Select Committee on Health Third Report

2 Causes

What has happened in our environment in terms of the history of human evolution is remarkable in the last two generations. We have never seen anything like this, where we have the coming together of the technological, electronic, television revolution and the highly available, high energy-dense and very cheap foods … where physical activity comes in is that you rapidly get into a vicious cycle of inactivity, sloth and weight gain: as soon as you start to gain a load of weight, it is all the more difficult to go up those stairs; as soon as you start to become a little less fit, you resist doing those things which in the first place will help you not to become overweight, and so it rapidly becomes a vicious cycle.[69]

                Professor Andrew Prentice

Gluttony or sloth?

67. Determining the root causes of obesity is central to any efforts to tackling it, and, according to an influential paper published in 1995 by two of our witnesses, Susan Jebb and Andrew Prentice, scientists at the Medical Research Council Human Nutrition Research Centre, "uncertainty over the aetiology of obesity remains one of the chief barriers to designing effective strategies for prevention and treatment."[70] Although much research has been carried out into the potential influence of genetic factors, such as possible metabolic defects, these have been largely abandoned, particularly as the dramatically escalating rate of obesity documented in recent years has occurred in a relatively constant gene pool. Instead, the key question remains that articulated by Susan Jebb and Andrew Prentice in 1995:

It is certain that obesity develops only when there is a sustained imbalance between the amount of energy consumed by a person and the amount used up in everyday life. But which side of this energy balance equation has been most altered in recent decades to produce such rapid weight gain? Should obesity be blamed on gluttony, sloth, or both?[71]

68. It is clear that people are overeating in relation to their energy needs, and that the cheapness, availability and heavy marketing of energy-dense foods makes this very easy to do, coupled with an increasing reliance on snacks and ready-prepared meals which makes selecting 'healthy' foods[72] harder. However, according to Jebb and Prentice:

The paradox of increasing obesity in the face of decreasing food intake can only be explained if levels of energy expenditure have declined faster than energy intake, thus leading to an over-consumption of energy relative to a greatly reduced requirement.[73]

69. Summing up the energy equation, the Royal College of General Practitioners suggested that food intake had fallen on average by 750 kcal per day; but activity levels by 800 kcal. Out of this small imbalance has come the wave of obesity.[74]

Nutritional causes

Changing nutritional habits

70. Although, according to Jebb and Prentice, "it is generally assumed that ready access to highly palatable foods induces excess consumption and that obesity is caused by simple gluttony", in their view the National Food Survey in fact points to an overall drop in energy consumption since the 1970s.[75] Even after adjustments for meals eaten outside the home, and for consumption of alcohol, soft drinks and confectionery, average per capita energy intake seems to have declined by 20% since 1970. The food industry has been quick to seize upon this evidence to point the blame for spiralling rates of obesity firmly on reductions in physical activity. However, this argument ignores many other complex changes in people's nutrition patterns that have taken place in recent years, and masks the important contribution that nutrition makes to obesity. Andrew Prentice was himself displeased by this use of his research by what he termed "rogue elements of the food industry":

We have been less than pleased at the way that paper has been wilfully misused by certain parts of the food industry, saying, "It is nothing to do with our products, it is nothing to do with food; it is all down to physical inactivity." [76]

71. An important note of warning is that the data used for the National Food Survey are self-reported, and, notoriously, individuals are reluctant to report consumption of foods they regard as being bad for them. As Tim Lobstein, for the Food Commission demonstrated:

the latest national diet survey says [adults] are eating 82 grams of confectionery each week, self-reported. If you look at industry sales figures, those are 250 grams per week being sold to somebody. Clearly there is a huge gap between what industry is selling and what people are reporting they are eating.[77]

72. Given the profound significance of overweight and obesity to the population we believe it is essential that the Government has access to accurate data on the actual calories the population is consuming, including figures for confectionery, soft drinks, alcohol and meals taken outside of the home. Although we acknowledge the difficulties of obtaining accurate data, given the limitations of any self-reported survey, the current information is very weak and clearly underestimates actual calorie consumption. We recommend that work is urgently commissioned to establish a Food Survey that accurately reflects the total calorie intake of the population to supersede the flawed and partial analysis currently available. The Food Standards Agency and Scientific Advisory Committee on Nutrition should advise on this.[78]

73. Even if overall calorie consumption has fallen, there have been significant changes in the composition of people's diets. Firstly, there has been an increase in the proportion of fat in the British diet: in the 1940s, each kJ of carbohydrate in the diet was associated with 0.6 kJ of fat but in the 1990s with 0.9kJ of fat, an increase of 50%.[79] Although both carbohydrates and fats produce energy, exactly where and how people take in their energy has a crucial role in obesity.

74. During the course of this inquiry, the food industry has made constant use of the formulaic argument that 'there are no such thing as unhealthy foods, only unhealthy diets', a phrase we have also, perhaps surprisingly, heard from sports officials and Government ministers. But it is patently apparent that certain foods are hugely calorific in relation to their weight and/or their nutritional value compared to others:

Weight and calorie content of snack foods[80]

Snacks  WeightCalories

Bag of Walkers crisps     35g      183

Snickers bar       61g       280

Apple         112 g       53

75. Besides portion size, calorie content is determined largely by fat, sugars and other refined carbohydrate content. More important than the total amount of energy (or calories) a food has is how much energy it contains in relation to its weight, that is to say its energy density. Put simply, energy density is a measure of a food's calories in relation to its total volume, and relates to how satiating, or filling, a food is. For example, a king size Snickers bar, which weighs 100g, has more calories than a main meal of sirloin steak served with potatoes and broccoli, which has a total weight of 400g.[81] Its high energy density means that the Snickers bar, although it is highly calorific, is not correspondingly filling, and so does not send the brain signals telling a person to stop eating in the same way that a filling main meal would. Foods that are high in energy density, and in particular high in fat, have only very weak effects on satiety —that is they do not fill you up. A Snickers bar, although it is in fact as calorific as some main meals, would typically be eaten as a snack between meals, and a person in the habit of having a Snickers bar with their mid-afternoon cup of tea could arguably be said to be having four meals a day rather than three.

