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Force-fed Doesthefoodsystemconstricthealthychoicesfortypical Britishfamilies? Methods Introduction:Ourtypicalfamily Our‘typical’familyisamiddle-incomehouseholdwithchildrenlivinginEngland.Middle-income householdsaredefinedasthosewithanequivalisedhouseholdincomethatfallswithinthe3rd quintileforequivalisedhouseholdincomeintheFamilyResourcesSurveyfortherelevantyear (DepartmentforWorkandPensions,2013).Equivalisationtakesintoaccountvariationsinthesize andcompositionofhouseholds,reflectingthefactthatafamilyofseveralpeopleneedsahigher incomethanasingleindividualsotheycanenjoyacomparablestandardofliving1.In2013, householdsinthethirdquintilehadanequivalisedgrosshouseholdincomeofbetween£24,388and £34,268.Forafamilycomposedoftwoadultsandtwochildren,onechildunder14yearsofageand onechildaged14yearsorover,thisequatestoagrosshouseholdincomeofbetween£37,000and £52,000. Althoughwemostlyreportresultsformiddle-incomehouseholds,estimatesforthetotalpopulation havebeenusedwhereincomedatahasnotbeenavailable.Wherepossible,anydemographic differences(e.g.byincomeorregion)havealsobeennoted. Chapter1:dietaryintakes Datasourceandpopulation UKNationalDietandNutritionSurveyRollingProgramme(2008–2012) DatafromtheUKNationalDietandNutritionSurvey(NDNS)RollingProgramme(Waves1–4 (2008/2009to2011/2012)wasusedtoexaminedietaryintakesforeachofourfamilymembers (NatCenSocialResearch,etal.,2015a).TheNDNSisarollingprogrammethataimstoprovide comprehensive,cross-sectionalinformationonthedietaryhabitsandnutritionalstatusof individualsagedone-and-a-halfyearsandolderlivinginprivatehouseholdsintheUK.Amultistage probabilitysamplingdesignisusedtocollectarandomsampleofprimarysamplingunits(PSUs). WithinthesePSUs,privateaddressesarerandomlyselectedforinclusion.Uptooneadultandone childperhouseholdarerandomlyselectedtotakepartinthesurvey. Interviewerscollectinformationonsocio-demographics,andshopping,cookingandeatinghabits, andparticipantsalsocompleteafour-dayfooddiary.Forchildrenaged11yearsandyounger, parentsorcarerscompletethefour-dayfooddiary.Aspartofthesurvey,anursetakes anthropometricandbloodpressuremeasurements,andcollectsbloodsamplesforlaboratory analyses.Bloodsampleanalysestestfornutritional,routinemetabolicandcardiovascularoutcomes. MoreinformationontheNDNSmethodologycanbefoundelsewhere(Bates,etal.,2014). TheNDNSalsoincludesresultsfromaseriesof24-hoururinarysodiumsurveysconductedon representativesamplesoftheUK.Saltintakecanbemeasuredusingurinarysodiumexcretion, 1 https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/432843/hbai-low-incomehow-is-it-measured-infographic.pdf 2 whichreflectsanindividual’ssodiumintake.Moreinformationontheurinarysodiumsurveyscanbe foundelsewhere(Sadler,etal.,2011). Nutritionaloutcomes 1.ProportionoffamilymembersmeetingUKdietandnutritionrecommendations TheproportionoffamilymemberswithmeandailyintakesmeetingUKdietaryreferencevalues (DRVs)forspecificmacronutrientsandfoodgroupsoutlinedinTables1–2wereobtained. Adequacyofmicronutrientintakeswasdeterminedbycalculatingtheproportionoffamilymembers withintakesbelowlowerreferencenutrientintakes(LRNIs)forkeymicronutrients(seetables5.14 and5.32inNationalDietandNutritionSurvey:ResultsfromYears1–4(combined)oftheRolling Programme(2008/2009–2011/2012)formicronutrientLRNIsandRNIs(Bates,etal.,2014).Thedata arenotshownbutarereferredtointhenarrativereport. Table1:Dietaryreferencevaluesforkeymacronutrients Macronutrient Recommendation Totalfat Populationaveragenomorethan35%offoodenergyfor individualsaged5yearsandabove. Saturatedfattyacids Populationaveragenomorethan11%offoodenergyfor individualsaged5yearsandabove. Transfattyacids Populationaveragenomorethan2%offoodenergy. 2 Freesugars Populationaveragenomorethan5%ofdailyenergyfromfoodand drinkforallages. 3 AOACfibre Populationaverageofatleast30g/dayforadults;15g/dayfor childrenaged2–5years;20g/dayforchildrenaged5–11years; 25g/dayforchildrenaged11–16years;and30g/dayforadolescents aged16–18years. Salt Maximumintakeof6g/dayforindividualsaged11yearsandabove; 5g/dayforchildrenaged7–10years;3g/dayforchildrenaged4–6 years. 