We are what we eat: food, health and inequality – with Anna Taylor and Sarah Hickey Episode 11 of the Health Foundation podcast

Jennifer Dixon 

Hello, and welcome to the Health Foundation podcast. I'm Jennifer Dixon, Chief Executive here at the Foundation.

In this podcast we examine the key issues affecting our health and care in the UK. Today we're focusing on food. Crucial to our health, it is now heavily implicated in our ill health. Not only that, but also health inequalities and damage to the environment. Last year has seen food more than ever in the spotlight.

The use of food banks in the pandemic, our high obesity rates contributing to higher COVID-19 mortality. Marcus Rashford's campaign to end child hunger. Brexit trade deals forcing us to decide what kind of food standards we want. And last month saw government action to help fight that other global pandemic: obesity. A ban on junk food adverts on TV and online after 9pm was announced, along with a ban on price promotions on unhealthy foods. And the second part of the National Food Strategy led by Henry Dimbleby was published as well.

This was a farm to fork independent review of the entire food and drink system in the UK, the most comprehensive for many years. The review recognised the upsides of the food system in providing affordable, convenient food for us all, but also the downsides that too much food produced and consumed is injuring health and the environment. But today we'll be discussing three related things: the government's obesity strategy and two bits of the Dimbleby review, reducing junk food and diet-related inequality.

So with me to discuss all of this, I'm pleased to welcome two guests. Anna Taylor is Executive Director of the Food Foundation, where she's been since 2015. She is a national and international expert on nutrition. She has advised the Mayor of London and the GLA and also served as independent advisor to Henry Dimbleby for the development of the National Food Strategy. And Sarah Hickey, who since 2016 has been leading the childhood obesity programme at Guy's and St. Thomas' Foundation. Sarah previously worked as senior policy advisor in the Cabinet Office and the programme she now leads in South London aims to close the inequality gap in childhood obesity in Lambeth and Southwark, working with communities, schools, businesses, families and others on the ground.

So welcome to you both. Let's start out with a picture of obesity in the country on the one hand, and perhaps at the other end of the spectrum, the extent of food insecurity. So Anna, I wondered if you might just kick off with some national trends to chart out for us.

Anna Taylor 

So at the moment, we have a problem which has been worsening in terms of obesity, and particularly in adults. So we've got a situation where one in ten children start school already obese, that worsens by two fold by the time children leave primary school and then enter into adulthood. And generally, if you start off life with a problem with your weight that's likely to continue through your life. And generally as we get older, we kind of accumulate body weight. So the problem gets more as you get older. So by the time we get to adulthood, about two thirds of adults are overweight or obese at the national level. And the problem that we've got is this sort of lag in the system. So as people accumulate the effects of an unhealthy weight through their life, that then starts to create health problems for them, which the NHS is then picking up in later life.

I mean, for some children, those problems start young, we now have adolescents being diagnosed with type 2 diabetes, but for the most part those problems accumulate through life. So that's the sort of obesity picture, in terms of food insecurity, we have a situation where about 9, 10% of households at the moment, are in moderate or severe food insecurity. So that means that they will in any given period, say six months period, they would experience having to skip meals, not eat for a whole day because there's not enough money or cut back on the amount that they're eating. So it's a quantitative reduction in the amount of food that they're eating because of money and access problems. That amounts to about 2.3 million children.

So we know that in those households where money is really, really tight, households are likely to prioritise food which fills children up and which doesn't go to waste because they're worried if children is sort of picky or something and then it has to go in the bin, then there's no money to buy something else. So it's got to be a dead cert that everybody's going to eat. And we know from the price statistics that unhealthy foods are three times more, sorry three times cheaper than healthy foods, calorie for calorie. So you kind of create a situation if you've not got very much money that the odds are really stacked against you in being able to put a decent meal on the table and protect your health.

Jennifer Dixon 

And just sticking with the trends for a minute, there's obviously been a relentless rise in obesity in the country. When did that start? And how do we compare internationally?