76. According to Professor Prentice, humans have evolved to have an "asymmetry of appetite control", often described as the 'thrifty genotype' theory:

We are very good at recognising hunger—it is an evolutionary obligatory fact that we should respond to hunger very well—we are very bad at recognising satiety. Indeed, if you think it through, we are almost predesigned to lay down fat.[82]

77. While in times of uncertain food availability this asymmetry could help people survive famines, in today's environment, it is very conducive to weight gain. Professor Prentice explained that while it does not necessarily pose problems for people who are very physically active, who are generally able to control their weight successfully on their hunger drive, the reverse is true for people who are very physically inactive: "the environment is pressing on you much more food than you need and your body, physiology, is just not designed to stop it; in fact it is designed to say, 'Thank you very much, I will lay that down as fat.'"[83]

78. Professor Prentice went on to describe to us how controlled experiments demonstrated this phenomenon:

You have experimental volunteers who you ask to eat normally but you secretly change the content of their foods—then, as soon as you add fat in and increase the energy density they overeat. It is extremely easy to replicate under any experiment: they automatically overeat. The reason they do this is they continue to eat the same bulk of food, the same amount of food, without recognising—their bodies simply do not recognise—that it has more calories, more energy in it.[84]

79. While the energy density of soft drinks, which are frequently highly calorific, needs to be considered differently from that of solid foods, recent research has demonstrated that consumption of soft drinks is likely to increase normal caloric intake—in other words, when people consume soft drinks, they do not recognise that they have taken in extra energy and compensate by reducing energy from elsewhere in their daily diet, or by expending additional energy; they simply add it on.[85] A standard 330 ml can of Coca-Cola contains 139 calories. Thus if a person were to consume a can of Coca-Cola with two meals per day, over a week that would result in an energy surplus of nearly 2,000 calories—more than a whole day's recommended calorie intake for the average woman, and about three-quarters of the recommended daily calorie intake for a man. Evidence from the British Soft Drinks Association suggests that children drink an average of 4.7 litres of soft drink per week, of which only 10% are fruit juice or water.[86]

80. Recently, the thesis that unhealthy food may have specific addictive properties has also been explored. John Blundell, Professor of Psychobiology at the University of Leeds, has argued that while there are fundamental differences between the brain's response to food and to addictive drugs, the pleasure and the positive reinforcement people obtain from eating food could lead to the development of a compulsive element to food consumption.[87] According to Susan Jebb, this is fostered not only by the taste of food but by "the whole aura surrounding food, the marketing, the lifestyle that you buy into."[88]

81. The past 20 years have seen considerable changes not simply to what people eat and how much, but also to the ways in which they eat. Snacking, eating out, and reliance on convenience food have all increased dramatically. These changing patterns of consumption are in part a response to the far reaching social changes of the last 50 years, including a greater number of women working outside the home, longer working hours, and higher levels of disposable income. However, while these changing eating patterns may not of themselves be a problem, they can be conducive to obesity.

82. Readily available snack foods and drinks are typically very energy-dense, and are usually consumed to supplement rather than replace meals, despite their high calorie content. Between 1993-98, sales of snacks to adults more than tripled in the UK, from £173 million to £541 million.[89] As the Department pointed out in its memorandum, British people now consume an increasing number of meals outside the home, with 25% of respondents to a consumer attitudes survey saying that they regularly used some form of fast food or takeaway outlet.[90]

83. There is also increasing consumer demand for convenience food, and a growing trend towards snacking and eating on the move. The average time spent preparing a meal in 1983 was an hour, but today it has shrunk to 13 minutes.[91] In the period 1990-2000 alone, purchases of convenience foods rose by 24%.[92] According to market analysts Mintel, between 1998-2002, demand for ready meals in Britain grew by 44%, compared to 29% growth across Europe as a whole, and figures suggest that Britain is now consuming the highest number of ready meals in Europe, double the amount consumed in France, and six times that in Spain.[93]

84. Eating ready prepared snacks or meals, whether pre-packed meals which are heated up at home, or food purchased from a restaurant or fast food outlet, reduces a consumer's choice and control over what they eat. When preparing a meal from scratch, a consumer will have full control over how much fat, sugar and other ingredients are put into the dish, control over what quantity to make, and over the portion size that is served. Buying a snack such as a bag of crisps, or a ready-prepared meal to heat up, effectively removes those choices. People eating out in a restaurant are even less likely to be aware of the fat or calorie levels of the meal they have ordered.

85. Consumption of alcohol, particularly amongst women and young people, has increased dramatically during the past years.[94] With most alcoholic drinks being at least as calorific as a high-sugar soft drink, such as Coca-Cola, it would seem intuitive that the massive increase in their consumption has had some impact on the nation's weight. Much attention has focused in recent months on the growing culture of 'binge drinking', particularly amongst young people. While the health risks associated with this are well documented, what is less publicised is that drinking five pints of lager over an evening adds an extra 1,135 calories, nearly half a man's daily energy requirement, and five bottles of an 'alcopop' such as Bacardi Breezer contain 990 calories, nearly half a woman's daily energy requirement.[95]

86. During the course of our inquiry, we have been continuously surprised by the lack of emphasis given to the impact of alcohol consumption on obesity. While the Department, and most experts who gave evidence to us were in no doubt that it must have an impact, there seemed very little definitive evidence in this area. We were also concerned to note that the Government's recent Alcohol Strategy made no mention whatsoever of the potential impact of alcohol consumption on weight gain, leading to a further set of health problems in addition to those already linked directly to alcohol.[96]

87. The relationship between alcohol consumption and obesity is too little understood. We recommend that the Department of Health commissions research into the correlation between trends in alcohol consumption and trends in obesity.

Information and choice

88. What people consume is, at its simplest level, determined by personal choice. However, changing lifestyles have made the nutritional environment, spanning supermarkets selling ready meals, restaurants, sandwich bars and fast food outlets, increasingly complex, and this means that making healthy, informed choices about nutrition is more complicated than ever. The nutritional environment of the United States was described in stark terms by Marion Nestle, from the Department of Nutrition, Food Studies and Public Health, New York University, who argued that American society had changed in ways that made it "much, much too easy for people to over-eat":

Food is extremely cheap in our country, and there are many, many driving forces keeping the cost of foods extremely low. Low-cost food encourages people to eat more. Food is extremely convenient; it is ubiquitous; it is available all day, 24 hours a day, 7 days a week; and it is available in larger and larger portions … Every single one of those aspects encourages people to eat more, and there is a considerable amount of research that demonstrates that. We have created a societal environment in which it is considered totally acceptable for people to eat anywhere, to eat all day long and to eat in larger and larger quantities; all of which encourages people to eat more and to gain more weight.[97]

89. While the UK may be some way behind the US in terms of its obesity epidemic, our evidence suggests that the information and tools consumers require to negotiate a changed nutritional environment have not kept pace with those rapid changes, and that frequently external factors are directing consumers towards unhealthy rather than healthy choices.

