UK Food Policy & Nutrition: Tracking

ProgressStrengthening accountability systems for nutrition in the UK

Foodfoundation.org.uk

Today’s speakers

@Food_Foundation

Lawrence HaddadSenior Research Fellow

IFPRI@l_haddad

Inge KauerExecutive DirectorAccess to Nutrition

@ingekauer

Boyd Swinburn - KeynoteProf. of Population,

Nutrition and Global HealthUniversity of Auckland

@BoydSwinburn

Fiona WatsonConsultant

The Food Foundation@Food_Foundation

Today’s panellists

@Food_Foundation

Lord Chris Haskins

Andrew OpieDirector of Food and Sustainability

British Retail Consortium @the_brc

Jo RallingCampaign Director

Jamie Oliver Food Foundation@FoodRev

Guy Poppy Chief Scientific Advisor Food Standards Agency

@GuyPoppy1

Corinna Hawkes - ChairProf. of Food Policy

City University London@CorinnaHawkes

www.foodfoundation.org.uk

Tracking progress on food and nutrition policies

Boyd SwinburnProfessor of Population Nutrition and Global HealthUniversity of Auckland

Co-Director, Global Obesity Centre, Deakin University

The Food Foundation SymposiumLondon, February 2016

Overview – healthy food policies

• What are the imperatives?• What are the priority policies?• How much progress is being made globally?• Strengthening accountability• INFORMAS

– International Network for Food and Obesity/NCD Research, Monitoring and Action Support

• Quasi-regulatory approaches• Importance of UK leadership

•  

Lim et al Lancet 2012

Food environments

What needs to be done?

WHO’s Global NCD Monitoring Framework

Mortality & Morbidity

Cancer incidence by type of cancer per 100

000 population

Unconditional probability of dying

between ages 30 and 70 years from cardiovascular

diseases, cancer, diabetes or chronic

respiratory diseases

Salt

Fruits and Vegetables

Saturated Fat

Overweight and Obesity (2)

Physical Inactivity (2)

Blood glucose/diabetes

Blood Pressure

Total Cholesterol

Harmful use of Alcohol (3)

Risk Factors

Tobacco use (2)

Access to palliative care

National Systems Response

Policies to limit SFA and virtual elimination of PHVO

Essential NCD Medicines

HPV Vaccine

Marketing to children

Drug therapy and counseling

Cervical cancer Screening

Hepatitis B Vaccine

25 In

dica

tors

Very little in monitoring food environments and policies

• No country has turned around the epidemic• Some countries show flattening/declines in

some child populations– Young, white, high SES, girls– Increasing disparities by SES and ethnicity

• Some countries introducing food policies

World Cancer Research Fund

Why so little progress on healthy food policies?

1. Food industry actions– Direct opposition (esp Coca Cola & Pepsi on SSB taxes) – Self-regulatory pledges/codes etc

2. Lack of government leadership– Weak governance systems, conflicts of interest– Belief in education approaches and market solutions– Unwilling to battle food industry (chill effect)

3. Lack of sufficient public demand for policies– Usually high majority support for most policies

(moderate/minority support for SSB taxes)– Not translated into pressure for change

Bellagio Declaration Obes Rev 2013

• Need to shift from responsibility pledges to accountability systems– Multiple parties involved– Agreed actions– Power relationships (includes sanctions)– Independent vs mutual accountability

Accountability Framework (Kraak V et al PHN, 2014)

What evidence persuades change-agents?• Monitoring and benchmarking progress under

their jurisdiction• Case studies of successful changes

– Evidence of impact and support– Stories– Visits, networks, personal recommendations

• Evidence of impact of policies and actions– Changes in reach and uptake– Changes in environments and behaviours– Changes in obesity (often not possible)

INFORMAS (www.informas.org)

• INFORMAS is a global network of public-interest organisations and researchers that aims to monitor, benchmark and support public and private sector actions to create healthy food environments and reduce obesity, NCDs and their related inequalities

