boyland, et al. “Changes in Household Food and Drink Purchases Following Restrictions on the Advertisement of High Fat, Salt, and Sugar Products across the Transport for London Network: A Controlled Interrupted Time Series Analysis.” PLOS Medicine 19, no. 2 (February 17, 2022): 1-17. https://doi.org/10.1371/journal.pmed.1003915.