1.1 Food insecurity is a result of many factors coinciding in individuals and communities. There is evidence of a continued and increasing gap between the wealthy and deprived in the UK (McGuinness & Harari, 2019), resulting in inequalities across many facets of life including food. In 2017/18, 42% of all disposable household income in the UK went to the 20% of people with the highest household incomes (McGuinness & Harari, 2019), and income inequality in the UK is among the highest in Europe (OECD, 2019). Food insecurity results from incomes too low to support healthy food choices, insecure income or lack of access to the food required to sustain a healthy intake. Data from the UK shows that users of Food Banks include those in work but whose income is too low or insecure to avoid use of emergency food supplies (Trussell Trust, 2019; Prayogo et al, 2017).
1.2 Also related is the issue of availability of secure and suitable social housing in some parts of the country. The use of unsuitable or emergency accommodation may also impact on food intake, adversely affecting the ability to store, cook and prepare foods. There are a number of contributory interacting factors to this, but the stripping away of funds from local authorities is likely to have played a part. In addition regulations around social housing and the top-slicing of funds by central government received from selling social housing reduces the availability of much needed funds to local government.
1.3 It may also be the case that the perception of social needs as being different from health needs, and the separation of funding and responsibility for both (social needs being allocated to local authorities, and health needs to the NHS), also plays a part in this. Food insecurity and malnutrition impact on both mental and physical health but they are viewed as social and not medical issues until such time as physical health is adversely affected. At that stage the symptoms but not the causes are addressed within the healthcare system. The root of the problem, in how groups within society have their needs for housing, secure employment, reasonable levels of income (considering actual costs of living including travel costs incurred in getting to work), dignity, access to food and so on are met, is not being addressed. In part this may be because the over-riding concern of national government for a number of years now has been on Europe. However the devolution of responsibility for such issues to local authority without adequate funding or support by national government, is also likely to have contributed.
2.1 Diet impacts upon public health by increasing or reducing the prevalence of chronic non-communicable diseases such as cardiovascular disease (heart attack & stroke), high blood pressure, type 2 diabetes, obesity and some types of cancer (WHO, 2002). All of these affect large proportions of the UK population and are therefore considered to be public health problems (NHS Digital, 2016). Common to many chronic diseases is obesity, caused by excess body fatness which may be stored around the centre of the body (central adiposity) or the hips and thighs (peripheral adiposity). Both the amount and location of excess fat affect the degree to which health risks are faced by the individual, but obesity is recognised as a major contributing risk factor to the diseases listed above (PHE, 2019a). Currently obesity is not officially classed as a disease in the UK. We have called for this to be changed so that obesity is recognised as a chronic relapsing recurrent disease requiring long-term support in its own right. Obesity is not uniformly distributed throughout the population but has a greater prevalence in those who are economically disadvantaged both as adults (Baker, 2019) and children (NHS Digital, 2018). These groups are also least likely to consume a healthy diet, with lower intakes of fruit and vegetables and higher intakes of fat, salt and sugary foods and drinks (PHE, 2019b). They are also least likely to take adequate amounts of exercise and more likely to be sedentary (NHS Digital, 2019).
2.2 Childhood obesity is of great concern because of the increased possibility of mental and physical ill-health associated with it, and the possibility that excess weight may ‘track’ from childhood into adulthood (i.e. that the overweight child remains overweight as adolescent and adult). If so the overweight child is exposed to the potential harm (mental and physical, including stigma and bias) of excess weight and body fat for a much greater proportion of their lives than seen in previous generations and we do not yet have data on the long-term implications of this. The fact that the prevalence of childhood obesity has remained reasonably stable is positive, nonetheless it remains stubbornly persistent affecting approximately 1 in 5 Reception aged children and increasing to 1 in 3 Year 6 children (4-5 years and 10-11 years respectively; prevalence figures relate to overweight & obesity combined), with double the prevalence in the most compared with least deprived areas (NHS Digital, 2019).
2.3 Much of the work to address this has been carried out locally with weight management programmes offered to affected children and their families. These programmes focus on the individual changes that children and families need to make to diet and activity behaviours. However it is clear that the environment in which they live promotes over-consumption so addressing individual behaviours alone is unlikely to be sufficient, no matter how good the programme may be. Funding for such provision is needed and long-term support for those who have gone through a programme is often lacking in all but a cursory way (e.g. an activity reunion once every 6 months or a year does not represent meaningful long-term support). This is a problem for local authorities with cash-flow problems. Given that childhood obesity is more common in deprived communities, areas with high prevalence will also have other significant problems to manage. Childhood obesity needs to be identified as a priority in order to support children and families and since public health funding is no longer ring-fenced, secure funding remains a serious problem.
