Environmental system drivers of health

Mandala

Theme: Environmental and system drivers of health

Mandala aims to transform the urban food system for population and planetary health.

The food system is not currently conducive to supporting population or planetary health. Poor diet and related diseases are a major burden on population health and healthcare resources, whilst food production practices and food waste have consequences for the sustainability of diets and for the environment. Poor diet is also strongly socioeconomically patterned and many households in the UK struggle to afford sufficient nutritious food, making this an important health inequalities issue.

The COVID-19 pandemic has highlighted the fragility of urban food systems and exacerbated food insecurity and existing dietary inequalities. Changes to the food system need to be made in order to make it healthier, more sustainable and more equitable while preserving economic viability. Changes that improve population and planetary health could be well-aligned as healthier foods such as wholegrains, fruits, vegetables, nuts and seeds have lower environmental impacts than less healthy foods, such as red and processed meats.

The Mandala project aims to use Birmingham, a large and diverse English city, as a case study to identify leverage points within the food system with the greatest potential to improve population and planetary health. This project is led by Prof Martin White, Professor of Population Health Research at the University of Cambridge, and brings together an interdisciplinary team of researchers from the Universities of Cambridge, Birmingham, Warwick, Exeter, Liverpool, UCL and LSHTM. As part of this large consortium, LSHTM will lead on curating data resources to inform and facilitate food system transformation, evaluations and modelling studies.

Funder: UK Research and Innovation (UKRI) Strategic Priorities Fund (SPF) as part of the Transforming the UK Food System for Healthy People and a Healthy Environment programme.

Dates: Mar 2021 - Mar 2026

Team members: Amy Yau, Steven Cummins, Sophie Hedges

www.mandala-consortium.org/

@mandala_food

The impact of ‘emergency’ food parcels on the dietary practices of low-income households in the South of England: A multi-method qualitative study (PhD)

Theme:

• Environmental and system drivers of health
• Food systems, economics and health
• Social policy and health

This research project aims to explore the extent to which food bank practices intersect with household dietary practices in Portsmouth and the London Borough of Brent.

Food insecurity in the UK has become a public health emergency. This has led to an increase in the use and demand of emergency food aid, commonly in form of food banks. Currently over 2,000 food banks are estimated to operate in an official capacity in the UK. Although emerging, little is known on the use of food banks at a household level and the extent to which food banks consider dietary needs and preferences. Those who use food banks have limited choice as the food available is pre-determined by donations, which has the potential to increase their nutritional vulnerability. The overall aim of this thesis was to therefore determine the extent to which food banks meet household dietary needs and preferences by exploring the intersection between emergency food parcels and household dietary practices. This project utilises a multi-method qualitative approach. Firstly, a critical discourse analysis of twelve government and third-sector publications from 2013 was conducted to determine how the role of food banks have been framed in the discourses of food poverty and hunger. Secondly, an ethnographic study of food banks in Portsmouth and the London Borough of Brent was conducted. Remote and in-person interviews were conducted with a sample of 47 participants including food bank staff and volunteers (n = 23), long-term food bank users (n = 21) and public health practitioners (n = 3). These were supplemented by participant observations in seven food banks.

Team members:

• Denise Ndlovu
• Steven Cummins
• Claire Thompson

Twitter: @NdlovuDenise

The impact of ‘emergency’ food parcels on the dietary practices of low-income households in the South of England

Simulating the effect of urban food system interventions on dietary behaviour: a qualitative system dynamics and spatial agent-based modelling approach (PhD)

Theme: Food systems, economics and health

Examine interventions to reduce exposure to food retail environments and decrease out-of-home consumption of high-fat, high-salt, or high-sugar (HFSS) foods through simulation.

Obesity is a complex public health issue, and studying the impact of exposure to the food retail environment is crucial in understanding the drivers of poor dietary habits and developing effective interventions. The local retail environment, including restaurants, convenience stores, and fast-food outlets are known to offer high-calorie, low-nutrient meals at low prices, while frequent out-of-home eating has been associated with poorer nutrient intake.

The overconsumption of energy-dense and nutrient-poor food, particularly from fast food outlets, contributes significantly to weight gain. The increasing consumption of food outside the home, coupled with the availability of low-cost unhealthy food, is a major factor driving the obesity pandemic. In the UK, two-thirds of adults are overweight or obese, and the trend towards eating out is growing.

The complexity of the obesity epidemic requires a deeper understanding of the factors that drive unhealthy eating habits, as traditional statistical models often struggle to incorporate intricate dynamics. Systems science methods, such as agent-based modelling and system dynamics modelling, are considered promising tools for investigating these intricate processes.

