Consensus Action on Salt, Sugar and Health Response to Environment, Food and Rural Affairs Committee Call for Evidence: COVID-19 and Food Supply

26 May 2020

Consensus Action on Salt, Sugar and Health Response to Environment, Food and Rural Affairs Committee Call for Evidence: COVID-19 and Food Supply

We welcome the opportunity to provide evidence to this inquiry. Given our expertise on the impact of diet on health, we have serious concerns that our food system does not enable health for all, and we are particularly concerned about the evidence demonstrating that obesity worsens COVID-19 outcomes.

For more information, please contact: Mhairi Brown, Policy Coordinator Mhairi.brown@qmul.ac.uk

Are the Government and food industry doing enough to support people to access sufficient healthy food; and are any groups not having their needs met? If not, what further steps should the Government and food industry take?

Obesity and Covid-19

Prior to the COVID-19 pandemic, the Global Burden of Disease Study demonstrated that poor diet is a leading cause of premature death and disability worldwide¹, with excessive amounts of calories consumed from fat and sugar leading to obesity and subsequently increase the risk of type 2 diabetes, heart disease, cancer and stroke, as well as mental health problems such as depression, anxiety and low self-esteem. Dietary intake of free sugars is the main cause of tooth decay in children, and a high salt intake is linked to raised blood pressure, decreased bone health, chronic kidney disease and stomach cancer. Saturated fat is linked to increased blood cholesterol and increased risk of heart disease.

The UK has one of the highest overweight and obesity rates among developed countries, with an expenditure of £6.1 billion a year on the medical costs of conditions related to obesity and overweight² and more than £14 billion in treatment of type 2 diabetes³. Neither of these figures include the social cost, which is estimated at £47 billion⁴.  

Children growing up in lower socio-economic areas are more than twice as likely to be obese than those in higher income households, with those coming from black and minority ethnic families also being more likely to be overweight or obese than those coming from white families^5,6. 

Government has long known the impact poor diet can have on health and for this reason they introduced a Childhood Obesity Plan in 2016, with a second chapter published in 2018^7,8. However, the majority of evidence-based measures put forward in these plans have yet to be implemented.

Increasing evidence demonstrates that obesity is an independent risk factor for more severe illness and death from COVID-19^9-17. Data shows that 78% of all confirmed Covid-19 infections are in overweight or obese individuals, along with 62% of hospital deaths^9,10. Linking UK COVID-19 data to that of a population cohort (428,225 participants, 340 confirmed COVID-19 hospital cases) and to electronic health records (17,425,445 participants, 5683 COVID-19 deaths) demonstrates that the more severe the obesity, the more likely to be hospitalised for COVID-19 and/or die from it^9,10.

Multiple mechanisms could explain the relationship between obesity and COVID-19, including:

• The enzyme that is exploited by the virus for cell entry (angiotensin-converting enzyme 2 (ACE2)) is present in larger quantities in those living with obesity^18,19
• Immune response in those living with obesity is weakened, making them more susceptible to the virus^20,21
• Obesity is known to negatively affect lung function, and when patients with obesity and the virus need to be admitted to intensive care units, it is much more challenging to ventilate them²⁰.

We strongly recommend that government prioritise any action for the food supply that will address overweight and obesity in the UK, to help protect the health of the nation from both a potential second wave of infections from the virus, and to prevent ill health from diet-related disease long term.

• Reformulation Programmes
• Fiscal Measures

We urgently need robust and transparent reformulation programmes, which benefit the health of the whole population but especially those from lower socioeconomic backgrounds. Salt, sugar, fat and calorie consumption levels tend to be highest in the most deprived areas and levels of obesity are highest in children from lower income groups^5,22. Current reformulation programmes have seen poor progress, with the sugar reduction programme achieving just a 2.9% reduction in average sugar (sales weighted) content of the main contributors to children’s sugar intake between 2015 and 2018²³. Similarly, an analysis of industry progress towards achieving the 2017 salt reduction targets found that almost half (48%) of average targets had not been met²⁴. Furthermore, while a much needed programme to reduce excessive levels of calories in food has been announced, it has yet to be implemented.

Given reformulation happens at the industry level and requires no behaviour change from consumers, government must make reformulation programmes mandatory to ensure all companies comply, and must release calorie reduction targets without further delay.