2.4 The bigger issue in our view is the lack of sustained long-term political will and leadership to address a serious health concern where long-term action is needed to address a dysfunctional food and activity environment. We are faced with large portions of unhealthy foods and drinks which are heavily marketed and advertised, often cheaper and more accessible than healthier options, and available 24/7, particularly in disadvantaged areas. Those for whom health is a concern, who have the health literacy to understand why healthy choices matter and the resources to make healthy choices, are more able to withstand commercial pressures than those who have limited ability and/or knowledge to make healthy (often more expensive) choices.
3.1 There is a difference between food being physically accessible (i.e. there in the local shops), and actually accessible to the individual (i.e. they can afford it, they see it as acceptable and appropriate for them, they are able to travel to the place to purchase/access the food). Both may be an issue. Healthy food may be less available in deprived areas and of lower quality when available. There may be a price differential between fresh healthy foods like fruit and vegetables, and less healthy processed or takeaway foods. The latter are known to be found in greater amounts in deprived areas and to be of lower quality in those areas (PHE, 2018a). In addition those with lower intakes tend to spend a greater proportion of their income on food (Corfe, 2018) and can therefore afford to take less risks with what they buy. Buying fresh foods which may be more expensive, perishable, and may not be acceptable to all members of the family may represent a risk that they are unprepared or unable to take.
3.2 Levels of knowledge and health literacy may vary between groups, and have been shown to be lower in more deprived groups (PHE, 2015). Health literacy is related to social circumstances (PHE, 2015). Health literacy requires knowledge, skills, confidence and understanding to access, navigate, understand and use information that is available and relate it to personal lifestyle choices.
3.3 Nutrition, in particular practical food education skills including cooking, was largely removed from the core school education, and these key skills made optional which means that those who did not learn about healthy eating or how to cook at home were far less likely to be able to do so at school. This resulted in a generational loss of knowledge with impacts far beyond the individual affected. In 2013 cooking lessons were made compulsory in schools (Department for Education, 2013); however what is possible within individual schools depends on the facilities available as well as the knowledge and skills of the teacher. Many schools themselves have lost kitchens as school food was outsourced, meaning that facilities in which children could learn to cook have been lost. Replacement of old schools with rebuilds where required, offers an opportunity to add much-needed facilities to schools so that children can learn basic kitchen skills. This will have a disproportionate benefit for those children from households where cooking is rare, many of which are likely to be deprived. However replacing and maintaining kitchens and investing in these skills for children requires long-term planning and investment.
3.4 Marketing & advertising of less healthy foods is common and although there are some important safeguards on what can be advertised especially to children on television, there remain many opportunities for children to be exposed through multiple means. Proposals to introduce a 9pm watershed on the advertising of high fat, salt and sugar products to children on TV and online, to mandate calorie labelling in the out-of-home sector and to ban promotions of high fat salt and sugar foods and drinks by price and location have been consulted upon. Despite this, the current green paper does not commit to action on these, or on extending the sugar tax to include sugary milky drinks popular with children (Department for Health & Social Care, 2019).
3.5 Perceptions of the value of particular foods may vary. The nutritional value of foods and drinks may be perceived to relate to calorie intake, in which case fruit and vegetables which contain less energy may be viewed less favourably than more energy dense foods and drinks, especially by those with limited income available to spend on food. On a per calorie basis, healthy food may be more expensive than unhealthy energy dense foods (Corfe, 2018), and on that basis it would be expected that those seeking value for money would be responsive to upsizing of portion sizes and multi-buy offers.
3.6 The physical availability of foods out-of-hours was traditionally lower in rural compared with urban areas, where shops are more common, opening hours may be longer and access to them is easier. Similarly takeaway foods were traditionally more available in urban areas. Increased availability facilitates impulsive purchases, which may have been less possible in rural areas where historically access to shopping opportunities needed to be more planned. With increasing urbanisation and the advent of home food delivery services such as Deliveroo and Just-Eat, that has now changed. These delivery services are currently being heavily marketed on television (indeed reaching inaccessible areas is highlighted as a key advantage of these services within a series of advertisements for delivery of takeaway foods on late evening television). While it may be argued that these ads and services are aimed at adults and not children, the eating behaviours of adults in the family will impact on the eating behaviours of children (Scaglioni et al, 2018).
