Cancer Research UK – Written evidence (FPO0043)

 

About Cancer Research UK
 

Cancer Research UK is the world’s largest independent charity dedicated to saving lives through research. We support research into all aspects of cancer which is achieved through the work of over 4,000 scientists, doctors and nurses. In 2018/19, we committed £546 million to fund and facilitate research in institutes, hospitals and universities across the UK. Thanks to research, survival in the UK has doubled since the 1970s so, today, 2 in 4 people survive their cancer. Our ambition is to accelerate progress and see 3 in 4 patients surviving their cancer by 2034. We work to prevent, diagnose and treat all cancers more effectively to achieve that ambition.


Cancer Research UK is a member of the Obesity Health Alliance (OHA), a coalition of over 40 leading health charities, medical royal colleges and campaign groups working together to influence Government policy to reduce obesity across the life course.

 

Submission Summary:
 

 

 

 

 

Answers to specific questions:
 

2) What are some of the key ways in which diet (including food insecurity) impacts on public health? Has sufficient progress been made on tackling childhood obesity and, if not, why not?


Obesity and cancer

 

  1. Diet significantly impacts on public health. Having an unhealthy diet can lead to being overweight and even obese and put people at risk of a number of diseases, including cancer. Obesity is the biggest preventable cause of cancer after smoking in the UK. It is linked to 13 types of cancers, including two of the most common (bowel and post-menopausal breast) and two of the hardest to treat (oesophageal and pancreatic). Every year around 22,800 cases of cancer in the UK are caused by overweight and obesity[1] and if historic trends continue, overweight and obesity could cause an additional 670,000 cases of cancer in the UK over the next twenty years.[2] Each year, it is estimated that obesity costs £5.1bn to the NHS and £27bn to the wider UK economy.[3]
     
  2. There is strong evidence that obesity is linked to social class, which has significant consequences for health inequalities.[4] The highest prevalence of excess weight is found among low socio-economic groups for both men and women,[5] and these adults are more likely to have a higher sugar intake compared to all other income groups.[6] If trends continue, almost half (49%) of women from the lowest income quintile could be obese in 2035.

Obesity and children

 

  1. Childhood obesity rates in the UK are among the highest in Western Europe, with around a third (34%) of children overweight or obese when they leave primary school. If trends continue, it is predicted that half of all children will be obese or overweight by 2020.[7] We estimate that more than 7 in 10 millennials are set to be overweight or obese between the ages of 35-44,[8] making them the most overweight generation since current records began. An obese child is around five times more likely to remain so as an adult[9].

 

  1. Obesity is more than twice as prevalent among the most deprived 10% of children in England[10] compared to the most affluent 10%, with similar patterns across Scotland[11] and Wales.[12] Moreover, the obesity gap between the most deprived and least deprived areas has increased in the last decade.[13]

Progress

  1. Sufficient progress has not yet been made in tackling childhood obesity. Despite three chapters of the UK Government’s Childhood Obesity Plan, there has been a lack of concrete policy made in this area in recent years, except on sugary drinks. UK Government has not gone fast or far enough in tackling the food environment, especially in regard to restricting marketing and price and location promotions for products high in fat, salt and sugar (HFSS).

 

  1. We welcome the UK and Scottish Governments’ commitments to a shared ambition of halving rates of childhood obesity by 2030. However, this will not be achievable without ensuring that the intentions set out in their respective national obesity strategies are delivered fully and without delay.

 

 

3) How accessible is healthy food? What factors or barriers affect people’s ability to consume a healthy diet? Do these factors affect populations living in rural and urban areas differently?

 

  1. A report from the Food Foundation[14] found that, on average, unhealthy products are three times cheaper, calorie for calorie. It also showed that the Government’s recommended diet would require the poorest 10% of households to spend three quarters of their disposable income on food in order to afford it.

 

  1. Cancer Research UK’s primary focus has been on removing the unhelpful nudges that influence people’s dietary habits to make the healthy choice the easy choice, by advocating for population-wide measures to tackle the obesogenic environment.
     

4) What role can local authorities play in promoting healthy eating in their local populations, especially among children and young people, and those on lower incomes? How effectively are local authorities able to fulfil their responsibilities to improve the health of people living in their areas?