2 Freesugars’includesallmonosaccharidesanddisaccharidesaddedtofoodsbythemanufacturer,cookor consumer,plussugarsnaturallypresentinhoney,syrupsandunsweetenedfruitjuices.TheNDNSdoesnot containaderivedvariableforfreesugars,onlynon-milkextrinsicsugars(NMES).NMESincludesstewed, cannedanddriedfruitwhereasthefreesugarsclassificationdoesnot.Therefore,NMESareusedbutmay resultinaslightoverestimateoffreesugarintake. 3 LatestrecommendationsforfibreareforAOACfibre.TheNDNSonlycontainsestimatesforNon-Starch Polysaccharides(Englystmethod)sothesevalueswereadjustedby1.33asper https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/404094/ERG_eatwell_mode lling_update_paper_final.pdf 3 Table2:UKrecommendationsforconsumptionoffruitandvegetables,redandprocessedmeat,and oilyfish Foodgroup Recommendation Fruitandvegetables Atleastfiveportionsperdayforchildrenaged11yearsand above.Oneportionisapproximatelyequivalenttoaservingof 80g. Redandprocessedmeat Nomorethan70g/dayforadults. (Includesbeef,lamb,pork, sausages,burgersandkebabs, offal,processedredmeatand redmeat) Oilyfish Atleastoneportionperweekforadultsandchildren(140g). (Includesanchovies,carp,trout, mackerel,herring,jackfish, pilchards,freshandcanned salmon,sardines,sprats, swordfish,freshtunaand whitebait) 2.Dietarysaltintakes Estimatesfordailydietaryconsumptionofsaltforeachfamilymemberandtheproportionof individualsconsumingmorethantheUKrecommendationsfordietarysaltintake(Table3)were calculatedfromthe24-hoururinarysodiumexcretiondatausingtheequation:17.1mmolofsodium excreted=1gofsaltconsumed.Thisassumesthatthedietaryintakeofsodiumisequaltothe urinaryoutput,andthatallsodiuminthedietcomesfromsalt.Resultsforestimateddailysalt intakesarebasedon24-hoururinecollectionsthatwereclassifiedascomplete. Table3:UKrecommendationsfordietarysaltintake Agegroup Recommendedmaximumsaltintake 4–6years 3g/day 7–10years 11–18years 19–64years 5g/day 6g/day 6g/day Urinecollectionsforadultsaged19to64yearswereclassifiedas‘complete’or ‘incomplete/unreliable’byeitheroftwocriteria:‘completebyPABA’,wheretheparticipanthas reportedtakingthreePABAtabletsandtheamountofPABArecoveredintheurinecollectionis consistentwithcompleteness;or‘completebyclaim’,whereparticipantsreporttakingfewerthan threePABAtabletsandreportedcollectionofallurinepassedduring23to25hours,jointlyreferred toas‘standardcriteria’.Forparticipantsaged11to65yearsandover,onlyresultsofurine collectionsclassifiedascompletebythesecriteriaareincludedinthenarrativereport.Childrenaged fourto10yearsaremorelikelytohavedifficultyswallowingtabletsthanolderparticipants,so compliancewiththePABAprotocolislikelytobepoorerinthisagegroup,particularlyatthe 4 youngerendoftheagerange.Therefore,forchildrenagedfourto10years,wealsousedan alternativechildcriterionwherecollectionswereregardedas‘complete’whentheywereclaimedto includeallurinepassedfor23to25hoursfromthestarttimeirrespectiveofPABAexcretion. 3.Proportionofenergyintakefrom‘lesshealthy’and‘morehealthy’foods. NutrientProfiling(NP)GuidancefromtheDepartmentofHealthwasusedtoinvestigatethe proportionofenergyobtainedfrom‘healthy’foodsbasedonanutrientprofilemodeldevelopedby theFoodStandardsAgencyin2004/2005(DepartmentofHealth,2011).Themodelusesascoring systemwherebypointsareallocatedbasedonthenutrientcontentper100gofafoodordrink.‘A’ pointsareawardedforspecificnutrients(energy,saturatedfat,totalsugarandsodium);and‘C’ pointsareawardeddependingonthecontentoffruit,vegetablesandnutsinthefoodordrink.The finalnutrientscoreisderivedbysubtractingthescorefor‘C’nutrientsfromthescorefor‘A’ nutrients. Anyfooditemisconsidered‘lesshealthy’iftheoverallNPscoreis4ormoreandadrinkitemis considered‘lesshealthy’iftheoverallNPscoreis5ormore.Usingthismodel,aNPscorewas calculatedforeachfood/drinkentryintheNDNSdatasetinordertoclassifyitas‘morehealthy’or ‘lesshealthy’.Themeanproportionofdailyenergyconsumptionfrommorehealthy/lesshealthy foodswasthencalculatedforeachfamilymember. 