• Progress– Phase 1: (2012) frameworks & indicators

• 2013 Obesity Reviews suppl – 14 Foundation papers– Phase 2: (2013/4) protocols, pilot testing– Phase 3: (from 2015/6) available globally

• Currently 17 countries using INFORMAS modules (or have grants under review)

Objectives1. Develop a global network of public-interest and

research groups to monitor, benchmark and support efforts to create healthy food environments and reduce obesity, NCDs and their related inequalities

2. Collect, collate and analyse data on public and private sector actions, food environments, population diets, obesity, and NCDs

3. Compare and communicate the progress on improving food environments against good practice benchmarks, between countries and within countries over time

4. Use the results to strengthen public health efforts, particularly by supporting the translation of relevant evidence into public and private sector actions.

Public sector policies and actions Private sector policies and actions

How much progress have (international, national, state and local) governments made towards good practice in improving

food environments and implementing obesity/NCDs prevention policies and actions?

(University of Auckland)

How are private sector organisations affecting food environments and influencing obesity/NCDs prevention

efforts?(Deakin University)PR

OCE

SSES

IMPA

CTS

OU

TCO

MES

Food composition

Foodlabelling

Food marketing

Food provision Food retail Food prices Food trade &

investment

What is the nutrient

composition of foods and non-

alcoholic beverages?(The George

Institute)

What health-related labelling

is present on foods and non-

alcoholic beverages?

(University of Oxford)

What is the exposure and

power of promotion of

unhealthy foods and non-

alcoholic beverages to

different population

groups?(University of Wollongong)

What is the nutritional

quality of foods and non-alcoholic

beverages provided in

different settings (eg.

schools, hospitals,

workplaces)?(University of

Toronto)

What is the availability of healthy and unhealthy

foods and non-alcoholic

beverages in communities

and within retail outlets?(University of

Auckland)

What is the relative price

and affordability of ‘less healthy’

compared with ‘healthy’ diets, meals & foods?

(Queensland University of Technology)

What are the impacts of trade and

investment agreements on the healthiness

of food environments?

(Australian National

University)

Population diet Physiological & metabolic risk factors Health outcomes

What is the quality of the diet of different population groups?

(University of Sao Paulo)

What are the burdens of obesity and other risk factors?

(WHO)

What are burdens of NCD morbidity and mortality?

(WHO)

INFORMAS module structure

ORG

ANIS

ATIO

NS

FOO

D EN

VIRO

NM

ENTS

POPU

LATI

ON

S

NZ Food-EPI • Positives:

international standard in 6

• Stronger infrastructure than specific policies

• Major gaps in implementation– Marketing to

children– Fiscal policies– Comprehensive

plans & funding

Top priorities (out of 34 actions)1. Comprehensive

plan2. Targets

– Childhood obesity– Population intakes

Na, SFA, sugar– Food composition

3. Funding (to $70m/y)4. Restrict marketing

to children

5. Healthy food policies – Schools– Early childhood settings

6. Health Star Rating food labelling

7. 20% excise tax on sugary drinks

Quasi-regulatory systems• Strengthens voluntary initiatives

– More accountable, credible, feasible, transparent, effective (for public health goals)

• Involvement of government– Including: set policy objectives, manage process,

determine the parameters, monitoring, communications, advocacy, threat of regulation etc

• Involvement of civil society– Including: advocacy for public health, independent

monitoring (process and impacts)• Example: Health Star Rating system

Importance of UK leadership• Strong public health traditions, culture, capacity

& expertise• Strong track record of public actions for healthier

food environments– Government– Academia– NGOs– Private sector– Individual champions

• World leading National Child Measurement Program

England’s National Child Measurement Program

0%

2%

4%

6%

8%

10%

12%

14%

Least deprived

Most deprived

Obe

sity

prev

alen

ce

Index of Multiple Deprivation (IMD 2010) decile

2006/07 2007/08 2008/09 2009/10 2010/11 2011/12 2012/13

0%

5%

10%

15%

20%

25%

30%

Least deprived

Most deprived

Obe

sity

prev

alen

ce

Index of Multiple Deprivation (IMD 2010) decile

2006/07 2007/08 2008/09 2009/10 2010/11 2011/12 2012/13

4-5 year oldsBy year & deprivation decile

10-11 year oldsBy year & deprivation decile

Future directions

Aims: 1. Monitoring progress for accountability 2. Underlying systems causes and solutions

www.lancetobesity.info

Conclusions• Current burden of unhealthy diets is very high

and future threats from climate change and population growth– Demands a robust food strategy and policies