 

  1. Local authorities have a role to play in providing weight management services to their local populations. Local and regional authorities are also well-placed to champion a ‘health in all policies’ approach that address the wider determinants of health – including environmental, social, economic and commercial determinants.

 

  1. However, councils are under increased pressure to deliver public health services due to cuts to the Public Health Grant. As seen with tobacco control and stop smoking services, we are concerned that should the responsibility for tackling children’s obesity fall on local authorities, the impact of cuts could be largest in the most deprived parts of the country, exacerbating existing health inequalities.

 

 

6) What impact do food production processes (including product formulation, portion size, packaging and labelling) have on consumers dietary choices and does this differ across income groups?

 

Calorie labelling

 

  1. Although academic evidence is limited, that which is available suggests that there is an association between calorie labelling and a reduction in the number of calories consumed. [15] [16] [17]

 

  1. Adults currently consume 20-25% of their energy intake out of the home. As the frequency at which individuals dine out or get takeaways increases, it is more and more important that people are aware of the calorie content of the foods they consume.[18] This is an important part of supporting and empowering people to make more informed, healthier choices.

 

  1. The retail sector is currently required to provide front-of-pack nutritional information, including calories, on food products. Introducing regulation to require calorie labelling in the out of home sector would level the playing field and allow people to access consistent nutritional information.

 

  1. One important indirect consequence of calorie labelling on menus can be a reduction in calories across the menu, which has been observed in academic research[19] [20] and also self-reported by those in the sector already trialling it.[21]

 

7) What impact do food outlets (including supermarkets, delivery services, or fast food outlets) have on the average UK diet? How important are factors such as advertising, packaging, or product placement in influencing consumer choice, particularly for those in lower income groups?

 

  1. Advertising, product placement, price promotions and packaging can heavily influence the food that people choose to buy and consume, which can then negatively impact on their weight. It is therefore important to ensure that the food industry and food outlets are helping make the healthy choice the easy choice for their consumers.

On the marketing of products high in fat, sugar and salt (HFSS)

  1. Although there is no silver bullet to reduce obesity, there is overwhelming evidence that marketing for products high in fat, salt or sugar (HFSS) impacts children’s eating habits[22] Advertising influences the type of food children choose, how much of it they eat,[23] and can lead to them ‘pestering’ parents to buy unhealthy products.[24] [25] The negative impact of HFSS advertising on children’s dietary behaviour and rising obesity rates has been recognised by both UNICEF[26] and the WHO[27].

 

  1. Research further suggests that marketing (both online and offline) could explain 5% of young people’s total energy intake from junk food, or the equivalent of 50 calories per day.[28] According to Public Health England, overweight and obesity is often caused by consuming a relatively small number of excess calories daily[29], and as little as 48 to 71 calories extra per day is enough to generate weight gain in children over time.[30] Thus, even a small daily reduction in energy intake, which could be precipitated by reducing exposure to junk food marketing, has an important role to play in reducing the risk of weight gain and obesity in children.

 

  1. In early 2018, Cancer Research UK’s Cancer Policy Research Centre published a series of reports, based on a YouGov survey of 3,348 young people in UK between the ages of 11-19. They provide further evidence to confirm the advertising of HFSS foods has an impact on what food and drink children and young people consume, and therefore impact on their weight.[31] [32] [33] This is seen across all ages of young people, and for advertising on both television and streaming or on-demand. 

 

  1. The pervasive harms of adverts also place disproportionate pressures among the most deprived in society.[34] Our research also showed that teens from the most deprived communities were 40% more likely to remember junk food advertisements every day compared to teens from better-off families.[35] With food advertising in the UK disproportionately featuring unhealthy food items, advertising could therefore play a role in increasing health inequalities.