4.Proportionofenergyintake‘ultra-processed’foods WeusedtheNOVAclassificationforprocessedandultra-processedfoodstoclassifyfoodentriesin theNDNSdatasetbasedonthedegreeofprocessing(Monteiro,etal.,2015).Theclassificationcan beusedtogroupfoodentriesintothreemaingroupsandsub-groups(Table4).Group1contains unprocessedfoodsthatareconsumedwithoutfurtherprocessingandpreparation,withthe exceptionofwashing,cuttingandsqueezing.Thesecondgroupcontainsprocessedculinary ingredients,includingplantoils,animalfats,andsugarsorsyrups.Group3containsprocessedfoods, furtherdividedintoprocessedfoodproductsandultra-processedfoods.Aftereachfoodentryinthe NDNSwasclassifiedintooneoftheNOVAgroups,wedeterminedtheproportionofeachofour familymember’sdailyenergyintakethatcamefromfoodsthatwereinGroup3(processedand ultra-processedfoods).Wereportthefindingsforultra-processedfoodsonly. 5 Table4:NOVAClassification Foodgroupsanddefinition Examples 1.Unprocessedandminimallyprocessedfoods Unprocessedfoodsareofplantorigin(leaves,stems,roots, tubers,fruits,nuts,seeds)oranimalorigin(meat,other flesh,tissueandorgans,eggs,milk),shortlyafterharvesting, gathering,slaughterorhusbanding.Minimallyprocessed foodsareunprocessedfoodsalteredinwaysthatdonotadd orintroduceanysubstance,butmayinvolvesubtracting partsofthefoodinwaysthatdonotsignificantlyaffectits use.Minimalprocessesincludecleaning,scrubbingand washing;winnowing,hulling,peeling,grinding,grating, squeezingandflaking;skinning,boning,carving,portioning, scalingandfilleting;drying,skimmingandfatreduction; pasteurisationandsterilising;chilling,refrigeratingand freezing;sealingandbottling(assuch);simplewrapping,and vacuumandgaspacking.Malting,whichaddswater,isa minimalprocess,asisfermenting,whichaddsliving organisms,whenitdoesnotgeneratealcohol. 2.Processedculinaryingredients Processedculinaryingredientsarefoodproductsextracted andpurifiedbyindustryfromconstituentsoffoods,orelse obtainedfromnature,suchassalt.Specificprocesses includepressing,millingandpulverising.Stabilisingor purifyingagentsandotheradditivesmayalsobeused. 3.Ready-to-consumeproducts 3.1.Processedfoodproducts Thesearemanufacturedbyaddingsubstancessuchasoil, sugarorsalttowholefoods,tomakethemdurableand morepalatableandattractive. Theyaredirectlyderivedfromfoodsandrecognisableas versionsoftheoriginalfoods.Theyaregenerallyproduced tobeconsumedaspartofmealsordishes,ormaybeused, togetherwithultra-processedproducts,toreplacefoodbasedfreshlyprepareddishesandmeals.Processesinclude canningandbottlingusingoils,sugarsorsyrups,orsalt;and methodsofpreservationsuchassalting,salt-pickling, smokingandcuring. 3.2.Ultra-processedproducts Theseareformulatedmostlyorentirelyfromsubstances derivedfromfoods,andtypicallycontainlittleornowhole foods.Theyaredurable,convenient,accessible,highlyor ultra-palatable,oftenhabit-forming.Theyaretypicallynot recognisableasversionsoffoods,althoughtheymayimitate theappearance,shapeandsensoryqualitiesoffoods.Many ingredientsarenotavailableinretailoutlets.Some ingredientsaredirectlyderivedfromfoods,suchasoils,fats, flours,starchesandsugar.Othersareobtainedbyfurther processingoffoodconstituents.Numerically,themajorityof theingredientsarepreservatives;stabilisers,emulsifiers, solvents,bindersandbulkers;sweeteners,sensory enhancers,coloursandflavours;andprocessingaidsand otheradditives.Bulkmaycomefromaddedairorwater. Micronutrientsmayfortifytheproducts.Mostultraprocessedproductsaredesignedtobeconsumedby themselvesorincombinationassnacks.Theydisplacefoodbased,freshlyprepareddishesandmeals.Processesinclude hydrogenation,hydrolysis;extruding,mouldingand reshaping;andpre-processingbyfryingorbaking. Fresh,chilled,frozenandvacuum-packed vegetablesandfruits;grains(cereals),includingall typesofrice;fresh,frozenanddriedbeansand otherlegumes(pulses),rootsandtubers;fungi; driedfruitsandfreshlypreparedorpasteurised non-reconstitutedfruitjuices;unsaltednutsand seeds;fresh,dried,chilledandfrozenmeat, poultry,fishandseafood;dried,fresh,pasteurised full-fat,low-fatandskimmedmilk,andfermented milksuchasplainyoghurt;eggs;teas,coffeeand herbalinfusions;tap,filtered,springandmineral water. Plantoils;animalfats;sugarsandsyrups;starches andflours;uncooked‘raw’pastasmadefromflour andwater,salt. 3.1.Processedfoodproducts Cannedorbottledvegetablesandlegumes(pulses) preservedinbrine;peeledorslicedfruits preservedinsyrup;tinnedwholeorpiecesoffish preservedinoil;saltednuts;un-reconstituted processedmeatandfishsuchasham,baconand smokedfish;cheese. 