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Hello, everybody, and welcome to the Oxford Martin School.

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My name's Charles Godfrey, I'm the director. And it's my great pleasure to welcome you to our latest in a series of talks this term on food,

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and the talk today is given by a very good friend of mine and colleague Susan Japp.

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I'm delighted to welcome to the school. She's on the lot with the school over the last few years.

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And Susan, Susan's going to be talking about diet and health from science to policy as it has been in Oxford for six years.

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She's in the Department of Primary Care. She's an expert in the obesity and many other aspects of diet and public health.

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And before this and came to Oxford, she was at the MRC Centre in Cambridge.

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Susan, welcome to the school and come up and give us your talk. Thank you very much.

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Nice introduction and great to be here. I want to really talk today about a broad topic of diet health and we'll touch on the environment to.

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It tries to bring together a lot of the research that I do with my team here in Oxford, which really spreads right across the university.

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I want to just touch on a number of of the projects we do today.

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I suppose the thing which underpins everything we do,

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the thing that makes me get up in the morning and feel like I'm working on something that really matters is a really strong and

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growing sense that our food system is failing and it's creating a kind of perfect storm of health problems really across the globe.

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We face this extraordinary situation where nearly one billion people have insufficient food.

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And yet at the same time, more than two billion are affected by obesity.

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And there's many, many more people who are eating diets that contain too much saturated fat, sugar and salt, and too little fruit and vegetables.

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And that's creating incredibly high and growing rates of diet related disease and premature mortality.

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So malnutrition in all its forms, as it's sometimes described these days, really covers obesity,

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undernutrition and the diet related disease caused by poor diet quality.

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And if you put these three things together, it's quite clearly the biggest contributor to the health burden around the world,

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greatly exceeding other major and very well recognised risk factors like tobacco or high blood pressure.

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And I think our failure to really fully acknowledge that is because in the past, we tended to treat these as three separate things.

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And instead, what we're now beginning to recognise is that there's a common underlying aetiology, which which is embedded in the way we eat.

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So if we look around the globe, clearly, the relative proportions of people who are overall undernourished varies but every single region.

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You can see that diet related disease tops the list. So I was thinking about what we eat.

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But of course, what we eat is in part a function of what's produced in our system of food production.

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It's one of the biggest ways in which humanity impacts on the environment.

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Even a decade ago of food production system was exceeding the planetary boundaries as far as greenhouse gas emissions were concerned.

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And that's projected to more than double by 2050.

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And at the same time, we're also set to exceed the boundaries for nitrogen, phosphorus, water, land use if we carry on as we as we are.

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And the single biggest contributor to this is shown in the in the red ball.

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And that's the production of animal products. So some of you may know I co-directed the Wellcome Trust funded Project Leap with with Charles Godfrey,

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that's livestock environment and people of what we're specifically trying to do in that project is to address the issue of animal source foods,

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bringing together the environmental aspects of food production, together with the health consequences of consuming too much meat and dairy.

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Now, that's not an easy topic. It's clear that we need to produce more food more sustainably to feed a growing global population,

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but we also going to have to change consumer demand for some of the most environmentally damaging commodities.

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I don't think we can just carry on eating the amount of meat we are if we were just to produce it in a slightly different way,

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at least at a global level. We're going to have to reduce overall meat consumption.

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How much of this type of thinking has been summarised in a couple of very big Lancet commission reports, which will come out over the last few years?

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And I think the time is now come to really heat the evidence of these reports and really move beyond just analysing the problem and start thinking,

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not even just thinking about solutions, but actually implementing solutions.

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Both of these reports are very good in setting out what we could do, but what are less clear about is how we are actually going to do that.

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What is it we need to do tomorrow, which is going to make this change happen?

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And there are a number of things which are sometimes called double or triple duty actions,

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which could benefit two or more of the failings in the food system.

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I've just highlighted a few here that feel particularly important to me and really resonate with the kind of work we're trying to do.

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So top of my list is absolutely reducing overconsumption.

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Eating too much wastes precious environmental resources to produce food, which goes on to damage our health.

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It is an absolute no brainer. Reducing consumption of very highly processed foods, I think, is also very important.

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We know that these foods are often the things which are particularly high in saturated fat, sugar and salt.

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The foods that are creating this poor diet. So they're an obvious target for policies to improve health.

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But actually, when it comes to the environment,

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it's a slightly more complex issue because many of these products, to be honest, are not big contributors.

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For example, two greenhouse gas emissions.

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I've said it before that sugary drinks are probably one of the most environmentally friendly ways to calm your health.

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But the truth is that actually beyond greenhouse gas emissions, they do have other environmental harms.

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So if you take something like like corn, for example,

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it's used extensively in highly processed foods as a sort of thickener and emulsifier, even just as a filler.

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And of course, in many countries, corns turned into high fructose corn syrup and used as a sweetening agent.

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So there's a lot of corn, which is used in processed food products, and corn has very corn production makes up very high demands on water,

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and it's associated with very heavy use of fertilisers, pesticides, herbicides and so forth.

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So in fact, the production of these highly processed foods is in of itself, environmentally damaging.

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And that's before you even start thinking of all the packaging that goes into these these types of foods.

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So reducing highly processed foods is going to be good for health, and it's going to be good for the environment, too.

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And of course, if we stopped subsidising these kinds of foods as heavily as we do in all of our economic systems,

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we could think about moving that subsidy elsewhere and supporting less processed foods.

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Going further down the list, the next to really come together,

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increasing our consumption of plant based foods and reducing the amount of animal source foods we consume.

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And that's really, I think, a very easy way where we can get better diet quality, huge environmental gains.

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And I think also, importantly, greater health equity.

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And finally, another one reducing waste. So that's obviously going to be good for the environment and it should help food insecurity as well.

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But you might be asking, how's that going to help obesity? You know, maybe we want to waste loads more food and that would reduce obesity.

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But I don't think that is true because all of the issues that we know is important is about is the when people don't

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value food quite as much as they should wear that casual about food wastage that leads people to effectively over cater.