 

TV adverts

  1. Junk food marketing is extremely prevalent on TV. Our research found has found that on ITV1, Channel 4, Channel 5 and Sky One, around half of all food adverts shown between 6pm and 9pm in May 2018 were advertising high fat, salt or sugar (HFSS) products. Fruit and vegetables - which are a key component of PHE’s Eatwell Guidance - were the primary focus of just 5% of all food ad slots between 6pm and 9pm.[36]

 

  1. Our research has also found that the more junk food adverts young people see on TV, the more they eat – potentially over 500 snacks over a year.[37] Recalling just one broadcast advert for junk food a day predicts the consumption of an extra 18,000 calories in a single year.[38] Lower recall of junk food marketing was found to be linked to a significantly lower risk of being obese. Further evidence from Cancer Research UK also found that children who watched over 3 hours of commercial TV per day were almost 3 times more likely to buy junk food products and over two 2 times more likely to have sugary drinks than children who watched little or no TV.

 

  1. Our latest research, ‘Still under pressure; but pressing for change’ builds on a previous study from 2016 which ran focus groups with 11 to 19 year olds to discuss factors impacting their diet and weight. However, three years later and despite two Chapters of the UK Government’s Childhood Obesity Plan, our research shows that children still say that feel that HFSS marketing is pervasive and specifically targets. They could also recall examples of when HFSS marketing had directly influenced their purchasing behaviours, either by buying HFSS products themselves or pestering their parents to buy them.[39]

 

Online adverts:

  1. Brands have been quick to adapt their marketing strategies to make the most of online platforms. A 2019 narrative review funded by Cancer Research UK shows that the food and drink industry have put digital media at the centre of their marketing strategies, using a sophisticated range of tactics from smartphone apps to social media. [40] These forms of marketing both reach and appeal to children and young people, who are exposed to and participate with HFSS marketing across multiple digital channels. Children have difficulty recognising subtle forms of digital marketing, which can leave them more vulnerable to their influence. This effect is magnified in teens from deprived backgrounds, whom Ofcom research found typically have lower critical understanding of digital advertising. [41]

 

  1. Our research has found that adverts from on-demand and streaming services are a clear and consistent risk for poor diet, just as adverts on TV are. Commercial screen time from both television and streaming services have a significant association with an obese BMI for a young person, indicating that both platforms influence weight outcomes in this demographic.[42] Analysis by the Obesity Health Alliance (OHA) reveals that children watching the 2018 Britain’s Got Talent (BGT) final via ITV Hub were inundated by adverts for unhealthy food and drinks. Up to one in three ‘full’ adverts were for HFSS products, including burgers, pizza, sugary soft drinks and sweets.[43] Our research further found that children who used the internet for over 3 hours a day are almost 4 times as likely to buy junk food products compared to those who spend little or no time online. In contrast, children who used the internet for more than 3 hours per day had a 68% reduction in vegetable intake.[44]

 

  1. Our recently published report, ‘Lessons from the digital frontline: Evidence to support the implementation of better regulation of digital marketing for foods and drinks high in fat, salt and sugar’19 investigated how digital marketing for HFSS food and drink is regulated in the UK and looks at alternative methods for regulating marketing online.

 

  1. In the UK, digital marketing for HFSS food and drinks is self-regulated by the advertising industry and manufacturers. Real-world investigations highlight potential difficulties, subjectivity, and inconsistencies in the regulatory process. The lack of mechanisms to handle non-compliance of marketing from organisations that are not signatories to the industry or regulatory codes and the lack of meaningful sanctions, means that self-regulation does not provide meaningful deterrents against non-compliance. The current retrospective approach and speed at which digital media has been produced and shared means that campaigns are able to reach large audiences before a decision on compliance is made. In addition, the 25% relative exposure audience threshold means that in absolute numbers, a high number of children can still be exposed to adverts for unhealthy food, especially on platforms popular with both adults and children.

 

 

Price promotions

  1. Our report ‘Paying the Price’ used data on take-home shopping.[45] It found that around 3 in 10 food and drink items purchased in Great Britain are bought on price promotion, and that households which make greatest use of price promotions tend to buy more unhealthy food. The overwhelming bias of price promotions towards unhealthy foods has an inevitable impact on the food and drink products that shoppers select. Shoppers who buy the most on price promotions purchase more from unhealthy food categories like cakes, confectionary, crisps, sugary drinks, puddings and sweetened yoghurts. Conversely, shoppers who buy the least on promotion bought more foods in healthy categories such as fruit, vegetables and unsweetened yoghurts. They also bought more items in ‘other food’, comprising staples such as bread, eggs, soup and prepared fruits and vegetables.