90. Information and education are clearly key to making healthy choices about what and how much to eat. Yet although the evidence-base about what constitutes a healthy diet has been well developed for many years, it is clear that people are not adhering to healthy eating recommendations. According to the Food Standards Agency (FSA), British children eat fewer than half the recommended portions of fruit and vegetables a day, and the vast majority have intakes of saturated fat, sugar and salt which exceed the maximum adult recommendations.[98]

91. Why, then, are these messages not getting through? Perhaps they are not being delivered loudly or consistently enough, meaning people are simply unaware of how to balance foods to make up a healthy diet that does not lead to weight gain. Alternatively, people may be insufficiently aware of the devastating health consequences associated with being overweight or obese. According to Tim Lobstein of the Food Commission healthy eating messages are well known, but external pressures prevent people from adhering to them:

When I go and give talks to even low-income families, they are fairly well aware of the sorts of things they ought to be eating more of, but they are not doing it and they are not doing it for a variety of cultural and economic reasons—and also for children there are fashionable reasons and so on. There are a number of other pressures besides the health education message that are encouraging them away from healthy eating.[99]

92. We address these other pressures, including commercial food promotion and food pricing later in this chapter.

93. In addition to a good theoretical understanding of what constitutes a healthy diet, being able to prepare a healthy meal is a cornerstone of healthy eating habits. Yet we have received evidence suggesting that a growing number of British people lack the basic skills and confidence to do this. The Nutrition Society also argued that the "lack of ability to cook amongst the school generation means that people are not as in control of their food supply as they might be."[100] Focus on Food echoed these sentiments by stressing that dietary behaviour could not be changed without teaching people relevant skills such as cooking, which reduce the reliance on high-fat, high-salt, processed foods.[101] The need for such skills to be taught is all the more marked, given that, for the first time, the current generation of children is being raised by parents whose main experience of cooking is preparing convenience foods, thus removing a major source of food education from children.

94. The national curriculum currently includes Food Technology under the remit of Design and Technology, and this covers learning about food preparation, food hygiene and the design of food products. Food Technology is compulsory up until the age of 11, but after that there is no compulsion for any practical cooking skills or food education to be learnt. Moreover the Qualification and Curriculum Authority states that the focus of Food Technology should be on manufacturing and processing food rather than practical cooking skills.

95. The dire state of cookery provision has led to a number of initiatives where mobile facilities for cookery teaching, dubbed 'Cooking Buses', travel to schools providing lessons for children and training for teachers. The existence of these schemes has clearly tapped into an unmet need and enthusiasm for cookery training at school, as many of these schemes have waiting lists of over a year.[102]

96. Even if people are well aware of what constitutes a healthy diet, and have full information about the nutritional value of what they are eating, their decision-making does not take place in a vacuum. Any health information about nutrition that consumers currently receive is heavily counterbalanced by advertising and promotion campaigns undertaken by the food industry. Table 5: Advertising spend across the top ten advertised food brands in the UK (2002)
Spend (£'s) % of Total
MCDONALDS - Fast-food restaurant 41,973,066
COCA COLA, ORIGINAL COKE - Soft-drink 15,531,274
KENTUCKY FRIED CHICKEN - Fast-food restaurant 15,140,219
BURGER KING - Fast-food restaurant 11,168,498
PIZZA HUT - Fast-food restaurant 9,357,014
COCA COLA, DIET COKE - Soft-drink 7,395,695
PRINGLES, CRISPS - Savoury-snack 6,700,914
KIT-KAT, CHOCOLATE BAR - Confectionery 6,469,021
WEETABIX - Breakfast Cereal 6,366,666
KELLOGG'S, CORN FLAKES - Breakfast Cereal 6,263,369

TOTAL (all food brands)*


Source: A C Nielsen cited in the Hastings Report (see below) 2003Table 6: Children's after-school snack products, market size and advertising spend,
Market size Adspend
1998 20021998 2002
£m £m£m £m
Chocolate bars and countlines 3,7453,494 68.991.0
Crisps and snacks2,078 2,38530.5 31.4
Sweets**1,770 1,76838.6 39.5
Sweet biscuits1,484 1,4627.2 16.3
Fresh fruit2,962 3,1504.5 2.8
** includes sugar confectionery and chewing gum

Source: Nielsen Media Research/Mintel

97. Figures from the Mintel study into advertising costs revealed that only a fraction of the amount of money spent advertising chocolate, sweets, crisps and snacks was devoted to advertising fruit. While a total of £178.2 million was spent in 2002 on advertising chocolate bars, crisps and snacks, sweets and sweet biscuits, over the same period only £2.8 million, less than 2% of this total, was spent on advertising fruit. Meanwhile, the £5 million annual budget of the Government's Five-a-day campaign is simply drowned out by the advertising budgets of large food companies.[103]

98. The food industry also deploys a full range of less explicit and visible, but no less effective, promotion techniques, such as inclusion within packs of collectible free gifts to encourage repeat purchase, and strategic placement of products within stores. Examples of this include placing high-sugar soft drinks in refrigerators alongside fruit juice, giving over a prominent end-of-aisle space to one product, or placing sweets near checkouts where they are guaranteed a captive audience of fractious children and hassled parents. In doing this, food manufacturers work closely with food retailers, in particular large supermarkets. While this relationship appears to work to the mutual benefit of both food manufacturers and retailers, the impact on the consumer may not be so positive. Packaging, pricing and the design of the products themselves are also used to encourage consumption. It is because product design is driven by consumer preference that so many children's food items are nutritionally poor. It was noticeable—and deeply regrettable—that when four food manufacturers (Pepsi/Walkers, McDonalds, Cadbury's and Kellogg) were giving evidence to us, only Kellogg gave a straight answer to the question "How much of your product would you advise a parent to give their five year old?" The other three representatives simply equivocated.[104] This points up the challenge facing parents when trying to help their children to eat healthily.

99. All these marketing efforts come together in evocative brands that have great emotional and psychological power. In a world increasingly dominated by such brands it is noticeable that the market leaders in the food industry—Coca Cola, McDonalds, Walkers—represent relatively unhealthy food options and are aimed heavily at children. However, the increasing availability of suitably healthy fruit and salad options at some fast food outlets is welcome if these are promoted energetically.

100. While food advertising is an ever-present and accepted part of daily life, it is assumed that adults are sufficiently media-literate to be able to separate advertising claims from fact, to recognise the commercial motivation of advertising, to balance advertising messages against other relevant information, such as healthy eating messages, and to make their decisions accordingly. However, questions are now being raised about the legitimacy of explicitly targeting children, who may not be as able as adults to negotiate the pressure put on them by food advertising. According to the International Association of Consumer Food Organisations, children may be "technologically savvy" but they are "nutritionally inexperienced and ill-equipped to distinguish inflated sales messages from objective fact."[105] This is particularly concerning given that the promotion and advertising of unhealthy foods is targeted far more intensively at children than at adults: we were shocked to hear from research carried out by Sustain that during children's programming, adverts were screened between two and three times more frequently than during adult programming:

Food advertisements were shown more frequently during children's programmes (45-58% of all advertisements) than during adult programming (21%).

The overwhelming majority of the foods advertised during both adult (86%) and children's (95-99%) programmes were high in fat, sugar and/or salt.

There were no adverts for fresh fruit and/or vegetables during either the adult or children's programmes.[106]

101. In addition the FSA commissioned a systematic review of the literature from a team of academics headed by Professor Gerard Hastings, at the University of Strathclyde (hereafter 'The Hastings Review'). This examined the academic literature on the amount and nature of food advertising to children over the last 30 years. It concluded that:

children's food promotion is dominated by television advertising, and that the majority of this promotes pre-sugared breakfast cereals, confectionery, savoury snacks, soft drinks and, latterly, fast-food outlets.

