The history of healthy weight policy

Explainers · Obesity, nutrition and physical activity | June 19, 2023

Globally, over two billion adults are malnourished, with 1.9 billion overweight or obese, and 462 million classed as underweight.

Malnutrition, according to the World Health Organisation (WHO), refers to “deficiencies, excesses or imbalances in a person’s intake and/or nutrients”[i] and can be interpreted in terms of being both underweight and overweight. Obesity and other forms of malnutrition, such as nutrient deficiencies, are not mutually exclusive, and the excess levels of consumption in people’s diets does not equate to a nutrient-rich, balanced diet. In England, The Health Survey estimated that in 2021 63.8% of the adult population were overweight or obese. In Scotland, Wales and Northern Ireland there were similar rates, with 67%, 61% and 65% respectively.[ii] [iii]

The causes of such high levels of malnutrition are complex but one major driver is food insecurity. The Food Foundation estimates that in January 2023, 9.3 million adults experienced food insecurity.[iv] Insufficient access to food compromises health, as people prioritise long-lasting, filling foods, causing a reliance on cheap, nutrient-poor, calorie-rich options.[v] Healthier foods are also nearly three times as expensive per calorie as less healthy foods, and the poorest fifth of UK households would need to spend 43% of their disposable income on food to meet the cost of the Government-recommended healthy diet, compared to just 10% for the richest fifth.[vi]

Access to a balanced diet is essential from the early years to ensure proper childhood development and to give children their best start in life.

In recognition of its importance, the NHS Healthy Start Scheme was launched in England in 2006 to support low-income pregnant women and families, pregnant under-18s and children under four. The scheme provides a food voucher to be spent on fruit and vegetables, milk and access to free supplements and aims to be a nutritional safety net to support better eating habits for the nutritionally vulnerable.[vii] [viii] Similarly in Scotland, the Best Start Grant and Best Start Foods provide support for buying healthy foods.[ix]

For school-aged children, the Education Act 1996 stipulates that maintained schools must provide free school meals to disadvantaged pupils aged between five and 16 years of age. Although over two million pupils qualify,[x] in September 2022, there were an estimated 4 million children found to be experiencing food poverty.[xi] Since the mid 20^th Century, Government policy and campaigns have been used to support the dietary health of vulnerable people and educate people of all ages about the importance of healthy diets. In the early 1940s, the welfare food service, supplementary wartime rationing for infants, pregnant women and the elderly, provided cod liver oil, orange juice and vitamin tablets.[xii] [xiii] By 1946, the post-war Government introduced free school milk.

In 1994, The Balance for Good Health was launched by the Department of Health. This was relaunched in 2007 as the Eatwell Plate and once again as the Eatwell Guide in 2016.[xiv] The Eatwell Guide, which divides food and drink into five main food groups and shows the proportional volume that they should make up in our diets, aims to support consumers in making healthier choices around food and the content of their diet.

The Government launched Change4Life in 2009 to try and get control of the rising levels of obesity and overweight in the population, and to support people to maintain a healthy weight by also encompassing an active lifestyle.[xv] It recommended seven healthy behaviours, including the importance of an active lifestyle, reducing salt intake, and eating five portions of fruit and vegetables each day. In its first year, the campaign reached 99% of targeted families, with over 400,000 families involved.[xvi]

In 2015, a study by Public Health England found that promotional offers on HFSS products increased the volume of products bought by 22%.[xvii] One measure introduced to combat this effect, was the so called ‘sugar tax’. This soft drinks industry levy, introduced in 2018, is applied to UK-produced or imported soft drinks containing added sugar.[xviii] Designed as an anti-obesity policy, the levy was informed by proposals from public health experts and central to the 2016 Childhood Obesity Strategy[xix], aiming to incentivise soft drink reformulation to lower-sugar recipes. Since its introduction, according to researchers at the University of Cambridge there has been an 8% relative reduction in obesity levels in age ten to 11 year old girls, equivalent to 5234 cases per year.[xx]

In response to the Covid-19 pandemic and the urgent need to address the issues of hunger and ill health, the Government commissioned an independent review of UK food systems. The National Food Strategy, carried out by Henry Dimbleby,[xxi] was developed into two parts. Part one, published in July 2020, gave seven specific recommendations to support the most disadvantaged families in the UK to eat well, protect the UK’s high food standards and ensure proper scrutiny of any trade deals. Part two, published a year later, looked at food systems’ negative impacts on both ecosystems and our health. Dimbleby’s recommendations included an ‘eat and learn’ initiative for schools; sugar and salt reformulation taxes to contribute to reducing the price of fresh fruit and vegetables for low-income families; and setting clear targets alongside new legislation for long-term change.

