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The Nutrition Society Summer Conference 2022 was hosted collaboratively by Sheffield Hallam University, the University of
Sheffield and Sheffield City Council on 12–15 July 2022
Conference on ‘Food and nutrition: Pathways to a sustainable future’
Symposium: Rank prize fund lecture
Opportunities to improve population health: possibilities for healthier
food environments
Amelia A. Lake
1,3
* , Helen J. Moore
2,3
, Matthew Cotton
2,3
and Claire L. O’Malley
1,3
1
School of Health and Life Sciences, Teesside University, Middlesbrough, UK
2
School of Social Sciences, Humanities and Law, Teesside University, Middlesbrough, UK
3
Fuse, The Centre for Translational Research in Public Health, Newcastle upon Tyne, UK
The recent Covid-19 pandemic highlighted stark social inequalities, notably around access
to food, nutrition and to green or blue space (i.e. outdoor spaces with vegetation and
water). Consequently, obesity is socio-economically patterned by this inequality; and
while the environmental drivers of obesity are widely acknowledged, there is currently little
upstream intervention. We know that living with obesity contributes to increasing health
inequalities, and places healthcare systems under huge strain. Our environment could
broadly be described obesogenic, in the sense of supporting unhealthful eating patterns
and sedentary behaviour. Evidence points to the existence of nearly 700 UK obesity policies,
all of which have had little success. Obesity prevention and treatment has focused on edu-
cational and behavioural interventions targeted at individual consumers. A more sustainable
approach would be to try and change the environments that promote less healthy eating and
high energy intake as well as sedentary behaviour. Approaches which modify the environ-
ment have the potential to assist in the prevention of this complex condition. This review
paper focuses on the role of wider food environments or foodscapes. While there is an imper-
fect evidence base relating to the role of the foodscape in terms of the obesity crisis, policy,
practice, civic society and industry must work together and take action now, in areas where
current evidence suggests change is required. Despite the current cost-of-living crisis, shaping
the foodscape to better support healthful eating decisions has the potential to be a key aspect
of a successful obesity prevention intervention.
Key words: Food environments: Public health nutrition: Obesity: Obesogenic environments:
Food security: Urban planning
There has never been a time when the importance of
food, the cost of food and the impact of food on our
health been more discussed
(1,2)
.Emergingfromaglo-
bal pandemic and entering into a global cost-of-living
crisis has had significant impacts on the wider food sys-
tem and ultimately the food environment. The food
environment,orfoodscape, encompasses any
opportunity to obtain food and includes physical,
socio-cultural, economic and policy influences at
bothmicroandmacro-levels
(3)
. The foodscape can
include both physical and virtual (online; grocery
and takeaway foods) food offering; the online food
environment has grown significantly since the first
2020 Covid-19 pandemic
(4)
.
*Corresponding author: Amelia A. Lake, email Amelia.Lake@tees.ac.uk
Proceedings of the Nutrition Society, Page 1 of 8 doi:10.1017/S0029665123002677
© The Author(s), 2023. Published by Cambridge University Press on behalf of The Nutrition Society.
This is an Open Access article, distributed under the terms of the Creative Commons Attribution
licence (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution,
and reproduction in any medium, provided the original work is properly cited.
Proceedings of the Nutrition Society
https://doi.org/10.1017/S0029665123002677 Published online by Cambridge University Press
Our food-related behaviours occur within an environ-
ment that promotes and actively encourages less healthy,
sedentary lifestyles. This is important in terms of health
outcomes, and specifically those related to obesity
(5)
.
The wider food system has a huge effect on the health
of populations and upon planetary health. Dietary guide-
lines need to reflect both underlying health and environ-
mental sustainability goals if food system changes are to
address the twin challenges of climate change and food
insecurity
(6)
.Dietary sustainability is a fast-evolving
field with increasing buy-in from nutritional profes-
sionals
(7)
. However, as highlighted by the Lancet EAT-
Commission on Food, Planet and Health
(8)
, there is a
need to reduce the intake of animal sourced foods (pri-
marily in G20 countries) and increase the intake of
healthy plant-based foods globally. Yet the cost and
unaffordability of healthy diets remains a key chal-
lenge
(9)
.Muchresearchhasfocusedontwo‘end-points’
within the wider food system: agricultural production
and consumer dietary intake
(10)
. Less research and policy
attention has focused upon changes to food supply chains,
including food processing, transport, surplus redistribution
and waste management: a problem often described as the
‘missing middle’of food system sustainability
(11)
.
