Consultation response - Advancing our health: prevention in the 2020s

Low breastfeeding rates are a long term and multifactorial issue that will require a range of actions to improve. These should include:

• Reintroducing the infant feeding survey, as the Government has already committed to do, and use this to inform a new national breastfeeding strategy with specific targets included. The survey needs to include questions to review why mothers feel unable to breastfeed and what would help them to do so.
• Support the roll-out of the UNICEF Baby Friendly Initiative to all maternity services.
• Take further action to ensure that women are given the time and space to continue breastfeeding when returning to work. This should include requirements (rather than recommendations) that women are afforded breaks to breastfeed or express, and a safe and clean environment in which to do so.
• Actively promote a wider change in culture and public attitudes through public information campaigns to highlight the benefits of breastfeeding and the legal protections in place to allow women to breastfeed safely and in public.
• Ensure that all new mothers have access to evaluated, user-friendly and structured breastfeeding support. This needs to include further funding for and support of Midwifery and Health Visiting services. Public health funding cuts have resulted in a lack of investment in front-line public health provision such as health visiting and infant feeding support groups.
• Ensure that a wider range of healthcare professionals (HCP) who may have contact with pregnant women or new parents are enabled to better support breastfeeding. This should include being able to explain the benefits of breastfeeding, and advise on technique and responsive feeding. HCPs should be aware of where to refer for further information and support.
• Dietitians should have involvement both pre- and post-natally as part of a multi-disciplinary team. This includes provision of general dietary advice for during pregnancy and lactation to the team and for group sessions with clients, backed up by client referrals for more specific dietetic issues.   

Successfully supporting children to eat well and maintain healthy weight needs to include support for the whole family to do the same. Many current efforts around preventing obesity and improving diets are specifically aimed at children, but we know that the weight and eating habits of parents have huge influence on their children, which indicates that a holistic approach should be used whenever possible. Ideally these efforts should start pre-birth.  

We need to improve access to evidence-based multi-component interventions for all, especially those families with children aged under five, as evidence shows that most excess weight before puberty is gained before five years of age and this is a particularly important contributory factor in later childhood obesity. The National Institute for Health and Care Excellence (NICE) has clear guidelines on how interventions such as these should be commissioned, and on the core elements of any such programmes. The BDA supports the view that all dietary, lifestyle and weight management programmes are designed and developed with input from a multidisciplinary team, which should include a registered dietitian.

We are supportive of the Government’s plans to challenge industry to improve the nutritional content of commercially available baby food and drinks. Structured reformulation programmes and policies have been effective at reducing salt from everyday food and sugar from soft drinks in recent years. The programme should learn from the existing voluntary sugar reduction programme, where progress to date has been mixed across the categories. We also support steps to restrict the promotion of high fat, sugar and salt foods (HFSS) even to young children, as evidence shows that children as young as three are influenced by marketing. This should include further restrictions on broadcast advertising, including a 9pm watershed, and changes to the way retailers are able to promote products. This should be re-enforced by a National Whole School Approach to good nutrition, with adequate support from dietitians, the school staff and parents etc. 

We believe the Government needs to reinvigorate and upgrade the Healthy Start Scheme. Current uptake levels are too low, and many people eligible remain unaware that they could be claiming free healthy foods and vitamin supplements. The value of the vouchers has also remained frozen for a long period, and should be raised in line with inflation as a bare minimum.

Controlling portion sizes is key in achieving energy balance, but many consumers have poor understanding of portion sizes appropriate for age and activity level. The government’s Foresight report makes clear that reduced exposure to an obesogenic diet includes a focus on reducing portion sizes. The BDA supports PHE’s suggestion that relevant foods and drink should have portion sizes capped, especially when marketed to children. We also support measures to further improve food labelling, and to highlight appropriate portion sizes for children as well as adults

Ensuring that everyone has access to fully funded and well implemented weight management services from tier one to tier four is very important. This should include specialist services for those with mental illnesses, learning disabilities and other conditions which make them more likely to be overweight. Where weight management services do exist, they are often short term – 12 weeks or less – and we know that for people with obesity and overweight this may not be long enough. Extending interventions or ensuring that there is ongoing support is essential. Also, targeting as early as possible will be both more effective and easier – if someone is only overweight, it will be easier to manage this than if we wait until that person has obesity.

