Hello, everybody, and welcome to the Oxford Martin School.
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,
and the talk today is given by a very good friend of mine and colleague Susan Japp.
I'm delighted to welcome to the school. She's on the lot with the school over the last few years.
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.
She's in the Department of Primary Care. She's an expert in the obesity and many other aspects of diet and public health.
And before this and came to Oxford, she was at the MRC Centre in Cambridge.
Susan, welcome to the school and come up and give us your talk. Thank you very much.
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.
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.
I want to just touch on a number of of the projects we do today.
I suppose the thing which underpins everything we do,
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
growing sense that our food system is failing and it's creating a kind of perfect storm of health problems really across the globe.
We face this extraordinary situation where nearly one billion people have insufficient food.
And yet at the same time, more than two billion are affected by obesity.
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.
And that's creating incredibly high and growing rates of diet related disease and premature mortality.
So malnutrition in all its forms, as it's sometimes described these days, really covers obesity,
undernutrition and the diet related disease caused by poor diet quality.
And if you put these three things together, it's quite clearly the biggest contributor to the health burden around the world,
greatly exceeding other major and very well recognised risk factors like tobacco or high blood pressure.
And I think our failure to really fully acknowledge that is because in the past, we tended to treat these as three separate things.
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.
So if we look around the globe, clearly, the relative proportions of people who are overall undernourished varies but every single region.
You can see that diet related disease tops the list. So I was thinking about what we eat.
But of course, what we eat is in part a function of what's produced in our system of food production.
It's one of the biggest ways in which humanity impacts on the environment.
Even a decade ago of food production system was exceeding the planetary boundaries as far as greenhouse gas emissions were concerned.
And that's projected to more than double by 2050.
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.
And the single biggest contributor to this is shown in the in the red ball.
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,
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,
bringing together the environmental aspects of food production, together with the health consequences of consuming too much meat and dairy.
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,
but we also going to have to change consumer demand for some of the most environmentally damaging commodities.
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,
at least at a global level. We're going to have to reduce overall meat consumption.
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?
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,
not even just thinking about solutions, but actually implementing solutions.
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.
What is it we need to do tomorrow, which is going to make this change happen?
And there are a number of things which are sometimes called double or triple duty actions,
which could benefit two or more of the failings in the food system.
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.
So top of my list is absolutely reducing overconsumption.
Eating too much wastes precious environmental resources to produce food, which goes on to damage our health.
It is an absolute no brainer. Reducing consumption of very highly processed foods, I think, is also very important.
We know that these foods are often the things which are particularly high in saturated fat, sugar and salt.
The foods that are creating this poor diet. So they're an obvious target for policies to improve health.
But actually, when it comes to the environment,
it's a slightly more complex issue because many of these products, to be honest, are not big contributors.
For example, two greenhouse gas emissions.
I've said it before that sugary drinks are probably one of the most environmentally friendly ways to calm your health.
But the truth is that actually beyond greenhouse gas emissions, they do have other environmental harms.
So if you take something like like corn, for example,
it's used extensively in highly processed foods as a sort of thickener and emulsifier, even just as a filler.
And of course, in many countries, corns turned into high fructose corn syrup and used as a sweetening agent.
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,
and it's associated with very heavy use of fertilisers, pesticides, herbicides and so forth.
So in fact, the production of these highly processed foods is in of itself, environmentally damaging.
And that's before you even start thinking of all the packaging that goes into these these types of foods.
So reducing highly processed foods is going to be good for health, and it's going to be good for the environment, too.
And of course, if we stopped subsidising these kinds of foods as heavily as we do in all of our economic systems,
we could think about moving that subsidy elsewhere and supporting less processed foods.
Going further down the list, the next to really come together,
increasing our consumption of plant based foods and reducing the amount of animal source foods we consume.
And that's really, I think, a very easy way where we can get better diet quality, huge environmental gains.
And I think also, importantly, greater health equity.