To better understand how individual interaction with the food retail system produces unequal patterns of consumption in the population, this study uses systems dynamics and agent-based modelling, with a focus on reducing consumption of high-fat, high-salt, or high-sugar (HFSS) food consumed out of home.

This study aims to accomplish three goals. Firstly, to understand the mechanisms involved in the food retail system by creating a Causal Loop Diagram (CLD). The CLD will help identify the system drivers that influence the decision to purchase HFSS food. Secondly, to develop a spatial agent-based model that simulates how individuals interact with their environment and how this affects their consumption of HFSS food. The model will identify the factors that are most effective in reducing inequalities in exposure to the food retail environment. Thirdly, using the developed ABM, the thesis will simulate the impact of up to three policies aimed at modifying these identified targets for intervention to explore if they influence the food retail environment and out of home food consumption.

This study was supported by the National Institute for Health Research (NIHR) School for Public Health Research (SPHR), Grant Reference Number PD-SPH-2015.

Team members: Amanda Karapici, Steven Cummins 

Twitter: @amik89

How do beliefs influence the decision to undertake active travel in complex social networks: an agent-based modelling approach (PhD)

Theme: Environmental and system drivers of health

This project uses agent-based modelling, an artificial intelligence approach, to explore how individuals make their decision about how to commute based upon what they believe.

Active travel, which is travel by more active modes, such as walking and cycling as opposed to driving, reduces the risk of a wide range of diseases, including obesity and cancer, as well as improving mental health. It also has benefits for climate change and air pollution. However, how we best intervene to increase levels of active travel is unknown, and the evidence is mixed. This may be because our ‘transport-relevant beliefs’ – which influence, but may not directly be about, transport behaviour – both cause transport behaviour and arise by observing the behaviours of others. This results in a complex spread of beliefs and behaviour around social networks; those not directly to interventions may still change their behaviour because of observing behaviour and adopting beliefs from those who were exposed to the intervention. A better understanding of the role beliefs plays in transport behaviour, the role transport behaviour plays in informing our beliefs, and the spread of beliefs around social networks may help us design more effective interventions.

The belief–desire–intention (BDI) model of an individual’s decision to perform behaviour, states that an individual’s beliefs impact their desires – behaviours an individual would like to perform. The individual then chooses between their desires to obtain intentions – behaviours an individual is actively planning to perform. If we wish to change our behaviour, which, according to the BDI model, stems from our intentions, we must target policies and interventions earlier in the chain, by targeting beliefs.

The aims of the project are: (i) to understand how transport-relevant beliefs influence travel behaviour; (ii) to assess whether active travel influences the spread of transport-relevant beliefs and how this spread affects the success of interventions seeking to increase active travel; and (iii) to investigate whether active travel interventions can be designed in a way that exploits the spread of transport-relevant beliefs around a social network. To achieve this, this project will: build upon existing models of beliefs to develop a mathematical model for belief–behaviour interaction which considers the spread of beliefs; conduct a systematic review to understand how beliefs impact travel behaviour; design and implement an agent-based simulation platform and use this to investigate a range of active travel interventions.

An agent-based simulation platform is a model-based artificial intelligence approach to modelling a complex system where agents, in this case individuals, are given simple rules for how they interact with one-another and with the environment. For example, if I believe that cycling is good for the planet, then I will be more likely to cycle. Through these simple rules, emergent behaviour may occur. This is behaviour which was not anticipated and arises due to the combination of simple rules.

This PhD studentship is funded by the Medical Research Council (as part of the MRC-LID scheme), from September 2020 to December 2023.

Team members: Robert Greener, supervised by Steven Cummins

Twitter: 0x_r0bert

Evaluating the effects of maternity, paternity and parental leave policy changes on parental mental health using quasi-experimental methods (PhD)

Theme: Environmental and system drivers of health

This project will look into the effects of a series of UK policy reforms to maternity, paternity and parental leave on the mental health of parents.

Early parenthood might be an important time for future mental health and wellbeing. New parents can lose sleep and have demands on their time, money and emotional resources. Social policies supporting paid maternity, paternity or parental leave might influence the mental health of parents in the short term by supporting them at this time, and in the long term by affecting their future working life.

Leave policies vary around the world, with different lengths of leave, levels of payment and amounts of time allocated to mothers and fathers. Although there is growing evidence that taking maternity leave is linked to maternal mental health, it is unknown what leave policies would lead to the best outcomes.

The UK is an interesting case study. It has unusual maternity and paternity leave policies, with a comparatively short period of statutory entitlement to high-rate maternity pay, and limited leave rights reserved for fathers.