• Accountability systems also needed to speed up progress– INFORMAS platform for creating the data for

monitoring, benchmarking, evaluating, and modelling• Excellent opportunities to build on UK expertise

– Regulatory, quasi-regulatory, programmatic, community systems-based approaches

Acknowledgements

• INFORMAS collaborators internationally and the coordination team at University of Auckland

• www.informas.org• Twitter: @_INFORMAS #INFORMAS • Funders:

How does the UK compare with other high income countries on key nutrition

indicators?

Lawrence HaddadInternational Food Policy Research Institute

10 February 2016

Outline

Nutrition Status Drivers Policy and Legislation Missing Data Conclusions

GreeceSp

ain USA Italy UK

Belgium

German

yFra

nce

Netherlands

Australi

a

Canad

a

New Zeala

nd

Denmark

Norway

Irelan

d

Sweden

10

8 87 7 7 7 7 6 6 6 6 5 5 5

5

Low Birth Weight (%)

Source: UNICEF 2015

Greece Italy

France

Netherlands

Spain

Belgium

Denmark

German

y

Sweden

Australi

a

Norway

Irelan

d

Canad

a

New Zeala

nd UKUSA

20 19 19 18 18 18 18 18 18 18 17 17 1715 15

12

Anaemia in women of reproductive age (%)

Source: WHO 2015Note: all data estimated for 2011

Off course On course

USA

Canad

a

Australi

a

New Zeala

nd UKSp

ainFra

nce

Greece

Irelan

dIta

ly

Norway

Belgium

Netherlands

Sweden

Denmark

German

y

67 64 64 64 63 61 61 61 60 59 59 57 56 56 55 55

Adult overweight and obesity (%)BMI ≥ 25

Source: WHO 2015Note: all data estimated for 2014

High and increasing Low and increasing

USA

New Zeala

nd

Australi

a UK

Canad

a

Irelan

dFra

nceSp

ain

Norway

Greece Italy

Sweden

Belgium

German

y

Netherlands

Denmark

3429 29 28 28

26 24 24 23 23 21 21 20 20 20 19

Adult obesity (%)BMI ≥ 30

Source: WHO 2015Note: all data estimated for 2014.

Off course On course

English Data (not in GNR)

Overweight children 54-66 months All: 22.6% (2013-14)(Greater than or equal to the 85th BMI centile in reception class) Source: National Child Measurement Programme. England 2014-2015 school year http://www.hscic.gov.uk/catalogue/PUB16070/nati-chil-meas-prog-eng-2013-2014-rep.pdf p.17

Obese Adolescents 13-15 yearsBoys = 17% Girls = 22% (2013)(Greater than the 95th UK National BMI centile) Source: Health Survey for England 2013. http://www.hscic.gov.uk/catalogue/PUB16076/HSE2013-Ch11-Child-BMI.pdf p.18

Norway

Irelan

d

German

yIta

ly

Sweden UK

Spain

Netherlands

GreeceFra

nce

Belgium

Denmark

New Zeala

nd

Australi

aUSA

Canad

a

41 41 40 38 38 38 37 37 36 36 35 35 33 32 30 30

Raised blood pressure (%)

Source: WHO 2014.Note: all data estimated for 2008

Off course On course

German

y

Denmark UK

Irelan

d

Belgium

Italy

France

Norway

Netherlands

New Zeala

ndSp

ain

Australi

aUSA

Canad

a

Sweden

Greece

66 65 63 63 62 62 62 62 6156 56 55 54 53 52

48

Raised blood cholesterol (%)

