1. The purpose of this submission is to raise awareness of continued and increasing instances of malnutrition. As malnutrition literally means poor or bad nutrition, it is felt that obesity should therefore also be classed as a form of malnutrition, as the cause is often the consumption of too much cheap, high calorie but low nutrient food.
Our submission offers explanations as to the causes and risk factors of malnutrition before outlining some recommendations on potential courses of action to halt the ongoing obesity epidemic.
The key message of this report is that there is no quick fix, and any quick fix policies are almost certainly going to fail.
What is needed are long term, evidence based and largely preventative interventions. This requires cross-party consensus and collaboration because the outcomes of these interventions will frequently outlive the existence of their political architects.
Q. 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?
KEY TO UNDERSTANDING
2. The “microbiome” – the gut flora and fauna that protects us against germs, which breaks down food to release energy, and produces vitamins; is unable to function if bombarded by low quality, high sugar low nutrition food stuffs. This is the equivalent of putting chip fat into a formula 1 car (Nature Communication 2017). Simply put, poor nutrition leads to obesity, a form of malnutrition. Importantly the lack of certain amino acids, in particular choline both reduces intellect, and drives fat into the liver. Children aged 11 to 16 with obesity levels of some 32% are subject to delays in puberty, poor academic performance, psychological damage, fat shaming and bullying.
3. Obesity continues to be an issue that places a great deal of stress on the public health system. While the most recent research seems to suggest that obesity rates may have plateaued or slightly declined, the overwhelming trend over previous decades has been that they are increasing. As figure 1 demonstrates there has been a 10% increase in adult obesity rates in England in a 23-year period, resulting in a population where approximately 1 in 3 adults are obese and close to 60% are obese or overweight. This is despite numerous policy initiatives and research papers highlighting the health implications and attempting to reduce it (figure 2).
(figure 1, NHS ENGLAND)
(figure 2, source Evolution)
4. Perhaps more worryingly, due to the implications it has for physical development and future quality of life, rates of obesity among children are also increasing. Data from Public Health England suggests that childhood obesity has a strong and directional link with deprivation, with those from the most deprived backgrounds are more than twice as likely to be obese at the age of 4-5, than those from less deprived areas.
(figure 3, NHS ENGLAND)
5. Part of this staggering income-obesity differential is access to healthy food including fruit and vegetables. As fruit and vegetable consumption increases, obesity at reception age has been shown to decrease (figure 4), however fruit and vegetables, while healthy, are subject to shortened shelf lives, higher prices, and lower satiation coefficients than unhealthy foods which can be accessed more readily and at a lower cost.
(figure 4 NHS FINGERTIPS DB)
6. The economic cost of obesity today to the UK has been estimated at £27bn rising to £49.9bn by 2050[i], when factors such as sickness, work absence and healthcare utilisation are taken into account. £5.1bn of which is the annual NHS spend on obesity related sequalae. On an individual level, obesity increases the risk of heart disease, type 2 diabetes, cancer and premature death. The failure of previous policies to significantly reduce obesity rates when it is in the interests of individuals and society as a whole is therefore hard to explain, but factors such as lower activity rates, higher consumption of processed and convenience food, the short term nature of many projects and a normalisation and acceptance of an overweight society have all undoubtedly been influences. This is evidenced by figure 5, from data collected in 2018 from Public Health England, demonstrating that Devon is considered a ’green’ or below average location for obesity, despite 60.1% of the population being obese or overweight in Devon. Obesity will continue to be the single
(Fig.5 NHS FINGERTIPS DB)
biggest public health challenges of modern times with some 15 million people in England alone being overweight and / or obese.
7. Malnutrition (not including obesity) has, surprisingly for an economically developed country such as the UK, become increasingly prevalent. According to Purdam et al (2015) three million people in the UK are at risk of malnutrition with £13bn a year spent on diseases related to it. Falling wages and rising house prices since the 2008 financial crisis have been contributing factors affecting access to healthy food for many families, but so too has failing government policy which sees many of the most vulnerable children excluded from initiatives such as free school meals, due to both parents being in work, despite the fact they are still classed as living in poverty. This issue has also been extensively highlighted by the All Party Parliamentary Group on Hunger.
Q. 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? What impact do food outlets (including supermarkets, delivery services, or fast food outlets) have on the average UK diet?
8. One thing that is clear with regards to obesity and malnutrition is the increased incidence of both occurring in lower income and less educated sectors of society. Research has also shown that those people living furthest away from their local supermarket were at greater risk of obesity than those living closer (Cambridge University, 2017), ease of access to affordable nutritious food should therefore be an important consideration for future policy developments. Children in deprived areas are three times more likely to be obese than those in the wealthiest areas, which can be attributed in part to lower participation levels in sport, with children from wealthy areas five times more likely to participate in regular sport than those in the poorest areas (figure 6) but 60 – 100% of weight gain in the UK is attributed to dietary excess according to Bleich et al (2008).
