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Recipe for health: a plan to fix our broken food system Contents

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Recipe for health: a plan to fix our broken food system

Chapter 1: Diagnosing the problem

The shocking scale of the problem

1.The country is facing an epidemic of unhealthy diets, obesity and diet-related disease. Obesity has overtaken tobacco as a risk factor for disability in England, causing major health conditions including cardiovascular disease, cancer and type 2 diabetes.1 After tobacco, diet-related risks now make the biggest contribution to years of life lost.2 Beyond the toll to human life, this costs society billions each year in healthcare costs and lost productivity.3

2.The trends and statistics on obesity are shocking. The Department of Health and Social Care (DHSC) states that, among adults:

• The UK has one of the highest adult obesity rates both within Europe and among high income countries.
• From the late 1980s, the prevalence of adults living with obesity has risen faster in the UK than the European average.
• Two-thirds of adults (64%) are classified as living with overweight or obesity. Among adults, 29% are living with obesity.
• Obesity prevalence among adults is highest in the most deprived areas (36%), and lowest in the least deprived areas (22%).

3.The statistics are even more startling among children:

• Data indicates that 21.3% of children start primary school living with overweight or obesity, rising to 36.6% by the time they leave.
• The prevalence of obesity in children in England is more than twice as high among children living in the most deprived areas than those living in the least deprived areas.
• Children living with obesity are approximately five times more likely to be living with obesity in adulthood, and more likely in turn to be parents living with obesity.4

Figure 1: Chart showing BMI categories in relation to height and weight

Source: Healthy Weight Grampian, BMI Chart: https://www.healthyweightgrampian.scot.nhs.uk/on-line-training/toolkit-materials/getting-started-2/bmi-chart/ [accessed 20 September 2024]

Box 1: Overweight and obesity

Overweight and obesity are typically defined using body mass index (BMI). This is a person’s weight divided by the square of their height (kg/m²). A person is classed as ‘obese’ if their BMI is 30 or higher, and BMI is marker of excess body fat (adiposity). Because BMI focuses on weight, it does not distinguish between fat and other kinds of tissue, cannot be used for pregnant women, and can be inaccurate for people with a lot of muscle (e.g. athletes, bodybuilders) or older people. However, BMI is generally considered the most useful metric for tracking rates of overweight and obesity in the population as a whole because it is a non-invasive assessment, relatively simple to measure and inexpensive. The prevalence of childhood overweight and obesity in England is measured in the National Childhood Measurement Programme (NCMP). Local authorities measure children’s height and weight annually in reception (ages 4–5) and year 6 (ages 10–11) and report this as BMI prevalence standardised for childhood populations.5 The Health Survey for England provides estimates of adult obesity based on the BMI of a representative sample of people from aged 16.6

Source: House of Commons Library, Obesity policy in England, Research Briefing CBP 9049, 20 June 2023; Q 98 (Professor Maria Bryant)

4.Obesity is a rapidly growing global problem. More than a billion people worldwide are estimated to have been living with obesity in 2022, with the rate of childhood and adolescent obesity four times higher than in 1990.7

Figure 2: Prevalence of obesity among adults, G7 countries and Brazil, 1990–2022

Source: World Health Organization, ‘The Global Health Observatory’, 2024: https://www.who.int/data/gho/data/indicators/indicator-details/GHO/prevalence-of-obesity-among-adults-bmi--30-(age-standardized-estimate)-(-) [accessed 26 September 2024]

The key drivers of obesity

5.DHSC states that:

“Obesity is caused by a combination of complex genetic and physiological factors, mediated through environmental and socioeconomic factors impacting over a life course. It is subject to influences ranging from the individual level (e.g. individual choices, calorie requirements, access to facilities and knowledge about cooking) to the system level (e.g. advertising, pricing). However, weight is gained when energy from food and drinks consumed is greater than that expended to maintain our bodies and through physical activity. Excess calories are stored in the body mainly as fat.”8

6.Unhealthy diets are generally considered the primary driver of overweight and obesity. DHSC told us that on average, the UK population is exceeding the recommendations for saturated fat, salt and sugar, and not meeting recommended intakes for fibre, fruit and vegetables and oily fish. People in lower income groups generally eat a less healthy diet; however, all income groups fail to meet dietary recommendations on average.9 The Government has estimated that adults consume on average 200 to 300 excess calories per day.10