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And once you've over prepared food or you've bought a larger portion, because why not?

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It seems like really good for you. We know that you're much more likely to overconsume.

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And so actually, being casual about food waste leads on to people in fact eating more than they need.

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So these aren't the only targets, but there are some good targets there, a good place to start,

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and the question really is how are we going to achieve these goals for the rest of my talk,

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I really want to focus on some of the interventions which might actually change behaviour.

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Now most of the examples that I'm going to give you relate to reducing consumer demand for less healthy products,

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because that's where most of the evidence lies of present.

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But in fact, most of these interventions could also be applied in the context of reducing the demand for meat.

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And that's an area of work that we're developing within that within the Leap programme.

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I think what's absolutely clear is there wasn't going to be one thing that's going to fix it.

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We're going to need a whole portfolio of interventions. And that's likely to include both individual level strategies,

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things targeted at individuals which motivate and encourage them to actually change their own diet.

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So in a way to empower this little guy to push the boulder up the hill.

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But at the same time, we're also going to need population level strategies, which make it just a little bit easier for everybody.

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The boulder a bit smaller, the hill a bit less steep things which make it easier for everyone to have a healthy, a healthy diet.

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I'm going to start with some individual level interventions and I'm going to focus on obesity where I think we've had some real success.

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It's not often you hear obesity and success in the same sense. So let's just celebrate the moment.

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Obesity is a really major public health problem. It affects one in four adults and in children in particular.

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They're are really marked inequalities. It causes multiple health problems affecting pretty well, every organ system of the body.

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And the consequence of that is that there's a heavy cost to individuals,

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to employers through time, off work and to the NHS and the social care system.

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Now, treating obesity means reducing energy intake.

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And the good thing is that that will generally have the benefit of reducing saturated fat, sugar and salt.

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At the same time, because people are having fewer calories and most people compensate for having

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rather little on their plate by increasing the amount of vegetables they consume.

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So in fact, successfully tackling obesity, we've shown, is a very good way to improve diet quality overall.

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So the question is, how might you do that?

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Well, our research has shown that offering people access to formal weight loss programmes leads to very successful weight loss.

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Because one in four adults are overweight, we are interested in very scalable interventions.

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And so this is a study looking at what happens if JP's gives people the option to attend

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the local community slimming group things like Weight Watchers or Slimming World.

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What you see is that actually just encouraging people to take action on their weight means that all three groups lost weight even two years later.

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But the two groups who were offered the opportunity to attend the weight loss group did

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significantly better than just giving them a bit of advice and leaving them to manage on their own.

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And although they did regain some weight at the end of the first year when we stopped providing the intervention we were

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able to show was that this was highly cost effective and even this modest weight loss reduces the risk of later disease.

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But of course, weight loss would be better.

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And so we recently published this study looking at the use of total diet replacements again in routine primary care.

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This is not a specialist bespoke service. What you see here is that people were able to lose on average 10 kilos after one year

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and 45 percent of people lost more than 10 percent of their initial body weight.

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That's incredibly successful by any standard in terms of treating obesity.

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That's great news, but the fact is that evidence alone is not sufficient to make this happen in practise.

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And so we've put a lot of attempts. Sorry, we've put a lot of attention into how we can actually ensure that evidence is used within the system.

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So we work with Public Health England and others to produce guidance for commissioners to help them to commission these programmes.

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Guidance for GP and other health professionals about how to raise the issue of weight with people.

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And we've been absolutely delighted that in the NHS long term plan, which was published at the start of this year,

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there are now three major commitments for the NHS to offer support to people to lose weight,

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which are based heavily on the work that we've done in our team at the same

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time as trying to change the system to make these interventions more likely.

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Well, we've also done is a lot of public engagement and involvement work to really work with people who are overweight,

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to find out what it is they need,

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and also to try to build the patient voice, demanding and looking for action and help to support them in their weight loss attempts.

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And I think this perhaps is one of our best examples of how we've been able to take

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basic scientific research and see it right through into changing policy and practise.

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Now, when it comes to changing diet quality, more generally, I'm here, I'm talking about changing diet for everybody,

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not just people with obesity, but improving the quality of diet for all.

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The fact is, it's much harder to point to individual interventions, which are going to make the difference.

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This has to be the intervention has to be something which is incredibly scalable so that it's going to actually reach every single person.

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And that means it's going to have to be jolly, low cost. And that's a pretty tricky combination.

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We've there's been a lot of work, for example, in things like nutrition labelling.

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If you just give people more information about what's in their food. Will that help them to make better choices?

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The answer is yes. It helps a little bit, but it's it's not. It's not transformational.

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We've been trying to take that one step further using technology to really help us deliver

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very personalised nutrition support to people at the time where it might be most useful.

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And that's when they're in the supermarket doing their shopping because frankly,

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once it's in your kitchen cupboard, you're probably going to eat it at some point.

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So we want to intervene a little bit earlier in the system to stop it ever leaving the shop.

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So here are two studies which are which well, this one's just completed where we took data from people's loyalty cards with their permission,

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and we converted it into a nutritional report and we were able to identify in this instance the foods,

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which for that individual household were actually contributing the most saturated fat to the diet and then to offer people personalised swaps.

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And then a month later, we sent them another report telling them how they were getting old.

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So using some behavioural techniques to try to support people to make progressive changes and this is an oops, sorry.

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This is a this is a study which is just about to start whole swap shop.

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This is an app we've developed,

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which allows people to scan the barcode of a product and to see to get a number of alternative swap suggestions of things that they might have.

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Instead, if you're about to buy, you know, a bar of chocolate, it doesn't say have a banana instead,

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but it might find you a bar of chocolate that was a bit lower calorie.

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So it's possible that using this kind of technology, we can deliver individual interventions at scale,

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but it really remains to be seen whether these will be particularly effective and

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also whether they'll contribute in any way towards narrowing health inequalities.

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The risk being that they might actually make it slightly worse.

