4 Diet and obesity—reforming
the food environment
"Normalisation"
of overweight and obesity?
95. Some two thirds of the adult population are now
overweight or obese. Public Health England argue that "excess
weight is now considered a social norm in England" and that
"this has potentially de-sensitised people's judgements about
their own weight, and that of their children."[116]
However, in the view of Professor Susan Jebb, most people
who are overweight would like to lose weight, and need better
support to enable them to do so:
Without doubt, overweight is now the average,
the typical, the normal. But I do not believe personally that
that is making the problem worse. The reality is that most people
who are overweight would like to lose weight. There are a few
who profess to be very happy the way they are, but the vast majority
of people who are overweight would like to lose weight. We need
to support and enable them to do that. One thing that we do know
is that people respond much better to a supportive structure than
they do to criticism, discrimination and so forth[117]
96. The Committee noted the changes in dress sizing
over the years which may have helped to normalise this.
NHS prevention and treatment
services
97. The NHS has a role to play in both preventing
and treating obesity and overweight. However, as highlighted by
the NHS Forward View, "it makes little sense that the NHS
is now spending more on bariatric surgery for obesity than on
a national roll-out of intensive lifestyle intervention programmes
that were first shown to cut obesity and prevent diabetes over
a decade ago."[118]
Professor Jebb reinforced this point in her oral evidence:
There is absolutely a place for bariatric surgery,
for sure, as we have heard, and I am not going to continue that
theme. I would also remind you that weight losses of maybe 20
kilos in an individual really makes you sit up and take notice,
and that would be very typical after bariatric surgery. But that
is one individual and we should not underestimate the benefit
of having 10 people who all lose 2 kilograms because, again, at
a public health level, that is going to bring similar health benefits.
So we need a mixed economy and we need these tiered kinds of services
where we are intervening earlier, before problems get more serious,
with some of these less expensive, more behavioural interventions,
which hopefully achieve some weight loss but, crucially, if they
are following good practice, because they are founded on getting
people to improve their diet and to become more physically active,
will have the other independent health benefits that come from
changing those fundamental behaviours. We have to see what I call
behavioural weight management programmes as being that hybrid
of preventing chronic disease associated with obesity but also
treating the early stages of overweight and obesity. I think they
are much underused…We are missing opportunities to intervene
earlier with behavioural weight management programmes. Linking
it into health checks is an absolutely prime opportunity to do
that.[119]
98. Public Health England and the Academy of Medical
Royal Colleges were amongst many to support the need for further
investment in lifestyle weight management services.
Sufficient evidence on the benefits of weight
loss exists to justify the continued development of and increased
spend on locally commissioned lifestyle weight management services.
There is, however, an unmet population need for weight loss support
and sustaining a healthier weight. This places a significant pressure
on local commissioning of obesity services and is a burden exacerbated
by the continuing financial issues that local authorities are
facing. Compounding this is evidence that access to lifestyle,
complex behavioural obesity services and bariatric surgery differs
across localities. The future direction of these services therefore
requires prioritisation and PHE acknowledges there remains significant
work to be done to ensure national strategy and investment enables
local delivery.[120]
The health departments in the four nations should
together invest at least £100m in each of the next three
financial years to extend and increase provision of weight management
services across the country, to mirror the provision of smoking
cessation services. This should include both early intervention
programmes and, greater provision for severe and complicated obesity,
including bariatric surgery. Adjustments could then be made to
the Quality and Outcomes Framework, providing incentives for GPs
to refer patients to such services.[121]
99. According to Public Health England,
there is an unmet population need for support for weight loss
and sustaining a healthier weight. NICE have recommended cost-effective
interventions in this area and we recommend that these are funded
and implemented as a matter of urgency. The Committee regards
it as inexplicable and unacceptable that the NHS is now spending
more on bariatric surgery for obesity than on a national roll-out
of intensive lifestyle intervention programmes that were first
shown to cut obesity and prevent diabetes over a decade ago. All
tiers of weight management services should be universally available,
and need to be well integrated.