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.
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.
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
value food quite as much as they should wear that casual about food wastage that leads people to effectively over cater.
And once you've over prepared food or you've bought a larger portion, because why not?
It seems like really good for you. We know that you're much more likely to overconsume.
And so actually, being casual about food waste leads on to people in fact eating more than they need.
So these aren't the only targets, but there are some good targets there, a good place to start,
and the question really is how are we going to achieve these goals for the rest of my talk,
I really want to focus on some of the interventions which might actually change behaviour.
Now most of the examples that I'm going to give you relate to reducing consumer demand for less healthy products,
because that's where most of the evidence lies of present.
But in fact, most of these interventions could also be applied in the context of reducing the demand for meat.
And that's an area of work that we're developing within that within the Leap programme.
I think what's absolutely clear is there wasn't going to be one thing that's going to fix it.
We're going to need a whole portfolio of interventions. And that's likely to include both individual level strategies,
things targeted at individuals which motivate and encourage them to actually change their own diet.
So in a way to empower this little guy to push the boulder up the hill.
But at the same time, we're also going to need population level strategies, which make it just a little bit easier for everybody.
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.
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.
It's not often you hear obesity and success in the same sense. So let's just celebrate the moment.
Obesity is a really major public health problem. It affects one in four adults and in children in particular.
They're are really marked inequalities. It causes multiple health problems affecting pretty well, every organ system of the body.
And the consequence of that is that there's a heavy cost to individuals,
to employers through time, off work and to the NHS and the social care system.
Now, treating obesity means reducing energy intake.
And the good thing is that that will generally have the benefit of reducing saturated fat, sugar and salt.
At the same time, because people are having fewer calories and most people compensate for having
rather little on their plate by increasing the amount of vegetables they consume.
So in fact, successfully tackling obesity, we've shown, is a very good way to improve diet quality overall.
So the question is, how might you do that?
Well, our research has shown that offering people access to formal weight loss programmes leads to very successful weight loss.
Because one in four adults are overweight, we are interested in very scalable interventions.
And so this is a study looking at what happens if JP's gives people the option to attend
the local community slimming group things like Weight Watchers or Slimming World.
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.
But the two groups who were offered the opportunity to attend the weight loss group did
significantly better than just giving them a bit of advice and leaving them to manage on their own.
And although they did regain some weight at the end of the first year when we stopped providing the intervention we were
able to show was that this was highly cost effective and even this modest weight loss reduces the risk of later disease.
But of course, weight loss would be better.
And so we recently published this study looking at the use of total diet replacements again in routine primary care.
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
and 45 percent of people lost more than 10 percent of their initial body weight.
That's incredibly successful by any standard in terms of treating obesity.
That's great news, but the fact is that evidence alone is not sufficient to make this happen in practise.
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.
So we work with Public Health England and others to produce guidance for commissioners to help them to commission these programmes.
Guidance for GP and other health professionals about how to raise the issue of weight with people.
And we've been absolutely delighted that in the NHS long term plan, which was published at the start of this year,
there are now three major commitments for the NHS to offer support to people to lose weight,
which are based heavily on the work that we've done in our team at the same
time as trying to change the system to make these interventions more likely.
Well, we've also done is a lot of public engagement and involvement work to really work with people who are overweight,
to find out what it is they need,
and also to try to build the patient voice, demanding and looking for action and help to support them in their weight loss attempts.
And I think this perhaps is one of our best examples of how we've been able to take
basic scientific research and see it right through into changing policy and practise.
Now, when it comes to changing diet quality, more generally, I'm here, I'm talking about changing diet for everybody,
not just people with obesity, but improving the quality of diet for all.
The fact is, it's much harder to point to individual interventions, which are going to make the difference.
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.
And that means it's going to have to be jolly, low cost. And that's a pretty tricky combination.
We've there's been a lot of work, for example, in things like nutrition labelling.
