Take it away: a masterclass in healthy takeaways

Post by Scott Lloyd, Advanced Public Health Practitioner at Public Health South Tees and Karen Pearson, Catering Monitoring & Advisory Officer at Redcar & Cleveland Council

Whether it is the Golden Cod or the Taste of India, independent hot food takeaways get a bad rap in Public Health circles. They serve food and drink that is predominantly higher in fat, salt and sugar and may contribute to noise pollution and other environmental ills. Furthermore, they may not be the best option for our beleaguered high streets as they tend to be shuttered up during the daytime.

Up to March 2018, for a variety of reasons (including health), 164 out of 325 Local Authorities (50.5%) have introduced powers through Local Plans or Supplementary Planning Documents (SPD) that aim to restrict the proliferation of hot food takeaways (Keeble et al. 2019)[1].

Watch this video to find out more about how we worked with takeaway owners
(click here if the video doesn't appear above)

But let’s be honest – that horse has already bolted. Analysis by Public Health England has shown that there is an average of 96.1 hot food takeaways per 100,000 population in England (Public Health England, 2018)[2].

Where we work in Redcar and Cleveland, the Local Authority introduced a SPD in 2008 that restricted the percentage of hot food takeaways (A5 class use in planning terminology) in any commercial centre to no more than 5% - but even then, each commercial centre already had more than 5% hot food takeaways.

So we have to accept that hot food takeaways are here to stay – at least for the foreseeable future. Many Local Authorities have implemented interventions such as award schemes that engage these businesses to support them to improve the healthiness of their food offerings, but with limited evaluation (Hillier-Brown et al. 2017)[3]. Indeed, we have a Food4Health award in Redcar and Cleveland, which is open to all out-of-home caterers. We were doing OK in engaging hot food takeaways but we wanted to try something different.

In 2015, the Foodscape team organised a Fuse Quarterly Research Meeting on developing interventions with out-of-home caterers. One of the presentations was by Louise Muhammad from Kirklees Council on the healthy takeaway masterclass that they had developed and delivered to over 20% of the eligible businesses on their patch. The masterclass was described as a three-hour session in which hot food takeaway owners and managers learn about the small, sustainable changes they can make so their food is a little healthier without costing a huge amount or that will actually save them money/generate new custom.

A few months later, we travelled down to Huddersfield to watch a masterclass being delivered. It was clear from the start that this was something that engaged businesses and had potential. The decision to repeat it in Redcar and Cleveland was easy.

Takeaway owners and managers learning about small changes to make their food healthier

We worked with the teams from Kirklees and Foodscape to deliver our first masterclass in May 2016. In line with what Kirklees do, we invited hot food takeaways with a food hygiene rating of three or above – the feeling was that any outlets with less than this really needed to concentrate on food hygiene first. In total, 181 invitations were sent out and 18 attended, representing 10% of those eligible – a figure that we practitioners were happy with (if not all the academics!).

The Foodscape team conducted a mixed methods evaluation to explore the acceptability and feasibility of the masterclass intervention (Hillier-Brown et al. 2019)[4]. The takeaways businesses that attended made a variety of pledges – the ones that required less effort and cost (e.g. reducing salt and sugar in pizza dough) were implemented more so than other more potentially costly or difficult changes (e.g. stocking reduced sugar tomato ketchup).

Pledging to use healthier alternatives

Has this work made the hot food takeaways in Redcar and Cleveland healthy? No it hasn’t. Like the rest of us, businesses owners have a living to make and will cater to what their customers want. But as an example, Carol - the owner of a sandwich shop in Guisborough who stars in the film above - pledged to take 10% of the sugar out of her baking. Did her customers notice? No. Did, this make her flapjacks ‘healthy’? Of course not but they are now a little healthier. Hence, has the masterclass via all the pledges made their food offerings a little healthier? Probably.

We have since delivered a further six masterclasses, with the offer extended to other out-of-home caterers such as restaurants. About 30% of all eligible takeaways in Redcar and Cleveland have now attended a masterclass, with follow up support provided by the Food4Health award.

Engaging with hot food takeaways can be difficult. We are now struggling to attract new businesses onto the masterclass and may hit a saturation point at 35% or 40% of those who are eligible. Some owners have other priorities and some may not accept the healthy eating messages. Also, some hot food takeaway owners are not even resident to the UK so engaging them is nigh on impossible. But we have to continue to try.

Another key learning point is that we need to work more closely with suppliers. The majority of masterclass attendees pledged to start using healthier alternatives, such as reduced sugar tomato ketchup or reduced salt soy sauce but they were unable to source these items from suppliers at a reasonable cost or not at all. Hence, wider work is needed with suppliers which, as one of the other Foodscape projects showed, is possible (Goffe et al. 2019)[5].

But the masterclass is an acceptable and feasible intervention to engage a good proportion of hot food takeaways. We will continue to deliver it once or twice a year as long as there is sufficient demand. We’re hoping to run the next class in September, so lookout for that.