Reforming the food environment
100. While there is clearly a role for NHS services
to prevent and treat overweight and obesity, our evidence overwhelmingly
highlighted the importance of the food environment. Professor
Susan Jebb told us that:
On the prevention side, there is a lot of work
going on around diet in terms of information for people, but we
are not changing the environment. We have absolutely got to look
at some of those more fundamental structural measures, and I come
back to the issues I raised at the very start about looking at
the sheer availability and accessibility, and one might also add
the affordability, of food. In spite of recent price rises, the
reality is that food today is very cheap…The question should
be: what are the policy levers which are going to make that happen?
That is an incredibly important discussion to have, about how
you drive change within the food industry.[122]
101. The Public Health Minister told us that she
was strongly in favour of re-setting the nation's 'default', to
make healthy choices easier and more automatic:
The idea of setting the nation's default is absolutely
vital. I hesitate to say this, but I think that we are at a bit
of a national turning point. The publication of the Five Year
Forward View for the NHS, putting public health and prevention
at the heart of sustainability for our health services—right
there as part of that strategy—is a really important moment.
It set off a really big, grown-up national conversation about
prevention and feeds into all of the work that PHE is doing.
You can see in so many other ways that it leads
to other conversations. We have the £8.2 billion of ring-fenced
money that local government has had around public health. Suddenly
we are all beginning, essentially, to have the same conversation.
That does not mean that we have not got an awfully long way to
go, but it feels like the beginning of a really important national
conversation, where everyone is saying, "What can we do at
family level, individual level, corporate level and Government
level?"[123]
102. A key plank of the Government's action to improve
the food environment has been its Public Health Responsibility
Deal. The Responsibility Deal is a voluntary partnership through
which the Government asks organisations to make 'pledges' of action
to improve public health. Most of our witnesses expressed the
view that while some progress had been made, under the Responsibility
Deal, this was not enough. Dr William Bird put it bluntly:
Have they been successful? No. We still have
hospitals that have certain shops at the front of the hospital.
We still have the sugary drinks. We have all these things still
pushing against our efforts to move things forward, so I do not
think it has been successful.[124]
103. Sue Davies of Which? argued that
There is a lot of consistent evidence showing
where action is needed on things like product reformulation, access
and affordability of products, looking at things like promotions
and consistent labelling. That is something, through the Responsibility
Deal, on which there have been some discussions, but our concern
is that the pace of change and level of action across the board
have been far too slow given the scale of the problem that we
are facing and need to tackle.
We found it quite a frustrating process. It has
achieved some things. Some of the areas where it has achieved
change are things that were already in train to some extent. The
saltreduction work has been really positive and there have
recently been some 2017 saltreduction targets published.
But there are still quite a few big players, particularly on the
manufacturing side, that have not committed to those targets yet.
There has also been some progress on things like removing trans
fatty acids and outofhome energy labelling in things
like fast food restaurants, but on some of the more contentious
issues the Responsibility Deal has found it hard to make progress.
There is a caloriereduction pledge, but
that is a very vague, woolly, toolkittype approach. What
we wanted to see was more specific targets around reducing sugar
and saturated fat in products, recognising that that probably
was not as straightforward to do as reducing salt, but making
clear what were the key product categories where there needed
to be more reformulation.
The really big issue still is tackling promotions,
both in terms of promotions to children but also promotions within
supermarkets, whether that is about product positioning or price
promotions. Because that is such a contentious and difficult issue
for the food industry, it is very difficult to make any progress
through the Responsibility Dealstyle mechanism.
The other positive thing…is the rollout
of trafficlight nutrition labelling, which, as Susan Jebb
said, is a significant step forward. Hopefully, by the end of
this year it will be very visible. Some of those that have committed
have not actually put it on pack yet but it will be very clear
with two thirds of the market providing it. That was something
that was sparked by a regulatory initiative—the review of
the food information regulations at EU level—rather than
necessarily being through the Responsibility Deal.