In 2021, high fat, salt and sugar (HFSS) legislation was introduced as a public health measure – aiming to reduce obesity and obesity related conditions such as diabetes and heart disease. The legislation placed restrictions on promotions of HFSS products by placement and price, prohibiting end-of-aisle or shop entrance positioning. [xxii] ‘Volume price restrictions’ such as “3-for-2” or “buy-one-get-one-free” offers are due to be prohibited by October 2025.[xxiii]

In June 2023, the Department of Health and Social Care (DHSC) announced funding for a two-year pilot study to make obesity drugs accessible to patients living with obesity.[xxiv] This strategy of ‘treating’ obesity is based on evidence that when prescribed alongside diet, physical activity and support services, people taking the drug could lose up to 15% of their body year after a year. However, there is also evidence to show that a year after withdrawal of the drug, individuals regain two-thirds of their prior weight loss.[xxv] There are also wider concerns within the public health community at the emphasis placed on these drugs as a solution to the problem of obesity. Preventative measures, which support people to maintain a healthy weight, rather than single intervention solutions, are both more effective and long lasting.

Public health professionals argue that the combination of exposure to highly sophisticated marketing and advertisements, confusing packaging and easy access to cheap, unhealthy convenience food has created a society where there are huge barriers to achieving healthy weight and preventing malnutrition. With healthy food three times more expensive than unhealthy alternatives, such ‘commercial determinants of health’ are further compounded by large variations in access to affordable ways of keeping active.

This means that while healthy weight is often framed as the responsibility of individuals, in reality, Directors of Public Health and their teams are working to support people to make healthy choices in an environment that is stacked against large sections of the community.

Another emerging issue impacting our relationship with healthy eating is that of food sustainability. As climate change poses ‘the greatest global health threat facing the world’[xxvi], the sustainability of our food and the practices we use to produce it are coming into question. The 2021 Food Sustainability Index which included 78 countries, found the UK’s sustainable agriculture performance to be ranked 47^th with an overall ranking of 20^th.[xxvii]

Improving the sustainability of food systems is necessary to ensure accessibility to a wide variety of nutrient-rich foods is equitable for all, and to reduce the impact of farming on climate change. Improving how we produce foods which are highly impacted by climate change such as meat, fish and crops will also ensure that they continue to be available in the long-term and mean that the population is more resilient to disruptions of global and regional food systems caused by changing weather patterns and extreme weather events, such as droughts and flooding.

DsPH across the UK are working with local partners to improve this situation. In our 2023 Annual Report Celebration, which recognises outstanding Public Health Annual Reports, both Oxfordshire[xxviii] and Walsall[xxix] County Councils were recognised for how their reports highlighted the associated public health impacts of food production.

These, and other similar, local, community solutions hold the key to improving both food sustainability and addressing the commercial determinants. However, successful local policies such as collaboration with planning departments to restrict the number of fast-food outlets, will need to be replicated nationally to have a consistent, sustainable effect on society.

By drawing attention to the need for a whole range of measures at a national level – for example, reformulation, marketing restrictions, affordability and accessibility, the goal is to tackle these underlying societal – and commercial – determinants of health.

To this end, both individually, and as a member of the Obesity Health Alliance (OHA), a coalition of over 50 health organisations, ADPH advocate for national policies that will improve population health, promote healthier eating and address obesity and other preventable illness.

[i] https://www.who.int/news-room/fact-sheets/detail/malnutrition

[ii] https://researchbriefings.files.parliament.uk/documents/SN03336/SN03336.pdf

[iii] https://www.gov.wales/national-survey-wales-quarterly-survey-january-march-2021

[iv] https://foodfoundation.org.uk/initiatives/food-insecurity-tracking#tabs/Round-12

[v] https://publications.parliament.uk/pa/cm201719/cmselect/cmenvaud/1491/149105.htm

[vi] https://foodfoundation.org.uk/initiatives/dietary-inequalities#stats

[vii] https://www.gov.uk/healthy-start

[viii]https://static1.squarespace.com/static/59f75004f09ca48694070f3b/t/6053616cbc52605e3d58aa26/1616077169167/Healthy_Start_Report_for_web.pdf

[ix] https://www.mygov.scot/best-start-grant-best-start-foods

[x] https://explore-education-statistics.service.gov.uk/find-statistics/school-pupils-and-their-characteristics

[xi] https://foodfoundation.org.uk/publication/new-data-show-4-million-children-households-affected-food-insecurity

[xii] https://discovery.nationalarchives.gov.uk/details/r/C10953#