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So the reason we need to look beyond just individual level interventions is not only because

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it's hard for me to go around and influence every single person in the entire country,

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but also because we all of these individual things require significant cognitive effort.

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They are asking people to be very thoughtful about what they're purchasing or what they put into their mouths.

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And what we've come to recognise is the most eating isn't all that thoughtful.

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Mostly, it's quite automatic. It's sort of happened before.

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We've really thought all that much about it.

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You know, I didn't see a cake and sort of think, Oh my goodness, I don't really need those extra calories.

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Extra calories may not gain weight by gaining weight. I increase my risk of diabetes.

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I probably shouldn't eat the cake. I eat on the cake before I even got to, you know, you've got to first base on that.

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And if I can't manage that with, you know, quite a lot of nutritional knowledge, you know,

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it's pretty difficult for anybody else who hasn't, you know, got such insights into food.

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So we can sometimes think of this as the sort of two processes.

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If you like the sort of ice time brain where we're terribly reflective and thoughtful and think about it a lot, but actually a lot of the time,

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it's the sort of Homer Simpson bit of our brain which has taken over and, you know, automatic reactions kick in.

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And the problem when it comes to policymaking is that policy makers insist on believing that individuals are indeed not just policymakers.

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We all like to think we call them rational, intelligent people who are going to make good choices,

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even though the evidence actually is completely opposed to that.

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And because we think we're rational people, we believe in willpower.

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We have this extraordinary sense that somehow, you know, some people have willpower and some don't,

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and that even if they don't, maybe we could teach them willpower. And that's what dieting is all about.

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You have to have more straight. This is just a silly little cartoon which tries to make the point that actually there's no such thing as willpower.

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It's just a clash between a slump in motivation and adverse external circumstances.

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So most of the time, you know, I have ups and downs in my motivation to eat healthily during the day.

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But the time when I'm likely to have an unplanned chocolate eating incident is when I missed the train, you know, I mean, I've been in London.

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Rubbish day of meetings, grants been rejected. Get to the station.

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Just miss the train feeling fed up, and I'm surrounded by newsagents, coffee shops, a whole raft of opportunities to buy.

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High calorie, high sugar, high fat food. And that's when it all goes wrong.

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And so for all of us, at some point, the dip in motivation coincides with an adverse environment.

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And this has nothing to do with willpower. It's just circumstances have overwhelmed us.

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A few calories seems a pretty small price to pay for a boost in my quality of life at that point.

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So what this tells us is that if we want to change what we eat,

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we're going to have to change the environment in which these so-called choices are being made.

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So what does that mean in practise? Or Ms. Well, there's a whole raft of evidence of what would work to change the food environment.

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And I'm just going to pick a few examples based on some of our work in these three areas around products, promotions and price.

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So let's take the first one products portion sizes have increased.

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I could show you a bit of evidence,

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but most of us are probably willing to accept the case that most foods are sold in bigger portion sizes than they were before.

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And even if the standard product hasn't changed and new products been introduced,

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which is twice the size of what we know from a big Cochrane systematic review,

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if the evidence is that if people are offered larger portions, they are more likely to over consume.

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It's an incredibly consistent finding, and you can see that nearly all of these interventions lie to the right hand side of the line.

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And we've estimated that if we may portion sizes smaller across all foods,

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you'd get about almost a 60 percent reduction in energy intake for adults could be extremely meaningful.

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The other thing we could do with products is we could make every product the healthiest it could be.

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And there's been a huge push in the UK on this particular agenda around reformulation that strip

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out unnecessary nutrients and across a whole range of products over the last 10 or 15 years.

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There have been quite significant changes in nutrient composition, particularly with respect to salt,

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and the SALT reformulation programme in the UK is without doubt world leading.

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And we've seen more than a 15 percent reduction in salt intake in a decade,

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which is almost entirely driven by changes in the salt content of food products.

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It's not so much what the people are eating differently. It's simply the products they're eating contain less salt.

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Public Health England are now trying to use a very similar strategy to encourage reductions in the sugar content of of all diet.

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It's a great aim. The problem is the effectiveness is much less clear.

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So they set a target that we were going to reduce by sugar content in these 10 categories by 20 percent by 2020.

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We are now in 2019 and we're at, well, not quite three percent just yet.

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Progress has been extremely limited and extremely small.

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It does vary by different food categories. You'll see that you'll get some breakfast cereals have made moderate progress,

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but if you look at some things like confectionery down here at the bottom, there's been absolutely no change whatsoever.

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And that's in part, of course, is because things like sweets are quite difficult to reformulate.

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If you take the sugar out of a sweet, you don't have much of a sweet left.

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And so we really, really need to wean ourselves off the idea that reformulation is going to do everything reformulation can do part of the work,

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but we're also going to need some other interventions as well.

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One of the things that we think is potentially very effective is about changing the availability of healthier options within micro environments.

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And so this was a study we did with a series of workplace canteens looking at changing the availability of healthy to less healthy products.

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So there was a similar range and this was both in snacks and in main meals.

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But the proportion of the healthier items was increased. And what you can see across six different sites, if you average those,

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there was a seven percent reduction in the number of calories purchased in those canteens during the phase of the of the intervention.

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I mentioned promotions, and this is a really, really important point in the UK,

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about 40 percent of all the food that we purchase is bought on some kind of promotion.

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And it's estimated that that increases the amount we we purchase by about what by about a fifth.

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And this is a slide at one of my DPhil students kindly took for me in the local co-op just the other day where you can see that,

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you know, there's no doubt at all how much this costs. I'd be interested if they'd like to put some health messages with a similar size sized logo.

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Why does this matter? Well, promotions, drive, sales and promotions happen in all kinds of ways.

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Price is an obvious one, but this is just about promotions on the end of the aisle.

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So products on the end of the aisle extremely prominent.

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And what we've shown is that this significantly increases the amount of these products that people purchase.

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So in the case of soft drinks up by about 50 percent,

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that's the same uplift in sales that you would get if there was a 20 percent reduction in the price.