This project will investigate what happened to mental health for parents after three different changes to their leave rights.

Funder: MRC-LID

Team members: Emily Humphreys

Start date: September 2021

SALIENT: food System triALs for Impact on Environment, Nutrition and healTh

Theme:

• Environmental and system drivers of health
• Food systems, economics and health
• Social policy and health

The SALIENT project aims to design and trial 10 innovative food system interventions within England to improve public and planetary health.  

Unhealthy, less sustainable foods that are cheaper to produce and consume are contributing to some of the biggest challenges for public health and the environment facing society today. In response to the urgent need for healthier and more sustainable food systems, the SALIENT project aims to take an ambitious and innovative approach to designing and trialling 10 food system interventions. Working across 10 institutions, the SALIENT team consists of over 20 interdisciplinary experts specialising in behavioural science, public health, systems and environmental science and health economics. The project has been funded by the UKRI Economic, Social and Research Council (ESRC) and will be co-led by experts in food systems research Professor Martin White and Professor Peter Scarborough.

In the first phase of the project (January-May 2023), we will identify which interventions to study in phase two. Alongside working with two public panels and policymakers from relevant government departments, researchers in PHI|Lab will conduct a review of the evidence to develop a list of possible interventions. Our analysis will inform meetings with potential food system partners, which consist of both large and small organisations working in the retail, catering and community support sectors. To transition into the delivery phase, the team will decide which interventions are likely to have the best chance of having large, equitable, and long-term effects on healthy, sustainable food purchasing.

If our application is approved, in the second phase (June 2023 - March 2025) we will deliver these interventions in real-life food purchasing settings to try and understand what works best and why. Our interventions will focus on five mechanisms that have been shown to affect behaviour: availability, size, promotions, price and provision of information. We will prioritise interventions that are equitable, effective and scalable, whilst recognising that they must also be deliverable and cost-effective for partners.

Team members: Professor Steven Cummins, Dr Laura Cornelsen, Dr Claire Thompson, Bea Savory, Dr Oliver Huse, Dr Gregory Hartwell, Lily Barnett

Food system trials to encourage healthy, sustainable diets

Associations between residential greenspace exposure and premature mortality in London, UK: a data-linkage study

Theme: Environmental and system drivers of health

Does access to greenspace influence mortality in London?

This project had a focus on creating population-wide spatially referenced environmental exposure data linked to large-scale secondary data resources. The aim was to unpick causal associations between environmental exposures and clinical endpoints and assess effects on health inequalities of environmental exposures using exposure to greenspace as a case-study.

Urban greenspaces might reduce non-communicable disease risk but the links between greenspaces and mortality related to non-communicable disease remain unclear. In this project we estimated the associations between residential greenspace quantity and access with all-cause, cardiovascular disease, cancer, respiratory, and type 2 diabetes mortality.

We linked 2011 UK Census data of London-dwelling adults (to data from the UK death registry and the Greenspace Information for Greater London resource (N=4 645 581). We calculated percent greenspace area, access point density (access points per km²), and distance (metres) to the nearest access point for each respondent's residential neighbourhood (defined as 1000-m street network buffers) for greenspaces overall and by park type using a geographic information system. We then estimated associations using Cox proportional hazards models, adjusted for a range of confounders. 

Funder: Health Data Research UK

Duration: Sept 20 - June 22

Team members: Professor Steven Cummins, Dr Samantha Hajna (now at Brock University) and Dr Vahe Nafilyian (now at ONS)

Kids’ Environment and Health Cohort (KiTE)

Theme: 

• Environmental and system drivers of health
• Social policy and health

Developing a large-scale e-resource to explore the impact of the environment on child health, wellbeing and development.

Children are much more vulnerable to health-damaging features of the environment in and around their homes and schools than adults. This can include air pollution, overcrowding, fast food advertising near schools, and lack of access to greenspaces. Children who are exposed to these environmental factors are at greater risk of developing long-term conditions such as asthma or mental health problems, and not doing so well in school.

The government is introducing policies to improve local environments and housing, partly to slow and mitigate the effects of climate change. Several changes are also taking place in the social environment around where children live and go to school, due to austerity policies and the Covid-19 pandemic, including closure of libraries, childcare providers and high street shops.

In this project, we will set up a new national data resource that will allow researchers to examine how the local physical and social environment influences children’s health and schooling across England.

The Kids’ Environment and Health Cohort project is led by University College London, in collaboration with London School of Hygiene and Tropical Medicine, and City, University of London, in partnership with the Office for National Statistics (ONS), working with NHS Digital and the Department for Education.