If you just give people more information about what's in their food. Will that help them to make better choices?
The answer is yes. It helps a little bit, but it's it's not. It's not transformational.
We've been trying to take that one step further using technology to really help us deliver
very personalised nutrition support to people at the time where it might be most useful.
And that's when they're in the supermarket doing their shopping because frankly,
once it's in your kitchen cupboard, you're probably going to eat it at some point.
So we want to intervene a little bit earlier in the system to stop it ever leaving the shop.
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,
and we converted it into a nutritional report and we were able to identify in this instance the foods,
which for that individual household were actually contributing the most saturated fat to the diet and then to offer people personalised swaps.
And then a month later, we sent them another report telling them how they were getting old.
So using some behavioural techniques to try to support people to make progressive changes and this is an oops, sorry.
This is a this is a study which is just about to start whole swap shop.
This is an app we've developed,
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.
Instead, if you're about to buy, you know, a bar of chocolate, it doesn't say have a banana instead,
but it might find you a bar of chocolate that was a bit lower calorie.
So it's possible that using this kind of technology, we can deliver individual interventions at scale,
but it really remains to be seen whether these will be particularly effective and
also whether they'll contribute in any way towards narrowing health inequalities.
The risk being that they might actually make it slightly worse.
So the reason we need to look beyond just individual level interventions is not only because
it's hard for me to go around and influence every single person in the entire country,
but also because we all of these individual things require significant cognitive effort.
They are asking people to be very thoughtful about what they're purchasing or what they put into their mouths.
And what we've come to recognise is the most eating isn't all that thoughtful.
Mostly, it's quite automatic. It's sort of happened before.
We've really thought all that much about it.
You know, I didn't see a cake and sort of think, Oh my goodness, I don't really need those extra calories.
Extra calories may not gain weight by gaining weight. I increase my risk of diabetes.
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.
And if I can't manage that with, you know, quite a lot of nutritional knowledge, you know,
it's pretty difficult for anybody else who hasn't, you know, got such insights into food.
So we can sometimes think of this as the sort of two processes.
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,
it's the sort of Homer Simpson bit of our brain which has taken over and, you know, automatic reactions kick in.
And the problem when it comes to policymaking is that policy makers insist on believing that individuals are indeed not just policymakers.
We all like to think we call them rational, intelligent people who are going to make good choices,
even though the evidence actually is completely opposed to that.
And because we think we're rational people, we believe in willpower.
We have this extraordinary sense that somehow, you know, some people have willpower and some don't,
and that even if they don't, maybe we could teach them willpower. And that's what dieting is all about.
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.
It's just a clash between a slump in motivation and adverse external circumstances.
So most of the time, you know, I have ups and downs in my motivation to eat healthily during the day.
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.
Rubbish day of meetings, grants been rejected. Get to the station.
Just miss the train feeling fed up, and I'm surrounded by newsagents, coffee shops, a whole raft of opportunities to buy.
High calorie, high sugar, high fat food. And that's when it all goes wrong.
And so for all of us, at some point, the dip in motivation coincides with an adverse environment.
And this has nothing to do with willpower. It's just circumstances have overwhelmed us.
A few calories seems a pretty small price to pay for a boost in my quality of life at that point.
So what this tells us is that if we want to change what we eat,
we're going to have to change the environment in which these so-called choices are being made.
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.
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.
So let's take the first one products portion sizes have increased.
I could show you a bit of evidence,
but most of us are probably willing to accept the case that most foods are sold in bigger portion sizes than they were before.
And even if the standard product hasn't changed and new products been introduced,
which is twice the size of what we know from a big Cochrane systematic review,
if the evidence is that if people are offered larger portions, they are more likely to over consume.
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.
And we've estimated that if we may portion sizes smaller across all foods,
you'd get about almost a 60 percent reduction in energy intake for adults could be extremely meaningful.
The other thing we could do with products is we could make every product the healthiest it could be.