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And of course, things which are on the end of aisle, there's often a whole raft of marketing going on around that because you get a very

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prominent block of the same item and there's often a price promotion attached as well.

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So if we want to change the food environment, we are going to have to persuade the food industry to work with us in order to make this change happen.

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And this really raises an interesting question about how might that occur?

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How is it we're going to get industry to change? Can we do it as we're trying,

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mostly at the moment to somehow persuade or cajole or perhaps even incentivise change through purely voluntary mechanisms?

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Or are we going to have to use much harder policy measures effectively mandating change through some kind of regulation?

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As I mentioned, the emphasis of the moment is on is on voluntary measures.

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And the truth is that whilst you know we've seen a bit of reformulation,

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we've not seen anything like enough progress and we've seen pretty well, nothing on promotions.

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For a while, I chaired something called the responsibility deal,

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where we tried to work with the food industry to encourage them to make positive changes.

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And at the end of that of that initiative,

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I wrote a blog basically saying that it was clear to me that promotions were so commercially sensitive it was really

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impossible to make progress on a voluntary basis because any company which moved first would be commercially disadvantaged.

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And so in that area, I think we do need a mandate in order to create a level playing field.

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But before we just move on from voluntariness,

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I think one area that we haven't adequately explored is how much we could use the investment community to help drive change.

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If I ask this big business to change, they take no notice at all.

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If government asks them, they move a little bit.

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But actually, I suspect that if their investors start asking for change, then things might happen rather more quickly.

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And I was very pleased that a couple of years ago, Rathbone some Schroders put together this nice report,

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which started to consider how the investment community could support and encourage change, particularly in relation to reducing sugar.

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And one of the things which makes it difficult for investors is how do they know who is doing the right thing?

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You know, which are the good companies and which are the more recalcitrant companies.

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So this is a really nice piece of work that's being done by Lauren Venti, who is the DPhil student here in Oxford,

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where she's been developing tools which pull together different data sets in order to allow

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us to look what different manufacturers and retailers are doing in terms of reducing,

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in this case, reducing sugar in soft drinks.

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But it's a method that could be much more widely applied, and I'm absolutely delighted that Lauren's paper was just accepted for publication today.

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So I'll have to update the reference on that shortly.

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This is important because without good monitoring, we're not going to be able to effectively police what's going on.

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Once we can monitor it, we can benchmark and then we can hope to start perhaps getting a little bit more change in the system.

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But let's turn now for a moment to regulation, so as I said earlier, I think there is a place for regulation within the food system.

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Much of what we're seeing effectively is a market failure. The system's not doing what it was.

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We wanted it to do. But if we're going to get effective mandatory action,

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there's a whole raft of of elements which are going to have to be put in place in order for it to be effective.

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We certainly need some strong political leadership. We need the public to be on board with that idea that we need to set stretching goals.

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There's no point let's take reformulation in mandating change if the changing mandate is only this big.

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And we've seen that in some other countries. South Africa, for example, has mandatory targets around salt,

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but they're far less stretching than the voluntary targets that we set in the U.K. and which of those works best?

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Well, we need monitoring and evaluation to see what's going on.

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And if we're going to have a mandatory system,

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we've got to have some sanctions if the goals are met because otherwise the next time you try to do it, it will all be meaningless.

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The other problem is, I think there's a limit to the areas in the food system where one can easily introduce regulation.

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Sure, we could on labelling. I think we could and should on promotions.

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I think there's opportunities around the public procurement of food.

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The public purse pays for a surprisingly large amount of food in schools, hospitals, prisons, cetera.

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And if we started to use that, buying power of government to only purchase healthier and indeed more sustainable products,

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I think we'd see quite significant change in the system. And this also, of course, the opportunity to think about using fiscal measures.

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I just want to show you a quick example of that. This is work on the on the soft drinks industry levy, which was introduced last year.

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And this is evaluation which is done by colleagues in population health.

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And they have this fantastic resource called Food TV,

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which is able to continuously continuously monitor the nutritional composition of the food supply by extracting data from supermarket websites.

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And so what they've been doing is tracking the products in relation to whether they're not taxed by the levy in the green,

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whether they're in the middle tier or whether they're in the full tax level.

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And what you can see is there's been dramatic change. The first line shows when the tax was announced at the second when it was introduced.

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I think that's very clear evidence that this policy intervention has driven a substantial change in the system.

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And on the right, you see again, some of Lorence work, which is looked at the reduction in sugars in the food system.

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It's what the blue bar shows you is that there's big oops,

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sorry is that there's been a 29 percent reduction in the total volume of sugars between 2015 and 2018.

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And when you look at how that's been achieved, what the grey area shows you is the reduction which has been brought about because of reformulation.

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This is the reduction in the sugar content of the products, and the dog for the top is the reduction,

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which is a consequence of changes in consumer behaviour, people purchasing different types of products.

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What that tells me, loud and clear, is it's an awful lot easier to change products than it is to change people.

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Now it's taxes on sugary drinks work when sugary drinks actually only contribute a couple of percent of all total energy intake.

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Perhaps we should be thinking about using price as a mechanism to change behaviours with some of the foods as well.

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We published a paper in The BMJ about a year ago suggesting that confectionery and other high sugar snacks would be an obvious place to look now.

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This wouldn't be a fiscal measure to encourage reformulation because we've already seen reformulation is pretty difficult.

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This will be intentionally to raise the price of these products in order to discourage consumption,

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just as we've done with things like tobacco and alcohol. And what this analysis shows is the the modelling,

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which looks at the likely effect on obesity on the most important thing is that you

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can see that this effect works pretty well across the population in terms of weight,

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status, healthy weight, overweight and people with obesity.

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But it also works across different social social groups.

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So very, very generalisable effect. So where does that, where does that take us?

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What I've shown you is that there is actually plenty of evidence of what would work in order

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to change the food environment and to make it more likely that people would choose healthier.

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And I think one could also set up similar interventions to produce more sustainable food choices.

