Impact of physical activity and diet on health - Health Contents


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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Prepared 25 March 2015