This project will set up a national database containing de-identified data from schools, hospitals and community pharmacies, on health and education histories for all children born in England from 2006 onwards - around 11 million children. This data will be linked to information about their mothers’ health during pregnancy as well as data on local environments in and around children’s homes and schools. The data will be linked under approvals from the Confidentiality Advisory Group, the ONS, NHS Digital and the Department for Education.

Funder: ADR-UK via ESRC.

Dates: December 2022 – December 2025

Team members: Professor Steven Cummins, Dr Emilie Courtin and Dr Samantha Hajna (now at Brock), Nina Rogers

Kids’ Environment and Health Cohort

ADRUK Kids’ Environment and Health Cohort

Evaluation of planning policy to regulate takeaway food outlets for improved health in England

Theme:

• Environmental and system drivers of health
• Food systems, economics and health
• Social policy and health

The impact planning policy to reduce the proliferation of fast-food in England.

Poor diet and obesity are leading causes of mortality. Takeaway food outlets (‘takeaways’) sell energy dense food, with frequent consumption linked to weight gain. There are 60,000 takeaways in England with more in deprived areas and annual growth four times that of population growth. Physical access (‘exposure’) to takeaways is associated with takeaway consumption and obesity.

Urban planners are unable to remove planning permission from existing takeaways, but they can refuse permission to new takeaways. The most common form of planning policy is the school-based ‘exclusion zone’ adopted by 44 of 325 LAs in England to date. The intent of this intervention is to prevent further takeaway proliferation around schools by denying new takeaway planning applications. While appearing to target children, our previous findings suggest this is a politically acceptable means to reduce whole population takeaway exposure. The health and other impacts of exclusion zones are unknown.

The aim of our study is to assess what the impact of exclusion zones on the number of takeaways is. Using a dataset of all food outlets in England, we will compare takeaway numbers in areas with and without exclusion zones, two years before and after zones are introduced. We will also study areas just outside zones in case takeaways are displaced there. Any health impacts of zones are likely to be small and take a long time to occur. We will use statistical modelling to estimate the impact of zones on obesity and health.

We are also exploring how planners and those in public health practice have implemented the policy and will produce a toolkit to other local councils implement the policy in their area. In addition, we will conduct research with young people to explore how they feel about these kinds of policies in their neighbourhoods and how they use their local food environment to buy and consume takeaway food.

This project is led by Dr Tom Burgoine at the MRC Epidemiology Unit, University of Cambridge.

Funder: NIHR

Dates: April 2021 – March 2024

Team members: Professor Steven Cummins, Dr Suzan Hassan, Bea Savory

Evaluation of planning policy to regulate takeaway food outlets in England

Understanding the influence of the digital food environment on the diets of young people: a qualitative study of how the platform economy shapes the dietary preferences and food purchasing behaviours of 11-18 year olds

Theme:

• Environmental and system drivers of health
• Food systems, economics and health

This project will at look at understanding how the digital food environment influences the attitudes, purchasing and consumption of food and drink for young people.

The way we are introduced to, and purchase, food and drink for consumption in and outside of the home is being radically re-shaped by the rise of the so-called platform economy.

Digital on-demand technologies are changing food distribution and delivery, making groceries and ‘fast-food’ more accessible and convenient. Other digital platforms (e.g messaging services, gaming and social media including YouTube, TikTok, SnapChat and Instagram) are actively mediating preferences and purchase decisions through marketing and promotions, and through food influencers and viral content. Combined, this might promote unhealthy food choices and increase the frequency of purchasing such foods, especially in the takeaway sector.

A small and emerging evidence base in adults suggest that use of online delivery services, for example, is becoming increasingly normalised, optimises the purchase process and acts as a potential vehicle for price promotions to increase sales of unhealthy foods. However, the dietary impact of these platforms on young people (aged 11-18) is unknown.

Given that adolescence is a key point for the establishment of dietary habits that track into adulthood, and considering these platforms as possible drivers of a generational shift in the way dietary preferences are shaped and how foods and drinks are purchased, understanding the behaviours of this age-group is key.

Our research questions:

• What does the current evidence base and literature inform us about the digital food environment for young people?
• How do young people interact with their digital environments and platforms in a food and drink context?
• How does the digital food environment influence the dietary preferences, and the purchase and consumption of foods and drinks for young people?

Objectives

1. Review and synthesise the existing evidence from a wide range of public health and social science literature to create a theoretical framework that conceptualises the digital food environments of young people
2. Describe and characterise how various digital platforms are experienced by young people and shape their food preferences and food and drink purchasing behaviours
3. Explore how these dietary preferences and behaviours are mediated by peer social networks, family and digital food cultures (e.g. food influencers, trends and viral content) and explore the resilience and susceptibility of young people to these influences.