 

  1. The report further found an association between overweight and obesity and high promotional purchasing. High promotional purchasers (the upper quartile of promotional purchasers) have 53% greater odds of being overweight, including obese, than low (the lower quartile of promotional purchasers) promotional shoppers, regardless of demographics factors such as age and income.

 

  1. Although price promotions are generally used to promote unhealthy rather than healthy food, multi-buy promotions have been singled out as a promotion where this held most true.[46] This leads to HFSS products being the cheapest, quickest and easiest to access.

 

  1. Temporary price reductions are also becoming increasingly prevalent – in Scotland, rising from 21% in 2010 to 26% in 2016.[47] A significant proportion of HFSS food and drink is bought on temporary price reduction – for example almost 40% of crisps, savoury snacks and confectionary, and over 30% of sugary soft drinks.[48] A CRUK survey also found that 78% of people agree that price deals that reduce the price of each item (e.g. 50% off) has an influence in getting people to buy unhealthy food at the supermarket.72

 

  1. Promotions are not free gifts and should not be considered so by UK governments or the UK public; they are mechanisms used to drive sales. Promotions encourage shoppers to spend more money than they otherwise would have planned to, rather than make overall savings on their total shop. [49] The Money Advice Service estimated that shopping offers can make consumers spend almost £1,300 more per year.[50] For the most disadvantaged, this is potentially hugely detrimental. [51] 

 

  1. Promotions also uniquely promote overconsumption rather than sensible stockpiling. People who buy crisps or biscuits on multi-buy will eat them more quickly and often purchase again the following week, while people who buy non-consumables on multi-buy are not likely to overconsume thereafter. [52]

 

  1. Recent research from Cancer Research UK found that use of price promotions in the UK was consistent across all demographics.[53] Low income households do not use price promotions more than high income households. This suggests that these families do not overly rely on price promotions in their food shop, and that they would not be disproportionately affected by restrictions on unhealthy price promotions. Additionally, households that buy more on promotion tend to buy less fruit and vegetables. Restrictions on price promotions on unhealthy foods may encourage these households to make healthier choices by shifting the balance of promotions on offer.

Location promotions

  1. In-premise marketing (product placement) is also used widely in the UK to promote high fat, salt and sugar foods, and is particularly influential for children and young people.[54] [55] Non-price-based promotions capitalise on trigger factors that encourage impulse purchases, for example through appearance or position in floor.[56] Impulse purchasing represents between 45% and 70% of food purchase, and 80% of purchases in some categories.[57] [58] [59] [60] The evidence base showing the influence on increasing consumer purchasing has been reviewed to be both strong and consistent.

 

  1. A recent report by the Obesity Health Alliance provided a snapshot of the extent of in-store promotions in 2018.[61] This study found that 43% of all food and drink products located in prominent areas – such as store entrances, checkouts, aisle ends, or free-standing display units – were for sugary foods and drinks (as defined by Public Health England’s sugar reduction programme). Some supermarkets had a higher proportion of sugary food and/or drinks at checkout than others, ranging from 30% in one major supermarket to 73% in another. Conversely, the study found that less than 1% of food and drink products promoted in high profile locations were fruit or vegetables.

 

  1. Evidence suggests that positional promotions increase consumer purchases independent of any price reduction, and that increasing visibility of products, for example by placing them in an island, may result in some consumers believing it to offer better value than it does. [62] This in turn can increase sales, as if there was a price discount.

 

  1. Recently published research led by the University of Cambridge identified that voluntary measures to restrict the promotion of sweets and confectionary at checkouts led to an immediate 17% reduction in purchases.[63] After a year, shoppers were still purchasing over 15% fewer of the items compared to when no policy was in place.

 

8) Do you have any comment to make on how the food industry might be encouraged to do more to support or promote healthy and sustainable diets? Is Government regulation an effective driver of change in this respect?