Source: WHO 2014.Note: all data estimated for 2008

Off course On course

USA

New Zeala

ndSp

ain

Canad

a

Norway

Greece

Australi

a

German

y

Belgium

Denmark Italy

Irelan

d

Sweden UK

France

Netherlands

1110 10 10 9 9

8 8 8 7 7 7 7 76

5

Raised blood glucose (%)

Source: WHO 2014.Note: all data estimated for 2008

Off course On course

German

y

Belgium

Australi

aSp

ain

New Zeala

ndUSA

Sweden

France

Norway UK

Denmark

Irelan

d

Canad

a

Netherlands

Italy

Greece

478 515 521 557 566 576 578 586 588 602 605 621 666 673782

967

Availability of fruit and vegetables (grams per day)

Source: FAO 2014Note: Data are for 2011.

Source: Euromonitor 2014, (US $ fixed exchange rates)

Norway

Australia

New ZealandIta

lyFrance

Canada UKSpain

BelgiumGreece

Sweden

Denmark

Germany

Netherlands

Ireland

USA

740 722 720650 618

538 532 526 526 509 503 495444 424 414

332

Consumer expenditure on fruits & vegetables(US$/cap/year)

New Zealand

Greece

Denmark

BelgiumSp

ain

Ireland

Netherlands

Norway

USA

Canada

Sweden

Australia Ita

ly

Germany

France UK

391 381

334 318 306 296275

254 247 242 236 226 218 200 196 181

Fresh food purchased (kg per Cap)

Source: Euromonitor 2014

Belgium

Irelan

dIta

ly

Australi

a

DenmarkFra

nce

German

y

Netherlands UK

Canad

a

New Zeala

nd

Norway

Spain

Sweden

Greece USA

Availability and stage of implementation of guidelines, protocols, and standards for the

management of hypertension

Not available

Available, not implemented

Available, partially implemented

Available, fully implemented

Source: WHO 2014

Not available

Available, not implemented

Available, partially implemented

Available, fully implemented

Source: WHO 2014

Australi

a

DenmarkFra

nce

German

y

Irelan

dIta

ly UK

Belgium

Canad

a

Netherlands

New Zeala

nd

Norway

Spain

Sweden

Greece USA

Availability and stage of implementation of guide-lines, protocols, and standards for the management

of diabetes

No action Few provisions law Many provisions lawVoluntary Law

Source: UNICEF 2014

Implementation of the International Code of Marketing of Breast milk Substitutes

Breast feeding in England• % of babies breastfed at birth 81% in 2010• % of infants 0–5 months old, exclusively breastfed 1% in 2010

Infant Feeding Survey – UK 2010, http://www.hscic.gov.uk/catalogue/PUB08694

New Zeala

nd

Australi

a

Irelan

d

Denmark

Canad

aUSA

Netherlands

France

Norway

Spain

Greece

German

y

Belgium

Sweden UK

Italy

8572 8513

4155

1691 16671147 1072 1050 939 754 742 707 700 699 691 507

Total Emissions (CO2eq) from Agriculture/cap (kg)

Source: FAO 2011

Summary of UK performance relative to comparators

Outcomes Poor: Overweight, obesity, raised blood cholesterol Middling: LBW, raised blood pressure Good: anemia, raised blood sugar

Determinants Poor: exclusive breastfeeding, fresh food purchases Middling: availability of fruits and vegetables; purchase of fruits and

vegetables

Policy and Legislation Middling: BMS Code, Hypertension and Diabetes Protocol Implementation Good: CO2 emissions from agriculture

USA

Germany

Netherlands

Norway

France

Spain UK

Denmark

Sweden

BelgiumIre

land

Australia

Greece Italy

Canada

New Zealand

1419

25 25 26 26 26 27 27 30 30 30 33 34 34 36

% Missing Indicators in GNR Nutrition Country Profiles

Conclusions

UK food system nutritionally weak compared to other high income countries e.g. fresh food purchases, obesity and overweight rates

Even when good or middling compared to other countries, still poor in terms of absolute levels

Significant scope to improve implementation of protocols and code application

Plenty of missing UK data when reporting on global goals SDG reporting will require every country to provide U5

stunting, wasting and overweight

Thank You

What is the food environment?The collective physical, economic, policy and sociocultural surroundings, opportunities and conditions that influence people’s food and beverage choices and nutritional status.