Methods

Using an ethnographic approach, the project will focus on qualitative methods such as interviews, focus group and digital/virtual methods (e.g. digital go-alongs).

Funder: SPHR-NIHR

Start date: October 2023

Team members: Anamika Basu, Claire Thompson, Steven Cummins

Food systems, economics and health

Understanding the impact of mandatory calorie labelling in out-of-home food environments in England

Theme: Food systems, economics and health

This project aims to evaluate the impact of the calorie labelling policy implemented in England in April 2022 by examining how it may have affected our purchasing habits, changes in the availability and prices of food and the views of young people on this policy and on healthy eating more broadly.

Aim

This project aims to understand the impact of calorie labelling in England. For example, what is the effect of the policy on people’s diets and health?

Background

Diet related disease, including obesity, is a major public health burden in England. Almost two thirds of adults are above a healthy weight and one in five children are living with obesity by the time they leave primary school. This puts a large part of the population at increased risk of diseases, such as heart disease, type 2 diabetes and cancer. The cost of these diseases for individuals, the NHS and society are high.

An unhealthy diet is a key driver of obesity and food environments play a role in determining whether you have a healthy diet. Food and drinks prepared away from the home are typically less healthy than food prepared at home and are widely available in England where there is a high density of (fast-food) restaurants, and online food delivery services are developing rapidly. This increases people’s access to foods that are high in calories, fat, salt, and sugar.

In April 2022, the government introduced a mandatory calorie labelling policy in England that requires large businesses selling food and drinks for immediate consumption (e.g., restaurants, cafes, fast food chains) to display calorie information at the point of purchase. The aim of this policy is to help people make healthier decisions when buying food prepared outside the home and to encourage businesses to provide healthier and lower calorie options.

This project will contribute to the evidence base about how calorie labelling influences health.

Design and methods

The project will be divided into four main areas of work:

1. Measuring changes in food and drink purchases before and after the labelling policy came into effect, this will be done using a nationally representative database of purchases for out-of-home consumption
2. Modelling the impact of the changes in purchasing due to labelling policy on population health outcomes and health care costs
3. Measuring changes in the availability and prices of foods within restaurants and online delivery platforms before and after the policy was introduced
4. Exploring the views of young people about the policy and their priorities for change within local food environments (this policy is particularly relevant to adolescents who are a key demographic of out-of-home food consumption)

Public involvement

We work closely with two panels of young people across two case study sites to inform framing of the project and design of the fourth area of work. The young people will be involved throughout the project.

Dissemination

Findings from the project will be communicated through policy stakeholder meetings, a dissemination event, research briefing, presentations at conferences and publications in academic journals. The young people involved will also help advise on how to present and disseminate the findings to various audiences.

Dates

June 2023 – May 2025

Team members: 

• Dr Laura Cornelsen
• Prof. Steven Cummins
• Dr Alexandra Kalbus
• Dr Oana Tanasache
• Dr Cherry Law

Partners

LSHTM, University of Exeter, University of Sheffield, University of Cambridge, University of Reading

Funder

NIHR School for Public Health Research (SPHR)

Understanding the impact of mandatory calorie labelling in out-of-home food environments in England

Impact of calorie labelling on online takeaway food choices: an online menu-based choice experiment in England

Theme: Food systems, economics and health

This project examines whether providing calorie information on online takeaway food menus leads to healthier food choices.

The out-of-home food choices that people make can have a direct impact on their health. Eating out-of-home is linked to higher energy intake and higher body weight, which are key risk factors for obesity and diabetes. In the UK, most main meals served in major restaurant and fast-food chains contain more than 600 kcal—the recommended energy content for a main meal. Additionally, one in four starters and one in five desserts in UK chain restaurants exceed the recommended energy intake for an entire meal.

In April 2022 England introduced Calorie Labelling Regulations for Out of Home Food (OOHF) Sector. This requires large businesses (defined as those with 250 or more employees) selling food in scope of the Regulations to display the energy content of the food in kilocalories (kcal), reference the size of the portion to which the calorie information relates and display the statement that ‘adults need around 2000 kcal a day’. The requirement extends to food that is sold on a website or mobile application, including third party delivery apps. Existing research has shown that providing calorie content of individual food items does not appear to have much of an effect in reducing calorie consumption. However, some evidence shows that providing information on the total amount of calories (nutrients) might lead to a greater effect.