  1. Mandatory restrictions are necessary to ensure that the food industry and retailers do more to support healthy and sustainable diets, as a voluntary approach in previous years by the food industry and retailers has not been effective. One such example is the UK Government’s Public Health Responsibility Deal. Analysis of this programme by the House of Lords Science and Technology Committee concluded that the pledges made by industry to reduce obesity “do not reflect the available evidence about how to tackle the problem of obesity”, and were “not a proportionate response to the scale of the problem”.[64] The House of Commons Health Committee also identified that voluntary controls on price promotions and discounting are unlikely to work and highlighted the need for mandatory measures.[65]

 

  1. Government regulation is an effective driver of change and the Soft Drinks Industry levy is a good example of this. The Treasury’s own analysis[66] found that on the day the Soft Drinks Industry levy was introduced, it had already resulted in over 50% of manufacturers reducing the sugar content of drinks since it was announced in March 2016. This removed 90 million kg of sugar from the UK’s diets. Reformulation has continued at pace since April 2018 too. One year on, the Levy has also created a price differential between sugared and sugar free drinks which is visible in store and will drive consumer choice. The healthy choice has now become the cheaper choice. For some well-known brands, the introduction of sugar-free variants has been the most successful product launches in their history.
  2. According to our research, children and young people support measures that will go further to tackle childhood obesity. They view the Soft Drinks Industry Levy (SDIL) positively and potentially support it being extended to other product, such as confectionary and chocolate and other products high in fat, salt and sugar.[67]

 

12) A Public Health England report has concluded that “considerable and largely unprecedented” dietary shifts are required to meet Government guidance on healthy diets. What policy approaches (for example, fiscal or regulatory measures, voluntary guidelines, or attempts to change individual or population behaviour through information and education) would most effectively enable this? What role could public procurement play in improving dietary behaviours?

  1. Tackling obesity requires a UK-wide, whole-systems approach that prioritises interventions aimed at reducing unhealthy choices in the obesogenic food environment, empowering and giving choice back to parents and families and therefore reducing their risk of cancer.

 

  1. This was echoed by Guys and St Thomas’ Charity, who have called for a ‘whole-systems, cross-sector approach’ to addressing children’s obesity in urban, diverse and deprived areas,[68] prioritising interventions that reduce unhealthy choices. We welcome such a focus on changing the food environment, and on recognising that local or regional action must be supported by a national approach.

 

  1. We are calling for population-level interventions to tackle obesity and improve dietary behaviours, as these are likely to have the most positive effect on health inequalities.[69] Tailored interventions for specific groups may only lead to behaviour change among more affluent groups, but population-level activity often benefits the most deprived communities where obesity rates are highest. Research indicates that obesity-related interventions which restrict or modify the choices available to the consumer are most effective at changing behaviour,[70] [71] whilst interventions which rely on voluntary behaviour are not only less effective but also seem more likely to increase health inequalities.[72]

 

  1. There is no silver bullet to tackle obesity. Given the wealth of evidence on the impact on junk food marketing and the fact that it would be fairly quick and straightforward to implement, we would prioritise the implementation of a 9pm watershed on HFSS food and drink. This would help reduce the unhealthy nudges and give choices back to parents. However, this needs to be part of a wider package of government policies which prioritises interventions aimed at reducing unhealthy choices in the obesogenic food environment, including by restricting price and location promotions, having clear labelling and implementing further fiscal policies.

Calls on the marketing of products high in fat, salt and sugar (HFSS)

  1. Cancer Research UK is calling for the UK Government to implement a comprehensive 9pm watershed on HFSS products across linear TV, catch-up and TV on-demand services, and also to adverts online and on social media. This would reduce children’s exposure, support parents to help keep their family healthy, provide a consistent approach for industry, and minimise the risk of displacement of HFSS marketing to other media. For similar reasons, there is a strong case to extend such restrictions to cover cinema, radio, outdoor, direct and experiential marketing; as well as new rules about what is permissible on HFSS packaging too.

 

  1. We support the use of the 2004/5 Nutrient Profile Model (or the latest model when approved), without any exemptions or additional criteria applied, to determine what is ‘less healthy’ and thus unable to be advertised within the restrictions.
  2. For regulating digital marketing in particular, the UK Government and the bodies it delegates regulatory responsibility to should introduce mandatory regulations with clear definitions, update these definitions as media evolve, and require marketing to meet minimum standards of design. This should be underpinned by a strong regulatory system. There is a compelling argument that the UK’s reliance on self-regulation by industry and lack of real consequences for non-compliance is not fit for purpose.[73] We would like to see robust independent monitoring and clear sanctions via formal processes to ensure compliance with restrictions.