The food environment is never static, food supply
and demand respond to a range of socio-political factors
and influences. The ‘perfect storm’scenario
(12)
of the
Covid-19 pandemic, worsening climate threats, global
geopolitical instability (notably the impact on grain pro-
duction in the wake of Russia’s invasion of Ukraine in
February 2022) and political institutional change
(replacing the EU Common Agricultural Policy with
domestic legislation through the Agriculture Act 2020)
has added layers of complexity to the long-term food
security landscape. The current global cost-of-living cri-
sis has resulted in marked rises in food insecurity. The
physical food environment, in terms of ‘high-streets’
and hospitality industries, has faced challenges before
and since the lockdowns of the Covid-19 pandemic
(13)
.
Obesity and inequalities
The Covid-19 pandemic and subsequent national lock-
downs illustrate both the structural weaknesses and adapt-
ability of the food system. Of note is how the pandemic
exposed systemic reliance upon emergency food aid and
food charities amongst members of vulnerable communi-
ties
(14)
. However, societal reliance upon food banks/food
parcel deliveries to meet chronic food insecurity needs
has subsequently raised political controversy: actors across
food policy networks highlight how food charity masks the
economic unsustainability of this approach
(15)
, how it nor-
malises food insecurity, and fails to tackle the root causes
of poverty
(16)
. Moreover, the unpredictable just-in-time
retail supply of food resources makes it difficult to coord-
inate the redistribution of perishable produce (and other
critical food items). Consequently, food banks struggle to
meet fluctuating patterns of supply and demand
(17)
,result-
ing in limited provision of nutrient-dense foods (including
meat, dairy, vegetables and fruits)
(18)
.
The Kings Fund reported in 2022
(19)
that the 2020/
2021 period saw rising rates of deprivation and obesity
across England, in step with growing inequality between
the least and the most deprived populations: the gap grew
by 1⋅5 percentage points (from 16⋅1 % in 2019/2020 to
17⋅6 % in 2020/2021). Rising rates of obesity amongst
vulnerable populations is associated with subsequent
rises in future population ill health, and increased stress
on health services. A healthy diet helps to protect against
malnutrition in all its forms, and reduces the risks of mul-
tiple non-communicable diseases
(20)
. People who live in
more deprived areas find it harder to consume a healthy
diet for a multitude of reasons, though the rising cost of
healthy food is a significant factor for many. A report by
the Food Foundation
(21)
showed that for anyone in the
lowest income decile trying to follow the Eatwell
Guide
(22)
would cost them almost 30 % of their disposable
income. This report was published in 2018, and does not
account for the contemporary cost-of-living-crisis within
food and energy consumption –a crisis that compounds
food insecurity risks
(23)
. Additionally, households at risk
are likely to be those who self-identify as ‘toorichtobe
poor’and who are experiencing in-work poverty
(24)
.
A recent systematic review and meta-analysis of 36,113
adults and children showed statistically significant asso-
ciations between food insecurity and obesity (OR
1⋅503, 95 % CI: 1⋅432, 1⋅577, P<0⋅05); highlighting
that food insecurity increased risk of obesity among
adults and children
(25)
. Within this same review, the nar-
rative synthesis showed association between different
types of food environments and obesity –for example
between the home-food environment or food obtained
from charitable sources –moreover, barriers to purchas-
ing fruit and vegetables were identified as significant risk
factors
(25)
. Findings from qualitative studies regarding a
reliance on energy-dense, nutrient-poor foods owing to
their affordability and accessibility aligned with findings
from quantitative studies. Results from both the qualita-
tive and quantitative studies explored potential links
between increased body weight and participation in
food assistance programmes such as food banks. This
comprehensive systematic review confirms that obeso-
genic food environments and food insecurity significantly
contribute to obesity
(25)
, adding to existing evidence that
cheap energy-dense foods are favoured over healthier
foods, notably fruits and vegetables. Research by Yau
et al.