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Of course, it's easy as academics to say we need more evidence, but actually we've got quite a lot of evidence already.

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And you know, the time has come that we start need to put that into action. We've also got a whole raft of policy documents.

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We draw on this evidence. This is not an area where policy makers don't know the evidence.

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They know it actually extraordinarily well.

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And so this goes back to the Foresight report back in 2007, which was probably the first big report to make the case that the environment really,

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really mattered right through to just recently a report from the chief medical officer, which really brought together,

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I don't know, about 100 possible areas, possible initiatives where we could think about taking policy action.

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And between those two, we've had two obesity strategies from two completely different kinds of government,

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and we've had three so-called chapters of the childhood obesity plan.

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We are absolutely not short of reports. But despite all this rhetoric, not much of this evidence is actually being deployed in policy interventions,

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and I'm beginning to feel increasingly frustrated that we are really struggling to get the evidence used in policy.

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It's being heard, but it's not being used. And if you want to hear me sounding off on that point any more,

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you can look at the transcript from the Health and Social Care Committee the other week when we were discussing this point.

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But I think that when I think about this, I think there are three really big barriers.

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The first and very, very important in the UK right now is the issue of competing priorities in the midst of Brexit.

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Boris is not thinking about how big should a biscuit be that is not on the priority list.

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The second is that the food opposition, a food industry opposition, is very, very real.

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Business as usual has served them very, very well,

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and that business model is largely predicated on producing food as cheaply as possible and selling as much of it as possible.

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And so they are bound to prevaricate when it comes to anything which is going to threaten that commercial success.

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And finally, whilst most people in that kind of calm, rational, objective moments want to be the healthiest person they could be.

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The fact is that the real me likes eating chocolate.

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And so we're very, very unlikely, I think, to see marches in Whitehall demanding smaller portions or asking for newsagents to stop selling sweets.

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I just, you know, we've really got to find new ways to try to mobilise public public support.

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So if we want to translate research evidence into policy, I think we also need to think much,

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much harder about how our research is going to help us bring industry and the public on board with this idea.

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And that actually needs to be a legitimate research area in its own right.

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And I think to do this, we need to start by creating some sort of shared vision about what kind of food system it is that we want for the future.

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So if we go back, I don't know, 100 years or so.

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Society was pretty clear that the priority was to produce more food more cheaply and to feed a growing

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urban population who were going to be dependent on the food industry to bring food products to their door.

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And, you know, the food industry delivered on those goals absolutely brilliantly.

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The problem is that now we need something which is very, very different.

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How are we going to get?

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There is a really big ask, and that's why people are now talking about the need for this great intergenerational food transformation.

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And that means the current generation of citizens,

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business folk and policymakers working together to transform food systems so that they become healthier,

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more sustainable, equitable and also prosperous.

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Because this has to be part, it has to be good for the economy, too,

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because that's the only way we're going to be able to deliver on this whole goals.

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Now, evidence is very, very important in the central, perhaps, but evidence alone is simply not enough.

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And here in Oxford, surrounded as we are by academic colleagues, that's really,

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really important for us to remember if we want to deliver this really big gift to the world.

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Thank you. But that was a really wonderful talk.

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Who would like to ask the first question?

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Can I remind you that we're being webcast and to wait till the microphone comes before you ask your question?

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Questions at the back and then one at the front. Thanks very much and thanks very much, Susan.

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Abuse spoken mostly about the UK because that's where your research is focussed.

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But looking across just European countries, for example, there are huge differences in obesity rates.

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To what do you ascribe those differences, are they all on the same trajectory towards higher levels of obesity?

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Or are there different kinds of policies and processes in different countries which are really making a difference?

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They are all pretty well on the same trajectory. It's it's going up everywhere.

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Some seem to start. You know, the big rise seemed to start earlier.

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And you know, in the UK, it's it's plateauing off at a far too high a level,

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but it is beginning to plateau and we're seeing that in some other countries, too.

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So I think that broadly, the pattern is similar, even if the absolute levels are different.

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Lots of people say, Oh, what are other countries doing? And the difficulty is those ecological comparisons are just so confounded and so hard to make.

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So typically, people will say, well, it's lower in France because they got a much stronger meal eating culture.

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They've been slower to adopt a snacking grazing. And that explains it.

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Then they'll say, Well, the Netherlands, of course, look at all the bikes as formal cycling, and that's what's doing it in the Netherlands.

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But truth is, I don't think we've got any high quality evidence which says, Haha, this is what's happened.

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It may be that societies are different, but if you want to look at specific policies,

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then you know that there just aren't enough of those policies being enacted in enough countries to start saying, Well, do they play out differently?

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Probably. The one where we can do most of the comparisons would be things like sugary drinks,

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taxes or levies, and they've been applied in slightly different ways in different places.

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But consistently, wherever they have been introduced, they've been actually remarkably effective.

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So that seems to cross cultures and cross cross boundaries.

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But I'm just not sure we really know. But I doubt it's that different in European countries or indeed high income countries.

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I totally acknowledge the situation is different in other parts of the world,

385
00:42:02,850 --> 00:42:10,260
and I should have done my disclaimer at the beginning that I was going to stick to what I know, which is which is the UK.

386
00:42:10,260 --> 00:42:14,640
Of course, the country is kind of a related question.

387
00:42:14,640 --> 00:42:22,730
I was just wondering how much of any investigation had been done into culture and the importance of emotion and

388
00:42:22,730 --> 00:42:31,940
kind of history of the country and traditions in terms of convincing people to move and change their diets.

389
00:42:31,940 --> 00:42:41,030
So you're way outside my comfort zone then, but there are other people standing over your tax unit who do quite a lot on that at that kind of work.

390
00:42:41,030 --> 00:42:46,100
So yeah, I am just going to refer you to others and I can put you in contact with them later.

391
00:42:46,100 --> 00:42:49,910
I think that's probably the best plan. But culture is clearly clearly important.

392
00:42:49,910 --> 00:42:53,960
The way we eat is socially and culturally grounded.

