Proposals to Improve the Out of Home Environment in Scotland Feb 2019
2nd March 2019
Statement submitted from Prof Bob Steele and Prof Annie S. Anderson, Co-directors of the SCPN
The Scottish Cancer Prevention Network (SCPN) is focused on moving evidence on cancer risk reduction into everyday life, practice and policy (https://www.cancerpreventionscotland.org.uk/). Whilst it is recognised that governments do much to support changing behaviours we also recognise that there is a need to increase capacity around cancer prevention and screening, and there is much more that agencies and government work streams can do to help to accelerate change. As an advocacy group we raise the profile of cancer prevention and screening research and action through a range of communication channels (newsletter, conference, workshops, social media and web-based activities) and support ongoing work in reducing the prevalence of cancer risk factors. The SCPN is funded by the Scottish Cancer Foundation charity (SCO28300).
Current evidence suggests that poor diet and obesity account for around 25% of all cancers. In addition emerging evidence shows that a 10% increase in the proportion of ultra-processed foods in the diet is associated with a significant increase of overall and breast cancer mortality; https://www.bmj.com/content/bmj/360/bmj.k322.full.pdf, https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2723626.
Furthermore, a recent review reported a positive relationship between consumption of ultra-processed food and body fat during childhood and adolescence https://www.cambridge.org/core/services/aop-cambridge-core/content/view/49F56538F32B05C3526E1C5523910A9A/S1368980017001331a.pdf/consumption_of_ultrapro
, which in turn is associated with greater risk of adult obesity and increased risk of 13 cancers. https://www.nejm.org/doi/10.1056/NEJMsr1606602?url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub%3Dwww.ncbi.nlm.nih.gov
These findings are particularly relevant for this consultation on the Out of Home Food Environment given the high volume of ultra-processed available for purchase out with the home.
1 Do you agree that the businesses listed above should be included within an Out of Home strategy for Scotland?
If no, please explain.:
We agree that an Out of Home Strategy should include all of the above but there are other settings that need to be included if we truly want to change normative beliefs and behaviours. These include charity bake sales and other fund raising activities and free food samples frequently given out on high streets/shopping malls/railways stations etc. Efforts to turn around the current ethos of excess towards moderation and positive health behaviours (this is not about banning cake sales!!) needs engagement from all sectors including voluntary/third sector agencies.
It is also important to see leadership in this arena from public sector worksites including National Government.
Addressing excess calories
2 Which of the following measures should be taken to reduce excessive calorie contents of food and drinks eaten outside the home?
reducing portion sizes, changing recipes e.g. by reducing fats and sugars and increasing fruit/vegetable/bean/pulses and fibre content, applying maximum calorie limits, ensuring single serve packs are available as an alternative to packs containing multiple servings, excluding very high calorie menu items, Other
If other, please specify. :
There is no single action that has been demonstrated to decrease our total caloric intake or achieve dietary balance and it is clear a wide range of activities are needed.
Please explain your answer/s.:
Reducing portion sizes is commendable but we need to ensure this embraces all three aspects of portion sizes e.g ensuring the “normal” portion is smaller than it currently is, increasing availability of a “small” portion size, and capping a maximum portion size for “large/super” sizes.
It is important that this work is not aimed at increasing the range of portion sizes which, in the past, has led to both smaller AND giant versions (e.g. the triple Bounty). Action must be aimed at decreasing all portion offerings. These actions also raise questions about value for money and ways to gain consumer support for such actions. Clearly small portions need to offer the same value as larger ones.
Changing recipes is a small part of action that might be taken to increase intake of wholegrains, legumes, vegetables and fruits. These are key dietary items that need to be increased to meet the Scottish Dietary Goals, https://www2.gov.scot/Resource/0049/00497558.pdf, and recommendations for cancer prevention from the World Cancer Research Fund, https://www.wcrf-uk.org/uk/preventing-cancer/cancer-prevention-recommendations/enjoy-more-grains-veg-fruit-and-beans.