What the masterclass doesn’t do is engage the big operators such as McDonald’s and Just Eat, accepting that the latter works mainly through local independent takeaways (but what requirements can the national corporation specify on their local deliverers?). It’s likely that national work is needed with those corporations, continuing the good work of Public Health England and others.

We also need to be mindful of the potential impact of “dark kitchens” – potentially the “satanic mills of our era”. But I’ll save that for another time…


Read our handy Fuse research brief to find out more about the Foodscape study.


References:

1. Keeble, M., Burgoine, T., White, M., Summerbell., C., Cummins. S., Adams, J. (2019). How does local government use the planning system to regulate hot food takeaway outlets? A census of current practice in England using document review. Health & Place, 57, 171 – 178. https://doi.org/10.1016/j.healthplace.2019.03.010
2. Public Health England (2018). Fast Food Outlets: Density by Local Authority in England. Available at: https://www.gov.uk/government/publications/fast-food-outlets-density-by-local-authority-in-england [accessed 27 May 2019] 
3. Hillier-Brown, F.C., Summerbell C.D., Moore, H.J., Wrieden, W.L., Adams, J., Abraham, C., Adamson, A., Araújo-Soares, V., White, M., Lake, A.A. (2017). A description of interventions promoting healthier ready-to-eat meals (to eat in, to take away, or to be delivered) sold by specific food outlets in England: a systematic mapping and evidence synthesis. BMC Public Health, 17 (1), 93. https://doi.org/10.1186/s12889-016-3980-2
4. Hillier-Brown, F. C., Lloyd, S., Muhammad, L., Goffe, L., Summerbell, C., Hildred, N. J., ... Araújo-Soares, V. (2019). Feasibility and acceptability of a Takeaway Masterclass aimed at encouraging healthier cooking practices and menu options in takeaway food outlets. Public Health Nutrition. https://doi.org/10.1017/S1368980019000648
5. Goffe, L. Hillier-Brown, F., Hildred, N., Worsnop, M., Adams, J., Araújo-Soares, V., Penn, L., Wrieden, W., Summerbell, C.D., Lake, A.A., White, M., Adamson, A.J. (2019). Feasibility of working with a wholesale supplier to co-design and test acceptability of an intervention to promote smaller portions: an uncontrolled before-and-after study in British Fish & Chip shops. BMJ Open, 9 (2), e023441. https://doi.org/10.1136/bmjopen-2018-023441

It is time to ban the sale of energy drinks to children in the UK

Guest post by Prof Amandine Garde, Dr Amelia Lake and Dr Shelina Visram

In 2016 in the UK alone we consumed 679 million litres of high sugar, high caffeine drinks known as “energy drinks”. Described as the fastest growing sector of the soft drink market, they have become a major public health concern and have been subject to both a House of Commons Science and Technology Committee Enquiry (April – December 2018) and a Department of Health and Social Care consultation (which closed on 21 November 2018).

In the report it published on Tuesday (4 December), the Committee found that “the current quantitative evidence alone is not sufficient to warrant a statutory ban”, though it noted that “societal concerns could justify a ban on the sale of energy drinks to children”. This conclusion is puzzling for several reasons.

Energy drinks and children

Firstly, a growing body of evidence has established that energy drinks consumption, particularly by children, is associated with a wide range of harmful effects.

• Whilst childhood and adolescence are periods of rapid growth requiring adequate sleep and good nutrition, energy drinks play a role in disrupting sleep (1 - see references below).
• It is established that energy drinks are highly erosive in terms of dental health: they have low pH and a high non-reducing sugar content (2).
• Consumption is also linked to increased energy intake and therefore obesity (3). Hence the proposal of the UK Government to ban the sale of energy drinks to children in the second iteration of its Childhood Obesity Action Plan, published in August 2018, and the public consultation that followed.
• However, energy drinks consumption is also linked to physical symptoms such as headaches, stomach aches and sleeping problems (with some evidence of a dose-response effect), as well increased risk-taking behaviours, including binge drinking, smoking, illicit drug use, screen time and poor dietary behaviours (4). Moreover, mixing energy drinks with alcohol increases the risk of injury and unsafe driving (5) and 6).

Secondly, the Committee has failed to engage with the fact that gathering “quantitative evidence” on the impact of energy drinks on child health would be unethical (other than the aforementioned studies, which tend to involve large-scale, school-based surveys).

To our knowledge, there have been no experimental studies involving children’s use of other age-restricted products such as alcohol, tobacco, aerosols, solvents, fireworks, knives, crossbows, petrol or even Christmas crackers (sales of which are restricted in England to those aged 12 and over). Why should energy drinks be subjected to a higher standard of evidence than any of these products?

