Prof Mark Hanson, Dr Chandni Maria Jacob, Dr Christina Vogel, Ms Ravita Taheem, Prof Janis Baird and Prof Keith Godfrey
We fully support and appreciate the government’s initiative to conduct an inquiry into the links between inequality, public health and food sustainability. By adopting a whole of government approach with co-ordinated action across government departments, the outcomes and changes in policies from this investigation have the potential to significantly improve the dietary quality among disadvantaged populations and prevent the rise of childhood obesity and the risk of non-communicable diseases through the life course.
Response to questions for consultation: Responses have been provided to questions 2, 4, 6, 7 and 13 that fall within the expertise of the Institute of Developmental Sciences, Faculty of Medicine, MRC Lifecourse Epidemiology Unit and the NIHR Biomedical Research Centre, University of Southampton.
Q2. 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?
2.1 Unhealthy diets are associated with low levels of income and education (Bates 2019, Robinson 2004), and these dietary inequalities can be exacerbated by unhealthy food environments (Burgoine 2016, Black 2014a). In the UK, there is a strong association between deprivation and childhood obesity, with obesity prevalence in Year R twice as high in the most deprived areas (12.8%) compared with the least deprived areas (5.7%) (Overall prevalence 9.5%). The overall prevalence of obesity is higher in Year 6 (20.1%), showing a similar pattern of high prevalence in the most deprived areas (26.8%) compared with the least deprived areas (11.7%) (NCMP data 2018). Similarly, adults living in the most deprived areas of England are 46% more likely to be obese compared with adults living in the least deprived areas of England (UK Parliament Obesity briefing).
2.2 Actions and targets in the UK Childhood Obesity strategy (2016) have focused on improving weight and physical activity with a focus on school children. According to the World Health Organization’s Commission on Ending Childhood Obesity (ECHO report 2016), adopting a life course approach by providing interventions in early life is crucial to preventing and managing the rising rates of childhood obesity. There is a general consensus that insufficient progress been made on tackling childhood obesity; the ECHO report points to one reason for this being limited focus on policies directed at preconception and the first 1000 days of life, when dietary influences start early in life and can have a lasting impact on physiological processes linked with obesity in later childhood. Major international studies including data from the UK have shown that children of mothers who were overweight or obese during pregnancy are at a higher risk of obesity themselves (Voerman l 2019); other modifiable influences including excessive gestational weight gain, maternal smoking, gestational diabetes and short duration of breastfeeding are also strongly linked with childhood obesity risk (Robinson 2015). Unhealthy eating behaviours and sedentary lifestyles are established during early childhood and track on to adolescence and adulthood. Thus, tackling the problem of childhood obesity requires that adequate attention be given to early interventions. This needs to be supported by programmes for couples and women preparing for pregnancy (in the preconception period), for pregnant women to avoid excessive weight gain during pregnancy, and after pregnancy in preparation for future pregnancies and for prevention and management of diabetes during pregnancy. Training tastes from infancy is especially important, and can be achieved through programmes to support women to breastfeed and for parents to provide healthy weaning foods.
2.3 Furthermore, the preconception period has been identified as an important life stage to improve dietary behaviours because the nutritional status of parents prior to conception can shape the health outcomes of the next generation (Fleming 2018). In England, more than half of all women aged 25-34 years are overweight or obese (Conolly and Byron 2018), and 37% of those aged 18-49 years have very inadequate iron levels (Stephenson 2019); thus indicating suboptimal diets. Adolescents have the poorest diets of any age group in England, with only 8% meeting the 5-a-day recommendations for fruit and vegetables and 16% and 56% having very inadequate folate and iron levels respectively Stephenson 2019). These trends are socio-economically patterned, with obesity and poor diet more extreme among women and adolescents from disadvantaged backgrounds. These groups represent current and future parents. Supporting young women and adolescents to adopt healthy dietary behaviours will have a positive influence on the health of the next generation and reduce levels of nutritional deficiencies and obesity.