The Soft Drinks Industry Levy should be escalated to reflect inflation increases each year, similar to tobacco taxation, to further incentivise sugar reduction across sugar-sweetened beverages and extended to milk-based drinks as originally intended, as these drinks currently enjoy a ‘health halo’ despite posing a risk to oral health due to high sugar content. This world-leading levy has had unprecedented success, leading to a 28.8% decrease in sugar content since April 2018²³. Income must be ringfenced to support evidence-based weight loss programmes and community dietetic services.

We also recommend the introduction of an energy density levy on all calorie dense processed foods that meet an agreed criteria set by government. This would encourage product reformulation to reduce both fat, in particular saturated fat, as well as sugar in unhealthy products. Fat is a bigger contributor to calories in unhealthy products than sugar and therefore essential that manufacturers are encouraged to reduce both in order to tackle the UK’s obesity crisis.

• Price Promotion Restrictions
• Marketing and Advertising Restrictions

We strongly support the mandatory restriction of all price and location promotions on all products high in salt, sugar and/or fat in all outlets where food and beverages are sold. Frustrated by the lack of action from DHSC, the Scottish government have since announced they will be restricting price and location promotions²⁵. If price promotions were shifted to healthy products, DHSC estimates that £3.1bn would be saved over 25 years due to lower calorie consumption in those living with overweight and obesity²⁶.

Advertising manipulates choice and the storytelling employed by brands to market HFSS products to the public, including children, creates an environment where HFSS products are desirable and more nutritious food is relegated to lower status. Government should be prepared to put the health of the nation above industry profit, and implement a ban on HFSS advertising and marketing.

• Nutrition Information in the Out of Home sector
• "Supporting" health workers with donations of food, including Krispy Kreme’s donation of ‘smiles’ (Original Glazed Doughnuts)³⁴, and Pizza Hut UK donating over 40,000 hot meals, with little nutritional benefit³⁵
• Capitalising on the ‘stay home, stay safe’ message to encourage consumers to buy their products, including Just Eat with their ‘stay home, order a takeaway and make a donation’ messaging on social media³⁶
• Donating to charity appeals to gain free exposure during charity appeals, such as Greggs donating to Comic Relief’s Big Night³⁷
• Utilising the increased sense of community during lock down as an advertising strategy, to play on our emotions. Cadburys are a key example with their ‘there’s a glass and a half in every one ‘ advertising video on their social media channels and on TV³⁸
• Encouraging people to recreate the brand's foods at home e.g. McDonalds sharing Sausage and Egg McMuffin recipe on This Morning³⁹

Calorie labelling in the out of home sector has been proposed and, prior to the impact of Covid-19, was due to be implemented this year²⁷. While the out of home sector has undoubtedly been severely impacted by the virus, large, multinational food companies have been able to reopen, largely in more deprived areas and with limited menus which predominately feature HFSS products. Those companies with the resources to open should be providing consumers with nutrition information at the point of sale, and should be prioritising the sale of healthier products, particularly while the virus impact is ongoing.

Food Insecurity

In addition to addressing obesity, government must address poverty and food insecurity in the UK. On average, 2.2 million people in the UK were living in food insecurity between 2015 and 2017²⁸. Of those, 47% were unemployed, 34% were in the lowest income quartile and women were more likely than men to live in a food insecure household (10% compared to 6%)²⁹. Low incomes and rising living costs, universal credit and the benefit system, and cuts to funding for local social care services are the main contributors to the cause of hunger, malnutrition and food insecurity, leading to many having to use Food Banks. The use of food banks has increased by 73.4% in the last five years, increasing by 18.8% in the past year³⁰.

The pandemic has hit the poorest in society hardest. The Food Foundation found that five million people in the UK living in households with children under 18 have experienced food insecurity since the lockdown started, with 1.8 million experiencing food insecurity solely due to the lack of supply of food in shops, leaving 3.2 million people (11% of households) suffering from food insecurity due to other issues such as loss of income or isolation³¹. Long term solutions are required to ensure all have the right to a healthy, productive life, not just those on higher incomes. However, as economic uncertainty continues in the coming months or years, it is vital the Government keeps taking steps to ensure the most vulnerable among society can afford their next meal. Healthy Start provides pregnant women and young children in low-income families with vouchers worth £3.10 per week to purchase vegetables, fruit, milk and infant formula, worth up to £900 per child. This system must be modernised via digitisation to support vulnerable families.

Access to Healthy Food

Those who are less mobile, either due to age, physical disability or lack of transport, whilst also living in ‘food deserts’ (areas without many food stores), may find it more difficult to access healthy, affordable food, with local stores often supplying more expensive products without a lot of fresh fruit and vegetables on offer³². Those self-isolating may also find they cannot access healthy food, with supermarket delivery slots rationed, leaving delivery companies such as Deliveroo and Just Eat providing the main access to food at this time.