102. It goes on to state that concerns should not be limited to television advertising and indeed that "There is some evidence that the dominance of television has begun to wane in recent years." The review suggests two reasons for this trend:

First, the rise of new media (eg. computers, text-messages, internet and email) has given rise to a host of new potential creative strategies, in themselves more likely to be both accessed and understood by young people than their parents (compared to television). Secondly, the evolution of brand stretching and globalisation has allowed promotional messages to cut across many different media and increased tie-ins with below-the-line marketing activities. These may now include links to new media (eg. branded, perhaps online, computer games), other new promotional channels (eg. in-school marketing) and more traditional avenues for below-the-line activities such as sports sponsorship.[107]

The review went on to conclude that:

The advertised diet varies greatly from the recommended one, and that themes of fun and fantasy or taste, rather than health and nutrition, are used to promote this to children. Meanwhile, the recommended diet gets little promotional support.

103. It is not difficult to see why children are prime targets for food industry promotion and advertising—a report in The Observer cited a food industry publication arguing that for soft drinks companies, an eight-year old boy was the ideal target customer, as he had 65 years of consumption ahead of him.[108] Marketers also engage in what is known as 'cradle-to-grave' marketing which is essentially relationship marketing with children. In recognition of children's potential as consumers to a firm over their lifetime, promotion can be used to create and foster ongoing relationships with them. Usually strategies of this kind focus on branding in an effort to develop an emotional and enduring connection between the child and the brand. Academic research has shown the importance of brands to children of all ages; the relationships that children form with brands often become central components of their lives.[109] Promotion is used to encourage children to develop awareness of and preferences for a particular brand.

104. Advertising agencies and food manufacturers were quick to describe today's generation of children as "media-aware" and argued that they were perfectly able to recognise advertising for what it was and interpret it accordingly from as young as five years old.[110] However, Andrew Brown, Director General of the Advertising Association and also representing the Food Advertising Unit, admitted that children did not know the full persuasive influence of advertising until they were about eight or nine, and research suggests that children below the age of five years generally regarded advertising solely as entertainment.[111] Academic research confirms that there is real cause for concern about advertising to children. Understanding of its persuasive intent only emerges at 7-8 years.[112] Prior to this, children show very little ability accurately to judge and critically to reflect upon commercial messages, and as a result are very trusting of them. One study showed that 64.8% of 6-7 year old children reported "trusting all commercials".[113] At around the age of 8 years, there is evidence that children are beginning to respond to advertising in a more sophisticated and critical way.[114]

105. It is clear advertisers use their increasingly sophisticated knowledge of children's cognitive and social development, and careful consumer research into their motivations, values, preferences and interests, to ensure that their messages have maximum appeal.[115] Moreover, our inquiry showed that children as young as three years old are being deliberately targeted by UK food companies.

106. We used our powers to send for persons, papers and records to require the advertising agencies working for a number of popular fast food, carbonated drink, cereal and confectionery manufacturers to supply material to us. We requested the following information from Abbot Mead Vickers, concerning accounts for Pepsi-Cola and Walkers Wotsits, from Leo Burnett, concerning accounts for Kellogg's Cocopops and McDonald's, and from Coca-Cola directly: contact reports; client briefs; creative briefs; media briefs; media schedules; advertising budgets; market research reports; links to other communications; and links to marketing strategy.

107. The promotional material supplied by Leo Burnett for the McDonalds campaigns gave detailed information relating to 12 different campaigns for Happy Meals within a one-year period, targeted at different aged children, ranging from 3-11 years.[116] There is no nutritional information relating specifically to the calorific content of Happy Meals on the McDonald's UK website, but by adding the calorific content of different components, a Happy Meal with a cheeseburger and a regular coke can be shown to contain 613 calories, which could represent nearly half the daily caloric need of a six year old girl, and over half that of a three year old girl.[117] There were a total of 98 toys to collect over a period of one year—if a child were to collect all the toys they would require a Happy Meal every 3.7 days. One McDonald's campaign, Microstars, ran for a five-week period and had 20 toys to collect in the series. To collect all the characters free the child was required to average four Happy Meals per week during the promotional period, consuming 2,452 calories per week solely from Happy Meals, and a total of 12,260 calories over the five-week period. When questioned about this, Bruce Haines, for Leo Burnett, argued that toys were not designed to promote consumption, telling us that:

the toys in a Happy Meal are considered by children to be an intrinsic part of the product, as is the packaging in which the food and toys are presented … the toys themselves are available for purchase in a McDonald's for about 99 pence in any case, so you do not actually have to eat the food to collect them. They are not free.[118]

108. However, this was directly contradicted by the creative and client briefs for some Happy Meal campaigns, which made it clear that an aim of some promotions was to "get children to believe 'I've got to have a Happy Meal so that I can have an X toy'."[119] We were also told by McDonald's that:

The objective of the promotion is not principally to drive people to come in more often, it is largely designed to get different people to come in to our restaurants … our intention is of course to raise the frequency slightly, but it is very slightly.[120]

109. Again, this was directly contradicted by the client brief, which stated that there was "scope to increase frequency from light to heavy users."[121]

110. Manufacturers and advertising agencies told us that advertising food to children could never be argued to undermine healthy eating messages, as ultimately parents retained full control over what children ate as it was they who bought their children's foods.[122] However, recent research has shown children's own spending-power to be increasing considerably. The Mintel report on snacking noted a steep rise in the average amount of pocket money allocated to children between 1997-2001. On average, 5-16 year olds enjoyed a 45% increase in their pocket money over the period, such that the average amount of weekly pocket money was £6.53.[123] The authors of the report noted that "with an average of over £6 per week to spend on themselves, children can easily afford snack foods." Crisps and savoury snacks are the most popular after-school snack for children and "this form of savoury snack is within almost all children's budgets. Indeed a number of brands specifically target children and are competitively priced at 10p or 20p."[124]

111. Furthermore, the written evidence we requested from advertising agencies revealed that despite the Advertising Standards Authority (ASA) code banning this, many campaigns have pester power as an explicit aim: the Wotsits client brief had a specific aim of getting children to "pester their parents to buy them", and in the Media Strategy Brief the stated "desired consumer response" for the campaign was "Wotsits are for me—I'm going to buy them when I get a chance and pester Mum for them when she next goes shopping." Walkers, whilst acknowledging the inappropriateness of 'pester power' as an explicit aim of the campaign, sought to downplay its significance, and cited the fact that the campaign had been passed by the ASA.[125] However, we were appalled that a £710,000 campaign, launched by one of Britain's largest snack manufacturers, deliberately deployed a tactic which explicitly sought to undermine parental control over children's nutrition by exploiting children's natural tendency to attempt to influence their parents. The fact that this campaign was approved by the Advertising Standards Authority does not exonerate it, but merely demonstrates the ineffectiveness of current ASA standards and procedures.