And there's been a huge push in the UK on this particular agenda around reformulation that strip
out unnecessary nutrients and across a whole range of products over the last 10 or 15 years.
There have been quite significant changes in nutrient composition, particularly with respect to salt,
and the SALT reformulation programme in the UK is without doubt world leading.
And we've seen more than a 15 percent reduction in salt intake in a decade,
which is almost entirely driven by changes in the salt content of food products.
It's not so much what the people are eating differently. It's simply the products they're eating contain less salt.
Public Health England are now trying to use a very similar strategy to encourage reductions in the sugar content of of all diet.
It's a great aim. The problem is the effectiveness is much less clear.
So they set a target that we were going to reduce by sugar content in these 10 categories by 20 percent by 2020.
We are now in 2019 and we're at, well, not quite three percent just yet.
Progress has been extremely limited and extremely small.
It does vary by different food categories. You'll see that you'll get some breakfast cereals have made moderate progress,
but if you look at some things like confectionery down here at the bottom, there's been absolutely no change whatsoever.
And that's in part, of course, is because things like sweets are quite difficult to reformulate.
If you take the sugar out of a sweet, you don't have much of a sweet left.
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,
but we're also going to need some other interventions as well.
One of the things that we think is potentially very effective is about changing the availability of healthier options within micro environments.
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.
So there was a similar range and this was both in snacks and in main meals.
But the proportion of the healthier items was increased. And what you can see across six different sites, if you average those,
there was a seven percent reduction in the number of calories purchased in those canteens during the phase of the of the intervention.
I mentioned promotions, and this is a really, really important point in the UK,
about 40 percent of all the food that we purchase is bought on some kind of promotion.
And it's estimated that that increases the amount we we purchase by about what by about a fifth.
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,
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.
Why does this matter? Well, promotions, drive, sales and promotions happen in all kinds of ways.
Price is an obvious one, but this is just about promotions on the end of the aisle.
So products on the end of the aisle extremely prominent.
And what we've shown is that this significantly increases the amount of these products that people purchase.
So in the case of soft drinks up by about 50 percent,
that's the same uplift in sales that you would get if there was a 20 percent reduction in the price.
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
prominent block of the same item and there's often a price promotion attached as well.
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.
And this really raises an interesting question about how might that occur?
How is it we're going to get industry to change? Can we do it as we're trying,
mostly at the moment to somehow persuade or cajole or perhaps even incentivise change through purely voluntary mechanisms?
Or are we going to have to use much harder policy measures effectively mandating change through some kind of regulation?
As I mentioned, the emphasis of the moment is on is on voluntary measures.
And the truth is that whilst you know we've seen a bit of reformulation,
we've not seen anything like enough progress and we've seen pretty well, nothing on promotions.
For a while, I chaired something called the responsibility deal,
where we tried to work with the food industry to encourage them to make positive changes.
And at the end of that of that initiative,
I wrote a blog basically saying that it was clear to me that promotions were so commercially sensitive it was really
impossible to make progress on a voluntary basis because any company which moved first would be commercially disadvantaged.
And so in that area, I think we do need a mandate in order to create a level playing field.
But before we just move on from voluntariness,
I think one area that we haven't adequately explored is how much we could use the investment community to help drive change.
If I ask this big business to change, they take no notice at all.
If government asks them, they move a little bit.
But actually, I suspect that if their investors start asking for change, then things might happen rather more quickly.
And I was very pleased that a couple of years ago, Rathbone some Schroders put together this nice report,
which started to consider how the investment community could support and encourage change, particularly in relation to reducing sugar.
And one of the things which makes it difficult for investors is how do they know who is doing the right thing?
You know, which are the good companies and which are the more recalcitrant companies.
So this is a really nice piece of work that's being done by Lauren Venti, who is the DPhil student here in Oxford,
where she's been developing tools which pull together different data sets in order to allow
us to look what different manufacturers and retailers are doing in terms of reducing,
in this case, reducing sugar in soft drinks.