This study aims to examine whether a policy that provides information on the total amount of calories ordered in an online setting leads to healthier food choices compared to a policy that provides calorie information for individual items only. To achieve this objective, an online Menu-based Choice Experiment (MBCE) will be conducted to model consumers’ responses to calorie labelling on online takeaway food menus. The design will also allow to examine whether either type of information on calories leads to healthier food choices compared to no information. This study has therefore direct relevance to the recently introduced regulations in England but goes a step further to examine whether provision of information regarding total calories ordered in addition to calories for individual items will impact food choices made in an online setting.

The MBCE was conducted as an online survey in November 2022 among a randomly selected sample of individuals in England (n=1,000) who were recruited from a large nationally representative panel. Primary interest for this study is the estimated likelihood of choosing healthier items from a menu consisting of one healthy and two less healthy meal food/drink items. Furthermore, we asked the respondents about their knowledge and perception of calorie labelling and factors they consider important when making food choices. Findings from this study will enhance the existing evidence base on the effectiveness of provision of calorie information in encouraging healthier out-of-home food choices with the potential of informing policy designs and thus improving health outcomes.

This project is funded by the Medical Research Council.

Start date: 1 July 2022

Contact person: Oana Tanasache (oana.tanasache@lshtm.ac.uk)

Team members: 

• Laura Cornelsen
• Oana Tănăsache
• Cherry Law
• Steven Cummins

Does product reformulation of sugar-sweetened beverages lead to healthier diets?

Theme: Food systems, economics, and health

This project examines whether industry-driven sugar reformulation initiatives lead to healthier diets.

Obesity has become a major global challenge. With the number of obese adults nearly tripling over the past forty years, obesity is now affecting more than 1.9 billion adults globally. Obesity is not only is a key risk factor for several non-communicable diseases, such as cardiovascular disease, some forms of cancer and diabetes. Aligned to these global trends, U.K. is severely affected by the prevalence of obesity. More than one in four people was obese in 2015 with obesity rates expected to affect 35% of the population by 2030. Obesity is not only affecting adults, but also children with a large share of children in England reported as obese or overweight.

Unhealthy dietary patterns are reported to be a key contributor to obesity rates. Excessive consumption of sugar-sweetened beverages (SSBs) is believed to contribute to these unhealthy diets especially among children. Several initiatives have been put forward in recent years to reduce consumption of these drinks. One of these initiatives is product reformulations of SSBs which involve a reduction in the added sugar content of these drinks (usually through sugar substitutes).

This project examines whether reformulation of sugary drinks usually consumed by children has a positive impact on diets. We do this by using a large representative dataset of British household food purchases over the 2012-2017 period and investigate whether reformulation of SSBs lead to healthier food baskets containing less calories and sugar.

Findings from this project will improve our current understanding of product reformulation as a tool for improving diets. These findings will also inform future policy initiatives in relation to health-related food policies.

Contact person: Oana Tănăsache (oana.tanasache@lshtm.ac.uk)

Team members:

• Laura Cornelsen
• Oana Tănăsache

Do healthy diets cost more?

Theme: Food systems, economics and health

This project examines whether healthier food baskets purchased by British households are more expensive than less healthy food baskets.

Healthy foods are widely reported to be more costly than unhealthy foods. This is often reported as one of the key barriers to a healthy and nutritious diet. The recently published UK National Food Strategy shows that highly processed foods, that tend to be unhealthy, are on average three times cheaper per calorie than healthier foods. However, price per calorie is not ideal for assessing the relative cost of healthy and unhealthy foods as healthier foods are typically lower in fat, sugar and refined carbohydrates and thus have fewer calories. A more appropriate alternative would be to look at the differences in the cost of food baskets between those consisting mainly of healthy foods and those containing predominantly less healthy foods.

This project will explore the association between the healthiness and cost of food baskets, using a large representative British household purchase panel of foods and beverages bought to consume at home in 2017. We will apply the Nutrient Profiling Model to classify food and drink items purchased that are high in fat, sugar and salt (HFSS) and use the share of calories obtained from HFSS to measure the healthiness of the diet. By examining within-household variations in 4-weekly food baskets over the data period, we will assess how the share of HFSS energy is associated with the per person food spending on the baskets. We will also examine if this association differs across socioeconomic groups to gain insights on any diet-related inequality.

Findings from this project will improve our understanding of the complexity of food choices and verify the commonly held view that healthier food baskets are more expensive than the less healthy ones. These findings will help policymakers in designing food policies to improve diet-related health.

Contact person: Cherry Law (cherry.law@lshtm.ac.uk)

Team members:

• Laura Cornelsen
• Cherry Law
• Richard Smith

CO-designing for healthy People and Planet: food system Economic Research (COPPER)

Theme: Food systems, economics and health

COPPER project will work with the public and policymakers to design food subsidy and tax scenarios to estimate their impact on health, health inequalities, household economics, macroeconomics and the environment.  

