“It shouldn’t have taken a global pandemic to make us pay proper attention to dietary inequality. It has long been visible to the naked eye. A modern diet of cheap junk food has the peculiar quality that it can make you simultaneously overweight and poorly nourished.”
So states the National Food Strategy, a recently published independent review for the British government of national food policy – or of what a national food policy might look like. A key focus is inequality, or unfairness. Whether the government is likely to accept the recommendations of the report it has commissioned seems sadly in doubt – the knee-jerk negative anti-tax response to its first recommendation, for taxes to be raised on sugar and salt, suggests a lack of willingness to listen thoughtfully to the arguments that are made.
The independent review was led by Henry Dimbleby, a co-founder of healthy eatery chain Leon. If Dimbleby’s passion for the subject wasn’t clear from that heritage, it comes across clearly in the report, and dynamically in an interview for BBC Radio 4’s Food Programme. There, he urges a change in culture that will deliver a food system that is “designed to deliver health and nature and happiness and love and care”.
As he summarises the report, it is seeking to encourage two things: over time to change way people think about the food system, and to promote several things that the government can do now to start that change. The four things the govt needs to do now, Dimbleby argues, are:
- Break the junk food cycle: “exercise, education and willpower alone is not going to change diets”.
- Reduce health inequalities: “We need to focus particularly on the poor. People who are poorest have the worst diets and by far the worst health outcomes.”
- Farming transition to use the land better. “For a long time now…we have really just used the land for food. We now need to use it to restore biodiversity, to sequester carbon, to produce energy and to produce food.”
- Change food culture in the long-term, including changing the way government operates.
This is actually the second National Food Strategy report. The government’s reception for the interim one last year, which urged that the lessons of the Covid-19 pandemic be learned, is not encouraging. There were seven recommendations in that Part One report. The government seemed to ignore most, including those on ensuring trade protections for agricultural standards and the extension of free school meals. That hasn’t stopped DImbleby and the group repeating those calls in the Strategy’s final 14 recommendations.
Naturally, this blog focuses on the recommendations regarding efforts to reduce diet-related inequality (though there is much to commend in the wider report). The report summarises that inequality:
“Children from the least well-off 20% of families consume around 29% less fruits and vegetables, 75% less oily fish, and 17% less fibre per day than children from the most well off 20%.”
But it is the consequences of that inequality that are if anything still more stark (both in graphic form and in the text that explains it):
“People living in the most deprived decile are almost twice as likely to die from all preventable causes, compared to those in the richest decile. They are 2.1 times more likely to die from preventable heart disease; 1.7 times more likely to die from preventable cancer; and 3 times more likely to have tooth decay at age 5. Their children are nearly twice as likely to be overweight or obese at age 11.” Covid [CVD on the chart] mortality is double amongst those from the most deprived areas.
Recognising that many of these harms are built in from childhood, four of the 14 overall recommendations are purely focused on delivering change during schooling:
Recommendation 3. Launch a new “Eat and Learn” initiative for schools
Recommendation 4. Extend eligibility for free school meals
Recommendation 5. Fund the Holiday Activities and Food programme for the next three years
Recommendation 6. Expand the Healthy Start scheme
The upfront costs of these would be funded from the proposed tax on sugar and salt which is the report’s first recommendation (which, it says, will raise significant revenues as well as inevitably driving positive reformulations of processed food products). In the long-term, the expectation is that these changes would more than pay for themselves through reduced healthcare costs. It accepts a need to provide additional support for the poorest because the report concludes that eating well is difficult for the poor. Healthy diets are regressive, in the sense that healthy food “is more expensive per calorie than unhealthy food (especially when you factor in the opportunity cost and difficulty of cooking from scratch)”. Hence the need for the state to lean against this burden.
This focus on the issues in childhood makes sense according to global analysis of deprivation. “[C]hildren are hardest hit by poverty. Deprivation causes life-long damage to the mind and body of infants and small children. Child development, especially in the first years in life, is a succession of biological developments for which there is seldom a second chance. Infant malnutrition, for instance, leads to irreversible damage to health. It impedes the learning capacity of the child, which cannot be repaired later in life,” states Unicef in Equity begins with Children, a study on poverty and childhood. It is also likely that failing to address poverty will perpetuate it to the next generation: “Investing in children is a prerequisite for breaking the poverty cycle.” And it is good economics: “No country has ever sustained economic growth on the basis of high levels of illiteracy, widespread malnutrition and rampant morbidity.” The National Food Strategy’s charts on childhood height, where the UK average sits well below those of other developed economies, shames us – and should shame us into action.
But the Strategy does not focus solely on children. In particular, recommendation 7 would have a broad application across deprived communities. This recommendation calls for a trial “Community Eatwell” programme, supporting those on low incomes to improve their diets. Among other elements of this is a proposal to adopt ‘social prescription’ whereby GPs could prescribe fresh fruit and vegetables rather than drugs, as well as building knowledge to put that fresh food to good use. It notes success in a trial of such a programme in Washington DC. The problem is not a small one:
“While almost everyone in the UK eats too little fruit and vegetables, the problem is particularly acute among the most disadvantaged. The poorest 10% of British people eat on average 42% less fruit and vegetables than recommended, while the richest eat 13% less.”
The report quotes 2019 figures that diets low in fresh fruit accounted for over 10,000 early deaths, and a further 200,000 years of reduced life expectancy (on a disability adjusted basis); diets low in fresh vegetables had impacts that were around half each of these numbers (based on Global Health Data Exchange analysis).
To those who argue that this sounds like the nanny state intervening in how people live their lives, Dimbleby is clear: the costs to the state are substantial of not intervening, and at present it is much harder for the poor to eat well than to eat badly. Unhealthy calories are cheaper, which may be the decisive factor for those with hungry mouths to feed on a small budget. And simple practicalities like time and accessibility of quality food shopping weigh against healthier decisions. A wise state would assist its people more, to save state healthcare costs in the long-run – and if that happens to be described as nanny statism, I suspect Dimbleby would accept that.
The opportunity from this is clear – or perhaps what is more clear is the opportunity cost of not taking these steps. Poor diets build up problems for later life and are one of the major drivers of poor health in older age. An excellent recent paper The Cost of Inequality – putting a price on health from the thoughtful people at CSFI tries to identify the fiscal drag from poor health outcomes in older age, highlighting the discrepancies in the experience of old age between different parts of the UK. It notes that the end of life is usually preceded by years of poor health, but before that there are healthy years after work (what the report calls inactive healthy years). The date boundaries between these and working life are highly variable across the country, dependent on relative poverty and other factors, as this chart shows:
The report states that: “a one-year extension in healthy life expectancy would add around 3.4 months to working lives and 4.5 months to overall life expectancy”. That is a wonderful gain, but it also brings a clear fiscal dividend as well: this “could reduce income taxes by 0.6 percentage points based on current data and policies”.
If there is to be levelling up, it is these sorts of discrepancies that need to be thought of. The epidemic of poor health associated with poverty and poor diet needs to be a core element of any such approach. These ideas deserve to be taken seriously, for the health of our economy as well as our health.
Plate of the Nation: Second Serving, the Food Programme, Radio 4, July 18 2021
Equity begins with Children, Jan Vandemoortele, Unicef Social and Economic Policy Working Paper 1201, 2012
The Cost of Inequality – putting a price on health, Les Mayhew, Centre for the Study of Financial Innovation, July 2021