112. The food industry's most frequently rehearsed argument in relation to the impact of advertising and promotion on the consumption of unhealthy foods, and hence its potential role in obesity, was that these tools simply increased the market share of a particular brand of food or drink, rather than expanding the total market by encouraging the consumption of a particular food group, such as chocolate or sweet fizzy drinks. Similar arguments have been rehearsed by the tobacco industry, as we noted in our report into that industry.[126] However, the Secretary of State for Culture, Media and Sport was clearly able to see this argument for what it was:

Dr Naysmith:  I just wonder what do you believe on that when advertisers come and tell you, as they tell us, that all they are doing is trying to get a bigger share of the market for their brand when, in fact, what they are doing is trying to create a bigger market?  

Tessa Jowell:  I suspect in practice it is a bit of both. What they are trying to do is to get you to buy Galaxy instead of Cadbury's milk or whatever it is, but they are also trying to increase overall levels of consumption, of course I understand that.[127]

113. As well as being an obvious commercial aim of those in the food industry, it is also clear from large-scale research that advertising of foods to children does have a marked effect on the category of foods they select as well as the brand. The Hastings Review, published in September 2003, provided the clearest evidence yet that advertising had a direct impact on the category of foods children selected, and increased consumption of unhealthy foods.[128] The food industry refused to accept the findings of this report, and commissioned its own report to rebut the findings of the Hastings Review and the large body of evidence on which they were based.[129] To resolve the issue, the FSA then commissioned an independent evaluation of the Hastings Review, which fully endorsed both its methods and conclusions.[130]

114. Advertising and promotion of foods to children is not limited to television, shops and restaurants, and we were surprised to learn of the full extent of food promotion now taking place in schools. Recent initiatives by Walkers and Cadbury's, which attempted to involve schools in promotion schemes by rewarding the purchase of crisps and chocolate with sports equipment for schools, were described by Susan Jebb as "an absolute Trojan horse", although both of these received full backing from Government ministers. [131]

115. According to Kath Dalmeny of the Food Commission, school breakfast clubs, originally conceived to ensure children received a healthy breakfast before school, are increasingly having to work in conjunction with the food industry:

Some of the breakfast clubs have sponsored foods that are given out, because the school needs to find funding for the breakfast club, so particular manufacturers will sponsor them. I have seen Burger King sponsoring some of the breakfast clubs. While it might not mean that there will be Burger King foods being supplied necessarily to the schools, the fact that branded goods—which may be high in fat, high in sugar, high in calories—are associated with those healthy eating schemes and associated with the endorsement of the school is problematic, I think, because it gives the message to children that these are good options to choose, that they are a regular part of their lives.[132]

116. An increasing number of schools also provide schoolchildren with access to unhealthy foods through vending machines installed in school premises. Schools are in many respects a 'captive market' for the food industry, as often vending machines represent the only opportunity schoolchildren have to purchase drinks and snacks during the school day. The motivation for schools to install vending machines is clear, as in total they contribute over £10 million each year to school budgets.[133] However, the impact on children's nutrition and health may be less positive. A pilot study funded by the FSA and carried out in 12 secondary schools has recently concluded that when given the option, children do make healthy choices. The 12 schools all installed vending machines containing healthier drinks, such as milk, water and fruit juice, and approximately 70,000 healthier drinks were bought during the 24-week duration of the trial.[134]

117. Supplying healthy meals at school not only provides an opportunity to influence a young person's nutritional and calorific intake in a positive way, but can also encourage young people to try new, healthy food they might not otherwise have access to, and shape their eating habits outside school. However, our evidence suggests that, far from doing this, school catering arrangements allow children to eat very unhealthily. The prevalence of cafeteria-style food outlets that allow pupils to opt out of healthy choices in favour of unhealthy ones remains high in schools, and a report by the Consumers' Association argued that the majority of school lunch menus "read like fast food menus"[135]. This is in stark contrast to the school lunch we sampled in Finland, where children were given no other option but a filling, healthy lunch, which included a portion of salad but no pudding, with the choice of beverage limited to water or milk. This confirms the findings of one of the key studies uncovered in the Hastings Review which showed that vending machines in school could be used to encourage the consumption of healthier food options with appropriate signage, pricing and offerings.[136]

118. With much school food provision now contracted out to independent suppliers, the onus appears to be on delivering palatable foods as cheaply as possible, with little recourse to health benefits. Sustain reported that some schools have available as little as 40p per child to provide the ingredients for a two course lunch.[137] The Welsh Food Alliance argued that according to one large commercial catering contractor, English public schools spend twice as much as the state sector on food ingredients for school lunches.[138]

119. Food labelling, detailing the calorific and nutritional content of foods, is a key element of the information people need to make healthy choices, and inadequate labelling can have a negative impact on nutrition in several ways. First, if nutritional information is absent, unclear or misleading, this could encourage the purchase of a product which a consumer would not buy if it were clearly labelled as high in fat or calories. An example frequently cited in our evidence was that of products claiming to be 'light' options when in fact they were still high in calories, and products claiming to be '70% fat free', putting the onus on consumers to notice that that this actually meant the product was 30% fat, and would in fact be termed by the FSA as containing a lot of fat.[139] Health claims may also be made on high calorie products to promote purchase, for example claims that breakfast cereals boost concentration and healthy bones, when the same health benefits could be accrued from products with a far lower calorie content.

120. Currently, nutritional labelling in England is largely voluntary. Not only does this mean that on some foods nutritional labelling can be entirely absent, but even when food is labelled, there is little consistency about the format or size of labelling, making it difficult to interpret or even to see. Some products give information per 100g, and some per packet, which is less useful for a consumer than the same information presented by serving. Even when products do give nutritional information by serving, the size of a 'portion' may vary between brands.

121. While there are many problems and inconsistencies about nutritional labelling on pre-packed food, information about the nutritional content of food purchased in restaurants or take-aways is virtually non-existent, and since this is now the fastest growing food sector, this problem is set to increase.

122. Despite the barrage of information consumers receive about food, whether through labelling, advertising, promotion, or health education, price remains a key determinant in choice, with research suggesting that cheap food is the priority for consumers using supermarkets. While 'healthy' versions of foods are becoming increasingly available, and consumers are seemingly very willing to buy them (research by the Consumers' Association suggested that 38% of shoppers claimed they would be willing to pay a little extra for foods carrying a 'healthy' logo[140]), instead of fostering this desire to eat healthily, the food industry appears to be exploiting it by selling foods with reduced fat or calories at considerably elevated prices. A recent survey by the Food Commission, illustrated that a shopping basket of 'healthier options' was 51% more expensive than a basket of standard processed foods. In April 2003, an article in Health Which? on supermarket healthy eating ranges, such as 'Good for You', 'Be Good to Yourself' and 'Eat Smart'[141] identified that in some cases there could be up to 200% price difference between the healthy and standard versions. In addition to this, they argued that many of the healthy options offered very little or no calorie saving, with some simply containing a smaller serving of the identical product.