(26)
confirms that those who are food insecure have
poorer diets, however, emergency food aid may not rem-
edy this situation. An earlier international mixed-
methods systematic review by Oldroyd et al.
(27)
updated
evidence on the nutritional adequacy of food parcels pro-
vided by food banks and reported that pre-prepared food
parcels supplied by food banks struggle to meet the nutri-
tional needs of their users.
Out-of-home food environment and deprivation
Access to healthy food is seen as an element to promote pol-
icy, systems and environmental change
(28,29)
. Important
within the broader concept of food access are the terms
A. Lake et al.2
Proceedings of the Nutrition Society
https://doi.org/10.1017/S0029665123002677 Published online by Cambridge University Press
‘affordability’and ‘availability’. For example, in England,
there is a strong correlation between a higher number of
fast-food outlets in more deprived areas
(30)
. It has also
been demonstrated that deprived areas have more takeaway
food outlets close to schools
(31)
as well as having an
increased amount of bus shelter advertising of unhealthy
food and drinks
(32)
.
Changing behaviours
Many of our food choices are automatic rather than
reflective
(33)
. Habits and behaviours shape food
choices
(34)
; food is intrinsically linked to cultures and
social practices of domestic life
(35)
. Our food choices
therefore both determine, and are determined by, our
food environments, making them a critical point of inter-
vention in food-related health and wellbeing. Preparing,
sharing and eating food is both an everyday occurrence
and a socio-culturally complex phenomenon
(36)
–it is
determined through multi-scalar national and inter-
national policies and governance-driven decisions
(37)
.
Our food environment mediates our eating behaviours
through the mechanisms of availability and accessibility
of food. Individual behaviours are influenced by our sur-
rounding environments. Using frameworks, such as the
ecological model from Story et al., can be helpful in con-
ceptualising this relationship
(38)
. However, measuring this
association has been problematic
(39)
, with studies in the
area presenting conflicting results. Lake
(39)
describes two
studies
(40,41)
that sought to understand the link between
food environments and behaviour. Since then, a study
has been published using smartphone self-reported data
from 164 926 US participants (MyFitnessPal app users)
and 2⋅3 billion food entries to study the independent con-
tributions of fast-food and grocery store access, income
and education to diet health outcomes
(42)
.Thisnew
work indicated there was an association between higher
access to grocery stores, lower access to fast food, higher
income and high educational attainment with higher con-
sumption of fruit and vegetables, lower intakes of fast
food and soda and lower risk of overweight or obesity
(42)
.
Notably, there were significant variations across areas (zip
codes) which had predominately black, Hispanic and
white demographic sub-groups
(42)
.
Though the burden of obesity and non-communicable
disease is a global problem, it is one that is transferring
from high-income to low- and middle-income countries
with the global distribution and marketing of ultra-
processed food
(43)
. Studies in Brazil
(44)
, South Africa
(45)
and India
(46)
highlight the public health risks to people’s
food choices and health associated with advertising of
ultra-processed, high in fat, sugar, or salt (HFSS) foods
on free-to-air television. Moreover, in South Africa, a
recent study using household survey data with publicly
available geospatial (Google) data on modern food
retailer locations showed that proximity to bigger-chain
supermarkets and fast-food restaurants was significantly
associated with overweight and obesity
(47)
.
Successive government strategies have sought to
address obesity in the last thirty years. Between 1993
and 2020, there were fourteen obesity strategies published
by the UK Government, containing fourteen strategies
and 689 policies
(48)
. However, these policies were not eas-
ily implemented in practice, and have overwhelmingly
put an emphasis and reliance on individual-level behav-
iour change. Actions to shape public behaviour are inef-
fective in the absence of wider environmental–structural
changes necessary to support such measures
(49)
. Theis
and White suggested that the emphasis and reliance on
individual-level behaviours is an important factor in the
UK’s high rates of obesity and significant health
inequalities
(48)
.