  

1. Analyse context

2. Collect relevant

info.

3. Evidence ground policies

and actions

4. Validate evidence with govt officials

5. Rate govt

policies and actions

6. Weight, sum &

calculate Food-EPI scores

7. Qualify, comment

& recommen

d

8. Translate results for

govt & stake-

holders

Methods

DomainsPOLICY

3. Promotion

2. Labelling 9. Governance

4. Prices

6. Retail

5. Provision

8. Leadership

INFRASTRUTURE1. Composition

7. Trade & Investment

12. Platforms for Interaction

11. Funding & Resources

10. Monitoring & Intelligence

13. Health in All Policies

1. FOOD COMPOSITION: There are government systems implemented to ensure that, where practicable, processed foods minimise the energy density and the nutrients of concern.

1.1 Food composition targets/standards have been established by the government for the content of unhealthy nutrients of concern in certain foods or food groups if they are major contributors to population intakes of these nutrients.

Good Practice Statements

Food Epi in the UK•Approach of current government:

- Dependence on individual choice - Voluntary control of the companies- Transfer of responsibility to local authorities

RESULT = http://www.legislation.gov.uk/

Katie in the UK

Minsŏ in South Korea Fatemeh in Iran

Some restrictions on advertising HFSS food and

drink on TV since 2008.

Advertising

Ban on soft drinks advertised on TV

since 2004.

Restrictions on advertising specific categories of food

during children’s TV, radio and internet

since 2010.

Katie in the UK

Daniela in Ecuador

Voluntary ‘Traffic light’ labelling on FOP lables

since 2010.

Labelling

Mandatory ‘traffic light’ labelling on packaged

food for fat, sugar and salt since 2014.

Victoria in AustraliaRestaurant chains required to display calorie content of food products on

their menu boards.

Katie in the UK

Crystal in Barbados

No sugar tax (yet)

Tax

Excise tax (10%) on sugary drinks introduced in August 2015

Esztera in HungaryTax (varying rates) adopted in

2012 on ready-to-eat HFSS foods

Katie in the UK

Frida in Denmark

School food regulations implemented. Milk, and fruit & veg for young

children.

School food

Fruit & veg daily for school children introduced in 2009.

Sigrid in EstoniaRestrictions on HFSS, sweet

treats and soft drinks in schools since 2008.

Brazil

Governance

• Multi-sectoral coordination

• Personal ownership and leadership from

President• Strong participation from

civil society• Private sector

engagement

Food Standards Agency

Dept. of

Health

DEFRA

Food Standards Agency

Dept. of Local

Communities

TreasuryHMRC

DEFRA

Local Authorities England

1. Analyse context

2. Collect relevant

info.

3. Evidence ground policies

and actions

4. Validate evidence with govt officials

5. Rate govt

policies and actions

6. Weight, sum &

calculate Food-EPI scores

7. Qualify, comment

& recommen

d

8. Translate results for

govt & stake-

holders

Next Steps for Food Epi in the UK

We are here• Partners?

• Devolved areas?

• Food environment or food system?

2016 GLOBAL ACCESS TO NUTRITION INDEX

FOOD FOUNDATION

LONDON, 10 FEBRUARY 2016

#ATNI2016

@ATNIndex

65

Encourage improvements in companies’ policies, practices and performance to result in:• Greater consumer access to more nutritious foods and beverages• An environment facilitating the consumption of healthier foods and beverages

InvestorsProvide context for company engagementMediaRaise profile of industry role in malnutrition

Civil societyFacilitate effective advocacy

PolicymakersInform regulatory and policy agenda

AcademicsStimulate research on best practices

Provide companies a tool for benchmarking their nutrition

practices

Serve as an impartial source of information for interested

stakeholders

Stimulate dialogue

and action

Given its size and reach, the private sector can make a significant contribution to addressing obesity and undernutrition.