Anna Taylor 

BMI has just sort of crept up and up and up and up over the decades. So it's been this kind of slow, incremental climb. And we've seen that, we see that also in the sorts of foods that we eat. So over that time period, you've seen this kind of rise in things like crisps, the rise in confectionery, the rise in ready meals, and a whole bunch of other convenience foods, which our diets have now become pretty heavily dependent on. So we're now getting about half of our calories from high fat, sugar and salt foods. So it's crept up on us, which is I think, part of our problem. If you were to say here and now, suddenly, there are 64,000 people dying every year from diet related disease, when you sort of compare that to the narrative that we've been having about COVID, people would be like, 'what?', shocked, we need to do something about this. But it's actually crept up on us year on year, and it's sort of a bit invisible in that sense.

Jennifer Dixon 

So Sarah, these national trends, presumably you're seeing some of this right on the ground in Lambeth and Southwark. Can you tell us a little bit about the levels of obesity and indeed food insecurity that I know you've worked on that?

Sarah Hickey 

Yeah, absolutely. I think Lambeth and Southwark, the boroughs Lambeth and Southwark are to me almost an extreme picture of national trends. We've got both the highest and lowest rates of child obesity in the country, I think probably because we've also got the highest and lowest incomes, which just shows the strength of that correlation. And, and I guess, just bringing it to the lived experience of parents, for example, like Anna said, I've never met a parent who doesn't care about the health of their child. They absolutely want to feed their kids healthy food, but they're also solving for a number of other things.

One, which is budget. So food also has to be affordable. Often solving for, you know, headspace, the time and energy it takes to, for example, live in poverty, and link to the price taste, you want food that fills your kids up. And going out into our current high streets and food environments, families often have to make a compromise on health. And on the other side, being bombarded with products that are affordable, convenient, tasty, but highly unhealthy in terms of being very high, ultra processed, high in salt, fat and sugar, and low in other other nutrients.

Jennifer Dixon 

And just on food insecurity in Lambeth and Southwark, are you still seeing a lot of dependence upon food banks? Obviously during the pandemic that was the case, but are you still seeing that? Is there a trend there over the last few years? Or is it really mainly pandemic-related?

Sarah Hickey 

We've certainly seen greater reliance on things like food banks, and huge support by the local community and charity sector during the pandemic. But I think in a way that was just exacerbating something that was there before, which is this huge inequality in access to food in and of itself, but especially, I think, access to good nutritious food.

Jennifer Dixon 

Let's move on to charting out the government policy on particularly obesity, I think it's worth having a look at. I was looking at a paper the other day, Anna I think we were talking about it two days ago, which looked at 28 years of government policy on obesity. And it showed that basically a strategy came along every two years, each one with 35 or so on average recommendations. It's clearly a wicked problem, as they say in policy land. It's a complex problem, you can't solve it with one or two things and expect it to work.

Anna, I wonder if you could just chart out for us the main elements of the last iteration of the obesity strategy, which came out obviously in 2020. How far does it go, in your view?  Yes, I mean, going back to that your discussion of trends earlier, I mean, if you look at the long run trend, there aren't any dents in it, that previous government policies have made a difference. They haven't, in fact, it's just marching upwards, as you say. And the analysis I saw of this last 28 years was indeed an emphasis on individual agency, as you say, and not an emphasis on the obesogenic environment and affecting the wider factors. But also very tentative and repetitive steps that were taken year after year. Sounds as if you're positive about some aspects, but needs to go further and faster.

Anna Taylor 

Well, I think from the perspective of a sort of growing, I suppose confidence on behalf of past government to actually intervene in the food system, there are some signs in the obesity strategy that that confidence is growing with respect to some quite bold measures on restricting advertising of junk food online and up to 9pm on television, and then also restrictions on promotions that we know that promotions are hugely important in terms of leading people to eat more of unhealthy foods than they otherwise would if those products weren't on promotion. So that's a really, really important lever that the government is using there to try and curb consumption of some of those really unhealthy foods. So those are two good signs.

And of course, they build on the sugary drinks tax, which has been now, you know, a number of evaluations published showing how effective that's been in driving reformulations. And the amount of sugar in soft drinks has gone down by about 30%. So there's really sort of a lot of sugars come out of those soft drinks. And so I think those things also are as a positive signal. But I think there's still quite a lot in that obesity strategy and putting quite a lot of emphasis on what you might call individual agency or individuals taking action in their own lives.