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.
So I'll have to update the reference on that shortly.
This is important because without good monitoring, we're not going to be able to effectively police what's going on.
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.
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.
Much of what we're seeing effectively is a market failure. The system's not doing what it was.
We wanted it to do. But if we're going to get effective mandatory action,
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.
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.
There's no point let's take reformulation in mandating change if the changing mandate is only this big.
And we've seen that in some other countries. South Africa, for example, has mandatory targets around salt,
but they're far less stretching than the voluntary targets that we set in the U.K. and which of those works best?
Well, we need monitoring and evaluation to see what's going on.
And if we're going to have a mandatory system,
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.
The other problem is, I think there's a limit to the areas in the food system where one can easily introduce regulation.
Sure, we could on labelling. I think we could and should on promotions.
I think there's opportunities around the public procurement of food.
The public purse pays for a surprisingly large amount of food in schools, hospitals, prisons, cetera.
And if we started to use that, buying power of government to only purchase healthier and indeed more sustainable products,
I think we'd see quite significant change in the system. And this also, of course, the opportunity to think about using fiscal measures.
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.
And this is evaluation which is done by colleagues in population health.
And they have this fantastic resource called Food TV,
which is able to continuously continuously monitor the nutritional composition of the food supply by extracting data from supermarket websites.
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,
whether they're in the middle tier or whether they're in the full tax level.
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.
I think that's very clear evidence that this policy intervention has driven a substantial change in the system.
And on the right, you see again, some of Lorence work, which is looked at the reduction in sugars in the food system.
It's what the blue bar shows you is that there's big oops,
sorry is that there's been a 29 percent reduction in the total volume of sugars between 2015 and 2018.
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.
This is the reduction in the sugar content of the products, and the dog for the top is the reduction,
which is a consequence of changes in consumer behaviour, people purchasing different types of products.
What that tells me, loud and clear, is it's an awful lot easier to change products than it is to change people.
Now it's taxes on sugary drinks work when sugary drinks actually only contribute a couple of percent of all total energy intake.
Perhaps we should be thinking about using price as a mechanism to change behaviours with some of the foods as well.
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.
This wouldn't be a fiscal measure to encourage reformulation because we've already seen reformulation is pretty difficult.
This will be intentionally to raise the price of these products in order to discourage consumption,
just as we've done with things like tobacco and alcohol. And what this analysis shows is the the modelling,
which looks at the likely effect on obesity on the most important thing is that you
can see that this effect works pretty well across the population in terms of weight,
status, healthy weight, overweight and people with obesity.
But it also works across different social social groups.
So very, very generalisable effect. So where does that, where does that take us?
What I've shown you is that there is actually plenty of evidence of what would work in order
to change the food environment and to make it more likely that people would choose healthier.
And I think one could also set up similar interventions to produce more sustainable food choices.
Of course, it's easy as academics to say we need more evidence, but actually we've got quite a lot of evidence already.
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.
We draw on this evidence. This is not an area where policy makers don't know the evidence.
They know it actually extraordinarily well.
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,
really mattered right through to just recently a report from the chief medical officer, which really brought together,
I don't know, about 100 possible areas, possible initiatives where we could think about taking policy action.
And between those two, we've had two obesity strategies from two completely different kinds of government,
and we've had three so-called chapters of the childhood obesity plan.
We are absolutely not short of reports. But despite all this rhetoric, not much of this evidence is actually being deployed in policy interventions,
and I'm beginning to feel increasingly frustrated that we are really struggling to get the evidence used in policy.
It's being heard, but it's not being used. And if you want to hear me sounding off on that point any more,
you can look at the transcript from the Health and Social Care Committee the other week when we were discussing this point.
But I think that when I think about this, I think there are three really big barriers.
The first and very, very important in the UK right now is the issue of competing priorities in the midst of Brexit.