4.1 Local authorities know their local populations and their health needs, as well as the local environment so have a unique opportunity to engage through the relationships that they have built up with community leaders. Local authorities also have a unique opportunity to influence the nature of the physical infrastructure through local planning and building regulations (which in some places have been used to restrict the density of fast food outlets near schools). However working with local groups to improve their health needs sustained investment, and investment is often on a short-term basis. Local authorities could encourage food businesses to work with local groups around donations of leftover foods for charity – for whom lack of suitable transport is often a limiting issue. They can also influence food businesses to favourably position and price healthy food and promote access to free tap water. They also have a strong influence over green spaces and making available opportunities for being physically active (e.g. playgrounds, cycling lanes). Through transport planning, an emphasis on active travel can be placed.
4.2 Local authorities procure food and are large employers, so insisting that only healthy food is procured would represent a strong message about the value placed upon healthy eating. In addition, local authorities can work with building developers to ensure that all plans including those for social housing include adequate opportunity for and access to physical activity opportunities for residents, including children and young people, and including safe walking and cycling routes. They can also promote breastfeeding through provision of adequate support for mothers, and through recognition of breastfeeding friendly local venues. Since breastfeeding rates are lower among more deprived women, this could benefit them more. In addition, local authorities can influence and/or provide workforce training on raising the issue of weight.
5.1 It is inappropriate that the responsibility for meeting food needs has devolved down to charities which themselves rely on donations. There is a lack of dignity implicit in the requirement for individuals and families to rely on charity to meet their food needs. The need for emergency food supplies has increased; the Trussell Trust which runs the majority of emergency food supplies in the UK reported a 73% increase in use of their facilities over the previous 5 years, with 1.6 million 3 day emergency food supplies given out in the financial year 2018-19, of whom more than half a million users were children (Trussell Trust, 2019). Food banks do an amazing job in helping those needing emergency relief. However the use of the Food Banks is not necessarily a one-off situation and typically people use them twice or more (Trussell Trust, 2019), which shows that their need is not a one-off emergency but a recurring issue. Users of Food Banks have been shown to be disproportionately low income, vulnerable and disadvantaged with the majority of users suffering from benefit-related problems or in low income jobs (Prayogo et al, 2017). These fundamental issues need to be addressed; the solution cannot be to address the symptoms of such problems by expecting charities to fill a gap not being met by government.
5.2 There is also an issue about the healthfulness of foods supplied by Food Banks and other charities. Their remit is meeting emergency needs, not long-term requirements for healthy eating. Therefore there is no onus on them to supply healthy foods and in fact it is difficult for them to do so, since they do not necessarily have the infrastructure to store and manage perishable goods. There is a disparity between the short-term nature of the function of Food Banks and the way in which they are now being used.
6.1 Food labels are not necessarily used and understood in the same way by all groups. There is evidence that their use is greater among those with an already greater interest in food and health (Grunert et al, 2010). Levels of food and health literacy may vary between groups (PHE, 2015). To those on low incomes and/or with poor food and health literacy, large portion sizes appear to be price efficient and there is often very little price difference involved in super-sizing a meal in a fast food outlet or buying two items for only slightly more than one in supermarkets, thus apparently representing better value for money. It has been estimated that such upselling can result in the average person consuming an additional 17,000 calories per year (RSPH & Slimming World, 2018). There is plenty of evidence that marketing and advertising is effective in altering consumer behaviour especially that of children, with a greater effect seen in children with overweight or obesity (Cairns et al, 2009; Boyland and Halford, 2013). Industry would not spend what it does on marketing and advertising if it were not effective. It is widely recognised that the environment in which we live affects many of our food-related decisions, often unconsciously (Butland et al, 2007), and that the so-called obesogenic environment is likely to have a disproportionately greater impact on those who are deprived (PHE, 2017).
6.2 Product formulation is an opportunity to alter nutritional intakes without changing individual food behaviours, thereby impacting upon all those who consume the product. It does not rely on individual behaviour change which is difficult to achieve and maintain. The current sugar reformulation programme organised by Public Health England has already been estimated to have achieved approximately 2% reduction of sugar in the first year of the programme, less than the stated aim of achieving a 5% reduction in that timescale (PHE, 2018b). Estimation studies suggest that if the programme were to achieve its goals, total reductions in childhood obesity of 5.5% in 4-10 year olds, 2.2% in 11-18 year olds and 5.5% in 19-80 year olds, with additional reductions in adult obesity-related diseases especially type 2 diabetes could be achieved (Amies-Cull et al, 2019). This assumes that the programme goals are achieved in their entirety without unintended changes to either consumer or industry behaviours. Sugar is one nutrient among many, and although this work is very positive and should continue, it is only one small part of a very complex jigsaw of interacting factors influencing intakes. PHE is also working on salt and calorie reduction programmes and on a whole systems approach to obesity, all of which are very much needed (https://publichealthmatters.blog.gov.uk/2019/07/25/health-matters-whole-systems-approach-to-obesity/). However a holistic approach to food is required which includes sustainability and food security, and the role of all aspects of the food supply chain, not just those of the retailer, manufacturer, retailer or consumer.