Calls on price and location promotion

  1. Given the evidence on the impact of price and location promotions (outlined in question 8), it is vital to help individuals and families to make healthier choices by modifying the options available in retail environments. UK governments should require retailers to ensure that all their volume-based price promotions on food and drink are on healthier products. Manufacturers and distributors should also be restricted from arranging with retailers the promotion of high fat, salt and sugar food in certain locations in the retail environment, including at store entrances, end of aisles and checkout areas. These policies should be as aligned as possible across the four nations. This will reduce (mostly unplanned) purchasing of typically unhealthy foods, saving families money and reducing excess sugar and calories consumed.

 

  1. On price promotions, the restriction of multi-buy price promotions should be prioritised by UK governments in the first instance. We would also like UK governments to commit to a review of the scope of regulations on price promotions two years after their introduction – i.e. using the first two years’ worth of Kantar (or similar) data. This review should consider extending the restrictions to other forms of price promotions such as temporary price reductions. We would encourage UK governments to conduct research on how restricting such planned temporary price reductions on HFSS food and drink would work, as well as any potential impact of these restrictions – including for lower income households.

 

  1. For location promotions, we would like to a see a policy which restricts the placement of HFSS items out of context. Products must be placed with other similar products, and not promoted to consumers in prominent locations or next to other items to drive purchases (e.g. HFSS popcorn with DVDs)

On reformulation

 

  1. Government should drive forward the efforts to reduce high levels of sugar and fat in our food, by getting tougher on companies not meeting the sugar and calorie reduction targets. This would provide a level playing field for all companies.

 

On fiscal measures:

  1. Fiscal and pricing policies have been shown to be effective in promoting healthy behaviours, as tobacco and alcohol taxes, and more recently the sugary drinks tax, have shown. These policies also tend to have progressive health impacts because the consumption of unhealthy products tends to be more concentrated in disadvantaged socioeconomic groups, and because those groups tend to be more responsive to financial incentives. impact.

 

  1. When the Sugar Drinks Industry Levy (SDIL) is reviewed in 2020, the UK Government should commit to extending the levy to sugar-sweetened milk-based drinks and consider tightening current sugar thresholds to encourage further reformulation. The UK Government should also work with devolved administrations to continue to build the evidence on fiscal measures and explore how these policies can aid reformulation and change business and consumer behaviour. 

 

On labelling:

 

  1. It’s important to ensure that the UK stays world-leading in this area and that people have access to clear nutritional information wherever they shop and whatever they buy.

 

  1. The UK Government should introduce mandatory front-of-pack colour-coded nutrition labelling, and mandatory calorie labelling for cafes, restaurants and other out-of-home food outlets.

 

 

14) What can the UK learn from food policy in other countries? Are there examples of strategies which have improved access and affordability of healthy, sustainable food across income groups?

 

 

Policy from other countries:

 

  1. This committee should look at reports which bring evidence from successful dietary fiscal and regulatory measures from other countries:

 

  1. A taxing issue’ looks at international examples where dietary taxation has been considered or successfully applied and considers which could be a viable innovation within the Welsh context.[74]

 

  1. The second report looks at international examples of regulatory marketing systems, and in particular compares the differences between our regulatory marketing system and the one in Chile, finding theirs to be more comprehensive.[75]

 

International law on protecting children:

  1. A report by UNICEF[76] identifies the rights threatened by marketing unhealthy food to children. These are the core rights to health; food; survival and development; education; information; rest, leisure, recreation and cultural activities; privacy; and non-discrimination.
  2. In addition, the United Nations Convention on the Rights of the Child came into force in the UK in 1992. It sets out the rights that every child is entitled to regardless of their ethnicity, gender, language, religion, abilities or any other status. The Convention is a recognition that children need special protections, and that adults and governments must work to ensure these. There is a strong case that these extra protections should include protecting children from exposure to HFSS food and drink advertising. 

 

15

 


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Cancer Research UK

 

12 September 2019