3.2.Ultra-processedproducts Chips(crisps),manytypesofsweet,fattyorsalty snackproducts;ice-cream,chocolates,candies (confectionery);Frenchfries(chips),burgersand hotdogs;poultryandfish‘nuggets’or‘sticks’ (‘fingers’);breads,bunsandcookies(biscuits); breakfastcereals;pastries,cakesandcakemixes; ‘energy’bars;preserves(jams),margarines; desserts;canned,bottled,dehydrated,packaged soupsandnoodles;sauces;meat;yeastextracts; soft,carbonated,colaand‘energy’drinks;sugared, sweetenedmilkdrinks,condensedmilkand sweetenedincluding‘fruit’yoghurts;fruitandfruit ‘nectar’drinks;instantcoffee,cocoadrinks;noalcoholwineandbeer;pre-preparedmeat,fish, vegetable,cheese,pizzaandpastadishes;infant formulas,follow-onmilksandotherbabyproducts; ‘health’and‘slimming’productssuchaspowdered orfortifiedmealanddishsubstitutes. (Adaptedfrom:FoodClassificationSystemsBasedonFoodProcessing:SignificanceandImplicationsforPoliciesandActions:A SystematicLiteratureReviewandAssessment.CurrObesRep.2014,3:256) 6 Analyses TheNDNSdatasetwasobtainedfromtheUKdataservice(UKDataService,2015).Statisticalanalysis wasconductedinStata(versionSE14.0;StataCorporation).Weightsandthe‘svy’surveycommand wereusedwhenconductinganalysestoallowforthecomplexsampledesign.Nutritionintake estimatesarisingfromNDNSdataarereportedformaleandfemaleadults(aged19to64years)and children(agedone-and-a-halftothreefourto10yearsand11to18years)livinginmiddle-income householdsinEngland(n=511).AllanalysesusingNDNSdatawereconductedusingdatafromall foursurveyyears(2008–2012)4. Chapter1:healthconsequences Datasourcesandpopulation HealthSurveyforEngland2013 Dataonhealthoutcomesforeachfamilymemberwereobtainedfromthe2013cross-sectionofthe HealthSurveyforEngland(HSE),anannualsurveyofanationallyrepresentativesampleofthe generalpopulationlivinginhouseholdsinEngland(NatCenSocialResearch,etal.,2015b).TheHSE utilisesamultistagestratifiedprobabilitysamplingdesignwithpostcodesectorsastheprimary samplingunitandthePostcodeAddressFileasthesamplingframeforhouseholds.Interviewersvisit participantstocollectdataondemographicandsocioeconomicindicators,informationonhealth andhealth-relatedbehaviours,andtakeheightandweightmeasurements.Withconsent,nurses visittotakeadditionalmeasurements,collectbiologicalsamplesandrecordinformationon medicationuse.DetailedinformationontheHSEmethodsandresultscanbefoundelsewhere Children’sDentalHealthSurvey2013 The2013Children’sDentalHealth(CDH)Surveyisaseriesofnationalchildren’sdentalhealth surveysthathavebeencarriedoutevery10yearssince1973(Health&SocialCareInformation Centre,2013).TheCDHsurvey2013usedaclustered,stratified,multistagedesigntorandomly selectarepresentativesampleofchildrenagedfive,eight,12and15yearsattendingstateand independentschoolsacrossEngland,WalesandNorthernIreland.Thesampleincludedacademies andfreeschoolsinEngland,butexcludedspecialschools. DatawascollectedthroughadentalexaminationcarriedoutbyNHSqualifieddentistsandnurses,a self-completionquestionnairecompletedby12-and15-year-olds,andaparentalself-completion questionnaire.Thesurveyprovidesinformationonclinicalindicatorsoforalhealth,reported perceptionsoforalhealth,andbehavioursanddentalserviceusagepatternscapturedfromthe parentalandpupilquestionnaires.Atotalof13,628childrenweresampled.Dentalexaminations werecarriedouton9,866children.Responseratesvariedbyagecohort:70%infive-year-olds;65% ineight-year-olds,83%in12-year-oldsand74%in15-year-olds.Theresponseratefortheselfcompletionquestionnairechildrenaged12and15yearswhoagreedtoadentalexaminationwas 99.6%.Theoverallresponseratefortheparentalquestionnairewas43%.Furtherinformationonthe 4 AllyearsoftheNDNSrollingprogrammewereusedtoincreasesamplesize. 