[00:00] Hugo Harper: The scale of the problem is huge. Most people in the UK, most adults, are living with excess weight. About 30% of people, so 1 in 3, are living with obesity. And that's doubled since the 90s, so it hasn't always been this way. It's a relatively new problem. The costs are huge. There is no bigger public health issue at the moment in the UK than obesity.

[00:25] Dr Dolly van Tulleken: If you're looking at a country like the UK, we are one of the largest consumers of unhealthy high fat, salt, sugar, ultra-processed food in the world. Even when you look at our near European neighbours, we have quite a different diet to countries like France and Italy that are so close geographically. We're much more like America when it comes to the food that we consume, and that's because the food that surrounds us in the places that we operate in—whether it's schools, hospitals, the high street, supermarkets—the majority of food that's in those places tends to be unhealthy.

[01:04] Joe Owen: Hi and welcome to The Policy Fix by Nesta, the research and innovation foundation. I am Joe Owen. Every episode, we take a policy problem and look at how to fix it. If you like this episode, please do like, share and subscribe wherever you get your podcasts.

For decades, UK governments of all stripes have correctly identified obesity as a major public health problem. There have been policies, plans and programmes, but the upshot: obesity in the UK has doubled in the last 30 years, and now nearly 1 in 3 adults live with obesity. The impact for our health service, for our economy and for our public finances is brutal.

So why haven't any of these worked to date? What have we been getting wrong, and how can this administration do things differently? Joining me today are two people who have thought and written about this topic a lot. We have got Dr Dolly van Tulleken, who is a health and obesity policy expert, and Hugo Harper, who is the Director of our Healthy Life Mission, which aims to halve obesity by 2030.

Dolly, Hugo, welcome. Hugo, can you tell us a bit more about the scale of the obesity problem in the UK? How does it compare to other health problems?

[02:17] Hugo Harper: The scale of the problem is huge. Most people in the UK, most adults, are living with excess weight. About 30% of people, so 1 in 3, are living with obesity. And that's doubled since the 90s, so it hasn't always been this way. It's a relatively new problem.

The costs are huge, you know, by rough calculations, £126 billion per year. That's made up of a couple of different things. That's not just the sort of direct costs to the NHS or the loss in productivity from the workforce, but that's also the sort of value government puts on people being unwell. You know, we should place a value on people's suffering if they're sick, and so that includes that. And so there is no bigger public health issue at the moment in the UK than obesity.

[03:08] Joe Owen: And the health impacts for individuals—like musculoskeletal issues—there's a whole range, right?

[03:14] Hugo Harper: Yeah, exactly. It's associated with loads and loads of stuff. So, some is sort of more obvious: musculoskeletal disorders, diabetes (you have these really clear links between), certain types of cancers you see associations with. There's some stuff which feels a little bit more bidirectional around mental health issues—you're not sort of sure which one's causing which, but the associative evidence is massive. And so, you know, if you're looking to improve health more broadly, looking to improve healthy life expectancy, if you're a government looking to close the disparity regionally between healthy life expectancy, you can't not tackle obesity.

[03:50] Joe Owen: Dolly, it's like really easy to reach for the mental model for obesity that it's like about individual choices, and the fix is for the individual to eat less or exercise more. Why is that wrong?

[04:03] Dr Dolly van Tulleken: We all like to think that we have got lots of free will, and very little influences our decision-making other than ourselves and our own decisions. It can be very hard to understand and see the drivers of our choices, and probably quite hard for a lot of us to let go of the idea that we're not necessarily in control of all the decisions that we make—or at least not in control enough that you can shape them in such a profound way.

And I try and reframe it so it's positive in a way: that we want to create a condition that makes you the most free to do what you want to do, that provides you with the biggest freedom to live the most fulfilling, happiest life, enable you to thrive. And part of that is being free from negative influences and harmful influences.

So trying to reframe it in a positive way, rather than saying actually there's all this stuff that shapes our decision-making—such as a really unhealthy food environment that we live in depending on where you are, what postcode you live in, your background. These things are all dictating the kind of decisions that are available to us. Rather than sort of feeling like we don't have that kind of power, being able to look around us and going: how can we create conditions that enable us to be the most free that we possibly can and want to be, and to be free from negative influences, is the kind of thinking that we would ideally move towards.

[05:34] Joe Owen: And what do we mean by "food environment"?