Box 2: A healthy diet

There is scientific consensus that a diet high in fruits, vegetables, legumes, nuts, seeds and whole grains as well as fibre and low in foods high in fat, salt and sugar supports health and helps protect against diabetes, cardiovascular diseases, stroke and cancer. The Government publishes dietary recommendations setting out reference intakes for energy and nutrients, based on evidence from the Scientific Advisory Committee on Nutrition (SACN). The Eatwell Guide published in 2016 offers dietary advice to the public, setting out what proportions of different food groups should be eaten to meet the dietary recommendations. The National Diet and Nutrition Survey provides data on food consumption, nutrient intake and nutritional status in the UK through a continuous, cross-sectional survey. While we describe healthy and unhealthy foods and diets in broad terms in this report, in Chapter 5 and elsewhere we make recommendations on the specific regulation of ‘less healthy’ or high in fat, salt and sugar (HFSS) food, and of ‘healthier food’. In that context, we mean as defined by the Nutrient Profiling Model.11

Source: World Health Organisation, ‘Healthy diet’ (2020): https://www.who.int/news-room/fact-sheets/detail/healthy-diet [accessed 7 October 2024]; Office for Health Improvement and Disparities (OHID) ‘The Eatwell Guide’ (updated 2 January 2024): https://www.gov.uk/government/publications/the-eatwell-guide [accessed 7 October 2024]; and written evidence from DHSC (FDO0052)

7.DHSC cites evidence that dietary choices and behaviours are influenced by the food environment, which in the last 30 years has witnessed “substantial change and increase in the numbers, types, production, availability and marketing of processed food such as ready meals, savoury snacks, pizza, ice cream and desserts, many of which are calorie dense or high in salt, saturated fat, and sugar.” The food industry spends a disproportionate amount on marketing of unhealthy foods compared to healthier foods, such as fruit and vegetables.12

The health costs of obesity

8.DHSC notes that excess weight and poor diet increase the risk of a range of health conditions including cardiovascular disease, type 2 diabetes, some cancers, non-alcoholic fatty liver disease13 and musculoskeletal issues such as osteoarthritis. Those who are living with obesity are also more likely to suffer from poor mental health.14

9.Excess weight in childhood or adolescence is likewise associated with increased risk of type 2 diabetes, coronary heart disease, high blood pressure and some cancers. Children and adolescents living with obesity are also at risk of poor mental health and low self-esteem.15 Evidence suggests that individuals are being diagnosed with Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD) at a much earlier age. A recent study showed that one in five young adults had fat accumulation within the liver.16 Anna Taylor, Executive Director of the Food Foundation, told us: “we used to call type 2 diabetes ‘late-onset diabetes’; it was never seen in children before the year 2000, when the first eight cases of paediatric type 2 diabetes were recorded.”17 The National Paediatric Diabetes Audit reported that 1,206 children in England were receiving care for type 2 diabetes from paediatric diabetes services in 2022/23.18 Poor nutrition also hinders healthy development, with UK five-year-olds now shorter than counterparts in nearly all high-income countries.19

10.The number of type 2 diabetes diagnoses doubled in the 15 years up to 2021. Over 85% of people diagnosed with type 2 diabetes are living with overweight or obesity. Excess weight is the second biggest preventable cause of cancer, after smoking. Over one in 20 UK cancer cases are due to excess weight. Obesity has been predicted to overtake smoking as the main preventable cause of cancer in women by 2043.20 The World Cancer Research Fund International explained that obesity is an established major risk factor for 13 different types of cancer, including common cancers like breast and colorectal cancer.21 Cancer rates in 25 to 49-year-olds in the UK increased by nearly a quarter between 1995 and 2019.22

11.Henry Dimbleby, former lead non-executive director at Defra (and former UK Government ‘food tsar’), and author of the National Food Strategy, said that unhealthy food is by far the biggest cause of avoidable illness. He said that HM Treasury had informed him that, for the 2.8 million people who are long-term sick and out of work, the four biggest drivers are type 2 diabetes, musculoskeletal problems, hypertension and mental ill health. The first three are directly caused by diet, and mental ill health is exacerbated by poor diet.23

The economic costs of obesity

12.Estimates of the total costs of obesity to society vary, and rely on different modelling methods, baselines and assumptions.24 However, it is agreed that costs are very high. The Institute for Government noted in 2023 that estimates of the annual social costs of obesity ranged between £29 billion and £58 billion, around 1–2% of UK GDP.25 Frontier Economics has since estimated the total annual economic cost of overweight and obesity at £98 billion, including costs to the NHS and social care, lost productivity, workforce inactivity and welfare payments.26 OECD analysis has found that the average UK tax bill is around £400 per person per year more than if everyone was a healthy weight.27 The Institute for Public Policy Research (IPPR) estimated in 2020 that obesity over the course of the lifetime of the current cohort of children will cost wider society an estimated £405 billion overall. It has also been estimated that people living with obesity take four extra sick days a year annually and an additional £4 billion is spent on welfare payments for obesity-related workforce inactivity.28