Opportunities to improve population health
In England, the wide-reaching and ambitious National
Food Strategy was bold in its vision to create a food sys-
tem that was good for our health and for planetary
health alongside addressing inequalities
(50)
. However,
the lack of a committed political response to this docu-
ment has proved disappointing and frustrating; this
includes the potential shelving of the long-awaited health
inequalities white paper
(51)
. While policy continues to
place the individual, rather than the environment, at
the heart of government strategy, there is little scope
for meaningful upstream intervention, such as the rela-
tively successful UK Government sugar levy
(5)
.
Food retail and the out-of-home food environment
Given the clear evidence that the food environment has
an impact on population health, there are surprisingly
few studies that decisively demonstrate clear evidence
supporting the food retail space as a successful opportun-
ity for influencing health. A recent systematic review
(52)
aimed to quantify the spatial methods used to measure
the ‘retail food environment’, and found great diversity
in how retail food environments were measured among
the 113 studies included in the analysis.
While food access and availability would intuitively
appear to be important areas of opportunity, access
and availability are often difficult to measure, and results
remain conflicting. A recent North American example
(53)
found that the introduction of a food store, in what had
been described as a ‘Food Desert’, had little impact on
people’s behaviours –highlighting that behaviour change
involves more than simply increasing accessibility.
However, within food supermarkets, there is evidence
that purchasing behaviours can be changed by increasing
the availability and promotions of healthier foods
(54)
.
While there is an acknowledged proliferation of
fast-food outlets, particularly in more deprived areas,
research has explored how to work with these food out-
lets (usually independent and locally owned) to improve
the dietary profile of the food they serve
(55)
. Working
with food businesses and the wider food industry, includ-
ing suppliers
(56,57)
, can help make small but important
changes. In England, the effectiveness of such changes
were well illustrated by the NIHR School of Public
Opportunities to improve population health 3
Proceedings of the Nutrition Society
https://doi.org/10.1017/S0029665123002677 Published online by Cambridge University Press
Health Research Foodscape study
(58)
. A combined pro-
cess of literature and scoping reviews, with co-design
input from businesses and practitioners, identified suc-
cessful interventions that modified meals offered by take-
aways with the aim of improving diets and/or reducing
obesity
(55,59)
. Examples of these meaningful interventions
included the introduction of five-hole rather than the
regular seventeen-hole saltshaker, which reduced salt
intake by over 66 %
(60,61)
; and the use of ‘light bite’fish
and chip boxes, significantly moderating portion sizes
and energy intake
(56)
. The ready adoption of this inter-
vention by the industry points towards long-term sustain-
ability and potential to be used by other out-of-home
food retailers. Other interventions, such as ‘master-
classes’for businesses, can improve the healthiness of
the food on offer
(57)
by changing the cooking practices
and menu options in takeaway food outlets among
those who attend training
(57)
. Such interventions were
deemed to be acceptable to business owners, required
minimal effort and were cost-effective with the potential
for wider use.
Other approaches that have been evaluated include the
Gateshead council (a local authority in the north-east of
England) multi-pronged, planning policy. Gateshead
aimed to reduce childhood obesity rates locally. One
aspect of this strategy was to implement three types of
planning guidance (a school exclusion zone, restricting
new outlets by retail density and restricting new outlets
by childhood obesity rates). Brown et al.
(62)
found that
this multi-pronged planning approach can significantly
change the proportion and density of fast-food outlets
in the short term (four years) compared with other
local authorities in the north-east of England.
Though such interventions have proved effective in
local and national policy, health strategy and planning
must compete with economic growth priorities. In the
current economic climate, these tensions may be
clearer
(5)
. For example, local authorities and planning
professionals have to decide which problem is better to
live with; boarded up, not-in-use, retail units or allowing
those units to become fast-food outlets
(63)
.