Thirdly, the evidence base has not prevented other countries from regulating the sale of energy drinks to children. In Europe, Lithuania introduced a ban on the sale of these drinks to under 18s in 2016, followed by Latvia, whilst Norway and Sweden are reflecting on similar legislation.

It is therefore unclear why the Committee has concluded that existing evidence is insufficient to adopt a similar law in the UK. The rationale seems to lie in the absence of a “causal link” between energy drinks consumption and childhood obesity, tooth decay and other diet-related diseases. This arguably demonstrates a lack of understanding by the Committee of the strategies required to address complex and multifactorial nature of these diseases.

It is indeed difficult to establish a causal link between the various measures adopted and the burden of non-communicable diseases: no single policy option can realistically tackle broad phenomena, such as growing obesity rates or tooth decay, when taken in isolation.

Governments must ensure that public health is effectively protected, and they can invoke the precautionary principle in the event of any outstanding scientific uncertainty regarding the impact of energy drinks consumption on public health. Hence, probably, the acknowledgement from the Committee that “it would be legitimate for the Government to go beyond the evidence that is available at the moment and implement a statutory ban based on societal concerns and evidence, such as the experience of school teachers and pupils”.

The logic of their reasoning is nonetheless difficult to follow. There is no doubt that the Government should introduce legislation banning the sale of energy drinks to children, following the lead of Lithuania and Latvia. This would not amount to going beyond the evidence; it would be acting on the basis of existing evidence. It is this body of evidence that has prompted very real and major societal concerns of the effects of energy drinks on our children’s health.

Fourthly, the call of the Committee for more effective labelling measures should not be envisaged as providing an alternative to a ban on the sale of energy drinks to minors; it should only be viewed as complementing such a ban. This is all the more so as labelling could increase existing health inequalities. Children and young people from all backgrounds consume energy drinks. However, as the Committee has noted “energy drinks are consumed disproportionately by disadvantaged groups”.

There may indeed be a link between regular consumption of energy drinks and eligibility for free school meals (FSM), which is often used as an indicator of lower socio-economic status. The 2018 Health-Behaviour in School-Aged Children Survey found that, among those who reported that they drank at least one energy drink per day, 23% received FSM, whereas those who said that they never drank energy drinks or did less than once a week, 11% received FSM (compared to 13% of FSM recipients across the whole sample). A study conducted in schools in the South West England also found that being eligible for FSM was significantly associated with drinking energy drinks once a week or more (Richards and Smith, 2016).

Energy drinks have no place in a healthy diet

Finally, the Committee does not seem to be aware that the Government has a duty to protect the rights of all children to the enjoyment of the highest attainable standard of health and to adequate nutritious food. Energy drinks have no place in a healthy diet. Shifting the responsibility of protecting them onto business actors, such as food manufacturers or food retailers, is highly problematic, not only because a voluntary ban will fail to create the level playing field within which all these actors should operate, but also because it will fail to protect child health and their rights and cannot therefore contribute to an effective obesity prevention strategy.

The Responsibility Deal has failed; regulatory measures that apply to all and are duly enforced are required to address the growing burden of obesity, tooth decay and other diet-related diseases. The conclusion that a statutory ban would be too restrictive is ideological rather than grounded in evidence.

A statutory ban is the most likely measure to ensure that children and young people are effectively protected from the many harmful effects of energy drink consumption.


About the authors:

• Professor Amandine Garde, Professor of Law and Director of the Law & Non-Communicable Diseases Unit at the University of Liverpool. 
• Dr Amelia Lake, Associate Director of Fuse - the Centre for Translational Research in Public Health and Reader in Public Health Nutrition at Teesside University. Amelia is a Dietitian and registered Public Health Nutritionist. 
• Dr Shelina Visram, Programme Lead of the Complex Systems Research Programme for Fuse - the Centre for Translational Research in Public Health and Senior Lecturer in Public Health at Newcastle University.

The views expressed here are those of the authors and do not necessarily reflect those of the author's employer or organisation.

References:

1. Do sleeping habits mediate the association between time spent on digital devices and school problems in adolescence?
2. Short Communication: In vitro assessment of Erosive Potential of Energy Drinks
3. Systematic review of the literature on the effectiveness of product reformulation measures to reduce the sugar content of food and drink on the population's sugar consumption and health: a study protocol
4. Consumption of energy drinks by children and young people: a rapid review examining evidence of physical effects and consumer attitudes
5. Alcohol Mixed With Energy Drinks and Risk of Injury: A Systematic Review
6. Alcohol mixed with energy drink use among U.S. 12th-grade students: Prevalence, correlates, and associations with unsafe driving

Steering the Coca-Cola Christmas trucks off course in 2018

Guest post by Beth Bradshaw, Alex Holt and Robin Ireland, Food Active

You may remember our guest blog for Fuse from last year, which discussed the media frenzy that goes into overdrive when the Coca-Cola Christmas Truck Tour sets off on its journey across various locations in the UK. We also noted our own campaigns and the efforts of others such as SUGAR SMART to make the case against welcoming the truck into towns and cities already grappling with a childhood obesity and oral health crisis.

