Special feature: Making the healthy choice the easy choice

Most of us don’t have to go far to find a healthy food desert – a place where affordable nutritious food is scarcely to be found but unhealthy food abounds. One example, from a residential area in Edinburgh, has a row of 15 or so businesses including a general store and newsagent; a store selling frozen foods; a dessert shop selling puddings, ice cream and milkshakes; a kebab shop; a bakery promoting sweet pastries and bacon rolls with on-street display boards; a café advertising fried breakfasts and burgers; an off licence; a Chinese takeaway; and a pizza place. To find any food that is not high in salt, fat or sugar, shoppers have to search for it.

The nearest large supermarket selling a wide range of fresh fruit, vegetables and unprocessed food is a 15-minute walk away, across several large roads. Two miles down the road in a much more affluent part of town, it’s a very different story. Here there are several supermarkets selling fruit and vegetables, and cafes selling freshly made soups and sandwiches alongside the sweet treats. The unhealthy food is on offer here too – there are cakes in windows, pizza places and a fish and chip shop – but it’s much less prominent in an area where it’s easier to find something wholesome to eat.

What’s striking is that food deserts are found almost exclusively in deprived communities. A 2018 study in Glasgow found that clusters of tobacco, alcohol, fast food and gambling outlets were found in ever greater prevalence as researchers progressed from the least to the most deprived communities. The wealthier you are, the easier it is to find affordable, healthy food; the lower your income, the more restricted your choice will typically be. 

This phenomenon is of acute concern for public health professionals, but it’s of even greater concern to consumers themselves. Last year, a series of citizens’ juries involving people from two contrasting communities in Glasgow, one lower income, one more affluent, explored public attitudes to the availability and marketing of tobacco, alcohol and unhealthy foods.

The participants had strong negative views about the way retailers and food manufacturers were marketing unhealthy foods at both adults and children.

One participant, sharing a photograph of his local high street, gave this commentary: “There’s the local shop where you can buy all your unhealthy food, alcohol and tobacco, there’s the bookie where you lose your money and there’s the funeral parlour where you end up.”

The clustering of unhealthy food options in deprived areas is thought to contribute to Scotland’s chasm-like health inequalities. Scotland’s health is deteriorating. Between 2019 and 2021 healthy life expectancy for men in our most deprived areas was 26 years lower than in the least deprived areas, the gap for women was 25 years. 

The NCD (Non-Communicable Diseases) Alliance Scotland of 24 leading health organisations, including charities and medical royal colleges, is campaigning to improve people’s choice over what they consume, particularly in deprived communities.

Kym Kestell of NCD Alliance Scotland, says: “We should be making the healthy choice the easy choice and at the moment, it isn’t. Too many people, particularly those living on low incomes, struggle to find healthy affordable food locally to where they live. Instead, they are bombarded with advertising for high fat, salt and sugar foods, and often that’s all that is readily available.”

Researchers freely accept that the cost of some fresh, unprocessed foods is a challenge for those on low incomes. However, even affordable healthy options are invisible on some high streets. Where healthier options exist, the prevalence of advertising for fast food and processed food means that they are pushed to the periphery. 

NCD Alliance Scotland believes that one of the most effective ways to give people more choice is to tackle the commercial determinants of health – the marketing, advertising, price promotion and over-availability of health-harming products – which retailers and food manufacturers use to shape people’s purchasing choices. 

You can buy all your unhealthy food, alcohol and tobacco, there’s the bookie where you lose your money and there’s the funeral parlour. - Citizen jury participant, Glasgow

Katherine Smith, professor of public health policy at the University of Strathclyde, says: “Restricting the overpromotion and the over-availability of these products are the two things you can do which should increase choice.”

She explains: “Large companies that produce and market products for widespread sale are in discussions with retailers about product placement, their goods are priced carefully, they obviously have adverts and through all of those processes they are trying to frame how we think about those products. 

“If you go to your local shop and all of these things have been carefully placed to entice you and there’s a sense that these things are easier and quicker and you’re short of time, and you’ve heard of them because they’ve been advertised, all of that is designed to restrict your choice, to make you conclude that that’s the product to buy.

“If we restrict the extent to which companies can market highly processed food and place them in certain ways, so that instead retailers are actually letting you see the healthier food to the same level, then that should be increasing your choice.”

The influence of unhealthy food ‘swamps’ is significant. People walking along their high street cannot escape the advertising for unhealthy products. “When you have these rows of shops with highly processed food and that’s what they are showing to you – and  kids are often walking past these areas on their way to school – you are being marketed at with that food and not with the healthier alternatives,” Smith says. 