The changing food environment
The dynamic nature of the food environment could be
seen as an opportunity for change. This dynamism was
highlighted by the Covid-19 pandemic and subsequent
national lockdowns. In England, the government intro-
duced temporary measures to relax food-related planning
regulations; allowing pubs and restaurants to operate as
hot food takeaways to support people having to stay at
home and support businesses
(63)
. These temporary regu-
lations permitted the change of use without the need
for a planning application. In research
(63)
with local
authority professionals (in north-east England) about
these temporary regulations, there were high levels of
concern about the impact these measures would have
on the food environment, influencing food access and
population-level public health. This included worries
about the implication an increase in the availability of
hot food takeaways could have for dietary intake and
levels of obesity
(63)
, as observed in other studies
(64)
. The
growth of the ‘online food ordering and delivery plat-
forms’industry, which, in the UK has grown 40⋅5%
per year on average between 2017 and 2022
(65)
, with fur-
ther growth predicted
(66)
as the ‘at-home’trend expands
after the lockdowns cease, has fuelled these concerns.
Many of the new at-home delivery platforms are ser-
viced by ‘dark kitchens’
(67)
. This is an international phe-
nomenon and can be defined as restaurants without a
shopfronts, no direct customer interaction and
delivery-only commercial kitchens that rent out shared
or private kitchen spaces to food businesses
(68)
.
However, there is potential for opportunities to improve
choices made within these platforms using tools such as
the design of a web-augmentation-based template to dis-
rupt platform provider behaviours, empower service
users and increase individual agency
(69)
or the use of a
universal ‘healthiness’rating
(70)
. This is an emerging
field and there is still much to explore.
Food advertising/marketing
The Transport for London ‘junk food advertising ban’,
which placed restrictions on the advertising of foods
and beverages high in fat, salt or sugar in order to help
tackle childhood obesity, appeared controversial in
February 2019 and garnered much negative press
(71)
.
However by April 2022, five local authorities (Bristol
and four London boroughs (Southwark, Haringey,
Greenwich and Merton)) had announced plans to take
similar action
(72)
. In June 2022, Barnsley announced
similar measures
(73)
with Brighton and Hove to make a
final decision in December 2022
(74)
. The impact of the
Transport for London advertising ban and the subse-
quent evaluation of the ban found a relative reduction
in energy, sugar and fat purchased from high fat, sugar
and salt products
(75)
; supporting policies using advertis-
ing bans as a method to reduce the purchase of these
products.
Outdoor food advertising has received less attention
compared with television and digital media: a recent
review
(76)
highlighted a need to understand more about
its influence on consumer behaviour and health. Finlay
et al.
(32)
note the complexities of measuring and monitor-
ing outdoor advertising, whilst exploring the value of
working with local authorities to shape the outdoor
advertising environment to produce positive health out-
comes for consumers.
Healthy planning
Shaping the spatial environment has been seen as a cred-
ible option to improving the health of populations. In
England, The National Planning Policy Framework
explicitly states the need to promote healthy communi-
ties
(77)
, and that decisions involving the use of planning
policies should ‘enable and support healthy lifestyles’.
The Office for Health Improvement and Disparities
A. Lake et al.4
Proceedings of the Nutrition Society
https://doi.org/10.1017/S0029665123002677 Published online by Cambridge University Press
actively encourages local authorities to use their planning
system to create ‘healthy weight environments’
(78)
.
However, the development and use of local ‘healthy
weight environment’policies is not a mandatory require-
ment. Multidisciplinary working across planning and
health will result in improved health and more equitable
communities
(79)
. Planning policy and implementation is
an important factor in creating sustainable and healthy
communities, however, it is not a quick fix, and the
wider issues around health and inequality cannot be
addressed by planning alone
(79)
.
There is growing acknowledgement of shared responsi-
bility between professions for broad wellbeing gains,
including the promotion of a health environment
(80)
.
Research has suggested that 50 % of English local govern-
ment areas have a planning policy related to the regulation
of fast-food outlets
(81)
. The most common approach is the
use of ‘exclusion zones’around schools
(81)
.Itisonly
recently that data have emerged around the effectiveness
of such approaches. Brown et al.