 

Every year, we are met with growing support from the public health community and the public including GPs, dentists, teachers and parents. Last year Public Health England issued guidance to local authorities about hosting the Coca-Cola truck. However, there was also some criticism of our position, especially where we were seen as ‘spoiling’ Christmas in some way.

However, this year, things seem to be different. We feel a change in the air this festive period with a scaling back of the Coca-Cola tour, both in terms of numbers of locations and less prominent venues.

There are a number of important changes that have happened both in the build-up and the start of the Coca-Cola Christmas Truck Tour for 2018. While these might appear small, together they demonstrate quite a significant shift by the soft drinks corporate giant.

This year, the Coke Truck allowed just three days between the announcement of the tour and its start, compared to 11 days last year. Within this time frame, SUGAR SMART coordinated an open letter to Coca-Cola bosses with over 40 signatories from local authorities, Clinical Commissioning Groups, and national campaign groups to oppose the truck visiting their areas [1]. This meant there was time to coordinate responses both nationally and locally, including a series of Tooth Fairy stunts, and for noise to be made to create negative publicity before the truck had even arrived.

The Coke Truck vs the Tooth Fairies

Another important shift is the size of the tour – downsizing by over a third (37% to be exact), from 38 stops last year to just 24 this year. The 2018 tour is also visiting some much smaller locations - the media has called it ‘snubbing’ cities such as Milton Keynes and Liverpool - and there are just four visits on council-owned land. We are pleased to see so few local authorities allowing the truck on council-owned land but would urge those that are welcoming the truck to seriously consider whether this is in the best interest of their local population.

There are also more stops hosted on supermarket car parks this year, with as many as ten of the stops to Asda and Tesco. The same Tesco that announced a five-year ‘strategic partnership’ with national health charities including the British Heart Foundation, Cancer Research UK and Diabetes UK to help ‘remove barriers to healthy habits’ earlier this year. A Coca-Cola truck pitching up in their car park is certainly a barrier to healthier habits, both literally and figuratively speaking. This move has also been met with criticism and Sustain and SUGAR SMART are calling on the public to write to Asda and Tesco to ask them to reconsider hosting the truck next year. On taking this action ourselves, we received a response from Asda customer relations which said:

“We have been in conversation with Coca-Cola prior to this tour and we are happy that they will be encouraging customers to sample their sugar-free brands. They will only provide Red Coke on request and they estimate that at least 90% of their drinks sampled will be sugar free.”

As of yet and unsurprisingly, we have had no response from Tesco.

Asda’s response is consistent with the quote provided by Coca-Cola’s press release, which also appears to have satisfied Public Health England’s concerns, as they have decided not to respond to the truck this year.

Finally, in the North West of England (where Food Active is based), the truck is visiting just one city in the region compared to six visits in 2016 and four in 2017. Over the past four years, Food Active has been lobbying against the arrival of the truck in the North West, including publishing an article in the British Medical Journal [2], writing an open letter to local and national press (with over 100 signatories) and supporting SUGAR SMART’s open letters to Coca-Cola bosses. We hope that this continued pressure, even in the face of significant criticism, has helped to steer the Coke truck away from the North West.

However, we know the battle is by no means over - 14 of the 19 stops in England have above average prevalence of excess weight amongst 10-11 years old, and in some locations including Manchester, over 30% of the children have experienced tooth decay.

Last year, our blog concluded that “our experience shows us that public health has to be persistent in ensuring our messages are heard in the current victim-blaming culture”. This statement is perhaps even more validated following this year’s experiences.

In the spirit of good will this Christmas, we thank Coca-Cola for helping more of our local authorities in the North West to help tackle issues of childhood obesity and dental decay in their areas - many of which are already disproportionately burdened with deprivation and health inequalities.

www.foodactive.org.uk

@food_active


References:

1. Ireland, R and Ashton, J.R. (2017) “Happy corporate holidays from Coca-Cola” i8633. Available at: https://www.bmj.com/content/356/bmj.i6833
2. SUGAR SMART (2017) Spending holidays in good health. Available at: http://www.foodactive.org.uk/wp-content/uploads/2017/11/Open-Letter-to-Coca-Cola.pdf

Images:

1. Courtesy of Beth Bradshaw
2. With thanks to Sustain and Sugar Smart UK: https://www.sustainweb.org/blogs/nov17_coke_truck 

Young people in the UK drink more energy drinks than any other countries in Europe

Posted by Amelia Lake, Associate Director of Fuse and Reader in Public Health Nutrition at Teesside University and Shelina Visram, Senior lecturer in public health at Newcastle University

It would be a bit shocking to see children and teenagers drinking espressos, yet it’s socially acceptable for young people to reach for energy drinks to give them a quick “boost”.