[05:36] Dr Dolly van Tulleken: So in terms of the food environment, essentially what surrounds us shapes us. So in terms of the kind of food that we have available, if you're looking at a country like the UK, we are one of the largest consumers of unhealthy high fat, salt, sugar, ultra-processed food in the world. Even when you look at our near European neighbours, we have quite a different diet to countries like France and Italy that are so close geographically. We're much more like America when it comes to the food that we consume. And that's because the food that surrounds us in the places that we operate in—whether it's schools, hospitals, the high street, supermarkets—the majority of food that's in those places tend to be unhealthy ultra-processed food options. And so that means that those are the decisions that we are offered, and therefore having to make as a result of that.

[06:28] Hugo Harper: Yeah, sometimes when people say "food environment", sometimes people think that you just mean like where shops are. And it's much broader than that. So it's the physical environment, but it's also the information environment (like what advertising you're exposed to), it's a social environment (what's sort of cultural), it's a financial environment (what's kind of cheap). So it's a very broad term. I think Dolly's "what surrounds us shapes us" is a pretty nice way to put it, and it's more like few things don't fit into the sort of food environment rather than it being a very exclusive category.

[06:57] Joe Owen: Let's move on to solutions and what the solution set looks like. But before we do what we should do now, I wanted to understand a little bit more about what we have tried. So Dolly, it's not like this is a problem that hasn't had the attention of government and politicians for the last however many decades. What have they tried, and why has it failed?

[07:21] Dr Dolly van Tulleken: They've tried a lot. You can't say that politicians and policy makers in government have not tried to do stuff about obesity and our food and health issue as an agenda for literally the last three decades. We've had efforts by the government, and you could even say that there's a whole host of policies that are even earlier than that. But the early 90s marked the first time that government for England introduced obesity reduction targets. So for that, essentially we can look at that obesity reduction target as the marking point of starting with their efforts to tackle obesity.

And in the last 30 years, between the early 90s and to very recent years, we've had almost 700 individual government policies to tackle obesity, and in that includes the reduction in health inequalities as well. And yet we haven't seen a reduction in obesity or the related health inequalities in that time.

And there are kind of three key reasons for why those many hundreds of government policies proposed haven't necessarily worked.

One is that the ideas have tended to focus on trying to get people to change their own behaviour, without doing what we've been talking about of concentrating on the food environment that's around people and making that as healthy as possible so that people basically don't really have to think about what they're doing. It's just the easiest, most affordable, most accessible thing to do is to eat and enjoy a healthy diet.

The second is that policies have tended to be voluntary. So even when they're proposed and even when they even go through implementation and are introduced, they tend to be voluntary, so there aren't really consequences on the responsible sectors—whether that's the food industry or schools or whoever's supposed to be doing the policy and enacting the policy—there aren't really consequences for not. And unsurprisingly, that means that you tend to have very low effective uptake and delivery of that. And those kind of policies, especially when they're voluntary, don't tend to have clear follow-ups or evaluation, so it's actually really hard to know if anything was ever done as a result of them.

And then finally, the implementation problem with government policy. And this is not just an issue related to obesity policy, this is a kind of government problem and how to solve it I guess is the big unanswered question. But essentially most policies that are proposed by government don't go through the full implementation process. So you get so many hundreds of policies proposed by government that never really get fully implemented, or they'll experience a weakening, a delay... and we may talk about some in more detail regarding this agenda, but the common story is that policies are either weakened, delayed, scrapped, introduced and then scrapped, or they're never introduced in the first place. But it's not all defeatist—we have had some good success stories when it comes to this agenda in more recent years.

[10:20] Hugo Harper: Yeah, because sometimes if you just hear the first bit and you say like, "Wait, so government have tried 700 things, therefore this must be impossible and you can't do anything about it." That's not real—like, they've announced 700 things. Most of them didn't really happen, and if they did, they were a watered-down version. So it's just, you know... I think we share this view of like: there's a lot of reason to be hopeful about this. The reason we're both really passionate about the area is like you should be able to have this massive progress on it. It's not like it's impossible. And you could feel like that if you just sort of look at some of the headlines on it—like we've been trying this for a very long time and it's gone, if anything, the wrong way. And so it's both true that we should be sort of critical of what's happened in the past, but also optimistic for the future.

[11:07] Joe Owen: I thought we could drill down into the advertising restrictions as a sort of case study. So those have been one of the recent big announcements. Why have they not worked, or are they working?

[11:21] Hugo Harper: Well, so full evaluation, like don't know if they're working yet, haven't seen it. And one of the big recent announcements—well, I thought initially they were happening in 2016, and then that got pulled back, and then in 2018 they were formally announced, and then eight years later they're actually coming in. So I mean that's one of the really big lessons here. You know, if you care about childhood obesity, well someone's gone from 0 to 8 in that time. You know, they've started and finished primary school. So this delay is really problematic, particularly if you care about children.