7 CDHsurveydesignandresultscanbefoundelsewhere(Health&SocialCareInformationCentre, ChildDentalHealthSurvey2013,England,WalesandNorthernIreland,2013). Healthoutcomes Overweight/obesity TheHealthSurveyforEngland(2013)containsinformationonanthropometricmeasurements:the interviewertookheightandweight,andthenursetookwaistmeasurements.Thisdatawasusedto determineratesforoverweightandobesityforadultsandchildrenlivinginmiddle-income householdsinEngland5. Diabetes TheHSE2013collectedinformationonself-reporteddoctor-diagnoseddiabetes.Objectiveblood measurementsofhighbloodsugarlevelsforadultsaged16yearsandoverarealsotaken.TheHSE interviewmakesnodistinctionbetweenType1andType2diabetesbecauseofchangingpatternsof thedisease.Inpreviousyears,itwasassumedthatparticipantswhoreportedhavingdoctordiagnoseddiabetesbeforetheageof35andwhowerehavinginsulintherapyatthetimeofthe surveyhadType1diabetes,andallotherparticipantswithdoctor-diagnoseddiabeteswere classifiedashavingType2diabetes.Asincreasingnumbersofpeoplearenowbeingdiagnosedwith Type2diabetesbelowtheageof35,andsomeadultswithType2diabetesarenowprescribed insulintherapy,thesedistinctionsarenolongerreliable.Theestimatespresentedinthereport thereforedonotdistinguishbetweenType1andType2diabetes. Dentalhealth TheChildren’sDentalHealthSurvey2013wasusedtoidentifydentalcariesinchildrenagedfive, eight,12and15yearslivinginEngland.Obviousdecayexperienceisthetraditionalmeasureusedin dentalepidemiologysurveysseekingtoestablishthenumberof‘cavities’tobe‘filled’. Analyses TheHSEdatasetwasobtainedfromtheUKDataService(UKDataService,2015).Statisticalanalysis wasconductedinStata(versionSE14.0;StataCorporation).Weightsandthe‘svy’surveycommand wereusedwhenconductinganalysestoallowforthecomplexsample.Estimatesforadult overweight/obesityanddiabetesoutcomeswereage-standardisedtoallowcomparisonsbetween groupsafteradjustingfortheeffectsofanydifferencesintheiragedistributions.Allage standardisationhasbeenundertakenseparatelywithineachsex,expressingmaledatatotheoverall malepopulationandfemaledatatotheoverallfemalepopulation.TheHSEdatasetcontainsa variablefornethouseholdequivalisedincome.Thiswasusedtoidentifyhouseholdswithan equivalisedhouseholdincomewithinthe3rdquintileintheFamilyResourcesSurveyfor2013.Health outcomeestimatesusingHSEdataarereportedformaleandfemaleadults(aged19to64years) andchildren(agedfourto10and11to18years)livinginmiddle-incomehouseholdsinEngland (n=1455). 5 Dataforadultswasage-standardisedtoallowcomparisonsbetweengroupsafteradjustingfortheeffectsof anydifferencesintheiragedistributions.Allagestandardisationwasundertakenseparatelywithineachsex, expressingmaledatatotheoverallmalepopulationandfemaledatatotheoverallfemalepopulation. 8 EstimatesfordentalcariesinchildrenweretakendirectlyfromtheChildren’sDentalHealthSurvey 2013reporttablesforEngland.ItwasnotpossibletoobtaindatafromtheChildren’sDentalHealth Survey2013stratifiedbyincomelevel.Therefore,estimatesprovidedinthereportareforall childrenlivinginEngland. Chapter2:Foodeatenandthrownaway Datasourcesandpopulation LivingCostsandFoodSurvey(2013) TheLivingCostsandFoodSurvey(LCF),previouslyknownastheExpenditureandFoodSurvey,isa nationalcross-sectionalsurveyofprivatehouseholdsconductedintheUnitedKingdom(ONS,etal., 2015) TheLCFemploysamulti-stagestratifiedrandomsamplewithclustering.Addressesaredrawnfrom thePostcodeAddressFile(PAF).TheLCFcollectsinformationonpurchasingatthehouseholdand individuallevel.Eachindividualaged16andoverinthehouseholdvisitedisaskedtokeepadiary recordofdailyexpenditurefortwoweeks.Informationaboutregularexpenditure,suchasrentand mortgagepayments,isobtainedfromahouseholdinterviewalongwithretrospectiveinformation oncertainlarge,infrequentexpenditures,suchasthoseonvehicles.MoreinformationabouttheLCF canbefoundelsewhere(Bulman,etal.,2013). Horizonsdata(2013/2015) Horizonsisasourceoffoodserviceinsights,dataandtrendsfortheUK,Europeanandglobal foodservicemarkets(Horizons,2015).Horizonsproduceareport,‘EatingOut-Look’,fromsurvey researchconductedintheeating-outmarket.EatingOut-Lookisapanelsurveyrunquarterly,twice withconsumersandtwicewithoperators(Horizons,2015).Thesurveycollectsinformationon