Energy drink sales in the UK are now worth more than £2 billion a year

Unaffected by the economic crisis, energy drinks are the fastest growing sector of the soft drinks market. Between 2006 and 2012 consumption of energy drinks in the UK increased by 12.8% – from 235m to 475m litres.

These drinks are very popular with young people – despite coming with a warning (in small letters on the back) that they are “not recommended for children”. A survey conducted across 16 European countries found that young people between the ages of ten and 18 in the UK consume more energy drinks on average than young people in other countries – just over three litres a month, compared to around two litres in other places.

More than two-thirds of young people surveyed in the UK had consumed energy drinks in the past year. And 13% identified as high chronic consumers – drinking them four to five times a week or more. Research also suggests that these drinks are more popular with boys and young men.

What goes into energy drinks?

Energy drinks are usually non-alcoholic and contain ingredients known to have stimulant properties. They are marketed as a way to relieve fatigue and improve performance: “Red Bull gives you wings”.

They contain high levels of caffeine and sugar in combination with other ingredients, such as guarana, taurine, vitamins, minerals or herbal substances. A 500ml can of energy drink for example, can contain 20 teaspoons of sugar and the same amount of caffeine as two cups of coffee.

Caffeine stimulates the central and peripheral nervous system. Consumed in larger doses, it can cause anxiety, agitation, sleeplessness, gastrointestinal problems and heart arrhythmias.

In the UK, there are no clear recommendations for caffeine intake for adults or children, although both the Food Standards Agency and the British Soft Drinks Association recommend that children should only consume caffeine in “moderation” and that caffeine content over [150mg/l] should be declared on the packaging. The current scientific consensus is that [less than 2.5 mg a day] in children and adolescents is not associated with adverse effects.

Should we be worried?

The evidence indicates that these drinks do not give you wings – or any other positive benefits. In fact their intake in young people, is associated with adverse health outcomes. There is growing evidence of the harmful effects of these drinks. Teachers are concerned about the detrimental impact these drinks have on pupils in their classrooms. There is also a known association between soft drink intake, dental erosion and obesity.

Lesser known are the effects of the cocktail of stimulant ingredients – such as guarana and taurine – contained within these drinks.

Our recent review of the scientific literature set out to look for any evidence of associations between children and young people’s consumption of energy drinks and their health and well-being – as well as their social, behavioural or educational outcomes.

We found that for young people, drinking energy drinks is associated with a range of adverse outcomes and risky behaviours. They are strongly and positively associated with higher rates of smoking, alcohol and other substance use – and linked to physical health symptoms such as headaches, stomach aches, hyperactivity and insomnia.

Why do young people buy them?

We also spoke with young people about their intake of these drinks. Discussions with our participants aged between ten and 14 indicated just how accessible and available these drinks are. They are also cheap – in some cases significantly cheaper than other soft drinks, as one of the girls we spoke to explained:

"I think it’s because like a normal can of Coke is like 70p, and [own brand energy drinks] are like 35p."

Our research found that energy drinks are often marketed on gaming sites and linked to sports and an athletic lifestyle – and are particularly aimed at boys. Taste, price, promotion, ease of access and peer influences were all identified as key factors in young people’s consumption choices.



Speaking with parents and teachers about these drinks there was confusion. Parents themselves identified the need for more information about energy drinks – and many admitted to not being fully aware of the contents and potential harmful effects on children.

Should they be banned?

Image used in a recent campaign led by Jamie Oliver
to ban the sale of energy drinks to under-16's

Recently there has been a move to restrict the sales of these drinks to under 16’s – an approach which has also been taken by other countries. This saw the self-imposed sales restriction by many larger retailers – including most supermarkets – to not sell to children under 16. But many places still continue to sell to young people – including convenience stores, which offer a wide range of brands, flavours and package sizes.

The Commons Science and Technology Committee’s enquiry into energy drinks called for submissions in April 2018 and will be reviewing in June 2018 – when we will also give oral evidence.

Of course, legislation to prevent the sales of energy drinks to under 16’s would be helpful. But the marketing of these drinks to young people through computer games and their association with sports is also a much wider issue. Far reaching discussions are needed about the direct and indirect marketing of these drinks (and other food and drinks) through multiple platforms other than TV – particularly through computer games.

This article was originally published on The Conversation. Read the original article.

When the Coca-Cola truck comes to your town

Guest post by Robin Ireland, Director of Research at Food Active and Beth Bradshaw, Project Officer at Food Active.

When Coca-Cola announced their 'Holidays Are Coming' truck tour (ironically coinciding with Sugar Awareness Week), our local media in the North West covered the story like it was the first sign of Christmas, the first cuckoo to be spotted in spring.

And in the run up to the big red shiny sugar-laden truck’s arrival to our towns and cities, from Bolton to Liverpool, Manchester to St Helens, the local newspapers will cover the story in page after page of advertorials, telling you where to get your picture taken posing with Coca-Cola's sugary products and even live blogs in some cases.