The food that we eat in the UK impacts on our health and our wallets, with particularly large impacts for the poorer in our society. It also impacts on planetary health and the UK economy. One option to address these challenges is to introduce food taxes and subsidies to incentivise healthy, sustainable food and support low-income groups. But taxes and subsidies are politically difficult to introduce due to concerns over individual agency and stigmatisation. For such policies to be successful, it is vital that they are co-designed with the public and policymakers and their potential impact across multiple outcomes is established. The aims of the COPPER project are to a) co-design tax and subsidy scenarios with public and policymakers, b) develop a research infrastructure of linked datasets and integrated health, economic and environmental impact models, c) estimate the impact of six policy scenarios and communicate our results with public and policymakers.

The team at LSHTM will use household food purchasing data linked with environmental outcome measures to fit a consumer demand model. We will estimate food demand sensitivity to changes in prices which will feed into evaluation of the impact of the scenarios on nutritional quality, price of the diet and environmental outcomes for different income groups. In addition, LSHTM team will estimate how the tax and subsidy scenarios change GDP, jobs in the food industry and tax revenue using a computable general equilibrium macroeconomic model.

Team members: Laura Cornelsen (PHI-Lab, GHECO), Marcus Keogh-Brown (GHECO), Henning Tarp-Jensen (GHECO)

Partners: University of Oxford (lead); University of Exeter; University of Reading; Food Foundation

Contact: laura.corneslen@lshtm.ac.uk

Funder: NIHR

Start date: May 2022

Vulnerability of the UK food system to climate change: exploration of indicators, impacts and policy responses

Theme: Food systems, economics and health

This PhD examines the vulnerability of the UK food system to climate change and explores how the UK measures and responds to these impacts.

Climate change will increasingly impact global food systems which has potential consequences for food security and diet quality. The Intergovernmental Panel on Climate Change (IPCC) reports of “irreversible damage to global food security as many natural and human systems are unable to adapt to climatic changes and further increase in global warming (between 1-2˚C) would contribute additional pressure to food production and access”. This can lead to many forms of malnutrition in vulnerable populations. Non-resilient and vulnerable food systems can be challenged by climate change through direct impacts on crop yields affecting food production, nutrient composition and bioavailability as well as influencing access to and affordability of food. The UK has a highly complex food system with long supply chains, and is dependent on imports often from highly climate-vulnerable countries as well as experiencing its own environmental challenges. Therefore, it is critical that climate change impacts and policy responses are understood to identify potential vulnerabilities and subsequent consequences for food and nutrition security.

Advances in agricultural production and significant transitions in global food demand, have shifted disease profiles such that food-related non-communicable diseases rather than undernutrition are now the largest contributor to the global burden of disease. However, inequalities in the distribution of food supply for adequate and healthy diets remain. Food insecurity is a known risk factor for many nutritional health outcomes such as diabetes, hypertension, overweight and obesity and poor mental health which can be exacerbated by economic, social and environmental shocks. The UK Food Security Report states that 2.2 million UK households regarded themselves as food insecure in 2019/20. Only 0.1% of the population currently meets all UK dietary guidelines, and micronutrient rich, high fibre foods such as fruits, vegetables and legumes are particularly under-consumed. Climate change poses an additional future risk to the UK’s food supply and food security as discussed above.

This PhD aims to examine the vulnerability of the UK food system to climate change and explore how the UK measures and responds to these impacts. Firstly, I will conduct a scoping review mapping climate-related food-system indicators used to monitor climate change impacts and compare this to how the UK currently monitors these impacts. I will then identify implemented actions to respond to climate impacts on food systems through a policy review of national and regional food strategies and national climate risk assessments across UK and Europe. Next, I will assess the impact of past extreme weather events on the UK food system by examining changes in food prices and consumer purchasing through a time series analysis of consumer food purchase data. Finally, I will explore policy responses to climate impacts in the UK food system and identify policy gaps, implementation barriers and facilitators for effective decision-making. This will be through a qualitative analysis of semi-structured stakeholder interviews. The studies conducted will inform a range of stakeholders by providing evidence-based recommendations to ensure the resilience of the UK food system.  

This PhD is affiliated with the NIHR Health Protection Research Unit in Environmental Change and Health led by LSHTM with the UK Health Security Agency, Met Office and University College London.

Contact person: Grace Turner (grace.turner@lshtm.ac.uk)

Team members: 

• Grace Turner
• Laura Cornelsen
• Cherry Law

The impact of price promotions on consumer behaviour and public health (PhD)

Theme: Food systems, economics and health

Price promotions form an important part of food and beverage marketing in the UK. This research seeks to measure the impact of these promotions on the choices people make while buying food and to what extent our diets are affected by them.