393
00:42:53,960 --> 00:43:00,080
And and what people value, you know, is part of of the way they've been brought up and so on.

394
00:43:00,080 --> 00:43:05,480
So I'm sure it's tremendously important, but I can't tell you the research base.

395
00:43:05,480 --> 00:43:14,870
I wonder if you could help me, at least by giving as an indication of the degree of reduction necessary in calories fat

396
00:43:14,870 --> 00:43:22,310
intake to get down to an appropriate level of obesity in society from a health point of view.

397
00:43:22,310 --> 00:43:24,380
And second, if I may follow that up.

398
00:43:24,380 --> 00:43:35,180
How much of that excess kilocalories per day could be got rid of by significantly reducing sugar, which is most of what you've talked about today?

399
00:43:35,180 --> 00:43:42,860
OK, I hope I haven't mostly talked about sugar because things like, um, like confectionery is got a lot of we tend to think of as high sugar.

400
00:43:42,860 --> 00:43:47,120
It's got a lot of fat in it, too. So I don't think this is just about sugar.

401
00:43:47,120 --> 00:43:52,730
I think this is about calories, it's about too many calories. And that's, you know, sugar provides 15 percent of our calories.

402
00:43:52,730 --> 00:43:57,140
So we're eating too much of a lot of other things as well.

403
00:43:57,140 --> 00:44:05,570
If you want to reduce it all down to absolute energetics, the weight gain in the UK over the last well, not the last 10 years,

404
00:44:05,570 --> 00:44:19,820
but maybe 20, five to 15, there was a government committee showed that on average that came down to about 25 calories a day.

405
00:44:19,820 --> 00:44:25,910
But of course, weight gain is not average across across the population, nor day by day.

406
00:44:25,910 --> 00:44:30,230
But the point is that population level weight gain is a very, very small error.

407
00:44:30,230 --> 00:44:35,180
And that's why many of these measures actually could be could be very effective.

408
00:44:35,180 --> 00:44:40,850
If, however, you are already overweight and you're trying to get down to a lower body weight,

409
00:44:40,850 --> 00:44:43,880
you're going to have to eat significantly fewer calories.

410
00:44:43,880 --> 00:44:53,300
And so you're talking about approximately three and a half thousand calories less than you require to lose a pound of of of weight.

411
00:44:53,300 --> 00:44:55,760
So, you know, those are the kind of energetics of it.

412
00:44:55,760 --> 00:45:02,840
But because it's so hard for anybody to know exactly how many calories they've eaten or exactly how many calories they've burned off.

413
00:45:02,840 --> 00:45:07,160
I think what we've learnt is trying to think, trying to reduce it down to that,

414
00:45:07,160 --> 00:45:14,300
that that currency actually hasn't been awfully helpful in making progress just very quickly

415
00:45:14,300 --> 00:45:21,710
is just a very thoughtful about how you said 15 percent of calorie intake comes from sugar.

416
00:45:21,710 --> 00:45:22,070
Yeah.

417
00:45:22,070 --> 00:45:30,800
And that sounds from what you were just saying that that significantly changing certain sugar consumption would be sufficient over the long term.

418
00:45:30,800 --> 00:45:38,060
To radically change your piece. Sure. So, so a policy which said trying to get that down to 10 percent.

419
00:45:38,060 --> 00:45:40,790
Well, the policy is to get it down to five percent.

420
00:45:40,790 --> 00:45:47,360
Well, the policy, the recommendation, the dietary recommendation is that we should have five percent of our calories from sugar.

421
00:45:47,360 --> 00:45:54,140
But, you know, recommendations don't in and of themselves actually change what happens.

422
00:45:54,140 --> 00:45:59,930
We need we need to introduce policies which actually will make that make that plausible.

423
00:45:59,930 --> 00:46:03,500
But you know, yes, that would work. I'm totally signed up to that.

424
00:46:03,500 --> 00:46:09,740
But I also think we we started to look at obesity through a sugar lens,

425
00:46:09,740 --> 00:46:14,780
and that actually isn't awfully helpful because there are lots of interventions to not particularly around.

426
00:46:14,780 --> 00:46:27,670
It's just people eating too much. Question right at the back with the James and then gentleman in front of the white shirt.

427
00:46:27,670 --> 00:46:28,960
Thanks very much.

428
00:46:28,960 --> 00:46:37,780
What do we know about what sort of interventions at the individual level, the policy level industry level would reduce meat consumption.

429
00:46:37,780 --> 00:46:45,850
And it's your intuition. If there isn't much evidence yet, it would be not dissimilar from interventions to reduce sugar.

430
00:46:45,850 --> 00:46:51,040
So both of those so we one of another of my DPhil students, Filippo Bianche,

431
00:46:51,040 --> 00:46:59,320
has published two systematic reviews which look at the extant evidence on interventions specifically to reduce meat consumption.

432
00:46:59,320 --> 00:47:06,520
There aren't that many, and they're relatively small, and they're often relatively poor quality.

433
00:47:06,520 --> 00:47:10,720
But what is absolutely interesting is the most effective things.

434
00:47:10,720 --> 00:47:19,090
Actually, all the same behavioural mechanisms, the same kinds of policy tools as we see to change dietary behaviour in other areas.

435
00:47:19,090 --> 00:47:25,190
So price is extraordinarily effective. Portion size is very effective at changing the availability.

436
00:47:25,190 --> 00:47:33,520
So just as I showed, if you have a lower calorie option, more lower calorie options than people consume fewer calories.

437
00:47:33,520 --> 00:47:38,470
So if you have more plant based options and fewer animal based options, people eat less meat.

438
00:47:38,470 --> 00:47:48,520
So the behavioural mechanisms which shape what people end up choosing actually appeared to be very, very similar across the team.

439
00:47:48,520 --> 00:47:56,650
Thank you. And then gentlemen, just in front of the white shirt, obviously, we're aware of the idea that you can't outrun a bad diet,

440
00:47:56,650 --> 00:48:04,600
but knowing the large numbers of adults and children don't do the recommended amount of activity your exercise per week.