It is important to ensure recipes/meal options/meal deals offer a decrease in calories so that the overall energy density of the item/s are decreased. Simply adding a piece of fruit or portion of veg to an existing meal will add increasing calories. Care should be given not just to consider sugar and fat but other dietary constituents of concern in the Scottish diet. Substituting any/all processed meats and some red meat with legumes offer not only a decrease in calories but also reductions in exposure to carcinogens that fit designs for sustainable food systems https://www.thelancet.com/commissions/EAT.
Despite SACN recommendations to increase dietary fibre intake (whilst decreasing sugar intake) there is little evidence of any action on this goal within the out of home sector. Current evidence is clear that higher dietary fibre is associated with lower risk of cardio-metabolic disease and colorectal cancer https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/445503/SACN_Carbohydrates_and_Health.pdf. Recent review level evidence also demonstrates that higher fibre intakes are associated with lower body weight https://www.ncbi.nlm.nih.gov/pubmed/30638909.
Wholegrain foods rich in dietary fibre can also decrease energy density and these dietary items should be considered in addition to fruits, vegetables and legumes. It would be useful to see any out of home food strategy embracing positive actions on each of these dietary constituents as a way to reduce total energy density.
Maximum calorie limits
In 2006, Lean et al https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1702473/
suggested in the British Medical Journal that warning labels should be used if meals/snacks were >700 kcals or >250 kcals, respectively. This approach should be reviewed.
In the (English) Change for Life programme guidance https://www.nhs.uk/change4life/food-facts/healthier-snacks-for-kids/100-calorie-snacks is provided on 100 calorie snacks. Few of these options are available in out of home outlets and most are highlighted for children! An out of home strategy that ensures every outlet currently selling snacks has competitively priced snacks of <100 cal could be usefully tested.
Maximum energy density: it might not be advantageous to cap this given that some foods such as oil rich fish and nuts provide a desirable source of nutrients in addition to calories.
Provision of small or half portions
3 Do you agree that consumers should routinely have easy access to small or half portions?
Please explain your answer:
The concept of smaller portion for adults has been widely used in outlets that cater for elderly adults with smaller appetites and provide a welcome opportunity to discreetly acquire portion sizes appropriate to caloric needs. It is likely that appropriate marketing and promotions of such portion sizes will be required to increase acceptability. Recent work from the North of England in fish and chip outlets illustrate that co-production of interventions to decrease portion sizes are feasible and acceptable to consumers and may be sustainable in the longer term https://www.ncbi.nlm.nih.gov/pubmed/30782880.
Value for money considerations need to be carefully considered.
Calorie labelling at the point of choice
4 Should calorie labelling at the point of choice* apply in Scotland?
Please explain your answer:
A recent review by Crockett et al https://www.ncbi.nlm.nih.gov/pubmed/29482264 (evidence graded low quality) indicates that calorie labelling in restaurants may reduce energy purchased although it is clear that further research is required in this area notably in relation to socio-demographic position. Calorie labelling has the potential to enhance knowledge and contribute to personal action to select appropriate food choices and should be supported. However, as a single action there is little evidence that it will achieve the degree of action required to reduce calorie intake and may be less well utilised by consumers with low literacy, visual impairments and limited cognitive skills e.g. some of our most vulnerable population groups. Serious consideration should be given to maximising communication through colour coding (in addition to numerical values) and consumer research with vulnerable groups.
Calorie labelling may also help to drive reformulation although the impact of this should be carefully monitored.
5 As a food business, would MenuCal help you to provide calorie labelling?
6 As a food business, what additional support would you require to provide calorie labelling?
Mandatory or voluntary calorie labelling at the point of choice
7 Should calorie labelling at point of choice be made mandatory in Scotland?
Please explain your answer. :
As we have the knowledge to provide caloric information on foods and drinks (including alcoholic beverages) we see no reason why this should be concealed from consumers. Mandatory action creates a level playing field across all business domains.
8 Should any business be exempt from mandatory calorie labelling at the point of choice?
If yes, which types of business should be exempt and why?:
It is likely that smaller enterprises may need greater support to provide information and should be eligible for assistance from government.
Full nutrition information for consumers
9 Where nutrition information is provided online and on printed materials should it be standardised in the way set out in the table above?