Boris is not thinking about how big should a biscuit be that is not on the priority list.
The second is that the food opposition, a food industry opposition, is very, very real.
Business as usual has served them very, very well,
and that business model is largely predicated on producing food as cheaply as possible and selling as much of it as possible.
And so they are bound to prevaricate when it comes to anything which is going to threaten that commercial success.
And finally, whilst most people in that kind of calm, rational, objective moments want to be the healthiest person they could be.
The fact is that the real me likes eating chocolate.
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.
I just, you know, we've really got to find new ways to try to mobilise public public support.
So if we want to translate research evidence into policy, I think we also need to think much,
much harder about how our research is going to help us bring industry and the public on board with this idea.
And that actually needs to be a legitimate research area in its own right.
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.
So if we go back, I don't know, 100 years or so.
Society was pretty clear that the priority was to produce more food more cheaply and to feed a growing
urban population who were going to be dependent on the food industry to bring food products to their door.
And, you know, the food industry delivered on those goals absolutely brilliantly.
The problem is that now we need something which is very, very different.
How are we going to get?
There is a really big ask, and that's why people are now talking about the need for this great intergenerational food transformation.
And that means the current generation of citizens,
business folk and policymakers working together to transform food systems so that they become healthier,
more sustainable, equitable and also prosperous.
Because this has to be part, it has to be good for the economy, too,
because that's the only way we're going to be able to deliver on this whole goals.
Now, evidence is very, very important in the central, perhaps, but evidence alone is simply not enough.
And here in Oxford, surrounded as we are by academic colleagues, that's really,
really important for us to remember if we want to deliver this really big gift to the world.
Thank you. But that was a really wonderful talk.
Who would like to ask the first question?
Can I remind you that we're being webcast and to wait till the microphone comes before you ask your question?
Questions at the back and then one at the front. Thanks very much and thanks very much, Susan.
Abuse spoken mostly about the UK because that's where your research is focussed.
But looking across just European countries, for example, there are huge differences in obesity rates.
To what do you ascribe those differences, are they all on the same trajectory towards higher levels of obesity?
Or are there different kinds of policies and processes in different countries which are really making a difference?
They are all pretty well on the same trajectory. It's it's going up everywhere.
Some seem to start. You know, the big rise seemed to start earlier.
And you know, in the UK, it's it's plateauing off at a far too high a level,
but it is beginning to plateau and we're seeing that in some other countries, too.
So I think that broadly, the pattern is similar, even if the absolute levels are different.
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.
So typically, people will say, well, it's lower in France because they got a much stronger meal eating culture.
They've been slower to adopt a snacking grazing. And that explains it.
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.
But truth is, I don't think we've got any high quality evidence which says, Haha, this is what's happened.
It may be that societies are different, but if you want to look at specific policies,
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?
Probably. The one where we can do most of the comparisons would be things like sugary drinks,
taxes or levies, and they've been applied in slightly different ways in different places.
But consistently, wherever they have been introduced, they've been actually remarkably effective.
So that seems to cross cultures and cross cross boundaries.
But I'm just not sure we really know. But I doubt it's that different in European countries or indeed high income countries.
I totally acknowledge the situation is different in other parts of the world,
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.
Of course, the country is kind of a related question.
I was just wondering how much of any investigation had been done into culture and the importance of emotion and
kind of history of the country and traditions in terms of convincing people to move and change their diets.
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.
So yeah, I am just going to refer you to others and I can put you in contact with them later.
I think that's probably the best plan. But culture is clearly clearly important.
The way we eat is socially and culturally grounded.
And and what people value, you know, is part of of the way they've been brought up and so on.
So I'm sure it's tremendously important, but I can't tell you the research base.
I wonder if you could help me, at least by giving as an indication of the degree of reduction necessary in calories fat
intake to get down to an appropriate level of obesity in society from a health point of view.
And second, if I may follow that up.
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?