Overall, we think it has achieved some things,
but it is not really doing enough in enough areas. There are still
some companies that do not join in and play their part. For those
that do not do that there is no sanction. So, if you do not sign
up to it, nothing really happens and you are just invisible.[125]
104. Jane Landon of the UK Health Forum told us that:
On the overall approach of the Responsibility
Deal, it has been an interesting natural experiment. It has demonstrated
some of the limits of voluntarism. That is useful because we know
what we can achieve under a voluntary approach and also what we
cannot achieve. The risk is that we see it as a substitute for
regulation rather than as a complement. It was always intended
to be complementary to a whole range of other policies, and it
has ended up rather isolated as being the only show in town. We
cannot hang all our expectations, in terms of all the things we
need to achieve on diet and physical activity, on voluntary pledges.
105. We have heard that the Government's
Responsibility Deal has achieved some successes, but should be
seen as a complement to regulation rather than a substitute for
it. We agree with the UK Health Forum, that we cannot hang all
our expectations in terms of all the things we need to achieve
in public health on voluntary pledges.
LABELLING
106. Several of our witnesses discussed the adoption
of a traffic light nutrition labelling system, prompted by the
labelling changes required by the EU's food information to consumers
regulations, with Which? describing it as "a significant
step forward". It is estimated that two-thirds of products
will carry the scheme over the next few months.[126]
Jane Landon argued that a public information campaign was now
needed to explain and reinforce the scheme.[127]
107. Progress has been made on introducing
a traffic light nutrition labelling system. We recommend that
Public Health England backs this up with a campaign to explain
and reinforce this scheme to the public to assist them in using
the new labelling to make healthy food choices.
REFORMULATION
108. Professor Jebb also mentioned the frontofpack
labelling scheme, but highlighted the limitations of labelling,
arguing that its impact assumes people will "get to the point
where they are interested enough to look at the label." She
went on to argue that "within any food category there is
a whole range of fat and salt content. Let us take sausages. Not
all sausages are the same; some sausages have far more fat and
salt than others. What can we do to ensure that the rest are as
good as the best, so that we have a much healthier sausage market
in general? The same applies, of course, for every other category
of food."[128]
109. As discussed above, work on salt reduction has
been described as a success; however, Which? argues that saturated
fat and calorie reduction pledges "have not had such wide
take up" and have been "more limited in scope".
Discussing this further in oral evidence, our witnesses told us:
We think, as you say, that the saltreduction
targets have been very positive. There was a bit of a delay and
we had them in 2010, 2012 and then 2017, but at least it means
that the whole approach, which is about gradual reduction so that
you are lowering salt across the whole of a product category so
that people's tastes adjust and they are not aware that they are
eating less salt, is continuing. It is important that those manufacturers
and retailers that are not signed up commit to it. We would like
to see a similar approach for sugar and saturated fat. We recognise
that it might not be as straightforward as it has been with salt,
but the key thing is to look at those product categories that
make the most significant contribution with sugar and saturated
fat to people's diets—things like soft drinks, for example—and
then look at the scope for reductions, but again setting targets
so that you have the whole industry acting together so that consumers
are getting gradual reductions rather than tasting one product
and thinking, "That tastes much better. I am going to buy
that rather than that product." We have to be careful. If
it is done too quickly and it puts people off the food, then it
will be counterproductive.
The salt reduction programme has shown how it
can be achieved and the importance of gradual reductions to maintain
taste with salt. With sugar and fat, there are some technical
issues about how they act together in certain products, particularly
baked products. If you reduce one, the chances are that the other
may rise. When we are talking about some of the discretionary
foods that are high in sugar and fat—the cakes and the biscuits—the
messaging is more about how much is appropriate to eat rather
than simply tinkering round the edges and making them least worst.