Please explain your answer. :
The format looks appropriate except that the total weight of the food in the package needs to be VERY CLEARLY provided. It is misleading to provide the calorie values per portion if the package contains more than one portion. A desirable portion and the portion size provided may differ considerably. A simple colour coded regimen (e.g. traffic light system) for front of pack/web/menu board use is highly desirable.
10 Where nutrition information is provided online or on printed materials, should it be mandatory that it is standardised in the way set out in the table above?
Please explain your answer. :
Promotion and marketing
11 Which actions would change promotion and marketing practices to support healthier eating outside the home?
Businesses dropping practices that encourage over consumption, businesses positively marketing and promoting healthier choices, raising consumer awareness through the use of social marketing campaigns, Other
If other, please specify. : Please explain your answer/s.:
All of the above are appropriate. However opportunities to promote increased consumption of foods which are highlighted in our dietary goals should not be missed including wholegrains, pulses, vegetables and fruits, providing such marketing is not used to promote less healthful products by stealth (e.g. deep-fried wholegrain products).
Social marketing campaigns might best be run in conjunction with other credible agencies including the third sector.
Food provided in the vicinity of schools
12 What types of actions could be taken to improve the food provided Out of Home in the vicinity of schools?This challenge must be addressed by local authority planning regulations. A review of the number, trends, content and marketing of foodstuffs around schools should be a core part of food and health monitoring programmes. It makes little sense to ignore the growing number of food outlets which re-enforce the public opportunity to access energy dense foods.
Children eating Out of Home
13 Which of the following should be changed to improve food provided for children:
Less reliance on menus specifically for children, Provision of children’s portions from adult menu items, Increased use of vegetables and fruit in dishes, sides and desserts, Reduced reliance on breaded/fried products, Reduced reliance on chips, Plain water and milk offered as standard options, Reduction of drinks with added sugar, Reduction of high sugar dessert options, Reduction of confectionery and crisps
If other, please specify. : Please explain your answer/s:
It is timely to explore why children’s menus are needed at all (beyond portion size considerations). Such menus serve to create consumer demand for the least nutritious food from the most vulnerable group in our society.
The use of crisps as part of children’s meals is particularly unnecessary with many parents commenting on how these are eaten before other meal components (e.g. sandwich) and often result in wastage of other foods.
Increased availability of low calorie dessert are needed. Importantly these should take account of sugar AND fat content.
14 Do you agree that recognition schemes are an effective means of supporting healthier eating in the Out of Home sector?
If yes, please outline your views on the key components required for a flexible recognition scheme(s):
There is clear potential for recognition schemes to assist movement towards healthier options. However, it is NOT clear how far the Healthy Living Award has contributed to improving healthier options and decreasing less healthy options. An evaluation of this system is long overdue.
Likewise, the very welcome HRS within the NHS seems to suffer from inadequate monitoring and regular reporting.
Both examples of these schemes suggest that the worst excesses may be addressed but fail to offer and promote wholegrains, pulses, vegetables and fruit. In addition, half-hearted catering and retail staff fail to endorse efforts.
We have developed a healthy meetings scorecard https://www.cancerpreventionscotland.org.uk/healthy-meetings/ which has been widely used as a recognition scheme within the conference world but less so in the worksite. It has become clear that efforts are greatest where champions take this work forward. There might be considerable merit in exploring this approach with any recognition scheme.
If no, what other approaches would enable businesses to make the changes needed?:
The public sector as an exemplar
15 Do you agree that the following actions should be adopted by the public sector?
Please explain your answer.:
See response to question 2 above.
Fundamentally, the balance of high energy dense foods to low energy dense foods needs to alter. If portion sizes change but the number of high energy options remain the same then we will continue to promote a culture where high fat and high sugar options remain the norm. We should seek to address this balance and need exemplars to lead the way. Demand for vegetarian and vegan options, and public concern about high sugar foods have never been higher. With careful management this support could be utilised to help turn around many menu choices to offer less calories, greater plant based options and better overall balance of foods.
16 Would the proposals outlined in this consultation impact on the people of Scotland with respect to:
Please explain your answer, considering both potentially positive and negative impacts, supported by evidence, and, if applicable, advise on any mitigating actions we should take.:
See comments above (question 4) re calorie labelling and considerations re colour coding