And then, is it working? Well, there are big old loopholes in it. So you know, when you hear the government has banned junk food advertising on TV and online, that sounds really good! Right, that'll have a massive impact. But there are like quite a few ways around it. Dolly, I don't know if you want to give some sort of examples of it?

[12:13] Dr Dolly van Tulleken: Oh god, it always makes me slightly depressed thinking about the examples of what you can get away with! But one of the exemptions that was talked about quite a lot—and I understand was pushed back against by the food industry and potentially the advertising industry as well to make sure that this was kept out—was brand advertising. So you can still, even if you don't show, for example, a Dairy Milk—if you don't show the actual chocolate bar, you can still talk about Dairy Milk. And as we know, you don't really need to say that much other than Dairy Milk to know what we're talking about!

So those kind of examples of going the real specifics when it comes to policy and regulation, especially in law, can be absolutely critical for what that means. Because people assume if you're talking about, "Yeah, you know, junk food advertising ban," we'll see no junk food adverts. It's like, no, there are lots of nuances to that.

But again, it's a huge step forward, and the fact that, you know, if you're in this space, we've been waiting essentially a decade for this to happen. So that has to be celebrated because when you do understand how difficult policy changes are to make, the wins are really, really important to celebrate and understand what we can learn from that. And make sure that there isn't a kind of sense for policy makers who are juggling so many different areas, that there's an idea of always striving for perfection that they're just going to be criticised for whatever they do. Because you get this sense of going, "Well why do anything if even when we try and get something done and we do achieve something, you've got a whole load of people going 'It's not good enough, you know, we need to do better.'"

So I think it's a really important message for people outside of government policy making to send to policy makers to go: we understand the realities of trying to make change on any agenda, this one being so difficult because there are so many political and policy barriers, and commercial barriers to making change happen, that we do need to celebrate the wins when they happen. But it can be hard when you see the exemptions!

[14:04] Hugo Harper: Yeah, it's really tricky. So to put some numbers on it: we think that of advertising spend on food and drink, we think plausibly the regulations capture about 8% of it. But when you then drill down to all the ways people could like easily divert—so you know, with the Dairy Milk example, you do that just like "Cadbury's" or something like that, or you move to outdoor advertising which is not covered by the regulations—we think that the real impact and reduction is probably more like 1%.

Now, 1% of the total advertising spend in the UK on food advertising spend in the UK is still a big number. And so this is the public health problem: any improvement in a way should be celebrated because it applies to so many people. But is it proportionate to the scale of the challenge? No.

[14:50] Joe Owen: I want to come back a bit later on to what is driving this sort of the concessions and the sort of watering down, and in particular the relationship with industry. But I wanted to pick up on the point of optimism in that, like, you know, there are good things that can happen. And this obviously isn't just a UK problem, and as we've said, it's not a new problem. So we have got some evidence about what interventions might actually work. I know, Hugo, you and the team here spend a lot of time with that evidence to try and understand what the option set looks like for ministers who are serious. What did it tell you?

[15:28] Hugo Harper: You need to do something that meaningfully changes the incentives for big food business. That's sort of the top line, right? It's great to do stuff on education and information—like, directionally it's nice, but it's completely insufficient for real change in this.

And so, the things that we've been looking at, the things that we talk about... you might have heard some of the government announcements around mandatory reporting, mandatory targets. The mandatory targets is the big thing. So you can't have something that's voluntary—you know, as we've discussed, that tends to not work. You could have something that's a tax as a type of regulation. You could ban a bunch of stuff. You could tell people, "You need to hit this target, we don't care how you get there."

But the key thing is you need something that incentivises meaningful change for big food businesses, which is a move away from providing information to individuals and telling them to just "be better". People are trying!

And so the main thing that we're excited about at the moment is the government's announcement of the Healthy Food Standard. And so that includes both mandatory reporting and then mandatory targets for large food businesses. And so if you can get even relatively small changes... like, there's no reason anybody should know this, but there's like this scale called the Nutrient Profiling Model, and you can do a version of it where it goes from 0 to 100. 0 is really bad, 100 is really good. If you move from a score of 66 out of it (which happens to be where most the average supermarket is at the moment) to about 69 on it, that would have an impact equivalent to reducing obesity by a fifth. So a massive impact!

So you can have these small changes... these small changes, rather, can have these massive impacts because you're targeting such a large proportion of food that is consumed by such a large proportion of people. And so then you can have these sort of potentially transformational improvements if you do the stuff that's well-evidenced and proportionate. So, you know, there have been 700 things, but none of them have been nearly the sort of scale of that. And so you need something that is that sort of scale if you want to make meaningful changes.