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.
It's got a lot of fat in it, too. So I don't think this is just about sugar.
I think this is about calories, it's about too many calories. And that's, you know, sugar provides 15 percent of our calories.
So we're eating too much of a lot of other things as well.
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,
but maybe 20, five to 15, there was a government committee showed that on average that came down to about 25 calories a day.
But of course, weight gain is not average across across the population, nor day by day.
But the point is that population level weight gain is a very, very small error.
And that's why many of these measures actually could be could be very effective.
If, however, you are already overweight and you're trying to get down to a lower body weight,
you're going to have to eat significantly fewer calories.
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.
So, you know, those are the kind of energetics of it.
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.
I think what we've learnt is trying to think, trying to reduce it down to that,
that that currency actually hasn't been awfully helpful in making progress just very quickly
is just a very thoughtful about how you said 15 percent of calorie intake comes from sugar.
Yeah.
And that sounds from what you were just saying that that significantly changing certain sugar consumption would be sufficient over the long term.
To radically change your piece. Sure. So, so a policy which said trying to get that down to 10 percent.
Well, the policy is to get it down to five percent.
Well, the policy, the recommendation, the dietary recommendation is that we should have five percent of our calories from sugar.
But, you know, recommendations don't in and of themselves actually change what happens.
We need we need to introduce policies which actually will make that make that plausible.
But you know, yes, that would work. I'm totally signed up to that.
But I also think we we started to look at obesity through a sugar lens,
and that actually isn't awfully helpful because there are lots of interventions to not particularly around.
It's just people eating too much. Question right at the back with the James and then gentleman in front of the white shirt.
Thanks very much.
What do we know about what sort of interventions at the individual level, the policy level industry level would reduce meat consumption.
And it's your intuition. If there isn't much evidence yet, it would be not dissimilar from interventions to reduce sugar.
So both of those so we one of another of my DPhil students, Filippo Bianche,
has published two systematic reviews which look at the extant evidence on interventions specifically to reduce meat consumption.
There aren't that many, and they're relatively small, and they're often relatively poor quality.
But what is absolutely interesting is the most effective things.
Actually, all the same behavioural mechanisms, the same kinds of policy tools as we see to change dietary behaviour in other areas.
So price is extraordinarily effective. Portion size is very effective at changing the availability.
So just as I showed, if you have a lower calorie option, more lower calorie options than people consume fewer calories.
So if you have more plant based options and fewer animal based options, people eat less meat.
So the behavioural mechanisms which shape what people end up choosing actually appeared to be very, very similar across the team.
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,
but knowing the large numbers of adults and children don't do the recommended amount of activity your exercise per week.
Do you think exercise is encouraging? Exercise has a role to play, if any.
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.
Most of us eat too much, and most of us do less activity than is good for our health.
Both of those would help control weight, but they would also have independent health benefits.
You know, high quality diets, good. Whatever your weight, more physical activities, good.
Whatever your weight, it's totally, totally signed up to that.
But it's not either all. And so you know, what we need is interventions which will help people to be more physically active.
And I can't really give you the detail on the evidence base for that.
It strikes me that one of the most difficult things around the public health of
obesity is you want to raise the awareness of the health harms of being overweight.
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.
How to navigate that really difficult path between the two?
Well, what you do is you appoint a really good sociologist and hope that she'll solve it for you,
which is what we've just done and delighted that Cindy Spratt has just just joined us.
So I think part of that? Well, firstly, we absolutely need to recognise that people with obesity are, you know,
there's appalling discrimination, appalling stigma, and they extremely badly treated.
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.
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.
But all the evidence tells us that Patently does not happen. We've spent decades, you know, a stigmatising.
And it's not helped one bit. In fact, what the research evidence tells us is it makes things worse.
And it's only when people feel confident in control and boost their self-esteem that they
better able to manage the cognitive effort that it takes in this world to manage your weight.