And I think what the evidence points to more and more is the fact that we really shouldn't be putting emphasis on that route for change within government policy and we need to be doing first category interventions, which are about making it easier for people to make those changes without having to make extra effort, whether it's through seeking out the right product in a huge kind of sea of products and working out which one's the most healthy, or walking even further to get to a shop that sells something healthier than the stuff that's near their neighborhood. So all the things which basically make it harder for us to to buy healthily and eat healthily, those are the things we've got to try and dismantle. And that's where government policy can play a vital role.  Yeah, much further and much faster. But I think building in this process of measurement and tracking, evaluating, being prepared to ratchet up interventions. We know that when we intervene in the system, the own dynamics of the system mean that the system's going to try and respond to that and create value elsewhere. And that might create other problems. So we need to be ready to adapt policy instruments quite quickly to respond to those system effects.

So yeah, I mean, I think we've got to sort of shift our whole mindset around policymaking in this area to be prepared a) to be in for the long haul b) to be prepared to do lots of different things and c) to really measure and learn and iterate as we go. And I think unfortunately we've been in a situation where things like you track the progress of getting the sugary drinks tax legislation. It takes an enormously long time, there's a huge campaign attached to it. It feels like a huge effort on the part of government to get us to that point. But that's just like a baby step on the journey. We have to be prepared to do that 100 fold. And that's the challenge.

Jennifer Dixon 

It's difficult this, isn't it, when it requires probably a 30 year commitment and set of policies that are then iterated over time, as you say, and course corrected. In a sense, failing that, there's still a lot of local agency isn't there, Sarah? And there's a lot of things that can be done locally, absent an overarching, intelligent strategy that's active enough. So I'd be interested to hear what you think your agency is locally, how much you think you can influence without this national cover, if you like. And also whether you also feel some of the steps being taken currently, the smaller steps, as Anna calls them, the junk food for example and the price promotions, whether they will make a difference to you in Lambeth and Southwark.

Sarah Hickey 

I mean, I agree that research on government strategies is quite depressing actually, in some ways isn't it? I mean, I think it shows that strategies are a bit meaningless if they aren't followed up by implementation and accountability. And this goes for local systems as well as national ones. I think one thing that's difficult with complex issues, and complex health challenges such as obesity is the complexity in and of itself, you know, the best meaning politicians and civil servants get stuck in the complexity of it. And therefore kind of try a scattergun approach, don't have a very, very focused and sustained push on what really the evidence base says matters.

Past strategies have tried to have a foot in two camps of trying to change our food environments through things like promotions, but also putting a lot on individual agency. And all this sort of weight management support that's coming out. I think all that really great advice is almost negated in the face of food environments that really work against us eating well. So I do think that both at national and local level, there's something about really thinking about the fact that the evidence base, you know, what's worked at all has been things that look at the food options around us, and how to connect with the commercial drivers, institutional ones that shaped those and change those, rather than put all the effort on individuals because it just doesn't work. And at worst, it exacerbates inequalities. At a local level, local government has some powers.

So for example, we're working with Southwark council to try and disrupt to some extent the school food system here. When we went into schools and realised that lots of the food that pupils were eating in school wasn't meeting School Food Standards, to nutritional quality, and just so many weren't, so it felt like this is something about the system not creating the right incentives for schools and caterers to really focus on nutritional quality.

Jennifer Dixon 

So you mentioned the National Food Strategy. So we had part one last year, which really focused a lot on food insecurity in the pandemic. And we had part two published just recently, which focused on four main areas. So this was reducing the junk food cycle, diet-related inequality, making the best use of land and creating a long term shift in food culture. For those of you who haven't read it, it's a very long report. But it's really, really interesting. I think it's fascinating reading, and really anyone interested in health, I think could give it a read. Now, Anna, you were very closely involved as one of the expert advisors, if not the expert advisor for Henry Dimbleby on some parts of it. I wonder if you might just outline the report for us, the review and what it was trying to do and how you were involved.

Anna Taylor 

It's been in the making for two years. The report comes out came out a couple of weeks ago. What happens next is so these are recommendations to government, and then the government has to respond within six months with White Paper. What the task was with the National Food strategy was to really think about how we could pivot the food system, so that it started to deliver better outcomes for the environment. So for climate and for nature, and also for public health. And that's the challenge is how to actually shift the system in a sustainable way.