441
00:48:04,600 --> 00:48:10,180
Do you think exercise is encouraging? Exercise has a role to play, if any.

442
00:48:10,180 --> 00:48:19,750
Oh, completely, absolutely completely. You know, I wasn't asked to talk about physical activity, but you know, be in no doubt we were pretty well.

443
00:48:19,750 --> 00:48:24,820
Most of us eat too much, and most of us do less activity than is good for our health.

444
00:48:24,820 --> 00:48:29,620
Both of those would help control weight, but they would also have independent health benefits.

445
00:48:29,620 --> 00:48:33,670
You know, high quality diets, good. Whatever your weight, more physical activities, good.

446
00:48:33,670 --> 00:48:38,230
Whatever your weight, it's totally, totally signed up to that.

447
00:48:38,230 --> 00:48:45,430
But it's not either all. And so you know, what we need is interventions which will help people to be more physically active.

448
00:48:45,430 --> 00:48:49,900
And I can't really give you the detail on the evidence base for that.

449
00:48:49,900 --> 00:48:52,840
It strikes me that one of the most difficult things around the public health of

450
00:48:52,840 --> 00:48:59,170
obesity is you want to raise the awareness of the health harms of being overweight.

451
00:48:59,170 --> 00:49:09,460
But then you don't want to victimise individuals and the movement of people who worry about fat shaming, which seems to be growing in in prominence.

452
00:49:09,460 --> 00:49:12,910
How to navigate that really difficult path between the two?

453
00:49:12,910 --> 00:49:18,310
Well, what you do is you appoint a really good sociologist and hope that she'll solve it for you,

454
00:49:18,310 --> 00:49:23,140
which is what we've just done and delighted that Cindy Spratt has just just joined us.

455
00:49:23,140 --> 00:49:29,710
So I think part of that? Well, firstly, we absolutely need to recognise that people with obesity are, you know,

456
00:49:29,710 --> 00:49:34,840
there's appalling discrimination, appalling stigma, and they extremely badly treated.

457
00:49:34,840 --> 00:49:41,080
And that makes me very, very cross. And I think we all have to stand sort of foursquare against that and say this is unacceptable.

458
00:49:41,080 --> 00:49:48,550
There is somehow this view that if you make people and if you just tell them this is really bad, then somehow it will all go away.

459
00:49:48,550 --> 00:49:55,010
But all the evidence tells us that Patently does not happen. We've spent decades, you know, a stigmatising.

460
00:49:55,010 --> 00:50:00,310
And it's not helped one bit. In fact, what the research evidence tells us is it makes things worse.

461
00:50:00,310 --> 00:50:05,320
And it's only when people feel confident in control and boost their self-esteem that they

462
00:50:05,320 --> 00:50:13,930
better able to manage the cognitive effort that it takes in this world to manage your weight.

463
00:50:13,930 --> 00:50:19,840
So I think that's one aspect of it is that we just got to recognise people will do better with support.

464
00:50:19,840 --> 00:50:28,360
The second is that, you know, there is a bit of a sort of policy view that this is a lot about individual responsibility.

465
00:50:28,360 --> 00:50:36,400
People ought to take more responsibility for their actions. And as I said, to underestimate the importance of the food environment,

466
00:50:36,400 --> 00:50:42,730
if we start understanding that actually the environment which is making it really hard for all of us,

467
00:50:42,730 --> 00:50:46,240
I think you then start to depersonalise this issue.

468
00:50:46,240 --> 00:50:53,380
And if people who are struggling with their weight have almost certainly got underlying susceptibility,

469
00:50:53,380 --> 00:50:57,820
some vulnerabilities to this adverse world, which I am fortunate not to have.

470
00:50:57,820 --> 00:51:02,530
And in every other case, if we have individuals who are particularly vulnerable,

471
00:51:02,530 --> 00:51:10,180
we go out of our way to try to help them and support them and and to change the environment to make it easier for them.

472
00:51:10,180 --> 00:51:16,780
And yet, for some reason, when it comes to weight, we just become, I don't know,

473
00:51:16,780 --> 00:51:20,560
we seem to lose all compassion and I don't know what's going on there.

474
00:51:20,560 --> 00:51:27,750
Thank you. Lady there in the pale orange.

475
00:51:27,750 --> 00:51:33,450
And thanks for your talk, I thought I was really interested in your your work or your theme student,

476
00:51:33,450 --> 00:51:38,310
Lawrenceburg, about the impact of the sugar tax on the sugar content of soft drinks.

477
00:51:38,310 --> 00:51:43,410
And I wondered whether that sugar has replaced has been replaced by artificial sweeteners

478
00:51:43,410 --> 00:51:47,550
and whether you are concerned about whether there might be unintended consequences of that.

479
00:51:47,550 --> 00:51:52,890
So I should say there's a big evaluation of the sugar drink industry levy, which is is underway at the moment.

480
00:51:52,890 --> 00:51:59,160
So this isn't the formal evaluation, but this is a sort of a side product of the work that Lauren's been been doing,

481
00:51:59,160 --> 00:52:02,820
looking at what companies have done. And it chimes very much with Public Health England.

482
00:52:02,820 --> 00:52:09,030
So an analysis of what's happened, how have they achieved it?

483
00:52:09,030 --> 00:52:14,460
Yes, by most mostly by using non-nutritive sweeteners,

484
00:52:14,460 --> 00:52:21,180
that is absolutely the case so that it's maintained the sweetness of the product, but without the calories.

485
00:52:21,180 --> 00:52:27,030
All of the evidence tells us that that is helpful in terms of weight, fewer calories.

486
00:52:27,030 --> 00:52:29,640
You get better if you look at the trials.

487
00:52:29,640 --> 00:52:37,530
People randomised to the low calorie arm have a lower weights at the end of the study than people who have the high sugar drinks.

