Anna became the Food Foundation’s first Executive Director at the beginning of June 2015, after five years at the Department for International Development. At DFID she led the policy team on nutrition and supported the delivery of the UK’s global commitments to tackle undernutrition. Previously, she worked for Save the Children, UNICEF and the Department of Health. In 2014 she was awarded an OBE for her work to address the global burden of undernutrition.
Over 11,000 four-year-olds will start school already obese. They face a lifetime of ill-health and disadvantage. What can halt this disaster?
One in 10 four-year-olds. When you hear it enough times it stops having an impact. And yet that amounts to over 11,000 children who will start school in London in September already disadvantaged before they’ve even learned to hold a pencil and spell their name. They’re already obese and these children rarely get back to a healthy weight. After all, there is very, very little public investment targeted at them, even though they will, over the course of their (truncated) lifetime, use a disproportionate amount of resources from the NHS because they will face a whole cluster of accumulating mental and physical health problems. Some will get type 2 diabetes in their teens, a disease until recently only affecting adults over 40 but which is now devouring more than £10bn per year (10 per cent of the NHS budget) as people require injections in their eyes, amputations of their limbs and treatment for stroke. Others will be bullied, suffer from low self-esteem and go on to earn on average much less than their slimmer peers. The girls may become mothers and maternal obesity will bring a whole set of additional risks for them and their children.
So what do we know about the problem of obesity – apart from that it’s a big problem? We know that trying to prevent it is best done by focusing on interventions that do not rely on a lot of individual agency, but rather change the environment in which we live and eat to make healthier lifestyles the easiest and cheapest choice. We know that it results from a complex mix of lifestyle, environment and genetics. We know that it’s about energy out (exercise) and energy in (food) but that the latter has become a more important cause of obesity in recent years as our food has become more and more ubiquitous, energy-dense, low in fibre and cleverly engineered to guarantee the ‘bliss point’ – the sensory profile created through fat, sugar and salt that makes you come back for more. We know too that obesity in childhood goes hand-in-hand with deprivation.
Just as geographers at UCL have cleverly constructed a tube map of life expectancy and Danny Dorling has looked at inequality along the Central line, the ward-level data on obesity shows huge variation across the city. The spectrum runs from 19 per cent of reception-aged children in Faraday (Southwark) who are obese compared to 2 per cent in Raynes Park (Merton). We know too that many people in positions of power still think the obesity epidemic is a result of retrograde behaviour among sections of society – mothers who no longer know how to cook for their children, children who don’t know where a carrot comes from and, generally, a lack of discipline and common sense around eating. While you’d be wrong to place exclusive blame for the obesity crisis on income levels and our food system, neither does it, in the words of Susan Jebb, make any sense to shape food policy on the basis that we’re facing a “national collapse in willpower”.
So what can be done? Are we at the mercy of the major food corporations and retailers, in the hope that some will exercise a higher level of accountability to the public good? After all, we’re eating from a global food basket, relying for 60 per cent of our calories on highly processed food manufactured by a few major global corporations. Or can London take action?
The team at the Food Foundation took a closer look at the problem in London by conducting a transect walk through a cluster of wards with the highest levels of obesity in the city, recording what we saw. We walked from Turkey Street (EN3) to Stamford Hill (N16) through Enfield, Haringey and Hackney Boroughs, from the inner edge of Zone 6 to the outer edge of Zone 2. This walk took the team through a stretch of 12 electoral wards with childhood obesity rates well above the all-London average, including New River, Northumberland Park and Edmonton Green, in each of which over 17 per cent of reception-aged pupils are obese. We saw good, bad and ugly when it comes to food.
There was a lot of fresh fruit and vegetables. Of the 143 food shops along the eight-mile route, 80 sold more than five varieties of fruit and veg and most were displaying it on beautiful stands outside small independent stores. These were displays largely selling loose, unpackaged vegetables with a variety not found in mainstream supermarkets, reflecting the ethnic preferences of the local population. This is fantastic and is surely something good to build on.
158 takeaways, equivalent to one every 79 metres for eight long miles! The vast majority were displaying foods that were very likely to be high in fat, sugar and/or salt, and a third of them were offering price promotions on these products. There were eight instances where three of these takeaways were side by side. To say they dominate the high street is a major understatement. Like the independent grocery stores, they were selling varieties of fast food from countries around the world – but with a few dominant themes (fried chicken, kebabs and burgers). The restaurants, of which there were far fewer (38), weren’t much better, with about a third offering foods high in fat, sugar or salt to passers-by. Of course, some takeaways can be healthy and there is great work being done by the London Food Board to shift takeaways from using vegetable to rape-seed oil, as well as by Tower Hamlets’ Food for Health award (which recognises when places to eat out make changes to the food they cook and sell to make healthy eating easier). But the companies offering fast food including plenty of fruit and veg, which we see in central London (Itsu, Toss’d and Leon might be examples), are nowhere to be seen in this stretch: the sheer numbers of unhealthy takeaways makes the job of rebalancing a very big one.
Adverts and promotions to kids. Takeaways with special signs offering deals to school kids: ‘School kids offer: two sizzling wings and fries only £1’. Adverts outside schools for ice cream. And at least two leisure centres with a sad-looking fruit bowl by the counter competing with a jam-packed, colourful display of confectionery, crisps and soft drinks. We can do much better than this.