eating-outbehaviourfromrepresentativesamplesof2,000consumersand300operators,including frequencyofeatingout,wherepeopleeatoutandwhoeatsoutthemost,amongothers.Boththe consumerandoperatorsurveyareconductedonline. KantarWorldpanel(2013) Dataonhouseholdretailfoodanddrinkpurchasingfor52weeksending26May2013wasobtained fromKantarWorldpanel(Kantar,2015).KantarWorldpanelconductsconsumerpanelresearchin theUK.Purchasingdataiscollectedbyacontinuouslyreportingpanelof30,000demographically representativeBritishhouseholds.Panellistsareaskedtorecorddetailsofallfoodanddrink purchasedforhouseholdconsumption,includingvolumesboughtandpricespaid.Thesampling frameforKantar’ssurveywasGreatBritain(n=32,545).Moreinformationaboutthedatacanbe viewedelsewhere(Kantar,2015). SchoolLunchTake-upSurvey(2013/2014) TheSchoolLunchTake-upSurvey,commissionedbytheDepartmentforEducation,wasconducted inthe2013/2014financialyear(DepartmentforEducation,2015).Thesurveyisasourceof 9 independentdataonschoollunchtake-up,schoollunchprices,typesofcateringprovisionand school’sperceptionsofschoollunchtake-up.Althoughthesampleframewasallprimary,specialand secondaryschoolsinEngland,thereportcontainsfindingsfromonlyprimaryandspecialschoolsdue tosecondaryschools’lowresponserate.Schoolswerestratifiedbyschoolphase,typeofschool,size andtheproportionofpupilseligibleforschoolmeals.Schoolscompletedthesurveyeitherviaan onlineExcelspreadsheetorbytelephone.Theoverallresponserateforthesurveywas19%ofthe sample.Theresponseratevariedbyschooltype,i.e.primary,specialorsecondary. HouseholdFoodandDrinkWasteintheUK(2012) WRAP(Waste&ResourcesActionProgramme)isaregisteredcharitythatworkstohelpbusinesses, individualsandcommunitiesintheUKtoreducewaste,increasesustainabilityanduseresources moreefficiently(WRAP,2016).WRAPconductedresearchintothequantityandtypesoffoodand drinkwastegeneratedbyUKhouseholdsin2012(WRAP,2013).Theestimateswerederivedfroma combinationofthreemaindatasources: 1. Datafromwasteauditscommissionedbylocalauthoritiesanddatasubmittedto WasteDataFlow,aweb-basedsystemformunicipalwastedatareportingbyUKlocal authorities(WasteDataFlow,2016). 2. Datacollectedfrom1800consentinghouseholdsin2013ontheweightandtypesoffood anddrinkwasted. 3. Diaryrecordsofwastefromalldisposalroutesfromthehomein2012. MoreinformationabouttheHouseholdFoodandDrinkWasteintheUKreportcanbefound elsewhere(WRAP,2013). Expenditureandwasteoutcomes Wheredowebuyourfoodandhowmuchdowespend? TheLivingCostsandFoodSurvey(LCF)2013wasusedtolookathousehold-levelexpenditureon foodanddrinkpurchasedforhouseholdconsumption,aswellasfoodconsumedoutsideofthe home.Dataontotalspendingonretailfoodanddrink,householdshoppingfrequency,spendper householdandspendpertripwasobtainedfromKantar.Kantaralsoprovideddataonthegrocery marketshareofmajorretailersandprovidedalistofthetop80productcategoriesintermsof annualspending.Thetop20itemsinthislistaccountedfor50%oftotalannualconsumerspending onretailfoodanddrinkpurchasedforhouseholdconsumption.AsKantardatawasforallUK households,expendituredatausedinthemainnarrativewasobtainedfromtheLCFdatarather thanKantardatatoallowafocusonmiddle-incomehouseholdswithchildren. Eatingatschool Estimatesforschoollunchuptakeinprimaryandspecialschoolsanddifferencesinuptakebetween freeandpaidluncheswereobtainedfromtheSchoolLunchTake-upSurvey2013/2014. Eatingout Horizon’sEating-OutlooksurveyprovidedinformationonhowoftenconsumersintheUKeat outsideofthehome.Eatingoutexpenditureestimatesprovidedinthenarrativereportwere obtainedfromtheLCF2013survey.TheLCFsurveyrecordedexpenditureondifferentitemsdefined aseither‘household’or‘eatingout’expenditure,wherebyhouseholdexpenditurecoversallfood 10 anddrinkboughtforconsumptionathomeandeatingoutcoversfoodthatneverentersthe household.Eatingoutexpenditureincludesexpenditureonitemssuchasrestaurantmeals,school mealsandsnacks,andmealsboughtandeatenatwork. AccordingtoHorizon’sdata,McDonaldsUKwastheQuickServiceRestaurantwiththebiggest marketsharein2013sowelookedinmoredetailattheirmenuandthepricesfordifferentfoods. Informationonthenutritionalcompositionofmenuitems,includingtheamountoffat,saturated