Increasing prevalence of overweight and obese people in England has led policymakers to consider regulating the use of price promotions on foods high in fat, sugar and salt content.

In Britain, price promotions are used as a key part of the marketing and competition strategy in national supermarket chains, as well as independent stores. Price promotions involve discounting prices at the point of sale and are available to all customers. They consist of total price reductions (TPRs), in which the good is offered at a price below recommended retail price, often presented as a percentage discount off the price or volume-based discounts (multi-buys), in which an additional percentage or whole units are offered upon purchase of a specified amount (e.g., buy-one-get-one-free deal, or 30% extra free). Both types of promotion are often indicated by brightly coloured, large stickers which describe the terms of the price reduction.

This study focusses on the analysis of Kantar GB Fast Moving Consumer Goods (FMCG) panel, a data set recording the shopping behaviour of over 30,000 households in Britain. It uses micro-econometric techniques to estimate the extent to which this promotion based marketing disrupts the content of people’s shopping baskets.

In January 2019 the Government opened a consultation programme for a policy proposal which significantly restricts the use of price promotions that can induce consumers to buy higher volumes of unhealthy foods and beverages. These proposed policies are the first of their kind in public health and are believed to reduce excess purchasing, and therefore over-consumption of unhealthy products. While the impact of price promotions on sales has been of interest to marketing academics for a long time with modelling studies showing its use increases food and drink sales by 12-43%, it is only now being picked up in the public health sphere. However, the existing evidence rarely considers the “overall” impact of price promotions as a strategy, more often focussing on the sale of individual brands and products.

With the government’s policy proposed, but delayed and not yet enacted, this analysis is making a timely contribution to public debate.

Publications include:

Reducing consumption of unhealthy foods and beverages through banning price promotions: what is the evidence and will it work?

The impact of price promotions on sales of unhealthy food and drink products in British retail stores

Team members: Toby Watt, supervised by Laura Cornelsen, Walter Beckert (BBK) & Richard Smith (Exeter)

Understanding the consumption of ultra-processed food in England

Theme: Food systems, economics and health

To investigate the consumption of ultra-processed foods (UPF) in England.

Project funded by SPHR-NIHR.

Categorising foods according to the level of processing is a relatively new approach in public health nutrition research. The most used NOVA classification (1) separates food into four categories: unprocessed or minimally processed foods, processed culinary ingredients, processed foods and ultra-processed foods (UPF). This classification is gaining more traction as studies are starting to emerge, including in England, linking consumption of UPF with adverse health outcomes (2-4). However, little is known about population level consumption trends of UPF and how these associate with the widening dietary health inequalities. Furthermore, as this classification is relatively new, it is unknown the extent to which consumers understand it or take it into account in their purchase decisions.

The overall aim of this PhD project is to examine the consumption of UPF in England. This will be achieved through answering the following indicative research questions:

1. What is the role of UPF in current food baskets in England, including in the cost of the basket
2. What is the association between UPF purchases and household socio-economic and BMI status;
3. What is the current consumer knowledge, attitude, and preference towards UPF foods.

For research questions 1-2, a highly disaggregated longitudinal data from around 30,000 British households on food and beverage purchases and nutritional composition of the products is available to be used (2012-2019 and 2022). Existing NOVA classification to be used with the data will be refined and applied to the data. Subsequent analyses are expected to be carried out using longitudinal panel data analysis methods. Research question 3 can be answered via primary data collection through a survey, including a discrete choice experiment.

References

1. MonteiroCA,CannonG,LevyRB,etal.Ultra-processedfoods:Whattheyare and how to identify them. Public Health Nutr 2019; 22: 936–941.
2. ChangK,KhandpurN,NeriD,etal.AssociationBetweenChildhood Consumption of Ultraprocessed Food and Adiposity Trajectories in the Avon Longitudinal Study of Parents and Children Birth Cohort. JAMA Pediatr.2021;175(9):e211573.
3. LevyRB,RauberF,ChangK,LouzadaMLDC,MonteiroCA,MillettC,Vamos EP. Ultra-processed food consumption and type 2 diabetes incidence: A prospective cohort study. Clin Nutr. 2021 May;40(5):3608-3614.
4. Rauber, F., Chang, K., Vamos, E.P. et al. Ultra-processed food consumption and risk of obesity: a prospective cohort study of UK Biobank. Eur J Nutr 60, 2169–2180 (2021). 

Team members: Karen Ullian, Laura Cornelsen, Steven Cummins