(82)
explored the short-
term (three-year) impact of planning guidance restricting
new fast-food outlets within 400 m of a secondary school
and its influence on the food environment in the local
authority of Newcastle Upon Tyne, UK. Using food out-
let data three years pre-intervention (2012–2015), the
intervention year (2016) and three-years’post-intervention
(2016–2019); a difference-in-difference approach compared
postcodes within the school fast-food outlet exclusion zone
to those outside the fast-food exclusion zones
(82)
.The
effects of this guidance in the short term (three years)
were not statistically significant when compared with a
control zone. However, the authors and others in this
field agree that the use of planning to improve population
health is likely to be a long-term policy plan to create a
sustainable healthy food environment
(79,82)
.
Food security
The current cost-of-living-crisis and rising rates of infla-
tion means that even more of the global population
will be pushed towards food insecurity
(83)
.Thisis
described by the World Bank as a ‘global crisis’and is driv-
ing many millions to poverty, hunger and malnutrition
(83)
,
while the status quo of expansion of food banks normalises
food poverty and fails to address the deeper social chal-
lenges of food insecurity. The defined long-term solution
is to take action to end income and health inequalities,
and to ensure populations have access to affordable and
nutritious food
(84)
. In the short term, populations, including
those livingin high-income countries, need to find models of
food supply to those who are food insecure. While research
has highlighted the nutritional inadequacy of pre-prepared
food parcels given to individuals experiencing food insecur-
ity from foodbanks
(27)
, there is scope to improve thequality
of the food provided by these life-lines to people who are in
need. Overall, there is an urgent need to plan and holistically
redesign food systems to improve access to healthy afford-
able food.
Understanding how we can reduce food insecurity and
stigma, improve access and availability to healthier foods
in deprived communities is important in addressing
health inequalities across all ages. One solution is the
‘social supermarket’: a social enterprise model which
sells surplus food, available at discounted prices in low-
income areas
(85,86)
; these are usually open to the wider
community (not always the case for food banks).
Co-produced research is currently underway by the
authors to understand more about this food insecurity
intervention, examine and generate an understanding of
the best ways to help social supermarket customers use
healthier produce, thus having a positive impact on
health and wellbeing outcomes, cost savings and food
system sustainability improvements by reducing the
waste of surplus food
(87)
. Some population groups
appear to be more at risk of food insecurity; this includes
individuals living with a severe mental illness (SMI).
There is an urgent need to understand feasible and
acceptable approaches to assist people with SMI to
access healthy, affordable food. This is a new field of
work and collaborative research with people living with
SMI is currently underway
(88)
. Partnership-working
with communities is core within a broad whole systems
approach model
(89)
.
Conclusions
Opportunities to create healthier food environments and
reduce rates of non-communicable diseases associated
with obesity remain challenging within ongoing global
economic and environmental crises. Solutions will
require social innovation, design thinking and partner-
ship working to be successful. For the food system, this
may include, for example, upstream interventions such
as alternative distribution and delivery models to
improve long-term access, availability and uptake of
healthier diets. Regional and national policy must ensure
that local food environments allow populations to have
access to food with dignity, ensuring that it is healthy,
nutritious, culturally appropriate and desirable. Food
systems must also improve community wellbeing and
resilience to supply ‘shocks’through supply chain disrup-
tion. Food is rooted in cultural identity and social prac-
tices, cutting across ethnicity, generational divides and
geography
(90)
, requiring bottom-up community-focused
social innovation to be successful. Local and national
policies, such as planning regulations, must therefore
adapt to fit with the dynamism of the food environment
and address the widening inequalities.
Financial Support
This research received no specific grant from any funding
agency, commercial or not-for-profit sectors.
Conflicts of Interest
None.
Opportunities to improve population health 5
Proceedings of the Nutrition Society
https://doi.org/10.1017/S0029665123002677 Published online by Cambridge University Press
Authorship
A. A. L. conceived the paper and drafts were developed
collaboratively by C. L. O.’M., H. J. M. and M. C. All
authors reviewed the final version.
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