fat,salt,sugarandenergyper100goftheproduct,wasobtainedfromtheMcDonaldswebsite (McDonalds,2015). TheWorldHealthOrganizationRegionalOfficeforEuropeNutrientProfilingModelwasusedto identifywhethereachfoodanddrinkitemonthemenuwouldberestrictedfrommarketingto children(WHORegionalOfficeforEurope,2015).Foodanddrinkitemswereclassifiedintooneof thecategorieslistedinthemodel.Oncetheappropriatecategorywasidentified,thenutritional contentofthefoodproductwascrosscheckedagainstthethresholdsofthemodel.Ifoneormoreof thenutrientswereabovethesetthreshold,theitemwasnotpermittedtobemarketedtochildren. Forsomeitems,addedsugarsandnon-sugarsweetenerswerenotpermittedinanyamounts. Nutritionalinformationonthesewasnotavailableonthenutritioninformationsectionofthe website,howevertheingredientslistforeachproductwascheckedtolookforitemsthatwould containorbeclassifiedasaddedsugarsornon-sugarsweeteners.PricesforMcDonald’smenuitems wereobtainedfromahighstreetstore. TheWRAPHouseholdFoodandDrinkWasteintheUKreportlistsestimatesforavoidablehousehold foodanddrinkwastefromUKhouseholdsforanumberoffooditems.Estimatesarepresentedas weightoftotalavoidablewaste(tonnes)andintermsofthecostofavoidablewaste(£millionper year).Avoidablewasteisaclassificationusedinthereportrelatingtofoodanddrinkthrownaway thatwas,atsomepointpriortodisposal,edible,e.g.milk,lettuce,fruitjuice,meat(e.g.Unavoidable wastewouldincludemeatbones,eggshellsetc.). TheWRAPestimatesforcostofavoidablewasteforparticularfooditemswerematchedasbest possiblewiththetop20productsintheKantarlistofproductcategoriesrankedintermsof consumerspendingonretailfoodanddrink.Foreachproductinthislist,wecalculatedthecostof avoidablewasteasaproportionoftotalannualspendingusingtheKantarfiguresforannual spendingoneachproduct. Analyses TheLCFdatasetwasobtainedfromtheUKDataService(UKDataService,2015).Statisticalanalysis wasconductedinStata(versionSE14.0;StataCorporation).Theunitofanalysesforexpenditure datausingtheLCFsurveywasthehousehold.TheLCFassignsweightstocasestocorrectforunit non-responseinthesurveysample.ExpenditureestimatesusingdatafromtheLCFsurveyare presentedformiddle-incomehouseholdsinEngland(n=192). TheLCFdatasetcontainsavariablefornethouseholdequivalisedincome.Thiswasusedtoidentify middle-incomehouseholdswithanequivalisedhouseholdincomewithinthe3rdquintileforthe FamilyResourcesSurveyfor2013.Thesamplewasalsolimitedtothesehouseholdswithoneor morechildren(n=~192households). 11 Chapter3:Driversoffoodchoice:labellingandformulationsdata Kantarprovidedalistofthetop80productcategoriesintermsofconsumerspending,themarket shareofeachitem,andthebrandleaderandbranddetail(e.g.Warbutonscrumpets)foreachofthe 80products. TheKantardatawasusedtodetermine4fourcommonlyconsumedprocessedproducts(bread, breakfastcereals,readymealsandyoghurts)inwhichhealthyproductsshouldbereadilyavailable. Eachproductinthelistoftop80itemswasrandomlyassignedaretailerbasedontheretailer marketshare.Foreachprocessedproductcategory,asampleofallavailableuniqueproducts availableintheretailer’sonlinegrocerystorewastaken(onedayonlyin2015).Foreachsample, informationwascollectedon:thenumberofavailableproducts;thetypesoffront-of-packlabelling usedandthelevelsofnutrientsreported(e.g.green,orange,redlabels);theproportionofproducts onpromotion;andtheproportionofproductswithhealthornutrientclaims. Theremainingdatainchapter3isdrawnfromsecondarysources,referringwherepossibleto systematicreviews. Chapter4:Thefoodsystemdriversoffoodprice Chapter4ofthereportisintendedtoillustratethewaysinwhichthepolicyenvironmentimpactson thepriceofitemsinourtypicalfamily’sdiet.Werandomlyassignedsupermarketstoallitemsinthe shoppingbasketbasedweightedbysupermarketmarketshare(seeabove).Wethenchosethe brandleaderoffourfoodcategorieswhichappearedinthetop20itemsoftheshoppingbasketto illustratedifferentproblemareasofthediet:vegetables(whitepotatoes,ownlabel,randomly assignedtoTesco),freshbeef(leanmince,ownlabel,randomlyassignedtoAsda),freshpoultry (wholechicken,ownlabel,randomlyassignedtoAsda)andyoghurt(Müllercorner).Vegetables