In previous years, at no time did the reporters consider that not everyone welcomed the truck in their neighbourhood. Many people are concerned that the truck was marketing Coke to children despite the company's protestations that they do not promote their products to the under twelves. Furthermore, in some locations in the North West the truck was allowed to promote their unhealthy drinks to children and families on Council owned landed. 

To demonstrate our concern, last year Food Active drafted a letter objecting to Coca-Cola's tour coming to the North West which was sent to the national and regional media. No less than 108 people signed in support including the current and past Presidents of the Faculty of Public Health, five Directors of Public Health, Professors, Doctors, educationalists and of course parents. If we are honest, we were shocked that the letter was almost entirely ignored. It would appear that Coca-Cola's commercial clout and public relations campaign counted more than the collective voice of those who are having to address the results of diets regularly fuelled by liquid sugar.

Just before Christmas 2016, Professor John Ashton and I (Robin) were in contact with the British Medical Journal concerning these issues and were invited to submit an editorial which was published in January [1]. In contrast to their previous experience the media attention was huge including coverage in over 60 regional and national newspapers and interviews on various channels including Sky News and Wales Today.

This year, the media attention and discussions around the Coca Cola Christmas Tour has continued. Before the tour was even announced, a news story hit the local press in the North West from Liverpool councillor Richard Kemp CBE (also Deputy Chair of the Community Wellbeing Board at the Local Government Association of England and Wales), who raised concerns about its arrival in Liverpool given the city is ‘in the grip of an obesity epidemic’ – although we know this is not an issue only in Liverpool – the whole country is in the grip on an obesity epidemic. Once the tour was announced, including six visits to the North West, we were pleased to see none were on council-owned land (in 2016 the truck visited Williamson Square in Liverpool which is owned by the Council)

Following this came a cascade of news stories from local and national newspapers and radio stations. This year, Food Active joined up with Sugar Smart to encourage Directors of Public Health, Council Leads and Clinical Commissioning Group Chairs across the country to sign an open letter to Coca-Cola opposing its arrival, given the health harms associated with the consumption of their products and calling for more responsible marketing during the festive period. The North West represented one quarter of the 29 areas, cities and towns who signed the letter. This advocacy may have helped to prompt a response from Public Health England and Public Health Wales – there is a sense that the argument against the Coca-Cola truck are now being taken seriously and media coverage of the 2017 Coca Cola Christmas Tour is not just about when and where you can get your photo taken - but also the health concerns. 

Coca-Cola says that it does not promote its products to the under twelves

Following excellent work by Public Health England, by national organisations including Action on Sugar, the Children's Food Campaign and many others, and of course by Food Active in the North West, we know that we must target sugary drinks as part of a strategy to address the tsunami of obesity, type 2 diabetes and dental disease we face in our poorest and most deprived communities. Moreover, as highlighted in a blog by Dr. Alison Tedstone, Director of Diet and Obesity at Public Health England, the truck will be visiting some of our poorest areas which are often disproportionately burdened with higher levels of obesity [2]. As such, a symbol of ill health should not be welcomed nor celebrated within our communities during a season of good will and cheer. 

However, this is not only about high sugar drinks. Protecting children from junk food marketing has been outlined as the number one priority in tackling obesity by the Obesity Health Alliance (a coalition of over 40 organisations committed to reducing obesity – of whom Food Active is a member). We must not mistake the Coca-Cola truck for anything but a very high profile marketing stunt. We do not allow products high in fat, sugar and salt to be advertised to children on children’s TV programmes, so why is the Coca-Cola truck welcomed into our communities year on year with such open arms? Speaking at the Socialist Health Alliance Public Health Conference, we called for junk food marketing controls to be extended to cover family attractions such as the Coca-Cola truck, as well as sports sponsorship and marketing communications in schools. By allowing the truck into our towns and cities, we are allowing Coca-Cola to exploit the festive period to market their products to the community – and to children in particular.

Our experience shows us that public health has to be persistent in ensuring our messages are heard in the current victim-blaming culture. There is little point in local authorities spending their ever restricted funds on promoting healthier eating and drinking if each Christmas we allow Coca-Cola and others to highjack our messages. There is certainly no excuse for local authorities at to allow this truck on their land and it is the responsibility of public health advocates to continue to make the case to Give Up Loving Pop in 2018. 

  

References:

1. Ireland, Robin, and John R. Ashton. "Happy corporate holidays from Coca-Cola." (2017): i6833. Available at: http://www.bmj.com/content/356/bmj.i6833
2. Tedstone, Alison. “An update on sugar reduction”. (2017). Available at: https://publichealthmatters.blog.gov.uk/2017/11/14/sugar-reduction-an-update/

Photo © Oast House Archive (cc-by-sa/2.0)


All views expressed in a post are exclusively those of the author or authors.