2.4 Aside from the Soft Drinks Industry Levy, which is showing promising results, little action has been taken to date by the UK government to address the environmental determinants of poor diet, namely the abundant availability, marketing and affordability of unhealthy foods. Systematic reviews of public health strategies to improve dietary habits have found that information and educational campaigns alone, such as 5-a-day or ‘Change4Life’, have limited effectiveness among disadvantaged groups and may widen dietary inequalities (Lorenc 2013, McGill 2015). It is socioeconomically advantaged, low-risk, populations that are more likely to engage with these types of interventions which rely on rational decision-making and adequate financial and psychological resources to enact these decisions (Adams 2016). We recommend that the government implement, in full, Chapter 2 of the Childhood Obesity Plan because many strategies outlined intent to curb marketing strategies that promote the consumption of unhealthy, ultra-processed food products that contain little nutritional value.
Q4. 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? Are you aware of any existing local authority or education initiatives that have been particularly successful (for example, schemes around holiday hunger, providing information on healthy eating, or supporting access to sport and exercise)?
4.1 Local authorities have a role in promoting healthy eating in their local populations, however competing priorities and budget constraints are important factors that can limit local action. A further consideration is the importance attached to improving the local food environment by local government. Researchers have highlighted that improving the local food environment may not have the same level of importance as other priorities such as preserving green space (Mitchell 2011) which may limit local action. There are numerous examples of local authority initiatives to promote healthy eating among the local population. These often differ between local authorities but range from programmes aimed at childcare providers, schools and workplaces as well as programmes to improve the nutritional quality of food served in fast-food outlets. However, programmes are voluntary and engaging enough settings and organisations to have an impact can be challenging due to the lack of meaningful sanctions or incentives. Therefore, local action needs to be supported by national measures, which could include legislation, incentives or best practice standards to support a wider culture of change.
Q6. What impact do food production processes (including product formulation, portion size, packaging and labelling) have on consumer’s dietary choices and does this differ across income groups?
6.1. UK households have been shown to purchase the highest proportion of ultra-processed foods across 19 European countries. In the UK, more than half (50.7%) all total dietary energy from purchases came from ultra-processed foods, compared to only 10.2% in Portugal and 13.4% in Italy. Furthermore, this research found that across all 19 countries, for each 1% increase in national purchasing of ultra-processed foods, obesity prevalence increased by 0.25% (Monteiro 2018).
6.2. Strategies to improve healthy eating would benefit from a strong focus on reduction in marketing of products (food and drinks) with high levels of extrinsic sugars and calorie content. Advertising and marketing by food industries, high content of sugars and saturated fat in processed food, easy availability and low prices of ultra-processed food are important barriers to healthy eating. There is strong evidence suggesting that marketing affects food choices (Gustafson 2012, Folkvord 2016, Hawkes 2018). Children also receive advertising input from multiple sources including social media, websites, advertisements on TV platforms and YouTube. This is particularly worrying as behaviours established during childhood and adolescence influence lifelong health, and the health of their children.
6.3. A Cochrane review of randomised controlled trials found good evidence for larger portion, package or tableware sizes of food increasing the quantities of food consumed among children and adults. The size of this effect suggests that, if sustained reductions in exposure to larger‐sized food portions, could be achieved across the whole diet, average daily energy consumed from food would decrease by between 144 and 228 kcal among UK children and adults (Hollands 2015). There is some evidence showing that individuals with lower socioeconomic status intend to eat more from larger than smaller portion sizes. It remains unknown, however, how interventions that reduce exposure to larger‐sized portions impact on existing dietary inequalities.
Q7. 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?
7.1. Our research with women of lower educational attainment and poorer quality diets in Southampton, a deprived city in the affluent south of England, highlighted a number of environmental factors that make it difficult for them to adopt a healthy diet (Barker 2008). These barriers include the easy and abundant access to takeaway food outlets, the higher cost of healthy foods compared to unhealthy foods, and that unhealthy foods were perceived as good value for money because of the marketing strategies such as multi-buys and price reductions on these products. These women are describing the modern food environment which is obesogenic, and encourages overconsumption of unhealthy foods.
7.2. There is good evidence across high-income countries that takeaways outlets are more prevalent in disadvantaged than more affluent neighbourhoods (Black 2014). Research in the UK has identified that takeaway outlets have increased by 45% in the past 2 decades, with the greatest increase in areas of high deprivation results in increased disparities over time (Maguire 2015). Our own research in Hampshire found that most children aged 6 years had more than 10 fast food outlets in the 800m radius around their home and school, and had some had more than 50 outlets (Barrett 2017). Furthermore, research examining the consumption of takeaway foods among adolescents aged 11-14 years in deprived London boroughs, found that over half reported consuming foods from takeaway outlets twice or more per week. Rather alarmingly, 10% of these adolescents reported consuming a food or drink item from these outlets every day (Patterson 2012). Cheap takeaways outside schools and in deprived areas are likely to be negatively influencing the diets of young people.