werechosenbecauseourtypicalfamilyeatstoolittlefruitandvegetablesandfibre.Meatwas chosenbecausemembersofourtypicalfamilyeattoomuchredandprocessedmeat,andbecause meathasasignificantenvironmental-footprint.Yoghurtswerechosenbecausetheyillustratea productforwhichhealthyoptionsareavailableaswellasprocessed,highsugaroptions.Wethen usedkeyinformantinterviewstotracethefoodbacktothefarm.Thiswaspossibleforthemeat andpotatoesbutnotfortheyoghurtforwhichMüllerwasnotwillingtoprovidetheinformation needed.Weusedkeyinformantinterviews,policyanalysis(below)andgovernmentdatato examinethepoliciesaffectingprice. Fortheanalysisoftheyoghurt,intheabsenceofinformationfromMüllerwehadtodeducethe amountofsugarandmilkintheyoghurtfromthecaloriesandcalciumlevelsintheproduct,using whererelevantMcCanceandWiddowsonasareference.AveragepricedataonMüllercrunch yoghurtsandNaturalyoghurtcamefromasnapshotanalysisofpricesinallfourmajorsupermarkets onthelastweekdayinJuneandNovember2015.Promotionswerecapturedinthispricedata whichwassourcedfromMysupermarket.com.Naturalyoghurtpriceanalysisincludedalltypesof naturalyoghurtbutthepriceperkcaldatawasbasedonwholenaturalyoghurt. 12 Policyanalysis Thepoliciesthathaveaninfluenceonthefoodsystemaresummarisedthroughoutthedocument. TheywereextractedfromanEvidenceSummarypreparedbytheFoodFoundationintheinitial stagesofpreparingaFoodEnvironmentPolicyIndex(Food-EPI)fortheUnitedKingdom(UK).The methodsforFoodEPIhavebeendevelopedbytheInternationalNetworkforFoodandObesity/ NCDsResearch,MonitoringandActionSupport(INFORMAS)andpilotedinNewZealand.Thegoalof theFood-EPIistoidentifyandprioritiseactionsneededtoaddresscriticalgapsingovernment policiesandinfrastructuresupport.Thefirststepintheprocessistoreviewevidenceandpolicy documentsthatrelatetothefoodenvironment,andtocompileanEvidenceSummary.TheFood-EPI hasbeenfullycompletedinNewZealandandisbeingundertakeninseveralothercountries, includingThailand,MexicoandSouthAfrica. Food-EPImethodsaredescribedindetailbySwinburnetal.inTheLancet(2015),Vandevijvere,S andSwinburn,B.intheBritishMedicalJournal(2014)andSwinburnetal.ObesityReviews(2013). TheEvidenceSummaryfortheUKFood-EPIwasbasedonareviewofgovernmentlegislation,plans andpolicies,parliamentarycommitteereports,expertadvisorygroupreportsandmajor authoritativeevidence-basedreportspertainingtofoodenvironments.6Thesewerederivedfroman internetsearchoforganisationdatabasesandgreyliterature.Atotalof211resourceswerecitedin thedraftEvidenceSummarydocumentby5November2015. ThepoliciessetoutinthisdocumentcovertheUK,whichismadeupoffourcountries:England, Wales,ScotlandandNorthernIreland.Devolutiontookplacein1999whenpowersweretransferred fromtheUKParliamentinWestminstertotheScottishParliament,theNationalAssemblyforWales, andtheNorthernIrelandAssembly.EnglandistheonlycountryoftheUKthatdoesnothavea devolvedParliamentorAssembly,andtheWestminsterParliamentdecidesonEnglishaffairs.Asa resultofdevolution,policiesincertainareas–includinghealth,agriculture,education,the environment,andlocalgovernment–isdeterminedbythedevolvedpowers.TheUKisamemberof theEuropeanUnion(EU),soallfournationsaresubjecttoEUlegislation.Specificlegislationand policiesthatapplydifferentlyinEngland,Scotland,WalesorNorthernIrelandarenoted. 6 Foodenvironmentisdefinedasthecollectivephysical,economic,policyandsocioculturalsurroundings, opportunitiesandconditionsthatinfluencepeople’sfoodandbeveragechoices,andnutritionalstatus. 13 Bibliography Bates,B.etal.,2014.NationalDietandNutritionSurvey:ResultsfromYears1,2,3and4(combined) oftheRollingProgramme(2008/2009–2011/2012),London:PublicHealthEngland. 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Swinburn,B.etal.,2013.Monitoringandbenchmarkinggovernmentpoliciesandactionstoimprove thehealthinessoffoodenvironments:aproposedGovernmentHealthyFoodEnvironmentPolicy Index.ObesityReviews;14(Suppl.1),24–37. UKDataService,2015.NationalDietandNutritionSurveyYears1-4,2008/09-2011/12.[Online] Availableat:https://discover.ukdataservice.ac.uk/catalogue/?sn=6533&type=Data%20catalogue [Accessed14July2015]. 15