7.1 Eating out accounts for 20-25% of adult energy intake (NatCen Social Research, 2017). When people eat out they are more likely to over-consume, with some research suggesting that 200 extra calories are eaten compared to food eaten at home (Nguyen & Powell, 2014). Portion sizes in the out-of-home sector tend to be larger than those at home (NatCen Social Research, 2017). Ninety six percent of people eat out, 43% more than once a week (FSA, 2017). Habitual over-consumption relative to energy expenditure causes gradual weight gain, and the scale of overweight and obesity prevalence in the UK suggests that habitual over-consumption is common. Retail sales index data for July 2019 shows that food store purchases represented 38.5% of overall purchases, including alcohol & tobacco (ONS, 2019c). The UK grocery retail market was valued at £184.8 billion in 2018 (RSPH, 2019). Kantar WorldPanel data demonstrated food sales of £29,116 million in the 12 weeks leading up to 27th January 2019, with the ‘big four’ supermarkets (Tesco, Sainsbury’s, Asda & Morrisons) representing 69.5% of market share (Kamcity, 2019). As such, they hold enormous power within the food retail chain, both over food producers and food consumers. One in five UK consumers say that supermarkets cause them to lose track of their weight management attempts (RSPH, 2019).
7.2 Influences on food choices are many and varied and the obesogenic environment itself is complex and hard to define (Kirk et al, 2010). Convenience, quality and value for money are important drivers of consumer food purchase habits (Retail Insight Network, 2019). However price promotions have been shown to influence quantities of foods and drinks purchased which are not offset on subsequent purchasing occasions (Martin et al, 2017; Hawkes, 2009). Likewise the positioning of products within the retail environment (e.g. end-of-aisle placement) has been linked to greater sales, particularly for high fat salt and sugar foods and drinks (Martin et al, 2017; Cohen & Lesser, 2016; Hawkes, 2009). There is no doubt that the environment, which includes marketing, advertising and promotions, influences us in our behaviours (Butland et al, 2007), and this influence can be modified to have a positive influence on health and obesity.
8.1 Yes. The voluntary Responsibility Deal was shown to be largely ineffectual (Knai et al, 2018), suggesting that reliance on voluntary agreements is likely to have limited impact. By contrast, some mandatory action has already been taken and shown to be effective. For example the tax on sugary drinks has resulted in an 11% reduction in sugar per 100mls (manufacturer branded products & retailers own products only). This compares with a 2% reduction in sugar per 100g in manufacturer branded and retailers own brand products in the first year of the voluntary sugar reformulation programme (PHE, 2018b).
8.2 Mandatory action appears to be more effective and in our view is needed but it is unclear how future trade deals may impact upon national efforts to achieve healthy intakes, especially if no agreement is reached with the EU (House of Lords, 2019). Price increases are likely in that case, which would impact more on those with lower incomes (House of Lords, 2019). We (and others) have concerns that the recent green paper (Department of Health & Social Care, 2019) did not commit to mandatory action on extending the sugar tax to include sugary milky drinks, nor did it commit to specific timing for the introduction of a 9pm watershed on the advertising of high fat, salt and sugar products to children on TV and online, to mandate calorie labelling in the out-of-home sector or to ban promotions of high fat salt and sugar foods and drinks by price and location. We believe that urgent action to address these is needed but action should not be limited to these areas. Action on smoking shows that regulation has been a key driver in changing the behaviour of smokers, in addition to practical support (e.g. making alternative nicotine-containing products and smoking cessation counselling available). Similar action is needed on food. Ideally such regulation would align with subsidies on healthy options like fruits and vegetables, thus reducing their cost.