As to foods where people are not expecting to find sugar—for
example, in ready meals—clearly there is a good argument
that there should be reformulation, as well as making the sugar
transparently clear on the label but also to reduce that. People
are not expecting to find sugar in ketchup, in ready meals, pasta
dishes, curries and sweet and sour dishes—or maybe yes in
sweet and sour dishes, but they are very high in sugar sometimes.[129]
110. Dr Mike Knapton of the British Heart Foundation
highlighted sugary drinks as a "relatively simple area that
you could make a big difference on"[130]
Dr Alison Tedstone of Public Health England agreed, describing
reformulation of fizzy, sugar-sweetened drinks as "'low hanging
fruit'. Sugar is not as easy as salt in some respects, because
it has functionality in some foods. In fizzy drinks, it is just
sweetening the drinks."[131]
111. While we welcome the changes to labelling we
have heard about during the course of this inquiry, as one of
our witnesses told us, the effectiveness of labelling depends
on "people [being] even interested enough to look at the
label." Reformulation—altering the composition of foods
to make them healthier—offers significant potential to improve
diet, and progress has been made in lowering the salt content
of foods. Lowering saturated fat, sugar, or overall calorie content
are all further ways in which foods could be reformulated.
We recommend that Public
Health England should take the lead by introducing clear targets
for reductions, and the Government should use regulatory measures
to enforce this, if voluntary approaches do not yield swift progress.
The Committee strongly recommends that the first focus of this
work should be on reducing the sugar consumed by children in sugar
sweetened drinks.
MARKETING AND PROMOTION OF FOODS
TO CHILDREN
112. An area that was frequently raised in our written
evidence was the marketing and promotion of unhealthy foods to
children. The UK Health Forum and the British Heart Foundation
both call on the Government to:
Address unhealthy food promotion in the retail
environment and extend restrictions on TV advertising of high
fat, sugar and salt (HFSS) food and beverages to children up to
the 9pm watershed. Strengthen restrictions on all forms of HFSS
food marketing and promotion to children in non-broadcast media.[132]
113. Which? gives further detail:
Ofcom restrictions limit TV advertising for unhealthy
foods (foods high in fat, sugar or salt or HFSS) during programmes
of particular appeal to children up to 16. The Broadcasting Code
of Advertising Practice (BCAP) places some additional restrictions
on the content—and the Committee of Advertising Practice
(CAP) Code which covers non-broadcast techniques includes some
restrictions for younger children. Several companies have also
signed up to an EU Pledge on food marketing to children. Despite
these initiatives, many gaps still remain in terms of the media
used, age of the children protected and nature of promotions considered
to be targeted to children. This therefore needs to be addressed
in order to ensure that food marketing to children complements
rather than undermines education initiatives and healthy eating
advice.[133]
114. Dr Tedstone gave further explanation of these
problems:
We know that, when Ofcom introduced regulations
around the control of advertising of foods to children in children's
programmes, it meant that for a while children were exposed to
fewer ads, but they moved outwards. What happened was that they
moved further away. Those Ofcom controls worked in terms of what
they were intending to do, but the industry was ahead of them.
That was some years ago. We should think more broadly about the
lessons learned from that to take it more broadly.[134]
115. The evidence we have received
has also called for wider restrictions on promotion of unhealthy
foods to children-in both broadcast and non-broadcast media, particularly
social media. We recommend that the next Government takes steps
to stop the marketing of unhealthy food and sugary drinks to children.
