This section covers NIHR funded research into the impact of the environments in which people buy, prepare, and consume food. These food environments shape what we eat. Our current food environment is dominated by unhealthy ‘junk’ foods (energy dense, and high in saturated fat, sugar and salt) (The National Food Strategy). Local authorities can influence food environments, and reduce health inequalities. ‘Healthier zones’ and ‘school superzones’, for example, limit the number of fast food outlets and advertising of unhealthy food in areas with many outlets, high levels of deprivation, or where children gather (UK Health Security Agency). Local authorities also enforce food standards regulations, including labelling.
What’s the context?
The food environment can undermine efforts at weight management.(1) Easy access to unhealthy food and drink, from takeaways for example, and prominent displays of unhealthy foods, such as of sweets at supermarket checkouts, drive the consumption of unhealthy foods and obesity. (2) People who are socially and economically disadvantaged, and some minority ethnic groups, are especially vulnerable (Foresight, The National Food Strategy).
Meals at cafes, restaurants and from takeaways (out of home meals) are contributing to rising levels of obesity. These meals tend to contain more energy (with higher levels of fat, saturated fats, sugar, and salt), and lower levels of micronutrients. There are more fast food outlets in deprived areas, on average, than in more affluent areas (Public Health England). Online fast food outlets in England are also more accessible in the most deprived areas.(3)
National policies aim to tackle obesity by altering the food environment. Efforts include a soft drinks industry levy (HM Treasury), and reducing sugar in the products children eat most (Public Health England). Sugar content declined in large UK chain restaurant menu items between 2018 and 2020 (possibly in response to these measures) but there was little change in salt and saturated fat.(4)
New initiatives include calorie labelling on menus in large food businesses including restaurants, cafes and takeaways (Department of Health and Social Care). Restrictions on the placement and promotion of food and drink high in fat, salt and sugar (HFSS) will come into force in October 2022. From January 2023, advertising of HFSS products will also be restricted. (Department Health Social Care).
Some local authorities choose which companies can advertise in bus shelters; others pass control of bus shelters to a third party. Local authorities can influence the position of billboards via the planning system, but generally not what is advertised on them. There have been calls for greater local controls to restrict junk food advertising where it is at odds with local health priorities (Food Active and Sustain).
Local authorities are responsible for enforcing the new requirement for calorie labelling on menus (Department of Health and Social Care). Existing measures on food labelling in shops have been shown to increase knowledge about the nutritional value of food,(5) reduce the purchase of HFSS foods,(6) and may stimulate product manufacturers to reformulate recipes (The National Food Strategy).
What does NIHR research tell us?
The wider environment, age, gender and socioeconomic status all influence food consumption
People living on low incomes can find it hard to eat healthily.(1) Healthier foods tend to cost more, and there are many deals on HFSS foods.(9) Better access to healthy food outlets (specialty stores such as greengrocers) at home and at school is associated with better dietary quality in young children.(7) People of higher socioeconomic status, older people, women and those not working overtime are more likely to eat home-cooked meals and not rely on out of home food.(8)
Interventions that require people to understand and act upon information (high agency) tend to be less effective than those that do not rely as much on individual decision-making (low agency). High agency interventions include food labelling or financial incentives that require effort from consumers (e.g. cash back incentives).(10) Low agency interventions include making healthy food cheap, available and accessible.
Targeting out of home food could reduce excess calorie consumption
Local authorities commonly give awards to food outlets that meet certain criteria (recipe reformulation, adding healthier options or smaller portions to the menu) to promote healthier eating. Outlet owners have been generally positive about such interventions, especially when they are cost neutral and use a ‘health by stealth’ approach. That means imperceptible changes to price, taste, or portion size. Customers are generally in favour of these changes and are often unaware they have happened. Further research is needed into the effectiveness of the interventions.(12)
Policies regulating the content of out of home food (e.g. levels of fat, salt or sugar) could influence what people eat. A modelling study suggested that policies to reduce fat content in this food could reduce obesity. A reduction of 20% in fat content could reduce the prevalence of obesity by 5.3%, and of overweight by 1.5%.(11)
Planning guidance to restrict new fast food outlets near secondary schools was not effective in decreasing the number of outlets at 3 years. This was possibly due to the low numbers of new outlets in the study area.(13)
Restricting food advertising can be particularly effective for those in the most disadvantaged communities
Several types of advertising (for food delivery services, digital advertising, and adverts in recreational environments) have been associated with increased obesity in adults. Exposure to advertising for HFSS food and drink is unequal across society. Younger adults, and those in lower socioeconomic groups are most likely to report having seen advertising of processed HFSS foods, sugary cereals and sweet snacks.(14)
Exposure to screen advertising (on TV, and in video games) for unhealthy food significantly increases children’s dietary intake.(15) Young children (aged 8 years or less) are especially vulnerable, and children from low socioeconomic and minority ethnic backgrounds are most exposed to this advertising.(16) Using celebrities or cartoon characters to market HFSS foods, has been found in laboratory-based studies to increase children’s preferences for these products (17), and to increase their consumption.(18) Modelling research has predicted that restricting advertising of unhealthy food and drinks between 05:30 and 21:00 could reduce childhood obesity by two-thirds, and help tackle health inequalities.(19)
Restrictions on HFSS advertising have also been shown to influence adults. Removing HFSS advertising on public transport networks in London in 2019 was followed by reductions in average weekly household purchases of HFSS foods.(20) Challenges in implementing restrictions included defining ‘junk food’, developing policy that complies with existing legal frameworks, taking account of the uneven impact of the policy on different industry stakeholders (due to differences in company size and product ranges), and balancing health and financial effects. Close communication with industry helped, along with an exceptions process to consider products (e.g. cough sweets) that might not contribute to children’s HFSS consumption.(21)
The Eatwell Guide provides a framework for government recommendations on eating healthily and achieving a balanced diet (Public Health England, 2016).
The Local Government Association together with national government and Public Health England, has produced a toolkit to help local authorities and businesses provide and promote healthier options for food eaten away from home, including the management of new business applications and working with existing food outlets to provide healthier food.
The government has also outlined ways in which local authorities can help businesses offer healthier food and drink, including planning policies to promote healthier diets, and restrictions on new hot food takeaway outlets.
How does living in a lower income community impact children’s responses to efforts to help them eat a healthy diet? (22) What impact do Universal Infant Free Schools Meals have on the diet of low-income infants? (23) How effective is a scheme in which households in areas of deprivation receive £5 weekly vouchers (along with recipes and healthy eating advice) to spend on fresh fruit and vegetables?(24)
What impact do online food ordering and delivery services have on different demographics, and health inequalities?(25)
What impact do fast-food exclusion zones have at scale? This research is using a dataset of all food outlets in England.(26)
What impact does mandatory calorie labelling in the out-of-home food sector have, and how effectively is it enforced?(27)
Interactions between local governments in England and harmful industries (large companies that sell unhealthy products) are being explored. This research aims to develop principles to inform local decision-making. (28) Other research is evaluating policies to improve the food environment, including mandatory, voluntary, and partnership approaches.(29)
Local policies to support restrictions on outdoor advertising for HFSS foods in council-owned spaces are being explored.(30)
The mission of the National Institute for Health and Care Research (NIHR) is to improve the health and wealth of the nation through research.NIHR Evidence is managed by NIHR with a funding contribution from Health and Care Research Wales, Welsh Government.