13.The Government cited an estimate by Frontier Economics that the NHS across the UK spends £6.5 billion annually on treating obesity-related ill health, based on the costs of obesity-related illnesses (primary care, medications and hospitalisation) and obesity-related antidepressants.29 Government analysis in 2017 reached a similar figure and projected this to reach £9.7 billion by 2050.30 Some estimates of NHS costs are much higher: the independent National Food Strategy cited a figure of £18 billion, on the basis of OECD modelling predicting that high BMI would cost the Government 8% of the total spend on healthcare on average per year between 2020 and 2050.31 The IPPR has predicted that excess weight among the current cohort of children will cost the NHS £74 billion over their lifespan. Diabetes care alone accounts for nearly 10% of the NHS budget.32 Henry Dimbleby noted that it is estimated that by 2035 it will cost more to treat type 2 diabetes than the cost of treating all cancers today.33 While there is increasing interest in the potential of new medicines such as semaglutide to reduce obesity rates, they are expensive, and are a targeted rather than a population measure. Nesta has estimated that attempting to halve adult obesity by 2030 using these drugs would cost £16.5 billion per year.34 This would place considerable additional pressure on the NHS.

Figure 3: ‘Increasing diet-related disease is costing the taxpayer a fortune’, from the National Food Strategy

Note: Bubble size is proportional to total spending amount.

Source: The National Food Strategy, The Evidence, July 2021: https://www.nationalfoodstrategy.org/wp-content/uploads/2021/08/NFS_Evidence-Pack.pdf [accessed 5 June 2024]

The provenance of this report

The July 2020 Food, Poverty, Health and the Environment Committee report

14.In July 2020, the House’s Special Inquiry Committee on Food, Poverty, Health and the Environment published its report Hungry for change: fixing the failures in food.35 Although that Committee’s remit extended to issues beyond our own focus on food, diet and obesity, it made a number of key recommendations relevant to our work, as set out in Appendix 4.

15.In its report recommending the appointment of this Committee, the Liaison Committee encouraged us to focus carefully on areas where we could best add value and not duplicate work already undertaken.36 In light of this, we do not seek in this report to duplicate the work of the Food, Poverty, Health and the Environment Committee, save where relevant to our arguments, in particular reflecting developments since their report was published.

16.The evidence we received not only confirmed the recommendations of the Food, Poverty, Health and the Environment Committee ‘Hungry for change’ report relevant to our remit, but also demonstrated that the situation has become markedly worse since it was published. It is deeply regrettable and a mark of its failure that the then Government did not accept so many of the Committee’s recommendations, and acted on so very few of them. It is evident that the previous Government failed to grasp the enormity of the problem. We endorse the recommendations of the ‘Hungry for change’ report and call on the Government to act on them, taking account of policy developments and trends in food, diet and obesity since it was published.

17.There have been two particularly significant developments since that report was published: the full publication of the National Food Strategy and the growing debate over ultra-processed foods (UPFs).

The National Food Strategy

18.In 2018, the then Secretary of State for Environment, Food and Rural Affairs, Rt Hon Michael Gove, commissioned Henry Dimbleby, the co-founder of Leon restaurants, the lead non-executive director at Defra and co-author of the School Food Plan, to undertake an independent review into developing a National Food Strategy for England. Part one of the review was published in July 2020, and part two was published in July 2021.

19.The National Food Strategy concluded that the fundamental cause of dietary ill health is the ‘junk food cycle’, as set out in Figure 4.

Figure 4: ‘Overview of the Junk Food Cycle’, from the National Food Strategy

Source: The National Food Strategy, The Evidence, July 2021: https://www.nationalfoodstrategy.org/wp-content/uploads/2021/08/NFS_Evidence-Pack.pdf [accessed 5 June 2024]

20.Henry Dimbleby described it as follows:

“We have an appetite that evolved in a time of calorie scarceness, which rewards us for finding calorie-dense foods … Food companies … have, over time, invested more and more of their resources into developing and marketing those products.”37

21.The National Food Strategy set out a number of key recommendations to break this cycle. Those relevant to the remit of this Committee38 are set out in Box 3.