PORTION SIZE
116. The British Heart Foundation raises the issue
of portion size:
Variation of portion size also presents a significant
challenge to individuals trying to maintain a healthy diet. As
demonstrated in the BHF report Portion Distortion, portion sizes
have increased dramatically between 1993 and 2013. The UK Government
has not updated its information on typical portion sizes for 20
years and there is currently no legislation on this issue. We
would like to see an urgent review of this by the Government.[135]
117. Developing this in oral evidence, Dr Mike Knapton
told us that "we basically think that there should be a review
to inform both consumers and industry about the production of
food and what sensible portion sizes are to have a healthy diet
in terms of calories and nutrition intake."[136]
Sue Davies of Which? added that
You have the problem at one end where sometimes
you will get a really unrealistic portion size to make the labelling
look better. Something that you might think is one portion, when
you actually look at the small print, is two portions. Then there
is also the situation, particularly when you are in the outofhome
sector, as you mentioned, that when you are at service stations
or train stations you often only get the large portion when you
actually want a smaller portion[137]
PRICE PROMOTIONS
118. Which? was also among many organisations that
called on retailers to use price promotions responsibly and make
it easier for consumers to choose healthier options, noting that
food promotions was the area where there had been least action.
Food promotions stand out as the area where there
has been the least action. This has always been a difficult area
to tackle through voluntary commitments alone and the Responsibility
Deal has initiated very little action. A few retailers have made
commitments to take sweets off checkouts, but the majority still
continue with this practice. Supermarkets, with the exception
of Sainsbury's and The Cooperative, do not have policies for the
balance of healthy and less healthy foods they include within
price promotions.[138]
119. Sue Davies gave further detail on this in her
oral evidence:
There are a huge amount of products that are
on promotion at the moment. When we asked the supermarkets if
they had policies for what they included in those promotions,
only the Cooperative and Sainsbury's told us that they had
actual targets, and their targets were only for about a third
of the products on promotion to be healthy. The others would not
give us them or they did not have them. That is a really important
area to tackle given that so many people are drawn to them.
It is probably about getting more of a balance,
because sometimes people will want to buy particular treats and
at the moment it is too much weighted towards the unhealthy food.
Perhaps ruling them out completely on unhealthy promotions might
be difficult, but there are certain areas such as the slightly
iconic things like the sweets at checkouts where quite a
few of the supermarkets seemed to make commitments about 10 years
ago but have gone back on those. Also, a lot of other types of
outlets promote chocolate at the checkout, when you are
buying a newspaper and that kind of thing as well. That whole
area is another one that can easily be tackled.
When we have asked people, the majority say that
they think they should stop sweets at checkouts and the
majority of people say that they want more promotions on healthier
products. We have not specifically asked them if they should be
ended altogether, but there is definitely a lot of support for
changing the balance and using the price promotions to help them
make healthier choices.[139]
120. Professor Theresa Marteau provided further detail
of research on position of products in her written evidence:
Availability is ranked third in the recent McKinsey
report (Dobbs et al 2014) for cost-effectiveness at reducing the
burden of obesity. We recently completed the first study aimed
at estimating the effect size of placing of products on aisle
ends in supermarkets (Nakamura et al., 2014). End-of-aisle displays
are often used by supermarkets to promote sales. We used data
from one supermarket in the UK (derived from 43,000 trolleys)
to establish the effect of displaying different types of drinks
on aisle ends (Nakamura et al., 2014). Placing products on end-of-aisle
displays substantially increased sales of drinks, to the extent
that altering these displays may have as much impact as some pricing
interventions currently being considered by policy-makers.[140]
121. Professor Susan Jebb, in her Chair's blog on
progress of the Responsibility Deal on food, highlights food promotion
as an area where now stronger measures are needed:
Another important lesson has come from our failure
to agree a generic commitment on responsible promotions. I recognise
these are tough economic times for businesses and that promotional
activity goes to the heart of business competitiveness. But nonetheless
80% of consumers are looking for a healthier diet and a collective
pledge would have sent a strong signal that food businesses in
England are putting health at the heart of their business strategy.
However, I do welcome the individual examples of companies using
their marketing resources to support other pledges within the
RD, such as the promotion of products with less saturated fat,
sugar or salt. I am also pleased to see that the movement towards
sweet-free checkouts is building, but the lack of a collective
pledge is disappointing.