Currently tier one and two services, which are where prevention is focused, have suffered significant cuts in some areas as they are funded from local authority budgets. We welcome the government’s commitment to increasing funding in real terms in the 2019 spending round, but more needs to be done to make up the huge gap that has now appeared. Local authorities’ public health grant was £850 million lower in real terms in 2019 than initial allocations in 2015/16. Ensuring that there are strong links between tier two services, run by local government, and tier three, commissioned in the NHS, is also critical.

Although exercise is an important part of maintaining health, evidence shows diet plays the greatest role in determining if someone is able to reach and stay at a healthy weight. Therefore, steps to change the food environment will be key. Action to reformulate food needs to continue, and government may need to consider moving beyond a voluntary scheme if a voluntary approach continues to miss targets. The success of the Soft Drinks Industry Levy (SDIL) in reducing sugar and calories in soft drinks is a clear indication of how successful government intervention can be.

Reformulation needs to be coupled with restrictions on advertising and promotion. There is clear evidence that multibuy promotions (including ‘Buy One Get One Frees’, ‘Buy One Get One Half Off’, ‘three items for the price of two’, and ‘X for £Y’) encourage the impulsive purchase of products, or increase the frequency of purchase and/or the volume of product bought. There is also evidence to show that when products are placed in convenient and eye-catching locations, such as shop entrances or aisle ends, sales of these products are positively impacted.

Advertising has been shown to impact on people’s behaviours, particularly children, which is why we support the imposition of a 9pm watershed for HFSS foods. Restrictions need to apply much wider than just broadcast, including digital and physical advertising, building on the success of existing programmes to restrict advertising of these products to children.

It is important to recognise that interventions to reach and stay at a healthy weight need to differ depending upon the age profile and other demographic measures of the target audience. For example, what constitutes “healthy eating” for children or working age adults is not the same as for older people over 75 years of age.

Encouraging healthy workplaces is also key. Full-time working people consume more than half their calories while at work, and many modern jobs are sedentary and not conducive to good health. Employers should be incentivised to help their employees eat a healthy diet and take appropriate exercise. Initiatives such as BDA Work Ready can help workplaces create a healthier work environment. Exercise is also very important in elderly people to reduce muscle loss and to maintain health.

In homes and neighbourhoods

Evidence shows that broadcast advertising has a significant impact on people’s food choices and eating behaviour, especially children. Children can begin to recognise brands from a very young age, and we know that most of the advertising children are exposed to is on television intended for “adults” during typical family viewing. Reducing our exposure to advertising of products that are not conducive to good physical and mental health, such as HFSS food, gambling and alcohol will have a positive impact.

Ensuring that people can easily access good and affordable food, with reduced exposure to takeaways and other sources of HFSS foods would be significant. Evidence shows that more than a million people live in “food deserts” where they struggle to access healthy food (such as fresh fruit and vegetables) due to poverty, a lack of supermarkets and poor public transport. Where supermarkets are present, they should be prevented from promoting HFSS foods through in store advertising and price promotions, which have been shown to be effective in driving increased sales and are disproportionately used to promote unhealthy options.

Councils need to be encouraged and empowered to reduce the number of hot food takeaways in any given area. Even for those that already exist, by working in partnership local authorities can increase the healthy food they offer and discourage pricing and advertising that targets children and young people with unhealthy options. Some local authorities have a food strategy committee or equivalent, with dietetic representation (e.g. in Leeds, West Yorkshire). This should become consistent policy nationally.         

When going somewhere

Transport is another place where advertising and promotion of products could be restricted. Transport for London have already taken steps to reduce the promotion of HFSS foods and beverages on their network, and it would be positive to see this replicated elsewhere with support from central and local government.  

Encouraging active travel is a positive way to encourage people to exercise more in a safe way.

In workplaces

Full-time working people consume more than half their calories while at work, and many modern jobs are sedentary and not conducive to good health. Equally, evidence shows that shift workers and those that work long hours with frequent overtime are at increased risk of developing conditions such as obesity and diabetes.

Employers should be incentivised to help their employees eat a healthy diet, maintain appropriate work/life balance and take regular exercise. This should include employee involvement in the planning and delivery of interventions, buy in from senior management and multi-level approaches. Initiatives such as BDA Work Ready can help workplaces create a healthier work environment.