ATNI seeks to

Tool for accountabilit

y

What ATNF aims to achieve – our theory of change

The private sector can play a powerful role….

66

… and has a financial and social responsibility to act

67

2016 Global Index methodology

68

2016 Global Index methodology

69

Overall ranking

• Unilever leads the Index, with a score of 6.4 out of 10

• Nestlé and Danone also remain in the top three, as in 2013

• Mars (16 to 5) & FrieslandCampina (19 to 8) have improved the most

• Eight have risen, six fallen, five stayed the same, three new entrants.

Overall findings

70

The world’s largest food companies must step up efforts to address the global nutrition crisis – investors can play a key role

• Some companies have made improvements but the industry as a whole is moving too slowly: the average score has only increased to 2.5 from 2.2 in the 2013 Index

• All companies must invest more in embedding nutrition into their global businesses– To tackle obesity, they should adopt stronger nutrition strategies and

policies and use robust systems to measure the nutritional value of all of their products and make their foods healthier, among other things

– To tackle undernutrition, they must invest within their businesses and work with governments and civil society to find innovative ways of providing affordable and accessible foods for poorer people

• Companies must take a global approach; US companies particularly must not just focus on their home markets, as they typically do

• The marketing practices of all six of the baby food manufacturers evaluated in a new element of the assessment fall short of international standards, undermining breastfeeding which is the optimal form of nutrition for infants

71

Category B - Products• Unilever leads with significant margin over Nestlé

• Higher ranking than in 2013: FrieslandCampina, Mars and Ferrero

• Lower ranking: Kellogg’s and ConAgra

• Inadequate efforts to improve products’ nutritional quality

• Nutrient Profiling system: only 13 companies report having one

• % of products that can be advertised to children• Proxy for healthiness of product portfolio• Only Danone and Unilever provided data

• Fortification of products to tackle undernutrition • Only Ajinomoto, Danone, FrieslandCampina,

Mondelez, Nestlé, Coca-Cola and Unilever have formulated a commitment

72

Category D - Marketing• Highest-scoring Category, Danone leads.

• Marketing to all consumers 7 companies without evidence of a responsible marketing policy

• Marketing to children • Most companies subscribing to self-regulatory

pledges • But significant gaps remain in pledges

• Not applied to all media• Do not cover over 12s• Audience threshold for children 35%

• Definition of marketability to children• Only Kellogg, Ferrero, Danone, Nestlé

and Unilever use a robust NPS

• GLOBAL policies on responsible marketing to children and adults, applied to all channels, particularly new media, are required.

• No data on marketing spending on healthy products

Categories C, E, F and G – average scores very low

73

Category C: Accessibility and affordability

Category E: Support for healthy and active lifestyles

• Most companies engage with nutrition stakeholders but unclear whether and how they use the results to improve policies and practice

• Very little engagement on undernutrition

• Much more transparency is needed on companies’ lobbying activities on nutrition

• Critical issue• Lowest scoring Category on the

Index, as in 2013.

• Companies expected to do much more to make healthy foods in developed and developing markets more affordable and more accessible.

• Generally a low-scoring Category• Employee wellness programs need to

be strengthened and extended• More focus needed on supporting

breastfeeding mothers at work• Companies need to move to

supporting independently designed and implemented programs to support consumers

Category F: Labelling and claims

• Back-of-pack labelling commitments reasonably good; generally not globally consistent and some key nutrients missed

• Lack of data from companies on extent of policy roll-out

• Focus needs to be on useful front-of-pack labelling and responsible use of health and nutrition claims. Category G: Engagement with

stakeholders and policymakers

74

Discussion

• Strengthen the UK country profile in the Global Nutrition Report (UK Government to make available relevant data)

• Complete the Food EPI exercise for the UK (Food Foundation to convene a workshop of experts to assess the UK Government’s level of implementation of policies and infrastructure support against international best practice for improving the healthiness of food environments)

• Conduct a Access to Nutrition Index for the UK that scores and rates the largest Food & Beverage manufacturers (ATNI to include the UK as a ‘Spotlight Country’).

www.foodfoundation.org.uk