Associate feature: Time to change the food environment

People in Scotland who are overweight or obese outnumber those of a healthy weight two to one. Many are aware of the impact that has on their own health and on their increased risk of heart disease, stroke, diabetes and cancer.

But even as that awareness has grown and new evidence has emerged, the ratio of people at an unhealthy weight has remained stubbornly high for 20 years. Body mass index (BMI) figures across the population, which rose in the 1970s and 1980s with the emergence of junk food, have since remained fairly static.

In Scotland, the figure hides a new trend, however. While more affluent areas appear to be taking on public health messages on diet and exercise and starting to see a resultant dip in BMI figures, this is simply not happening in the more deprived parts of Scotland.

In fact, among women and children, the inequality is increasing. While 21 per cent of women living in more affluent areas are obese, it is 37 per cent of those living in deprived areas.

It is no surprise, then, that the issue is a focus for Scotland’s health board tasked with tackling health inequalities, NHS Health Scotland.

Ahead of the Scottish Government’s diet and healthy weight delivery plan last year, the board produced a report which showed high levels of support for policy interventions.

The report’s author, Deborah Shipton, Public Health Intelligence Adviser at NHS Health Scotland, tells Holyrood the research, which used the Scottish Social Attitudes Survey, gave an insight into how different parts of society understand and respond to their own food environment.

“What it means is you have children in different parts of the country who have different opportunities to be a healthy weight from the early ages, and as they grow up,” she says.

“Then the serious consequences of being overweight they have to carry through their lives. It’s an inequality and unfairness we need to tackle.”

Evidence shows that while exercise can improve heart and lung function, it is diet which by far has the biggest impact on our weight.

There have been many high-profile campaigns and public health messages since the dawn of the Scottish Parliament with a focus on healthy eating and exercise levels, but the lack of progress suggests an awareness of the risks alone is not sufficient to change behaviours across the population.

Instead, the focus must be on a food environment which currently makes healthy choices difficult, particularly for those in areas of deprivation.

Shipton says these areas provide a “physical difference” to the lives of children, because they have far more fast-food outlets and often lack access to fresh fruit and vegetables.

“If there isn’t an array of fresh fruit and vegetables in your neighbourhood, then that’s going to affect what is being provided on the dinner tables at night as well.”

The way we eat has changed. With more people working longer hours, ready-made food has become the norm, but it is usually far higher in sugar, salt and fats. 

“When you’re making hundreds of decisions every day, about your family, your work, your car and so on, actually the decisions about eating this cake or that cake, whether to go for a walk, are unlikely to be up there on your list of priorities. Our environment has to support us,” says Shipton.

“The evidence on how to do this is there, we need to make the healthiest decision the easiest decision.”

The Scottish Government’s delivery plan sets out actions to transform the food environment. The Government has consulted on legislation to restrict promotions of unhealthy foods. Food Standard Scotland is also consulting on an Out of Home strategy, including on whether there should be calorie labelling on menus.

Policy needs to reflect the differences in cultures and attitudes across the socio-economic spectrum, Shipton suggests.

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“We have to be careful that you’re not taxing only the food and drink that a certain population eat and drink. The sugar levy was criticised because it was those on the lowest income who drink fizzy drinks the most,” she says.  

“But we also need to use interventions to make the biggest difference to those who are affected most. So there needs to be a balance there and it needs to be sensitive. I would say probably what we need to do more of, is to have the voices across society represented in the decision making.”

The results of Shipton’s research clearly show that the public supports bold action in Scotland. More than 91 per cent said cheap fast food is too easily available, 82 per cent wanted the food they like to be reformulated to contain less sugar, salt and fat, 62 per cent supported more tax on sugary fizzy drinks and 66 supported restrictions on what food could be displayed at supermarket checkouts.

“We’re in a unique position, because the population are totally behind this. They are ready for bold action,” says Shipton.

Obesity doesn’t have a ‘silver bullet’ option that can change behaviours overnight and the Scottish Government cannot act alone. It will require buy-in from the food and drink industry and retailers.

Shipton welcomes individual efforts by manufacturers and supermarkets but suggests a more holistic approach is needed.

For example, despite reformulation and resizing by most of the industry leaders in the sugary drinks industry, there hasn’t been evidence that overall sugar intake has markedly declined as a result.

“I don’t know if it’s a case of ‘I’m not having a Diet Coke so I’ll have a biscuit instead’, but across the population sugar intake didn’t change,” says Shipton. “We substituted, somehow. So you have to be careful. If you pick on one area to act, there could be unintended consequences elsewhere.  That’s why it’s important to take a holistic approach and to evaluate what action we do take.”

Similarly, some supermarkets have altered practice, creating loss-leading cheap fruit and vegetable options and removing confectionary from checkout aisles.

“Over 80 per cent of the food that we buy is in the big supermarkets so in terms of effecting change, that’s one defined area we need to effect change in.” says Shipton. 

“But again, it’s about the whole environment. It’s about what’s displayed at the front of the store, it’s about what’s displayed down by the checkouts and at the end of the aisles, and its promotions, too...”

Of course, the protracted legal battle around minimum unit pricing for alcohol means there may be some reticence to challenge industry, but Shipton says there could be a recognition that encouraging the purchase of healthy food “is the right thing to do”.

“I’m proud that Scotland has been bold in public health,” she says.

“We need to support all people in Scotland. The proposed promotions legislation on food and drink is bold, and we need to be bold if we are to see any change in obesity levels in Scotland.”

And Shipton points to a recent example where the public sector can lead the way.

The Healthcare Retail Standard (HRS) was introduced across Scottish hospitals and other NHS buildings in 2017 to ensure shops stocked and promoted healthy options, and it was shown to have a positive impact.

A study of customers leaving the hospital shops published a year later showed 47 per cent had chosen healthy options, compared with just 11 per cent before the HRS was introduced.

The HRS is also “leading the way” across the UK.

“Some of the big players, operating both in England and Scotland, when you first spoke to them it was a headache, but actually what they were saying is ‘this is the way the world is going. Scotland is forcing us to go that way’,” she says.

“Even in just the 70 static hospital stores in Scotland, the demand for extra healthy products meant the suppliers started reformulating. Imagine if the whole of the high street was demanding that? It would be massive.”

Whether it is tackling our choices of take-away or what we put in our supermarket basket, Shipton maintains the environment has a huge influence on our diet.

“What you’re doing is making healthier products more available. Evidence shows across the board – food, alcohol, tobacco – we make decisions based on what is in front of us and so you can’t go wrong if you focus on price, availability and promotion.” 

This article is in association with NHS Health Scotland