(figure 6, source NHS Fingertips)
9. Due to barriers such as food affordability, food prices and limited access to retail outlets providing affordable healthy food, access to food of adequate nutritional value is limited for many of the poorest members of society. As household budgets become ever more strained dietary choices change with approximately one quarter of the poorest households reporting that they have had to purchase cheaper but less healthy food, and over one third of those households believing that fresh products such as meat and fish were the most unaffordable while one in ten believed that to be the case for vegetables (Corfe, (2018) and Robertson et al (2013)). This is further evidenced by the Social Mobility and Child Poverty Commission Report (2013) that found purchases of fresh produce such as fruit, vegetables and unprocessed meat had declined in the poorest 10% of households while purchases of processed food had increased by nearly one third over the same time period. This increase in more processed and convenience food can be attributed in part to socio-demographic changes such as higher instances of families with both parents working and therefore less time for meal preparation (World Health Organisation). It seems that in many cases, the poorest members of society are eating nutritionally deficient food not through choice but through necessity.
Q. A Public Health England report has concluded that “considerable and largely unprecedented” dietary shifts are required to meet Government guidance on healthy diets.2 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?
Q. 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?
10. While there does need to be a holistic and long-term strategy for dealing with obesity and malnutrition, opportunities to implement effective and more immediate policies should not be ignored.
Available research clearly indicates a higher risk of both malnutrition and obesity when less fruit and vegetables are consumed and also the numerous issues relating to accessing fruit and vegetables in the most deprived areas, the most dominant of which is cost.
Our thesis is that there is an overwhelming economic and social case for policy makers to introduce targeted interventions into the most deprived areas, where cost has been shown to be a barrier to consuming the recommended five a day. The most cost-effective means by which to do that would be to subsidise fruit and vegetables in those areas.
By means of a case-study our health economist drafted an economic model using the following methodology and data from 2018 to demonstrate the impact of pricing and unaffordability on fruit and vegetable consumption :
Most deprived areas
The cost of such a scheme is relatively low when compared to the financial cost the NHS currently encounters in dealing with illness related to malnutrition.
11. There are many examples of policies that are demonstrating signs of having an impact, such as Food Dudes and Healthy Start. However, we strongly recommend a cautious and informed approach should be adopted when considering their role in future policies.
Many cultural, geographic and socioeconomic factors determine their effectiveness and they all need to be considerations when determining new policies and how to implement them.
Information and research, of which there is a great deal, is critical to this process but so too is effective analysis.
Our recommendation is that an analytical framework needs to be developed to allow a better understanding of the following:
Without this framework, policy makers in the UK will continue to rely on short-term solutions. Given the scale of the malnutrition crisis in terms of our health, social mobility and productivity, any such failure to adopt holistic and long-term solutions is sentencing a large proportion of our children and our children’s children to lifelong morbidity and early mortality.
Bleich S, Cutler D, Murray C, Adams A. Why is the developed world obese? Annu Rev Public Health 2008;29:273–295.
Cambridge University (2017) Available at: https://www.mdpi.com/1660-4601/14/11/1290
Corfe, S. (2018). Available at: http://www.smf.co.uk/publications/barriers-eating-healthily-uk/
Evolution, The evolution of policy and actions to tackle obesity in England, Volume: 14, issue: S2, Pages 42 – 59. (2013).
Nat Commun. 2017 Jun 13;8:15691. doi: 10.1038/ncomms15691.
The Lancet, (2010) https://www-sciencedirect-com.libaccess.hud.ac.uk/science/article/pii/S0140673610610604 Public Health England, (2017) Available at: https://www.gov.uk/government/publications/health-matters-obesity-and-the-food-environment/health-matters-obesity-and-the-food-environment--2#targetText=The%20overall%20cost%20of%20obesity,%C2%A349.9%20billion%20per%20year.
Purdam et al. (2015) Available at:
Robertson A, Lobstein T, Knai C. Obesity and socio-economic groups in Europe: evidence review and implications for action. Brussels: European Commission; 2007 (http://ec.europa. eu/health/ph_determinants/life_style/nutrition/documents/ev20081028_rep_en.pdf, accessed 4 December 2013)
SMCPC Social Mobility and Child Poverty Commission, State of the Nation 2013: Social mobility and child poverty in Great Britain, October 2013,p.88
World Health Organisation. Obesity and inequalities: Guidance for addressing inequities in overweight and obesity. World Health Organisation: Regional office for Europe.
Figure 1 – NHS England: Obesity Statistics. Hose of commons briefing paper number 3336. August 2019. Available at: file:///C:/Users/User/Downloads/SN03336.pdf
Figure 3 - NHS England: Public Health England: Fingertips database. Available at: https://fingertips.phe.org.uk/
Mr Simon Leigh (BSc, MSc (Health Econ) – Head of Value and Real World Evidence – Visformatics
Dr Max Noble BSc MSc (Health Econ), Ph.D. - MD Visformatics
Dr David Williams MB BCh MSc Dip Ther DCH FRACGP FACRRM, Chief Medical Officer Visformatics
Mr Hugh Goulbourne – Lawyer, Policy Adviser and Chair, National Right to Food Campaign
Mr Richie Palfrey, BSC Honours in Politics, Huddersfield University (final year)
12 September 2019