Box 3: Recommendations of the National Food Strategy relevant to our remit

Escape the junk food cycle and protect the NHS: Introduce a Sugar and Salt Reformulation Tax. Use some of the revenue to help get fresh fruit and vegetables to low-income families. Introduce mandatory reporting for large companies of sales of food and drink high in fat, salt and sugar, protein by type and origin, vegetables, fruit, major nutrients and total food and drink sales, as well as statistics on food waste. Launch a new “Eat and Learn” initiative for schools. Reduce diet-related inequality: Extend eligibility for free school meals. Fund the Holiday Activities and Food programme for the next three years. Expand the Healthy Start scheme. Trial a “Community Eatwell” Programme, supporting those on low incomes to improve their diets. Create a long-term shift in our food culture: Invest £1 billion in innovation to create a better food system. Create a National Food System Data programme. Strengthen Government procurement rules to ensure that taxpayer money is spent on healthy and sustainable food. Set clear targets and bring in legislation for long-term change. The National Food Strategy estimated that, taken together, its recommendations39 would over the long term have an economic benefit worth up to £126 billion.

Source: Defra, National Food Strategy: The Plan (July 2021), pp 140–164 (Chapter 16): https://www.nationalfoodstrategy.org/the-report/ [accessed 13 September 2024]

22.In response, the Government published a food strategy policy paper in June 2022.40 It was widely criticised for its lack of ambition, not least by Mr Dimbleby himself.41 Criticism was particularly directed at the Government’s decision in May 2022 to delay the introduction of restrictions on multibuy deals and advertising, which were due to come into force from January 2023.42 In March 2023, Henry Dimbleby announced his resignation as the Government’s ‘food tsar’, citing the Government’s “insane” inaction against obesity and adoption of an “ultra free-market ideology” due to “concern that dealing with these issues could be seen to be ‘nanny state’.”43

Ultra-processed foods

23.The National Food Strategy drew attention to the intensifying scientific and public debate over the role of ‘ultra-processed foods’ (UPFs) in relation to poor diet and obesity. The ‘NOVA’ definition of UPFs was first proposed in 2009 by academics at the University of São Paulo, led by Professor Carlos Monteiro, Professor of Nutrition and Public Health. It classifies food according to its level of processing, rather than its nutrient content. The issue has risen up research and policy agendas in recent years. In April 2023, Dr Chris van Tulleken, Associate Professor at University College London, NHS doctor and broadcaster, published a best-selling book entitled Ultra-Processed People: Why do we all eat stuff that isn’t food … and why can’t we stop? Dr van Tulleken and others have advocated urgent action to tackle UPFs. However, others have argued that a blanket approach to ultra-processed foods is unhelpful in identifying unhealthy foods because of its lack of focus on nutrients. We return to this issue in Chapter 4.

The work of the Committee

24.It was against this backdrop that the Liaison Committee recommended the appointment of this Committee “to consider the role of foods, such as ‘ultra-processed foods’, and foods high in fat, sugar and salt, in a healthy diet and tackling obesity”, to report by the end of November 2024. Given that this is a broad and complex topic, and given the time constraints imposed by the then forthcoming General Election, the Committee was invited to focus in particular on:

• UPFs as an emerging matter of intensive scientific and public debate and interest;
• current Government policy on tackling obesity;
• nutritional guidance and labelling;
• the role and influence of the food industry on the obesity policymaking process;
• scientific evidence on the impact of the over-consumption of salt, sugar and fat on public health;
• the impact of previously implemented measures including mandatory calorie labelling, the reduction and reformulation voluntary programme and the soft drinks industry levy;
• food advertising and promotions, and the rationale and impact of the Government’s decision to delay HFSS advertising and volume restrictions until October 2025; and
• international case studies exploring regulatory interventions and measures to tackle obesity.

25.Given the time constraints, and the strong evidence that diet is the key influence on the risk of obesity, our remit was specifically concerned with the links between food, a healthy diet and tackling obesity. Therefore, notwithstanding their importance, and on the basis that prevention is better than cure, we were not invited to focus on obesity treatment (such as medication or physical therapy). Neither did our remit extend to the role of the farming sector and the environmental impact of food policy. Nevertheless, we acknowledge the importance of this issue, which was discussed at length in the National Food Strategy.

26.Given that healthcare is a devolved competence, our focus has been on policy in England. However, we have considered the approach of the devolved governments, as well as international examples, by way of comparative analysis, as well as the UK-wide context where appropriate.