And, and unlike some of the other reports that we've been talking about in the history of obesity strategies, there are only 14 recommendations. And Henry was very deliberate in making sure that list was not too long. And also really focused on some of those big and important levers that could be pulled in different bits of the system to reorient it. And focusing on those areas where you could really see that these are actions which could be implemented tomorrow, if the will and commitment and public mandate were there. And we've, again, did a lot of engagement with citizens through the process and actually testing ideas hearing about their lived experiences. So it's very grounded in public viewpoints as well. It wasn't just, it wasn't just a sort of desk based exercise.

Jennifer Dixon 

Thank you. So it's really extending the sugar and salt tax levied on manufacturers and importers, was one and and a lot more about introducing reporting on food sales and waste for larger companies, which was, I think, a very interesting one, as well as some more eat and learn initiatives for schools to improve food knowledge amongst young young people. That was the sort of junk food cycle. Was that the main clutch there?

Anna Taylor 

That's right, yeah, those are the three main recommendations to try and break the junk food cycle, disrupt it. And then there was a kind of complimentary package around dietary inequalities. I think it's also important to note under that first heading, which you mentioned around changing food culture, there are a set of recommendations around sort of institutional arrangements and governance. And we talked earlier about net zero and the climate change committee and the sort of power in that process for maintaining long term commitment to the issue by embedding it in the right sorts of governance structures.

There are some recommendations in there under food culture to do exactly that around diet related disease, around the diet and health mix. So they're proposing that there be a food bill and in that food bill would extend the powers of the Food Standards Agency. It also would require the creation of a statutory target on reducing diet related disease or actually increasing healthy life expectancy as a result of poor diets. And to go alongside the net zero commitment, which is obviously a statutory target and the forthcoming targets around nature and biodiversity which are coming in the environment bill. So you'd have this triplet set of three, three metrics, which capture which are statutory targets, which would create some of that, I guess, the North Star and embed it in sort of government reporting over a long period of time.

Jennifer Dixon 

What's your sense about how far the government will go on some of these recommendations? I mean, this government is a bit, has gone further on the regulation of junk food and so on, as we've said that the advertising at least, but it's not necessarily the most state interventionist, is it when it comes to regulation or other things?

Anna Taylor 

I think it will vary by the 14 different recommendations. I think some, for example, there's a recommendation around public procurement, which the government was I think, waiting for and ready to receive and wants to sort of take forward and action. And there's a sort of process for doing so. And there are others, which are, I think, a lot will depend on the level of public support shown for these recommendations over the course of their debate in the coming sort of 6 to 12 months. I mean, some, some things may appear in the White Paper, but other things could be, could be landed through other routes, I don't think we should sort of necessarily expect everything to appear in the, in the White Paper, there are a package of four recommendations in there one around extending free school meals to more children living in poverty, and a similar recommendation around extending Healthy Start. And again, one around holiday provision for children on free school meals.

We know that that was tremendously politically charged last year around the question of vouchers and half term and Marcus Rashford's intervention. That's one which I think will have its own its own momentum. You know, aside from the other recommendations, so I think there's not a kind of a one answer to that question really. I think some will be probably quite easy to land, others will be harder. And I think the importance of really everybody chiming in and offering their views and getting involved in the conversation and particularly involving citizens as much as we can in that process. I think it's really vital.

Jennifer Dixon 

So some of the recommendations made in the National Food Strategy on this are actually very similar to some of the really interesting programmes you've got going in Lambeth and Southwark - on the, you know, supporting children in particular out of school, as well as in school with a breakfast box programme. What's your take on the recommendations? And how does it chime with what you're doing locally?

Sarah Hickey 

Actually on both sides... both the dietary inequality ones and the wider ones chime with us with our approach locally. I guess our starting point was, okay, from the point of view of children and families, it's the food around them that's really, really affecting their diet, especially when they're living in low income neighborhoods. So who shapes and controls that that food first of all? Again, one big shaper is clearly business. 80% of our food spend goes in supermarkets, so that's a huge one. The other is, for example, schools on that kind of side of who just shapes our food environments in general that really do affect all of us, I guess we think, okay, what are all the ways that we can convince those decision makers and shapers to do things differently, and, and we've got projects always trying to pull on every lever we can.