123. Price differentials are likely to be even greater when healthy versions are compared to supermarkets' 'budget' lines. Most supermarkets do not offer healthy alternatives within their own budget brands aimed at people shopping on a smaller budget. In a recent survey in the Sunday Herald ASDA was the only supermarket of the 'Big Five' which offered low-fat alternatives within its economy range, although it admitted that the items had "not consciously been developed as low fat".[142] In fact, research carried out by the Consumers' Association in February 2002 suggested that on average budget brand crisps had more fat, calories and saturated fat than standard versions.[143]

124. Naturally healthy foods such as fresh fruit and vegetables are also considerably more expensive than non-healthy alternatives. Comparing the prices of various fruits with high calorie snacks certainly demonstrates pricing differences. On the Tesco online shopping website, bananas are priced at approximately 13p each, with apples varying in price between 17-34p each. 'Funsize' small pears, marketed at children, cost 18p each, and satsumas are more expensive at 21p each. By contrast, small chocolate bars, some marketed specifically at children as 'breaktime' size, varied in price between 8p for a Milky Way to 16p for a Snickers. Crisps were even cheaper. Tesco's own brand crisps cost just 5p per bag for the budget range, or 8p per bag for the standard range, with Walkers branded crisps available at 11p per bag.

125. While many supermarkets claimed to support Government initiatives to promote fruit and vegetables to children, according to research carried out by Friends of the Earth pre-prepared fruit and vegetables packaged to appeal to children were being sold at vastly inflated prices by several of them. For example, Tesco's Kids Snack Pack carrots cost £5.50 per kg, 13 times the price of Tesco's 'value' carrots, while ASDA's 'Snack pack carrot crunchies' cost 10 times the price of normal carrots.[144]

126. An important form of price promotion is the phenomenon of 'super-sizing', where food is sold in larger quantities or portion sizes at little extra cost. Super-sizing is now visible everywhere from fast-food outlets, where it originated, to supermarkets. Although McDonalds have now withdrawn the largest of their super-size sizes, Julian Hilton-Johnson confirmed in evidence to us that all McDonald's staff are trained to promote super-size portions verbally when serving customers.[145] According to Professor Andrew Prentice, the falling cost of foods has directly contributed to super-sizing, as it is now very easy to use "bigger is better"[146] as a marketing tool. Susan Jebb, as a dietician, felt that super-sized portions were entirely superfluous to the energy needs of a normal person, arguing that "there is almost nobody in the UK who needs super-size portions, our energy needs are lower than ever."[147]

127. The evolution of super-size food portions began with the introduction of the McDonald's Big Mac in 1968 and accelerated in the 1970s with value meals, special packaging, promotional campaigns, and lower prices.[148] McDonald's Corporation executive David Wallerstein initiated the super-size hamburgers, french fries and colas in the 1970s, taking his lead from the cinema industry, where high mark-up of jumbo-sized snacks like popcorn and cola led to higher profits.[149]

128. Food companies in the USA have been able to cut prices and spend more money on innovating new and larger food products because of the drop in prices for sugar, soybean, corn, palm oil, meat and other commodities. When food price inflation reached an all-time high in the early 1970s, consumer groups mobilised and agricultural policies were reformulated to ease regulation and increase production.[150] The price of sugar fell with the discovery of a way economically to produce a cheaper sweetener called high-fructose corn syrup (HFCS) in 1971. This invention ended years of unnaturally high sugar prices due to foreign aid policies. HFCS was six times sweeter than cane sugar and could be made from corn so the cost of production was much lower, allowing companies to produce more food for equal or less cost. Low price led both Coca-Cola and Pepsi to switch from a 50-50 blend of sugar and corn syrup to 100% HFCS, saving both companies 20% in sweetener costs.[151] From the mid-1970s American trade policies also ensured low prices for palm oil. By the early eighties the price of every single commodity was down. Meat production worldwide soared as feed costs of soy meal and corn fell. Calorie-dense foods at supermarkets were more affordable due to growing surpluses of US corn producing more HFCS.[152]

129. So why are healthy foods so expensive, while unhealthy foods are sold so cheaply by comparison? Much of our evidence implicated the European Union Common Agricultural Policy (CAP), through its subsidies for withdrawal and destruction of good quality fruit and vegetables to maintain prices, consumption aid for butter, consumption aid for high-fat milk products in schools, and subsidies to promote sales of high-fat milk products and wine.[153] According to Tim Lobstein of the Food Commission:

Food supply is a lot of the push towards why our diets have been shifting over the last few years. The surplus amounts of sugar and butter and vegetable oils, which have been created under the Common Agricultural Policy, have to find a home somewhere. Surplus foods are disposed of and destroyed but the extra fats and oils all go into our food supplies.[154]

130. The problems with the CAP stem from the basic provisions of the original Treaty of Rome, which put the focus on trade and economic issues, with little or no concern for public health. This has to change if Britain's health is to improve.

131. Professor Marion Nestle, from the Department of Nutrition, Food Studies and Public Health, New York University, in compelling evidence to us, argued that food overproduction was the root cause of obesity in the United States, which currently produces approximately 3,900 calories of food per day for every man, woman and child in the country, roughly double the average calorific need.[155]

132. While we have not had the scope or expertise, during the course of this inquiry, fully to explore the agricultural and economic policies behind food pricing in the UK, it is apparent that the current situation does very little to facilitate consumers making healthier nutritional choices.

Causes of obesity related to physical inactivity

133. There is little doubt that the nation as a whole is not as active as it should be. Current Department of Health advice is for individuals to undertake at least 30 minutes of moderately intensive activity (e.g. brisk walking) on at least 5 days a week. However, only around 37% of men and 25% of women currently achieve this target.[156] Levels of activity in the UK are below the European average which is part of the explanation for higher obesity rates.[157] For children and young people, the Department of Health advice is that they should undertake one hour of moderate activity each day. The Chief Medical Officer's recent report into the impact of physical activity and its relationship to health "confirms that, according to the best evidence, these recommendations remain appropriate for general health benefits across a wide range of diseases."[158]

134. Game Plan, the strategy for delivering the Government's sports and physical activity objectives, jointly produced by the Department for Culture, Media and Sport and the Cabinet Office Strategy Unit in December 2002 estimated the cost of physical inactivity in England at around £2 billion per year, a figure roughly equivalent to the £2.2 billion spent at that time by Government and lottery sources on sport. Each 10% increase in activity across the population has a potential gain of £500 million.[159]

Changing lifestyles

135. The NAO report Tackling Obesity in England stated that the extra physical activity involved in daily living 50 years ago, compared with today was the equivalent to running a marathon a week.[160] So why have lifestyles changed so dramatically in the past 50 years? A first answer lies in the increasing use of motorised transport instead of active methods of transport, such as walking and cycling. The latest National Travel Survey indicates that the average person now walks 189 miles per year, a fall of 66 miles over 25 years.[161] According to Tom Franklin, of Living Streets, it is clear that "we are walking less than we have probably ever done in history."[162] Mr Franklin attributed the decline in walking to the loss of opportunities to walk, as well as to increased access to motorised transport. He argued that people would not walk to local services, be they schools, hospitals, GP surgeries or shops, that were sited more than 15 minutes' walk away, and moreover that increasingly services such as these were covering larger areas and so moving further away from residential centres.[163]