But the effort to find a deal on promotions has
not been in vain. I firmly subscribe to the view that regulation
should only be deployed when other approaches have failed. We
have given voluntary agreements to control the promotion of unhealthy
options the best possible opportunity to fly, but we now need
to look to harder policy options to secure progress. The challenge
for public health is to identify the very precise aspects of marketing
which can be controlled in a way which leads to public health
benefit.[141]
122. The area on which we have heard
the least progress has been made, but one which has the potential
for a significant impact on diet and health, is retail price promotions
on food. Voluntary agreements have been tried, but now we need
to look to harder policy options to secure progress. We recommend
that the next Government commissions either Public Health England
or NICE to review policy options in this area as a matter of urgency.
FISCAL POLICIES
123. We also received a considerable number of submissions
calling for the introduction of fiscal policies to promote healthier
diets, notably taxes on sugar, or specifically on sugar-sweetened
drinks. Using taxation to influence food choices is controversial.
As an earlier Health Committee noted in its 2004 inquiry on obesity,
the notion of taxing unhealthy foods is fraught with ideological
and economic complexities.[142]
However, the written evidence we received suggests that there
is a strong interest in at least exploring the possibility of
using fiscal measures to incentivise healthier food choices. Professor
Nick Wareham cited the example of Mexico:
There is evidence from countries like Mexico
of a 10% taxation on sugar-sweetened beverages giving rise to
a 10% reduction. I am not suggesting that these are instant fixes
or that the evidence base is perfect, but at least it ought to
be talked about.[143]
124. Fiscal policies can have an impact beyond taxation;
the possibility of introducing subsidies for healthy foods could
also be explored, and, as Professor Wareham pointed out, there
is a need to look at the impact of a broad range of policies on
food pricing and availability:
We have to move beyond the label, up the food
chain and right back to the source of the foods. There is a really
important illustration of that right now in that we are all concerned
about sugar, but the European Commission, through the CAP, is
regulating sugar within Europe through the import tariffs, price
guarantees, production quotas and export subsidies. They are about
to make changes which they themselves estimate will increase the
amount of highfructose corn syrup threefold and will drop
the price of sugar. While it is very important for us to talk
about education and labelling, we do have to think about these
market influences which are going to have a major impact on the
constituency of food in Europe.[144]
125. We have received evidence from
organisations supporting the introduction of a tax on sugar-sweetened
drinks. We look forward to the publication of Public Health England's
review of the evidence base for introducing a sugar tax, which
is expected later this year, and we do not seek to pre-judge its
outcome. We welcome the fact that Public Health England is carrying
out this review. Given the scale of the public health challenge
and growing health inequalities we urge the next government not
to shy away from difficult decisions around proportionate regulation
if these are supported by the emerging evidence.
116 Public Health England (IDH0063)
para 30 Back
117
Q31 Back
118
NHS England Five Year Forward View (October 2014), pg 11 Back
119
Q72 Back
120
Public Health England (IDH0063)
para 41 Back
121
Academy of Medical Royal Colleges (IDH0038) para 4.II Back
122
Q72 Back
123
Q253 Back
124
Q337 Back
125
Q90; q92 Back
126
Which? (IDH0097) para 14 Back
127
Q100 Back
128
Q53 Back
129
Q107 Back
130
Q107 Back
131
Q253 Back
132
UK Health Forum (IDH0081) p1; British Heart Foundation (IDH0050)
para 10 Back
133
Which? (IDH0097) para 17 Back
134
Q271 Back
135
British Heart Foundation (IDH0050) para 11 Back
136
Q104 Back
137
Q106 Back
138
Which? (IDH0097) para 16 Back
139
Qq108-111 Back
140
Professor Theresa Marteau (IDH0073) p3 Back
141
Susan Jebb, New Year message, Responsibility Deal blog, Department
of Health website. Accessed 18th March 2015. Back
142
Health Select Committee, 2004, "Obesity: Third Report of
Session 2003-04", Volume I, HC 23-1, pg 113 Back
143
Q73 Back
144
Q53 Back
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