One is corporate leaders and business owners themselves. So for example, we work with a group called the Collaboration for Healthier Lives, which is a group of food manufacturers and food retailers who have come together to trial changes to their product manufacturing and store design, and the trials in Lambeth and Southwark. And they found really interesting kind of ways that you could affect the nutritional quality of people's baskets without hugely affecting profits. And the reason they're getting into it in the first place is because they don't see profits and health as necessarily opposed. So you've got business leaders themselves.

And we set up a good food fund, for example, which is a social investment fund that invests in, in what we call challenger brands. There's a huge bunch of entrepreneurs who are actually really committed to providing more affordable, healthier food to people who, especially people on a low income.

So there's that sort of business owners and then who else affects business? Well investors clearly do as they kind of care about what their investors say. And I think that speaks to the reporting recommendation in the National Food Strategy. So through an organisation called Share Action, we've been funding a campaign called Healthy Markets. It really uses restive dialogue to speak to companies about, actually the business risks of not taking their health impact on the population seriously. And as part of that, we try to create these benchmarks of what good looks like. And I think government, like the National Food Strategy recommended, introduce a mandatory reporting, again, you kind of introducing transparency, and maybe even competition in food industry to, you know, race to the top and try and provide really, really healthy environments. I think that's really important.

And then the third, the third thing that pressures these commercial drivers is clearly customer appetite. And the thing that pressures policy is clearly citizen voice. And I think that's another important, important thing to really support and grow. You know, the National Food Strategy did lots of consultation. It really mirrored what we're hearing, you know, people actually do want healthier food environments. They do support some of the policies, for example, around extending sugar taxes. And so how do we create a platform for those voices, especially those that are often unrepresented to be part of the conversation, to be part of the solution design?

I think with childhood obesity, it's interesting, we've been, you know, in talking about the problem for, like, over a decade, the voice of young people themselves, which is what the problem that problem is all about has been quite absent from that debate until recently. Anna's organisation is supporting a group of young food ambassadors, who not only are helping shaping the campaign calls, but also being the voice for them, I think is very powerful. And that's similarly what we try and do locally. So I think on that a lot of our local work really chimes with those recommendations on sort of government leavers to affect industry.

The food subsidy we ran with an organisation called School Food Matters, a healthy breakfast box scheme simply provided every fortnight a box of two weeks’ worth of healthy breakfasts to families that were really at risk of food insecurity and poor diet. I guess what that the two interesting things from that that scheme were that the group of families that schools identified went far beyond the current eligibility for free school meals. And also, the scheme also demonstrated that if you really put nutritional quality at the center, it is also possible to, I think, somewhat affordable to deliver but it you know, it has quality as well as access at its heart. I think that reflects, for me what we think about national food subsidy schemes, the two features they really need to have in mind is, one, eligibility or the people who need this scheme, are they are getting access to it? And like the National Food strategy said free school meals at the moment are not open to all those children who are living in food insecurity. So something about expanding access. And I guess our you know, our organisational view is probably that if you make these things universal, that's the absolute easiest way to get to the people who most need it. And you also sort of avoid or the admin burden of trying to find out who exactly is eligible, but at least extending it, I think, is really, really good step towards that.

Jennifer Dixon 

That's wonderful. Thank you. I mean, this is obesity itself. Going back to that is it is a global issue. But I do notice, firstly, that the trends in Britain they're just unhealthier than many other Western European nations. But also, I found this statistic, which I think was in the food strategy that 50% of UK household food purchases are ultra processed. This compares to 14% for France and 13% for Italy. So I presume there's significant poverty and deprivation in those countries as well. So how come the extent of ultra processed food consumption in Britain is just so much higher than those countries?

Anna Taylor 

It's quite, it's quite difficult to untangle all the reasons. And what we do see in the countries that have quite low levels of ultra processed food consumption, those numbers are creeping up quite quickly. So I don't think anybody is immune to this. But I think we are definitely ahead of the curve in terms of actually having this problem in quite a serious situat..., you know, quite a serious level already. I mean, certainly, we see in the UK, the sort of growing reliance on convenience food, and I think there's a number of reasons for that one.