488
00:52:37,530 --> 00:52:45,990
There's no proven evidence of any of any health harms. It doesn't mean there aren't any, but there isn't any any evidence that that's that's the case.

489
00:52:45,990 --> 00:52:55,480
What people worry about, I think, is that it maintains a preference for sweetness, and that is probably true and I share that concern.

490
00:52:55,480 --> 00:53:04,140
But if you if you used to have sugar in your tea and coffee and then you stop and you just stop completely taste dreadful for a while,

491
00:53:04,140 --> 00:53:10,230
then you get used to it. I presume that's because your taste threshold, your sugar threshold has gone down,

492
00:53:10,230 --> 00:53:14,820
whereas if you put artificial sweeteners in, of course, you maintain it at that higher level.

493
00:53:14,820 --> 00:53:20,400
So I would absolutely say that the best thing is not to have sugary drinks on tap water.

494
00:53:20,400 --> 00:53:27,810
I think there's very little doubt that's the best thing to do. The question is, is that a behavioural step too far for many people?

495
00:53:27,810 --> 00:53:39,030
And the evidence seems to suggest it is, and therefore that switching from this sugary products which are bad for your weight, bad for your teeth.

496
00:53:39,030 --> 00:53:44,580
You know, moving to these diet drinks, which is still bad for your teeth, I should say,

497
00:53:44,580 --> 00:53:50,190
but much, much less harmful for your weight is at least a harm reduction strategy.

498
00:53:50,190 --> 00:53:57,780
And and I think, you know, one we should support. Of course, I'd like to see the overall level of sweetness in the diet coming down.

499
00:53:57,780 --> 00:54:05,550
And one of the potential benefits if we can get large scale sugar reduction across a whole range of categories, as we might see that happening.

500
00:54:05,550 --> 00:54:14,010
And you know, in my great and glorious world, that would mean that people kind of rediscover the natural sweetness of of fruits and things like that,

501
00:54:14,010 --> 00:54:21,420
and that we up there delight in a fresh strawberry in a way which which we seem to have lost.

502
00:54:21,420 --> 00:54:26,100
OK, a final question at the back there. The gentleman that they lack.

503
00:54:26,100 --> 00:54:33,150
Thank you. And Susan, you mentioned prices effective and you mentioned them redirect subsidies to unprocessed food.

504
00:54:33,150 --> 00:54:38,190
I'm just curious how are processed food currently subsidised and how would you change that?

505
00:54:38,190 --> 00:54:46,230
Because you don't know what a grain goes into a bread or a cookie? Would we stop, you know, farming subsidies for sugar beet?

506
00:54:46,230 --> 00:54:50,580
Or what's the mechanism here? Well, there's a whole at the moment,

507
00:54:50,580 --> 00:54:59,820
there is enormous amounts of subsidies which are predominantly going into foods we want people to eat less of, and that doesn't make any sense.

508
00:54:59,820 --> 00:55:05,190
What we ought to be doing is putting them into foods we want people to eat more of.

509
00:55:05,190 --> 00:55:11,670
So for example, if we want more horticulture and let's take the U.K. more horticulture in the U.K.,

510
00:55:11,670 --> 00:55:18,390
producing more fruits and vegetables, actually, that is a very costly set up for for farmers.

511
00:55:18,390 --> 00:55:22,560
And so we'll might want to incentivise them in some way to do that.

512
00:55:22,560 --> 00:55:28,440
But, you know, I haven't, I'm not sure economist. I haven't begun to touch on how the money flows would work.

513
00:55:28,440 --> 00:55:35,700
But just the overarching principle that it doesn't make a lot of sense to be subsidising the production of foods we want people to eat less of,

514
00:55:35,700 --> 00:55:41,280
and it would be better redirected elsewhere. I got abused my position by asking one final question.

515
00:55:41,280 --> 00:55:45,220
So it's December the 12th we failed to elect a government.

516
00:55:45,220 --> 00:55:49,830
We're looking round and we put you as minister of health.

517
00:55:49,830 --> 00:55:56,490
You have a compliant parliament. What are the three things you would introduce and bring in as your priority?

518
00:55:56,490 --> 00:56:07,260
Well, I would have a cabinet committee on food because health picks up the the the the health problems caused by food,

519
00:56:07,260 --> 00:56:09,990
but it has very, very few of the levers to change it.

520
00:56:09,990 --> 00:56:17,970
So I think firstly, lasting the whole of food on the health minister is just never going to give you a good if you want gratitude.

521
00:56:17,970 --> 00:56:23,430
So I'd like a bigger, better job. I think that that's incredibly good.

522
00:56:23,430 --> 00:56:32,630
What would I do? I would take a. Well, I nailed my colours to the mast in a way I would tax confectionery for sure.

523
00:56:32,630 --> 00:56:38,450
I think that's an easy win and I just cannot see any other ways that we're going to reduce confectionery.

524
00:56:38,450 --> 00:56:47,840
And I would take action to control promotions and advertising because I think that's incredibly pernicious influence on people's food choices.

525
00:56:47,840 --> 00:56:54,680
And although people, you know, people I guess, want some some autonomy and advertising marketing is really taking that away from them.

526
00:56:54,680 --> 00:57:01,470
So I think promotions are are really fuelling at least the overconsumption element.

527
00:57:01,470 --> 00:57:09,350
Generally, the overconsumption on less healthy foods. But yeah, I'll write my manifesto and then I'll send it sandy.

528
00:57:09,350 --> 00:57:16,140
Just before I ask you to thank Susan again, can I tell you that the talk next week will be about us in later day,

529
00:57:16,140 --> 00:57:20,240
mostly laser on plant genetics from Mendel to Monsanto?

530
00:57:20,240 --> 00:57:25,880
It will be an absolutely fabulous talk. After having heard Susan this afternoon,

531
00:57:25,880 --> 00:57:34,250
you will understand why she is probably the most influential person in this country for affecting policy on on diets and things.

532
00:57:34,250 --> 00:57:54,123
And so please do join me for thanking her for a wonderful talk. That's partly because.