Delivery services have never been more necessary, but market leaders are choosing to influence consumer choice and make it easier to eat unhealthy food, particularly in more deprived areas.  An investigation by the Panorama programme showed that disruptor businesses such as Deliveroo often subvert planning laws and seem to operate outside of the legislative barriers of other food companies. Deliveroo was found to promote party buckets to poorer postcodes with higher levels of obesity, compared to sushi and noodles being promoted to more affluent areas with lower levels of obesity, further limiting the access to nutritious foods at affordable prices to those in the poorer postcodes³³. These delivery services undermine the work done by local authorities to reduce the amount of fast food outlets being opened by allowing easy access to unhealthy food. During this time, companies must prioritise offering healthy food via all outlets and delivery companies must not promote HFSS products.

What further impacts could the current pandemic have on the food supply chain, or individual elements of it, in the short to medium-term and what steps do industry, consumers and the Government need to take to mitigate them?

As stated above, advertising manipulates choice and many food and drink companies have demonstrated just how quickly they can adapt to the pandemic, developing marketing and advertising strategies to position those companies as ‘Feeding the Nation’. Frequently, these strategies have been designed to push out HFSS products. Key examples include:

Recently, Kellogg’s were exposed for irresponsibly advertising its Pringles snack products⁴⁰ to families at the start of PE with Joe exercise sessions on YouTube⁴¹, according to a successfully resolved complaint to the Advertising Standards Authority⁴².  The brand subsequently removed all of its advertising from Joe Wicks’ Body Coach YouTube channel rather than face a formal regulatory investigation into its online advertising practices⁴³.

We strongly recommend that all food & drink companies be made to refrain from advertising any food or drink high in fat, salt or sugar (HFSS) before 9pm across all media platforms during the COVID-19 pandemic. This should be until the government is able to resume its previously planned work to introduce a 9pm TV and online watershed on junk food advertising, as part of current Childhood Obesity Plan measures. 

How effectively has the Government worked with businesses and NGOs to share information on disruptions to the supply chain and other problems, and to develop and implement solutions? How effectively have these actions been communicated to the public?        

While we are aware that Public Health England have been instructed to review the evidence linking obesity to covid mortality by the Secretary of State of Health and Social Care, government has had a Childhood Obesity Plan in place since 2016, and so far few measures have been implemented although many have been consulted on. Due to the link between poor diet and poor health outcomes, and the link between obesity and Covid-19, government must take action now to ensure environments enable healthy lifestyles, and educate the public on healthy diets. We must make sure that the gradual easing of lock down restrictions, and our return to a functioning and thriving society, does not damage our physical and mental health in the long run.