How big food and drink are using sport

Guest post by Robin Ireland, Director of Research, Food Active and Healthy Stadia

You don't have to do much travelling to realise that the unhealthy alliance between sport and the Food and Drink Industry isn't only an issue in the UK.

I am lucky enough to be visiting New Zealand and Australia at the moment and it's easy to see all the same signs - and very similar marketing campaigns and messaging. Whether it's the All Blacks rugby team being pictured with the product of their "Official Hydration Partner", Gatorade, or the recent Australian Tennis Open full of alcohol advertisements (and I haven't even mentioned cricket), it's clear that the Food and Drink Industry have an international agenda.


Advertising featuring the All Blacks rugby team photographed in New Zealand

In January, the British Medical Journal published an editorial (Ireland and Ashton 2017)1 that I wrote (with Professor John Ashton CBE) about how Coca-Cola's publicity machine was subverting the Christmas message.

If anything, it's even more blatant in sport and we have been aware of it for some time from London's "Obesity Games" (Garde and Rigby 2012)2 to Rio's promotion of ultra-processed foods (Loughborough University)3. Even when spectators want healthier food, this choice is rarely made available to them.

George Monbiot recently referred to "Dark Money" (Monbiot 2017)4 which describes the funding of organisations involved in political advocacy that are not obliged to disclose where the money comes from. In public health terms, we may describe this as Commercial Determinants of Health where industry interests impact on our health. It is often linked to the increasingly sophisticated Corporate Social Responsibility policies being adopted by big corporations.

The latest of these is of course the deal just announced by the English Premier League and Cadburys criticised by the Obesity Health Alliance in a letter to The Times (Obesity Health Alliance 2017)5. Cadburys no doubt will argue that they are taking an ethical position to help educate people. But can we really take a chocolate company seriously that wishes to advise schoolchildren on nutrition, healthy eating and exercise?



FC Bayern München's branded energy drink

It is no coincidence that the mantra parroted by food and drink sponsors is that our diets are down to individual choice and that if we simply took more exercise we wouldn't be having the obesity epidemic now prevalent worldwide. This is rubbish. So called energy and sports drinks should have no part to play in the diet of the average member of the public. Kids do not need more sugar (or more protein for that matter) if they are eating a balanced diet with lots of fruit and veg. But of course the food and drink industry do not make their enormous profits in this way.

It is these concerns - amongst many others - that encouraged myself and colleagues to establish Healthy Stadia in 2005, of which I am a Director. Healthy Stadia takes a holistic and integrated approach to developing sports stadia and clubs as "health promoting settings":

"Healthy Stadia are those which promote the health of visitors, fans, players, employees and the surrounding community" (from Healthy Stadia website)6.

Healthy Stadia's Conference which will be held at the Emirates Stadium, London, in April will be discussing food and drink sponsorship in professional sport among other issues. I anticipate that these topics will come under increasing public scrutiny in years to come, as we develop more awareness of the impact that marketing has on our food and drink choices. (Cairns et al., 2013)7.

Sports fans and public health professionals alike should be questioning how 'Our Beautiful Games' are being manipulated by the Food and Drink Industry to promote ultra-processed food and drink - including alcohol - to audiences, often well populated by impressionable youngsters. Let's see if we can link up the campaigns in different countries to make a louder voice demanding change from the governing bodies of sport.

References:

1. Ireland R and Ashton John R. (2017). Happy corporate holidays from Coca-Cola. BMJ 2017;356:i6833. http://www.bmj.com/content/356/bmj.i6833. 10 January 2017.
2. Garde A and Rigby N. (2012). Going for gold – should responsible governments raise the bar on sponsorship of the Olympic games and other sporting events by food and beverage companies? Commun Law. 2012:356:42-9.
3. Loughborough University Press Release (2016). Loughborough research calls for change in spectator food and drink provision at sports mega events such as Rio 2016. PR/16/158. http://www.lboro.ac.uk/media-centre/press-releases/2016/december/loughborough-research-calls-for-change-in-spectator-food-and-drink-provision-at-.html. 05 December 2016.
4. Monbiot G. How corporate dark money is taking power on both sides of the Atlantic. The Guardian. https://www.theguardian.com/commentisfree/2017/feb/02/corporate-dark-money-power-atlantic-lobbyists-brexit. 02 February 2017.
5. Obesity Health Alliance (2017). Letter to The Times – Cadbury and Premier League Sponsorship. Accessed online at: http://obesityhealthalliance.org.uk/2017/02/06/letter-times-cadbury-premier-league-sponsorship/?utm_campaign=Cadbury%20letter. 06 February 2017.
6. European Healthy Stadia Network. http://www.healthystadia.eu/about.html
7. Cairns G, Angus K, Hastings, G and Caraher M (2013). Systematic reviews of the evidence on the nature, extent and effects of food marketing to children. A retrospective summary. Appetite 2013: 356:209-15. http://www.sciencedirect.com/science/article/pii/S0195666312001511. 03 March 2013.