7.3. Customer’s diets are also influenced by practices that occur in the in-store environment of retail and foodservice outlets. The four P’s of marketing (product, price, placement and promotion) are frequently used by businesses because they provide a set of techniques for promoting a brand or product’s unique selling points and achieving an advantage over competitors. These techniques are subtle, invoking unconscious reactions from consumers to these environmental stimuli (Marteau 2018). There is good scientific evidence that positioning products in prominent locations, like the front entrance, end-of-aisle or islands, and increasing the availability or shelf-space of a product achieves greater sales of these products (Hollands 2019, Bucher 2016). Our previous research of more 600 food retail stores in Hampshire revealed that discount supermarkets, small supermarkets and convenience stores had greater availability, price promotions and prominent placement of unhealthy foods than healthy foods (Black 2014b). This is concerning because these types of stores are also used more regularly by disadvantaged families and younger adults who have poorer dietary behaviours. Observational research in England has shown that exposure to unhealthy food environments could be exacerbating dietary inequalities. In Cambridgeshire, an association between greater exposure to takeaway outlets around home, work and the route between these two locations and higher body weight status was observed to be most pronounced for adults with low levels of educational attainment (Burgoine 2016). In Hampshire, our work found that compared to women with higher educational attainment, the diets of women with lower educational attainment are more affected by unhealthy supermarket environments (Vogel 2016). These findings provide some support for the concept of ‘deprivation amplification’ which purports that individual circumstances of deprivation, such as lower levels of education and income, can be amplified by environmental surroundings and indicate that unhealthy food environments may be exacerbating dietary inequalities.
7.4. The marketing strategies adopted to promote sales of unhealthy foods may be providing these food outlets with a competitive business advantage but are also likely to be intensifying the current public health crisis of poor diet and obesity. We applaud the UK government for its intention in chapter 2 of the Childhood Obesity Plan to introduce legislation that will control the pervasive use of marketing techniques to promote the consumption of unhealthy foods across the whole of the retail and out-of-home food sectors. This legislation will help customers to choose more healthy foods and create a level playing field for businesses to help curb economic practices that promote overconsumption. There is consistent evidence that healthier diets cost more and that disadvantaged families spend proportionally more of their income on household food than more affluent families. Trials in supermarkets have shown that 20-50% subsidies on fruit and vegetables can prompt increases in purchasing and consumption of these products (Ball 2015, Waterlander 2013, Brimblecombe 2018). There may be scope for the government to consider introducing subsidies on fruit and vegetables in an effort to increase consumption and the proportion of the population meeting 5-a-day.
Q13. 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. Current evidence on the importance of maternal health and early years on lifelong health, and the health of the next generation, has not been incorporated adequately into policies such as the UK government’s’ childhood obesity prevention strategy. The UK healthy eating guidelines are also unachievable for many people due to financial or cultural issues (Scott 2018). An integrated and multisectoral approach based on evidence from public health, environment and urban planning, food systems and education is essential. It is crucial that interventions to improve nutrition should not widen the gap further. To reduce inequalities in diet and obesity and to promote healthy eating at a population level, future policies could consider strategies such as restrictions on the marketing of unhealthy foods, controlling product placement strategies used by retail and foodservice outlets and enhance the prominent placement of healthier or non-food alternatives, restricting price promotions on unhealthy products and on the density of takeaway outlets in deprived areas, and introducing subsidies for fruit and vegetables.
13.2. Adopting a long-term vision by tackling inequalities in diet and health from early life is central to preventing obesity and non-communicable diseases such as diabetes. Public health programmes to improve nutrition and achieve a healthy weight needs to focus on women’s and adolescents’ health and lifestyle before and during pregnancy. The recommendations of the WHO ECHO report and the implementation plan (2017) can support efforts to reduce the increasing levels of overweight and obesity among children in the UK.
Prof Mark Hanson, Dr Chandni Maria Jacob, Dr Christina Vogel, Ms Ravita Taheem, Prof Janis Baird and Prof Keith Godfrey
1 October 2019