136. Measuring how active people are is difficult. The traditional approach has been to rely on questionnaires but such self-reporting is unreliable. As Chris Riddoch, an expert in physical activity based at Middlesex University, told us:

People will report what they remember doing. They tend to remember the things they plan to do. If they went for a walk with the dog they will remember that. What they do not remember are all the incidental things they do like nipping up the stairs to the office on the floor above. Self-report measures have a fairly large amount of error built in to them.[164]

A more effective measurement is achieved by the use of pedometers which record the actual number of steps taken each day.[165]

137. The increasing use of cars has led to a vicious circle of car dependency, as town planning has increasingly prioritised the needs of motorists above those of pedestrians and cyclists, meaning that in many places walking and cycling are at best unpleasant and at worst dangerous. At the same time, local neighbourhoods are increasingly perceived by parents as unsafe for children to play out in, implicitly discouraging active play and forcing children back in front of the television set. This phenomenon was repeatedly described by our witnesses.

138. England now reflects the result of two generations of planning centred on the use of cars. Car parks are readily available, but bike racks are not. Employees who want to walk or cycle to work frequently have no place to get showered and changed when they arrive at the workplace.

139. Tom Franklin suggested to us that the conditions for the pedestrian had actually deteriorated over the last half century: "The focus of people who are managing our streets has been about moving the traffic as fast and efficiently as possible and pedestrians have been shoved to one side."[166] John Grimshaw for Sustrans noted that the Highway Code stated that motorists should give way to pedestrians at junctions but that "no pedestrian who is alive has ever obeyed that rule."[167]

140. Pedestrians and cyclists are the 'second class citizens' of Britain's roads:

What you find is that people walking are sent underground, they are sent over bridges, they find railings at the side of the pavement so they cannot cross where they want to cross.[168]

141. The Environment, Transport and Regional Affairs Committee (whose remit is now covered by the Office of the Deputy Prime Minister), in 2001 undertook a major inquiry into walking in towns and cities, in which they argued:

In contrast to the changes made to every town and city to ease motor transport, walking has been made ever more unpleasant. Pedestrians have been treated with contempt. We are corralled behind long lengths of guard railing, forced into dark and dangerous subways and made to endure long waits at pedestrian crossings … The short walk to the shops has been made unpleasant so that the commuter can get to the centre of town more quickly.[169]

142. Dr Nick Wareham of the Institute of Public Health, University of Cambridge, graphically illustrated the decline in cycling when he pointed out that 23 billion kilometres were cycled in the UK in 1952 but only 4 billion kilometres were now cycled annually.[170] The decline in cycling has occurred at the same time as the UK car population has grown in size. Whereas there were 16 million cars in 1975 there are 27 million today.[171]

143. Cycle use in European countries such as the Netherlands differs from Britain where cycling drops off markedly in the mid-teenage years, particularly for women, whereas Dutch men and women maintain healthy cycle use into adulthood and old age. CTC, the national cyclists' association, suggested that cycle training was a key component in maintaining use.[172]

144. Less tangible, but probably at least as pertinent, has been the reduction in physical activity in everyday life arising from mechanised tools, warmer dwellings, labour-saving devices, lifts and escalators, more sedentary jobs, and the pursuit of more sedentary leisure activities. Only 20% of men and 10% of women are employed in active occupations. Television viewing has doubled since the 1960s, when the average person watched television 13 hours a week compared to 26 hours now.[173]

Children's activity levels

145. The Chief Medical Officer's recent report into physical activity suggested that 2 in 10 boys and girls undertake less than 30 minutes activity a day.[174] Once again, changes in lifestyle must bear much of the blame for the levels of activity of young people.

146. According to the organisation Working for Cycling, in 1985-86 only 22% of 5-10 year olds were driven to school; that figure had risen to 39% by 1999-2000. Paul Osborne of the National Heart Forum noted that fewer than 1% of school journeys were made on bicycles in this country. That compares to about 15-20% in Germany and 50% in Denmark.[175] This may be because at least one-third of primary schools have effectively banned cycling to school by refusing to allow children to bring bicycles onto the premises.[176]

147. As Tom Franklin for Living Streets pointed out, the impact of lowered physical activity will not fall simply on the health of the present generation of schoolchildren, but will be carried into adulthood and will be perpetuated when today's children become parents themselves:

For the first time ever less than half of our young children are walking to school. They have learned habits which they will take with them through the rest of their life which is that you drive round the corner rather than walk round the corner.[177]

148. Once at school, children struggle to meet the Government's target of two hours of PE per week. A national survey by Sport England indicates that Government guidelines on sport in schools have had mixed results. The survey showed that the percentage of children who do not take part in any sport at school on a regular basis had increased from 15% in 1994 to 18% in 2002. On the other hand, the percentage of children receiving two hours or more of PE a week increased from 33% in 1999 to 49% in 2002 (although the rate of increase seems to be slowing, with a rise of only three percentage points since 1994).[178] This last result is positive in that it shows the amount of PE in schools does seem to be increasing, although it remains a fact that one in two children does not receive at least two hours of PE in the curriculum. The Government aim therefore remains aspirational.

149. Our predecessor Committee, in its report into Public Health in 2001, noted that in many European countries, such as Austria, Norway, Portugal, Spain and Switzerland, an average of 3.5 hours per week was spent on school sport.[179] The European Heart Network has recommended a statutory minimum three hours per week dedicated to physical activity for all ages of young people.[180]

150. Activity levels appear to have fallen in every aspect of children's lives. Len Almond, from the British Heart Foundation National Centre for Physical Activity and Health, pointed to a "substantial decrease" in children's activity levels during school break-times, telling us that some schools had even put seats in playground so that children could sit down for the whole of the lunch break. There has also been a major reduction in active play at home, with children engaged in far less activity at weekends than they are between Monday and Friday. According to Professor Almond, active play:

is simply being completely eroded (1) through lack of opportunities to play and (2) through the fact that there is no repertoire of games or activities that children can play … They have no repertoire of games or activities to play because they have lost it all, it has been lost over a number of years, and as a consequence boredom—"I'm bored"—is very often a thing that young people complain to their parents at school holidays and weekends.[181]

69   Q296 Back

70   "Obesity in Britain: gluttony or sloth?" BMJ 1995;311:437-439 (12 August) Back

71   Ibid Back

72   In this report we refer at times to 'healthy' and 'unhealthy' foods. Below we discuss in detail the arguments surrounding the use of these terms. We are ourselves satisfied that they are appropriate descriptions and that most experts and indeed the public at large would accept them. Unhealthy foods tend to be energy-dense, and high in fats, sugars and/or salts. Back