All views expressed are exclusively those of the author.

Understanding the health benefits of the ‘sugar tax’: how will the soft drinks industry respond?

Guest post by Oliver Mytton, Centre for Diet and Activity Research (CEDAR) & MRC Epidemiology Unit, University of Cambridge
Today our paper, a health impact assessment of the government’s proposed ‘sugar tax’ was published in the Lancet Public Health. The government’s proposal, announced in April of this year, took health campaigners by surprise. Not only was it unexpected, but the government’s proposal was unusual.

Other countries, notably Mexico, have introduced a sales or excise tax on sugary drinks. However, the UK government proposed a levy on soft drinks manufacturers or importers based on the volume of sugary drinks sold. There will be two levels of tax, a higher level on drinks with more than 8g per 100ml, and a lower level on drinks with 5g to 8g per 100ml.

With others, I have previously modelled the potential health benefits of a ‘simple’ excise tax on sugary drinks, but the industry levy is more complicated.

Industry levy – how it might work  

The levy might lead to a reduction in sugary drinks consumption through a number of pathways, and from listening to industry experts and reviewing statements made by soft drinks manufacturers, it was apparent that nobody knew quite how the industry would respond.

The nature and magnitude of these responses might lead to very different health outcomes, which is what we describe in our paper. For our health impact assessment, we identified three broad responses that the industry might make:

1. reformulation (reducing sugar content); 
2. price rises that pass the cost on to consumers; and
3. changes in marketing practices to ‘shift’ consumer preferences, e.g. away from high sugar drinks to diet drinks.

For each response, we then identified a ‘best case’ and ‘worst case’ scenario.

Modelled health benefits

From these six scenarios, we were able to estimate changes in consumption of sugary drinks. We then estimated changes in health, using data describing the relationship between sugary drinks consumption and three outcomes (dental caries, type 2 diabetes and obesity).

The most beneficial modelled scenario for health was reformulation (reduction of sugar content by 15% for ‘mid-sugar’ drinks and 30% for ‘high-sugar’ drinks), with an estimate of 140,000 fewer adults and children with obesity; 19,000 fewer incident cases of diabetes each year, and 270,000 fewer decayed, missing, or filled teeth annually in the UK. Important reductions in disease were also associated with the maximum expected price increase (equivalent to half the levy cost being passed onto consumers) and changes in marketing share.

The least beneficial modelled scenario for health was a change in market share that resulted in consumers switching not only from high-sugar drinks, but also from diet drinks, to low sugar drinks. This might result in an (small) increase in consumption of sugary drinks and consequent (small) increase in disease (using the measures we looked at). If the price is passed on to all soft drinks (rather than just sugary drinks) the health benefits were also substantially reduced.

Across the scenarios the most striking finding was the concentration of the health benefits in terms of obesity and dental caries amongst children and younger adults. They are the major consumers of sugary drinks. Diabetes follows a different pattern with many more cases likely to be prevented amongst adults than children, because there are relatively few incident cases of type 2 diabetes among children and young adults.

In doing this, we have not made an overall estimate of the health benefits of the new levy, rather we have identified the benefits attributable to different industry responses to the levy and put upper and lower bounds on those responses.

Policy implications

Consumers appear to be turning away from sugary drinks

Our assessment shows that the health benefits of the levy will be greatly affected by how the industry responds. We have identified scenarios where the health benefit is minimal (or conceivably negative). However, we think this is unlikely: there are strong signs from industry that there will be significant reformulation, consumers appear to be turning away from sugary drinks and most of the scenarios we modelled were beneficial for health.

While we are not as optimistic about reformulation as others, our work does further suggest that reformulation of sugary drinks has potential to mitigate some of the health risks associated with regular consumption of sugary drinks. Reformulation of soft drinks probably has more scope than I previously thought. The government levy may, particularly by using two tiers, be a relatively effective tool to incentivise reformulation.

It also suggests that the industry levy may not be a ‘simple’ intervention. Whilst we have described discrete responses, it is possible that the levy may stimulate several changes. Not just the changes described in our study but others, e.g. changes in consumer attitudes, reductions in portion sizes and introduction of new low sugar products. If it does do this, the government’s approach may be very effective, perhaps more effective than a ‘simple’ excise tax.

On the flipside, it may also be more uncertain or risky as its success depends on how industry responds. This creates a potential role for government and health organisations to apply pressure on industry to respond in ways that improve health. This uncertainty also underscores the need for a careful evaluation that can capture the important industry responses.

Finally, whilst there are reasons to be optimistic and the government should be applauded for this initiative, it does underscore the need for ‘brave and bold’ action across a variety of areas concerned with food and physical activity (which the recent Childhood Obesity Plan failed to deliver) to markedly reduce obesity. As I have written before, this measure alone will not ‘solve’ obesity, but it can be an important step towards improving population health.