The Institute of Fiscal Studies did a really interesting graph showing the cost of, the relative cost of ingredients, time and pre prepared foods, and basically showed that while it's very easy to say all that you know, takeaway pizza costs you more than making, I don't know, a lentil stew at home or something... when you factor in the time factor, it actually starts to make huge amounts of economic sense. So there's a kind of a time issue there. There's obviously more people in the workplace, particularly when you look at it, historically, women working in going out the home, more people living on their own, which again, stimulates that kind of convenience. And then, of course, the junk food cycle, as described in the National Food strategy has meant that it's become very cheap to produce these, these foods because they can be sold on such a large scale and the ingredients goes back to kind of how we done our farming and the way how we've invested in the sorts of crops that we've really heavily invested in high yields at low cost, you know, that all feeds that same sort of cycle. So I think particularly our food culture hasn't been a drag on that.

And I think what you see, it's an interesting, for example, you look at some of the South Korea and Japan they've done, they've slowed down the junk food cycle, I think by doing a huge amount about their national cuisine. You know, they've really placed a lot of importance of protecting their national cuisine in schools and public procurement and, and take some pride in that national cuisine, and it's heavy into vegetables and fish, and so forth. And so, yeah, so there's a kind, definitely a kind of culture piece there, which we just don't seem to have kind of created that drag on the system and in the way that some other countries have. Obviously, when you look at Italy and France, food culture is a sort of stronger part of social life that perhaps it is in, in the UK, or at least historically has been in the UK.

Jennifer Dixon 

I think we all think that and look to government don't need to help to really coordinate action here. And that is clearly the right thing to do, but also not forgetting the huge agency that, as you mentioned, Sarah, that investors have. Investors do invest for the long term. They do think for 30 years, unlike governments. And just to say that actually, there was some good news earlier this year where Share Action did coordinate a shareholder resolution for Tesco. So to increase its proportion of sales from healthier products, to 65% by 2025. So Tesco has 27% of the British grocery market. And so they were they at least have been under pressure to disclose the share of food sales made up of health care products. And to increase that share by 2030. And publish a progress of its review in its annual report from 2022 onwards. So there is actually in the corporate band and then the investor land. So we can't just don't need to put all the burden on government, even though clearly, they should be leading all of this. So thank you for making that point.

So I think maybe let's finish by saying no, this is a hugely fiendishly complex area, both the food system and obesity, which we've been discussing today. We've also agreed I think that the government action has been tentative to date and not fast enough to be to stem the tide of obesity. What would you both like to see next, in concrete terms, maybe one or two things that you really think ought to happen next, to try to even begin to make more of a dent in these trends?

Anna Taylor 

Not surprisingly, I think I'd really like to see the some of the recommendations in the National Food Strategy taken into the next phase of work on the obesity strategy which the government takes forward. And particularly this sort of package of the sugar and salt tax combined with the package, which is around tackling inequalities. So making sure that children and I think you know, you could even extend that package to other demographics are, have those nutritional safety nets in place when they're at school and preschool, and so forth. I think that's a really important step.

And then the second would probably be around the governance arrangements to embed process of iteration and policy development over the long term and grounded in a statutory target to really focus minds beyond electoral cycles. That's probably where, yeah, that's probably where I'd start.

Jennifer Dixon 

That's a great place. Thank you. And Sarah, what would you say?

Sarah Hickey 

Yeah, Ditto that definitely. And I think behind that, I'd like to see just stronger recognition by government of the importance of the commercial drivers in influencing population health, and really for work to go hell for leather with a focus on that which I think the recommendations in the National Food Strategy really do.

Jennifer Dixon 

We must leave it there. I'd like to thank our two guests, Anna Taylor and Sarah Hickey, for their insight on this important topic. We will await the government's response in its forthcoming White Paper. For links to key reading on the things we discussed today, as ever please find them in our show notes wherever you find this podcast and don't forget to have a look at the National Food Strategy. Next month we'll be returning to the NHS. Meantime, thanks for listening and see you next time.