Local authorities make a difference
So what can London boroughs do? One of the key objectives must be to get children to eat fewer high-fat, sugar and/or salt foods. Our research shows that these foods are by no means an occasional treat. Instead, they make up 47 per cent of calories eaten by primary-school-age children and 45 per cent of calories eaten by secondary school children.
So, first, there’s a job for the planners to try to reduce the number of unhealthy fast food takeaways and replace them with healthier alternatives. Some boroughs have been successful in getting restrictions for new outlets around schools – but others have failed to get this provision past planning inspectors.
Last year, neighbouring boroughs Lewisham and Greenwich both applied for restrictions on fast food around schools and only Lewisham was successful. This is in spite of there being a GLA Takeaways Toolkit targeted at those working in environmental health, trading standards, public health, education and planning to help local authorities to develop strategies and programmes to tackle the impacts of fast food takeaways in their local communities.
Liverpool City Council is offering 12 shop units to rent for a pound a week for up to three years in two streets needing rejuvenation. They will not be permitting applications from fast food takeaways but will consider community cafes and healthy takeaways. Local Authorities can also look to lever funding and resources for healthier food options from landowners and building developers through Section 106 and Community Infrastructure Levy agreements.
Schools make a difference
What schools do also matters. The introduction of universal infant free school meals means that almost all 4–7 year olds now receive a healthy school lunch, but uptake drops among older children, and for secondary schoolchildren there is a complete dearth of data on uptake. Some London Boroughs (for example, Newham) have extended the national programme to provide free school meals for all primary school children. Even if boroughs can’t afford this, there’s a lot they can do to support headteachers to make food and the school meal a central part of school life and drive uptake. Food for Life, run by the Soil Association, is doing a lot of great work in support of this by promoting food as a way to improve the whole school experience – making lunchtimes a more positive feature of the day and enriching classroom learning. In addition, we need Ofsted inspectors to visit the school dining room and eat a meal with the children.
This will help to incentivise governors and teachers to go the extra mile and get kids eating the school lunch. Going even further, the London Food Board is now thinking about sugar-free schools in London. While the school meal may be relatively low in sugar, it creeps into other areas of school life (not least in packed lunches). Children are coming to school with a pint of ‘energy drink’ and packet of biscuits for breakfast; they are receiving sweets every time someone has a birthday in their class (that’s 30 times a year, six weeks of school); and then there are all the ‘treat days’: school fete, school play, last day of term, home clothes day. Sweets are rewards for being good; treats that are no longer special. There’s also a big, and neglected, job for nurseries. A recent survey showed that more than 80 per cent were serving sugary drinks such as squash to children and 30 per cent didn’t serve vegetables every day. The guidance for nurseries is not mandatory, and yet we know it’s during the early years that children lay down their food preferences for life.
Pernicious links to poverty
Third, there’s a job to protect those at greatest risk. If you live in a deprived area, your children have double the chances of ending up obese. Our Force-fed report showed that healthy foods are three times more expensive, calorie for calorie, than unhealthy foods. People on a low income often squeeze their food budget in order to pay for housing and utilities. If you don’t have much money, you go for cheap empty calories and these are the worst foods for your children. A representative survey conducted by Ipsos-MORI in London in 2013 reported that 42 per cent of parents were cutting back on the amount of food they buy or the amount they spend on food, and 8 per cent reported that at some point in the last year their children have had to skip meals because they cannot afford to buy food. This situation is toxic for children.
Data from Canada show children who experience two or more food-insecure episodes during their early years are nearly five times more likely to report poor health aged 10–15 years. By the time they reach 16–21 years, they have a three-times-higher chance of having a chronic health condition.
What can the boroughs do about this? There are two easy, low-cost steps that would move us in the right direction. First we need to make sure that all pregnant women and mothers of toddlers who are on a low income get access to Healthy Start vouchers (for fruit and vegetables) – a funded national programme which, currently, 1 in 4 of those eligible do not get because they’re not aware of it or because of implementation problems. Second, we must start to measure food poverty – it was last done in the UK more than 10 years ago. Without knowing how big the problem is and who is worst-affected it’s impossible to do anything about it. There are now globally standardised methods that could be used. We just need the political will to do it. Local authorities could do more to insist this data is collected in the national survey instruments.
And, finally, we must think very carefully about allocating resources to children who are already obese. In a context where public health budgets are being cut back even further, tough choices between priorities like drug and alcohol abuse, sexual health and obesity will need to be made. But the evidence to date suggests that obese children are at the bottom of the shopping list.
Action on obesity by London’s policymakers will be a critical part of the solution, but they will be fighting against the tide unless their efforts are accompanied by concerted action at the national (and, ultimately, global) level. Measures to control the marketing of foods high in fat, sugar and/or salt in all their forms (promotions, advertising, and sponsorship); targets to reformulate everyday foods with less sugar, salt and fat; policy shifts along the supply chain to rebalance the cost of food, making healthier food more affordable; measures to ensure every publicly funded place to eat (whether it’s a school, hospital, library or leisure centre) offers healthy and affordable food – these are just a few of the actions needed. Unless our government and business leaders fully grasp the profound consequences of our diets on our health – this goes far beyond childhood obesity – and take concerted action to reform our food system so it delivers healthy and sustainable diets, we will be stuck with a collection of isolated policy modifications that will never deliver the changes we urgently need.