References

1. The Global Burden of Disease Study. http://ihmeuw.org/4dks. 2017
2. Health matters: obesity and the food environment. https://www.gov.uk/government/publications/health-matters-obesity-and-the-food-environment/health-matters-obesity-and-the-food-environment--2
3. Diabetes UK. Cost of Diabetes https://www.diabetes.co.uk/cost-of-diabetes.html
4. McKinsey Global Institute. Overcoming obesity: An initial economic analysis. https://www.mckinsey.com/~/media/McKinsey/Business%20Functions/Economic%20Studies%20TEMP/Our%20Insights/How%20the%20world%20could%20better%20fight%20obesity/MGI_Overcoming_obesity_Executive_summary.ashx
5. NHS Digital. National Child Measurement Programme 2016/17. 2017
6. NHS Digital. National Child Measurement Programme 2015/16).2016
7. HM Government. Childhood obesity: a plan for action https://www.gov.uk/government/publications/childhood-obesity-a-plan-for-action
8. HM Government. Childhood obesity: a plan for action chapter 2 https://www.gov.uk/government/publications/childhood-obesity-a-plan-for-action-chapter-2
9. Ho FK, Celis-Morales CA, Gray SR, et al. Modifiable and non-modifiable risk factors for COVID-19: results from UK Biobank. medRxiv [Epub ahead of print]
10. The OpenSAFELY Collaborative, Williamson E, Walker AJ, et al. OpenSAFELY: factors associated with COVID-19-related hospital death in the linked electronic health records of 17 million adult NHS patients. medRxiv [Epub ahead of print]
11. Simonnet A, Chetboun M, Poissy J, et al. High prevalence of obesity in severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) requiring invasive mechanical ventilation. Obesity (Silver Spring, Md) [Epub ahead of print]
12. Lighter J, Phillips M, Hochman S, et al. Obesity in patients younger than 60 years is a risk factor for Covid-19 hospital admission. Clin Infect Dis [Epub ahead of print]
13. Yu T, Cai S, Zheng Z, et al. Association Between Clinical Manifestations and Prognosis in Patients with COVID-19. Clin Ther [Epub ahead of print]
14. Kalligeros M, Shehadeh F, Mylona EK, et al. Association of Obesity with Disease Severity among Patients with COVID-19. Obesity (Silver Spring, Md) [Epub ahead of print]
15. Petrilli CM, Jones SA, Yang J, et al. Factors associated with hospitalization and critical illness among 4,103 patients with COVID-19 disease in New York City. medRxiv [Epub ahead of print]
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17. Huang R, Zhu L, Xue L, et al. Clinical findings of patients with coronavirus disease 2019 in Jiangsu province, China: A retrospective, multi-center study. PLoS Negl Trop Dis 2020; 14: e0008280.
18. Kruglikov IL, Scherer PE. The role of adipocytes and adipocyte-like cells in the severity of COVID-19 infections. Obesity (Silver Spring, Md) [Epub ahead of print]
19. Kassir R. Risk of COVID-19 for patients with obesity. Obes Rev 2020; 21: e13034.
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21. Green WD, Beck MA. Obesity Impairs the Adaptive Immune Response to Influenza Virus. Ann Am Thorac Soc 2017; 14: S406-S9.
22. National Diet and Nutrition Survey, 2018 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/699241/NDNS_results_ye ars_7_and_8.pdf
23. PHE, 2019 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/832618/Sugar_reduction _summary__of_progress_2015-2018.pdf
24. PHE, 2018 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/765571/Salt_targets_201 7_progress_report.pdf
25. Scottish Government, 2019 https://news.gov.scot/news/restrictions-on-food-promotions
26. DHSC, 2018 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/770705/impactassessment-for-restricting-volume-promotions-for-HFSS-products.pdfLondon TFL ban
27. Health and Social Care Committee. Oral evidence: childhood obesity follow-up 2019 http://data.parliament.uk/writtenevidence/committeeevidence.svc/evidencedocument/health-and-social-care-committee/childhood-obesity-followup-2019/oral/106851.html
28. FAO, IFAD, UNICEF, WFP and WHO. The State of Food Security and Nutrition in the World. 2018, p.138
29. Food Standards Agency. The Food & You Survey. 2017, pp.27–28
30. The Trussell Trust. Record 1.6m food bank parcels given to people in past year as the Trussell Trust calls for end to Universal Credit five week wait.2019
31. Food Foundation, 2020 https://foodfoundation.org.uk/new-food-foundation-survey-five-million-people-living-in-households-with-children-have-experienced-food-insecurity-since-lockdown-started/
32. Social Market Foundation. What are the barriers to eating healthily in the UK?2018
33. Food Active, 2019. Deliveroo dishes out junk food deals to the obese – Food Active response.
34. Krispy Kreme, 2020 https://www.krispykreme.co.uk/coronavirus
35. Pizza Hut Twitter account, May 2020 https://twitter.com/pizzahutuk/status/1256267141306707969
36. Just Eat Twitter account, April 2020 https://twitter.com/JustEatUK/status/1253315260171210753
37. Greggs Twitter account, April 2020 https://twitter.com/GreggsOfficial/status/1253302707328372738
38. Cadbury UK Twitter account, May 2020 https://twitter.com/CadburyUK/status/1256214522945306635
39. McDonald’s UK Twitter account, April 2020 https://twitter.com/McDonaldsUK/status/1255072715804983297
40. Pringles Original calculated to have Nutrient Profile Model score of 11 and thus be classified as HFSS / ‘less healthy’. Nutrition data via https://www.sainsburys.co.uk/gol-ui/product/pringles-original-190g and NPM scorecard https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/216094/dh_123492. pdf
41. PE with Joe - on The Body Coach TV Youtube channel https://www.youtube.com/playlist?list=PLyCLoPd4VxBsXs1WmPcektsQyFbXTf9FO
42. Advertising Standards Authority webpage listing informally resolved cases https://www.asa.org.uk/codes-andrulings/rulings.html#informally-resolved
43. Details taken from letter sent from ASA to complainant explaining the informal resolution of complaint, 6 May 2020.