So I think that's one aspect of it is that we just got to recognise people will do better with support.
The second is that, you know, there is a bit of a sort of policy view that this is a lot about individual responsibility.
People ought to take more responsibility for their actions. And as I said, to underestimate the importance of the food environment,
if we start understanding that actually the environment which is making it really hard for all of us,
I think you then start to depersonalise this issue.
And if people who are struggling with their weight have almost certainly got underlying susceptibility,
some vulnerabilities to this adverse world, which I am fortunate not to have.
And in every other case, if we have individuals who are particularly vulnerable,
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.
And yet, for some reason, when it comes to weight, we just become, I don't know,
we seem to lose all compassion and I don't know what's going on there.
Thank you. Lady there in the pale orange.
And thanks for your talk, I thought I was really interested in your your work or your theme student,
Lawrenceburg, about the impact of the sugar tax on the sugar content of soft drinks.
And I wondered whether that sugar has replaced has been replaced by artificial sweeteners
and whether you are concerned about whether there might be unintended consequences of that.
So I should say there's a big evaluation of the sugar drink industry levy, which is is underway at the moment.
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,
looking at what companies have done. And it chimes very much with Public Health England.
So an analysis of what's happened, how have they achieved it?
Yes, by most mostly by using non-nutritive sweeteners,
that is absolutely the case so that it's maintained the sweetness of the product, but without the calories.
All of the evidence tells us that that is helpful in terms of weight, fewer calories.
You get better if you look at the trials.
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.
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.
What people worry about, I think, is that it maintains a preference for sweetness, and that is probably true and I share that concern.
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,
then you get used to it. I presume that's because your taste threshold, your sugar threshold has gone down,
whereas if you put artificial sweeteners in, of course, you maintain it at that higher level.
So I would absolutely say that the best thing is not to have sugary drinks on tap water.
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?
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.
You know, moving to these diet drinks, which is still bad for your teeth, I should say,
but much, much less harmful for your weight is at least a harm reduction strategy.
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.
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.
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,
and that we up there delight in a fresh strawberry in a way which which we seem to have lost.
OK, a final question at the back there. The gentleman that they lack.
Thank you. And Susan, you mentioned prices effective and you mentioned them redirect subsidies to unprocessed food.
I'm just curious how are processed food currently subsidised and how would you change that?
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?
Or what's the mechanism here? Well, there's a whole at the moment,
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.
What we ought to be doing is putting them into foods we want people to eat more of.
So for example, if we want more horticulture and let's take the U.K. more horticulture in the U.K.,
producing more fruits and vegetables, actually, that is a very costly set up for for farmers.
And so we'll might want to incentivise them in some way to do that.
But, you know, I haven't, I'm not sure economist. I haven't begun to touch on how the money flows would work.
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,
and it would be better redirected elsewhere. I got abused my position by asking one final question.
So it's December the 12th we failed to elect a government.
We're looking round and we put you as minister of health.
You have a compliant parliament. What are the three things you would introduce and bring in as your priority?
Well, I would have a cabinet committee on food because health picks up the the the the health problems caused by food,
but it has very, very few of the levers to change it.
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.
So I'd like a bigger, better job. I think that that's incredibly good.
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.
I think that's an easy win and I just cannot see any other ways that we're going to reduce confectionery.
And I would take action to control promotions and advertising because I think that's incredibly pernicious influence on people's food choices.
And although people, you know, people I guess, want some some autonomy and advertising marketing is really taking that away from them.
So I think promotions are are really fuelling at least the overconsumption element.
Generally, the overconsumption on less healthy foods. But yeah, I'll write my manifesto and then I'll send it sandy.
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,
mostly laser on plant genetics from Mendel to Monsanto?
It will be an absolutely fabulous talk. After having heard Susan this afternoon,
you will understand why she is probably the most influential person in this country for affecting policy on on diets and things.
And so please do join me for thanking her for a wonderful talk. That's partly because.