27.The Committee was appointed on 29 January 2024, and published a Call for Evidence on 19 February, in response to which we received 150 written submissions from a range of stakeholders. Between February and May 2024, the Committee held 20 evidence sessions with scientific experts, representatives of the food industry, campaigners, local authorities, planning experts, marketing and advertising experts, groups working with children and young people, and representatives of the Scientific Advisory Committee on Nutrition (SACN) and the Food Standards Agency (FSA). The Committee also heard evidence from members of the public, including parents and young people, sharing their lived experience of the challenges of a healthy diet and obesity.

28.Given the proximity of the General Election, the Committee chose to take evidence in May both from the then Minister of State for Public Health, Rt Hon Dame Andrea Leadsom MP, and the then Shadow Minister for Public Health, Preet Kaur Gill MP. The report therefore reflects on the policy of both the outgoing Conservative and incoming Labour Governments, and relevant citations refer to the policy of the Government in power at the time in question.

29.The Committee undertook a two-day visit to Blackpool, where it met Blackpool Council’s Director of Public Health and other officials, and visited a local primary school, food bank and community centre. The Committee also visited the fruit and veg on prescription project at Bromley by Bow in Tower Hamlets, run by the Alexandra Rose Charity.44 One of our witnesses, Professor Barry Smith, Director, Institute of Philosophy at the University of London, also arranged a taste testing exercise for the Committee of various products to demonstrate the techniques and ingredients that are used to enhance the palatability of food. We are grateful to all of our interlocutors for their assistance.

30.In view of the importance of hearing directly from food industry companies, we extended invitations to appear in public before the Committee to a large number of them. While some accepted our invitation, it was regrettable that Tesco, Asda, Waitrose, Morrisons, Lidl, Sainsbury’s, Co-op, Iceland, Mars Wrigley, Nestlé, Unilever, KFC, Pizza Hut, Subway, Greggs, Deliveroo and Uber Eats either told us they were unavailable to appear in public, referred us to trade organisations or did not respond. We acknowledge, however, that some of these companies submitted written evidence, as listed in Appendix 2.

31.As with all parliamentary committees, we have sought to hear from a range of witnesses in order to ensure that we have the fullest understanding of the issues within our remit and that we hear all perspectives and concerns. Inviting certain witnesses or organisations to give evidence does not mean that we agreed with or endorsed everything that we heard. Parliamentary committees are frequently tasked with scrutinising contentious public policy issues where there are strong feelings and interests on all sides. However, unlike members of the committee, whose interests have already been stated on the record and are published on the committee’s website, witnesses to parliamentary committees are not as a rule required to declare their interests. This is because it is the job of the committee to weigh what we are told in evidence and draw our conclusions. The responsibility for those conclusions is ours alone.

32.At the same time, we recognised that the issue of stakeholder interests is a subject of legitimate debate in the context of this inquiry, and we discuss this further in Chapter 3. Although it was inconsistent with Lords committee procedure to compel our witnesses to do so, for the sake of transparency we therefore gave all our witnesses an opportunity to declare voluntarily any interests that they deemed relevant to the work of this inquiry. Although the issue of influence on the policymaking process is an important one, we stress that it is not the role of this committee to criticise individuals personally. Nor is it appropriate or feasible for us to vet the interests of those who gave evidence to us, or to rule evidence out on that basis. Rather, it is our role to assess and draw conclusions from the evidence put to us based on the merits of the arguments made.

33.Professor Martin White, Professor of Population Health Research, MRC Epidemiology Unit, University of Cambridge, acted as Specialist Adviser to the Committee. His expertise has greatly assisted our deliberations during the course of this inquiry.45

34.Upon the Dissolution of Parliament on 30 May 2024 ahead of the General Election on 4 July, and in common with all parliamentary committees, the Committee formally ceased to exist and our work was paused. The Committee was reappointed on 29 July 2024, with a remit to complete its work by 30 November.

35.This report sets out the Committee’s findings as follows:

• Chapter 2: Government strategy
• Chapter 3: The role of the food industry
• Chapter 4: Ultra-processed foods
• Chapter 5: Making food environments healthier
• Chapter 6: Enabling healthy diets for infants, children and young people
• Chapter 7: Making healthy diets affordable and accessible

36.Obesity and its consequences constitute a public health emergency that represents a ticking time bomb for the nation’s health, wellbeing and finances. This emergency is primarily driven by over-consumption of unhealthy foods. In light of this, our central recommendation is that the Government must as a matter of urgency adopt a new, comprehensive and integrated food strategy to address the wide-ranging consequences of the food system failures identified in this report. Implementation of such a strategy will only be successful on the basis of strong and accountable leadership at the highest level of government. It is in the context of the need for urgent and bold action that we make this report for debate.

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