9.1 Food intake patterns will need to change dramatically in order to reduce the impact of diet on environmental sustainability (Willett et al, 2018). This will include reducing intakes of meat, increasing consumption of plant-based foods and reducing food waste. In addition reducing food miles, so that consumption of local foods is emphasised and imports are reduced, is needed. This will need a clear understanding and acceptance by members of the population and is likely to need a sustained and clear educational campaign. Food waste is currently high, at approximately 10 million tonnes per year, 70% of which was intended to be consumed (Wrap, 2019), and part of the reason for this may relate to lack of understanding of food labels and when food is safe to eat. Overall 69% of food waste occurs at the level of the household (Wrap, 2019). The UK currently imports 50% of foods; 40% of vegetables and 37% of fruit sold in the UK comes from the EU (House of Lords, 2019). Substantial changes to consumer intakes will be needed to change this, with acceptance that food cannot be available 24/7 and that reduced choice may be required. How acceptable is this likely to be? Dietary change is traditionally slow; the 5 a day campaign was launched in 2003 but intakes of fruit and vegetables in the UK still fall short of the recommendations, particularly among lower income groups (PHE, 2019). This represents a significant challenge and a change in mind-set for the population.
10.1 Potentially they could but to what extent this is realistic is unclear.
11.1 Opportunities to recycle food waste are now more widespread, made possible by the action of local authorities. However a step before that is reducing food waste in the first place. This is not just needed at the level of the consumer but also the food producers, importers and manufacturers, food businesses, restaurants, cafes and takeaways.
12.1 The impact of voluntary guidelines is likely to be limited; a review of the effect of the Responsibility Deal demonstrated little impact of these voluntary agreements (Knai et al, 2018). The key difficulty with individual behaviour change is the considerable effort needed to make and maintain dietary changes within the current environment. It is estimated we make over 200 food-related decisions daily, the majority without conscious thought (Wansink & Sobal, 2007). While education, knowledge and individual efforts remain important, changing the environment has the potential to support individual efforts and to encourage change even in those who are not consciously focusing on their diet (e.g. through product reformulation). The fact that progress towards meeting the sugar reformulation goals for the first years is lower than was hoped (PHE, 2018b), demonstrates that voluntary change is likely to be less than could be achieved. Sign-up to this voluntary scheme has been very low among the out-of-home sector (PHE, 2018b). Efforts to reduce smoking in the population demonstrate that mandatory action, alongside education and support, achieve much more than voluntary action (ONS, 2019a; OECD, 2019; Department of Health & Social Care, 2019). Food is much more complex than smoking cessation since there is no such thing as a healthy cigarette, but all nutrients have a role to play within a healthy diet. However it is our firm belief that mandatory action is needed and that the majority of the population agree that such action is needed (e.g. 93% of respondents agreed with mandating against the sale of energy drinks to children in a recent consultation (Department of Health & Social Care, 2019). Given that both poor diet and many chronic diseases are over-represented in those who are deprived, it is likely that they will disproportionately benefit from any such mandatory action and far from representing a ‘nanny state’, this is responsible government ensuring that the most vulnerable are protected. Public procurement represents an important route towards helping employees achieve a healthy intake. The public sector is a major national employer; as of March 2019, 16.5% of all people in paid work were employed in the public sector with the NHS and the Civil Service being the largest employers (ONS, 2019b). These organisations therefore have power to influence the health and wellbeing of their employees and users including through healthy food procurement as well as addressing sedentary behaviours and embedding opportunities for physical activity.
13. Has sufficient research been conducted to provide a robust analysis of the links between poverty, food insecurity, health inequalities and the sustainability of food production? How well is existing research on the impact of existing food policy used to inform decision making?
13.1 To what extent existing research on the impact of food policy is used to inform decision making is not something we can comment on. There are well documented health inequalities within the UK, as well as food insecurity and poverty (PHE, 2018c). Health inequalities themselves are evaluated and presented for local areas. How these link to sustainability and the extent to which they have been robustly evaluated is unclear.
14.1 Sustain may be able to comment on this and Amsterdam has a successful obesity strategy which would be worth looking at.
15. Are there any additional changes at a national policy level that would help to ensure efforts to improve food insecurity and poor diet, and its impact on public health and the environment, are effectively coordinated, implemented and monitored?
15.1 Such efforts will need high level buy-in, leadership and sustained effort. Effects will be long-term in nature which conflicts with the short-term nature of politics and creates a potential conflict between politicians and healthcare providers. There is potential to utilise industry’s effective promotional channels to counteract the promotion of unhealthy food promotion eg ‘Eat them to defeat them’ (https://vegpower.org.uk/). Evaluating this work and maintaining a sustained effort alongside restricting unhealthy food promotions could be one of the strands implemented in a coordinated whole systems approach.
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Dr Hilda Mulrooney on behalf of the Obesity Group of the BDA
12 September 2019