“If you’re feeling hungry, you’re thinking about those products because that’s what you’ve just seen and they are easier to access. A lot of supermarkets now are a bit of a walk or maybe a drive away. 

“The people who are living in some of the areas where we have these food swamps are often on lower incomes, not all of them will have cars and not all of them will go shopping to those bigger supermarkets. 

“There are smaller metro-style supermarkets in some urban areas, but their choice isn’t nearly as big and they have pretty limited fruit and vegetable sections.

“And even though many of us do buy our food from those bigger supermarkets, and those of us without cars might do an online shop, you still do often end up going to your local shop to pick up extras. If when you go to those shops all that’s available is the highly processed stuff, you are still being limited in your choice.” 

NCD Alliance Scotland aims to reduce mortality and ill-health from non-communicable diseases like cardiovascular disease, cancer and diabetes, which collectively caused over 52,000 deaths in Scotland in 2023 (83 per cent of the total). A fifth of those deaths were preventable. 

Key drivers of preventable NCDs are the consumption of tobacco, alcohol and unhealthy food and drink. Collectively, ill-health and disability caused by tobacco, alcohol and unhealthy food and drink is estimated to cost the Scottish economy between £5.6bn and £9.3bn every year.

NCD Alliance Scotland has highlighted a range of restrictions on the marketing and advertising of health-harming products to help prevent deaths, improve healthy life expectancy and tackle health inequalities. Opponents sometimes counter that the government intervening to restrict advertising is the overreach of the “nanny state”.

But Dr Nason Maani, lecturer in inequalities and global health policy at the University of Edinburgh, says: “The flip side of that nanny state narrative is that people’s choices are being deliberately and quite powerfully shaped all the time by people who have a vested interest in what our choices are. So I’d argue, who is the nanny? Because there are a lot of actors putting a lot of effort into shaping our choices quite powerfully.

“It can be said that it’s nobody’s business what we eat and drink, but it’s quite literally business’s business.”

Research for the campaign group Adfree Cities published last year showed that in England and Wales, communities that were home to the least well-off half of the population hosted more than four fifths of outdoor ads, like billboards, with fast food chains among the top industry spenders on outdoor advertising. Acting to restrict promotion of unhealthy products is about giving people a broader choice over what they consume.

“This is about being pro-economy and pro-health,” says Maani. “It’s the foundation of a healthier, more prosperous Scotland, ensuring that children are growing up healthy and ensuring the everyone has the ability to reach their full potential.

“Currently and on the horizon, non-communicable diseases are a huge challenge. The number of people off sick is at extremely high levels. Scotland has been a real leader in this space in recent years and the work of NCD Alliance Scotland is a really exciting development. It speaks to the commitment of the member charities to be doing this.”

Paul Johnston, chief executive of Public Health Scotland, stresses the importance of “bold action” to prevent non-communicable disease and welcomes the latest report of NCD Alliance Scotland in setting out the case for further action.

He says: “We have already seen progress through action in areas such as smoking restrictions and Minimum Unit Pricing for alcohol. We need to go further to address the advertising, availability and affordability of health-harming products.  

“When it comes to action on food, this is not about the ‘nanny state’. It is about ensuring that we all have freedom of choice, and the ability to access healthy options at an affordable price. At present, for many in Scotland, healthy options are not sufficiently available and affordable and, as a result, choice is severely curtailed.

“Those who produce and sell food make an important contribution to our economy and can be great employers who promote the health and wellbeing of their workforce. Many can also play a vital role in supporting the wellbeing of people across Scotland – helping people live longer and healthier lives.  

“We are working with the Scottish Government and Cosla on a long-term framework for improving Scotland’s health, and hope to see support from across the parliament in taking forward ambitious action to transform our health.”

The researchers who held the citizens’ juries in Glasgow last year were surprised by just how powerfully people from all backgrounds wanted to be liberated from advertising of unhealthy products, particularly where children were exposed to it. 

Smith says: “Given that we had deliberately recruited for diversity in terms of people’s income and political views and so on, I was taken aback by the strength with which people were saying this needs to change.”

Kestell concludes: “The benefits of taking action on health-harming products – in lives saved, improved wellbeing, NHS time spared and economic benefit – are clear. The public want action. We hope MSPs will move ahead at pace now to restrict the overpromotion of these products.”

This special feature is in association with NCD Alliance Scotland.