73   "Obesity in Britain: gluttony or sloth?" BMJ 1995;311:437-439 (12 August) Back

74   Appendix 18 Back

75   "Obesity in Britain: gluttony or sloth?" BMJ 1995;311:437-439 (12 August) Back

76   Q282 Back

77   Q294 Back

78   The Scientific Advisory Committee on Nutrition is an advisory committee of independent experts that provides advice to the Food Standards Agency and Department of Health as well as other Government Agencies and Departments. Its remit includes matters concerning nutrient content of individual foods, advice on diet and the nutritional status of people. See Back

79   Andrew Prentice and Susan Jebb, "Obesity in Britain: Gluttony of Sloth?", BMJ, 311 (1995), pp 437-39. Back

80;;  Back

81   Collins Calorie Counter Back

82   Q287 Back

83   Q287 Back

84   Q288 Back

85   Q290 Back

86   Appendix 22; Appendix 14 (Professor John Blundell) Back

87   Q367 (Susan Jebb) Back

88   Q367 Back

89  Back

90   Ev 9 Back

91   "Can't Cook. Won't Cook. Don't Care. Going Out", The Times, 17 November. 2003 Back

92   National Food Survey 2001 Back

93 Back

94   Ev 8 Back

95   http:/  Back

96   Alcohol Harm Reduction Strategy, Cabinet Office, March 2004 Back

97   Q461 Back

98   Food Standards Agency, (June 2000), The National Diet and Nutrition Survey of Young People aged 4 to 18 years, HMSO, London Back

99   Q303 Back

100   Appendix 13 Back

101   Appendix 34 Back

102   Appendix 34  Back

103   Department of Health press release, 5 October 2001 Back

104   Qq 771, 774, 784, 786 Back

105   International Association of Consumer Food Organisations, Broadcasting Bad Health, July 2003, p 8. Back

106   Parliamentary Office of Science and Technology, Improving Children's Diet, September 2003, p 45. Back

107   Gerard Hastings et al, Review of Research on the Effects of Food Promotion to Children, Centre for Social Marketing, p 98 Back

108   "The Junkfood Timebomb that threatens a generation", The Observer, 9 November 2003 Back

109   M F Ji, "Children's relationships with brands: 'True Love' or 'One-Night Stand?", Psychology and Marketing, 19(4): 369-87; M Lindstrom, and P Seybold, BRANDchild, 2003 Back

110   Q624 Back

111   Parliamentary Office of Science and Technology, Improving Children's Diet, September 2003 Back

112   D R John, "Through the eyes of a child: Children's Knowledge and Understanding of Advertising", in Macklin MC, Carlson L (eds), Advertising to Children - Concepts and Controversies, 1999 Back

113   T S Robertson, J R Rossiter (1974), "Children and commercial persuasion: an attribution theory analysis", Journal of Consumer Research, 1974, pp 13-20 Back

114   D R John, "Through the eyes of a child" Back

115   H Stipp , "New ways to reach children", American Demographics, August 1993, pp 50-56. Back

116   Material relating to the various advertising campaigns cited in this report was submitted as "commercial in confidence" to the Committee. While we have quoted selected material from these campaigns, contained in an analysis produced by the Centre for Social Marketing, University of Strathclyde, at Appendix 61, we have agreed not otherwise to release commercially confidential material. Back

117   See Annex 3 Back

118   Q592 Back

119   Appendix 61 Back

120   Q770 Back

121   Appendix 61 Back

122   Q594, Q763 Back

123   Mintel report, After school snacking (2002) p10 Back

124   Ibid Back

125   Q859 Back

126   Health Committee, Second Report of Session 1999-2000, The Tobacco Industry and the Health Risks of Smoking, HC 27 para 89  Back

127   Q1424 Back

128   Gerard Hastings et al, Review of Research on the Effects of Food Promotion to Children, prepared for the Food Standards Agency - Final Report, Centre for Social Marketing, 22 September 2003. Back

129 Back

130   Professor Stan Paliwoda and Ian Cranford, An analysis of the Hastings Review, "The effects of food promotion on children", December 2003, Back

131   Q313 Back

132   Q380 Back

133   Schools may receive an income of £10-15,000 per annum. See Back

134 Back

135   Ev 391 Back

136   S A French et al, "Pricing and promotion effects on low-fat vending snack purchases: The CHIPS Study", American Journal of Public Health, Vol 91, 1 (2001), pp 112-17 Back

137   Ev 109 Back

138   Appendix 38 Back

139 Back

140   Health Which? , April 2003 Back

141   Health Which?, April 2003 Back

142   Mona McAlinden, "Supermarkets fail to cut fat in 'value' brands", Sunday Herald, 23 November 2003 (based on a survey of the five leading supermarket chains in the UK: ASDA, Safeway, Somerfield, Sainsbury's and Tesco).  Back

143   "Do supermarkets' budget lines mean shrewd shopping or are they just a false economy?", Health Which?, February 2002, Back

144   Friends of the Earth, press release 8 November 2003,  Back

145   Qq 836-38 Back

146   Q369 Back

147   Q368 Back

148   "The Gorge-Yourself Environment", NY Times, 22 July 2003 Back

149   Greg Critser, Fat Land : How Americans Became the Fattest People in the World, 2003. Back

150   Ibid Back

151   Ibid Back

152   Ibid Back

153   For example, Alan Maryon Davies, Q567. Back

154   Q358 Back

155   Q461 Back

156   Health Survey for England Back

157   Ev 118 (National Heart Forum) Back

158   Department of Health, Chief Medical Officer, At least five a week: Evidence on the impact of physical activity and its relationship to health, 2004, p 2 Back

159   Ev 163 (Living Streets), Game Plan: A Strategy for Delivering Government's sport and physical activity objectives, p 47 Back

160   NAO, Tackling Obesity in England, 2001, p 13 Back

161   Ev 163 Back

162   Q 489 Back

163   Ibid Back

164   Q 490 Back

165   Pedometers are instruments attached to a person's waist which measure the number of steps taken. Some models will translate these into numbers of kilometres or miles walked and also calculate calories used in walking. The cheapest pedometers cost under £10. Back

166   Q496 Back

167   Q499 Back

168   Q560 (Tom Franklin) Back

169   Environment, Transport and Regional Affairs Committee, Eleventh Report of Session 2000-2001, Walking in Towns and Cities, HC 167 para 4 Back

170   Q339 Back

171; Back

172   Appendix 8 Back

173   Appendix 18 (Royal College of General Practitioners) Back

174   At least five a week, p 9 Back

175   Q388 Back

176   Q396 Back

177   Q476 Back

178   Appendix 19 (Sport England) Back

179   Health Committee, Second Report of Session 2000-01, Public Health, HC 30, para 191 Back

180   European Heart Network, Children and Young People - the Importance of Physical Activity, December 2001, p19 Back

181   Q400 Back

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