Sugar tax is a great example of something that is like conceptually the exact right sort of thing, but it only applied to fizzy drinks! So fizzy drinks are just not that much of the diet. So you have these amazing improvements, you know: massive reduction in sugar content (something like 40%), improvement in like volume sales for it (so businesses were fine), and then people were saying, "Well, how come obesity hasn't dropped?" Because fizzy drinks aren't most of the diet! You know, you just need something that applies to lots of stuff.

And that's some of the issue with the like more positive side as well: increasing fruit and veg—great thing to do, you know! But like, you would have to have a huge relative increase in the consumption of fruit and veg to move the dial nationally on obesity. And so, you know, if some schools are getting some fruit and veg for free, that is a positive thing, but it's totally insufficient to the scale of the challenge.

[18:19] Joe Owen: And so your theory is if most meals that people consume are not a lot—you know, 50-odd calories lower over a sustained period—you see huge change.

[18:30] Hugo Harper: Way less than that. Right, so if you were to see a 216-calorie reduction on average for people living with excess weight—so that's about a bottle of Coke every day—that's about an 8.5% reduction. So that would halve obesity rates nationally. So this is what we're sort of talking about in terms of like: if you have those changes across a large portion of your diet, you know, little changes across lots of things, you don't really notice it.

If I say "no more biscuits at 4pm for you", you'll revolt against it, you know, you don't get the fun things! So when we talk about it, we talk about making food healthier rather than necessarily healthy, because we don't like this binary distinction of like "good food" and "bad food". You know, like, it's fine to have cake on your birthday; it's not fine to have cake for breakfast every day! There's somewhere in the middle you get to a sensible consumption of it.

And there's lots and lots of different foods, so you don't want to be prescriptive with it, but you want to be pragmatic and quantitative and say like: these changes that are required, if spread out, shouldn't feel painful, shouldn't remove the joy from food, shouldn't make it impossible for business.

[19:44] Joe Owen: Yeah, that all makes total sense. I guess the skeptic listening or watching this might say, Dolly, like: why does the food environment matter now? We've got GLP-1s.

[19:53] Dr Dolly van Tulleken: Oh, it's a very good question! And, you know, one that is very high up on the media and public and government agenda at the moment with this.

There are very various sort of reasons why not, some very practical ones like the cost, which right now would be absolutely insane and completely impossible for government to fund, so that sort of feels like a very real reason why that's not the solution as of yet.

I love Sir Michael Marmot talking about: why do we treat people and then send them back to the conditions that made them sick in the first place? And I feel like that couldn't be more relevant when it comes to thinking about GLP-1s. We absolutely shouldn't be treating people for a condition that essentially was the result of the food environment around them, without changing that food environment. The idea that we would treat people and then send them back to the exact conditions that made them sick...

And you know, I'm in touch with a group of clinicians and I hear very disturbing stories about people who are taking GLP-1s with private prescriptions and eating a diet that is meaning that they are in an incredibly nutritionally poor situation, and not getting kind of proper guidance and support along the way. And that sort of feels like it represents the fact that we're essentially providing this treatment, but then putting people in exactly the same food environment that made them sick in the first place.

So I feel like it absolutely has to go hand-in-hand. Also, to prevent people from needing treatment, you also still need to absolutely transform the food context that people operate in. And as Hugo said, that's everything from the literal food that is available to the way that we advertise it and the way that we talk about it, think about it, the information around it. And that essentially is a cultural transformation.

And I think that a cultural transformation is the way that we should be thinking about it from a policy perspective, because to understand behaviour and understand what makes it easy for people to do a certain thing, we often talk about as being culture. We'll say that, you know, Japanese, Italian, French food behaviours are related to their culture, and we'll say, "Oh, that's just culture, you'll never get it." There are so many excellent examples, including in our country, related to smoking—the fact that we went from essentially a smoking culture to a non-smoking culture that was completely related to policy change.

And another example that I often go to to demonstrate that, when we talk about the Dutch as being cyclists and we just think "Oh, that's the way that culture has always been"—that was a huge policy change over a 10-year period that essentially resulted in huge investment in the infrastructure that has resulted in a cycling culture, but that wasn't necessarily always the case.

So I think we have to believe in the possibility that Britain can have this nourishing food culture and an incredible food system that supports good health and sustainability and all of the other factors that we would be interested in—equity, justice, you name it. We have to believe in that cultural transformation, but in order to do it properly, we have to think of it in that way: that it's a multi-pronged approach.

[23:09] Joe Owen: And where does it come from? How do you drive that? Is that a... it needs political leadership in order to do it? Is it that the politics will always be following the culture and therefore there are things outside of government that need to happen? What are the ingredients of the sort of successful cultural change, do you think?

[23:26] Dr Dolly van Tulleken: Well, I mean, I can't help but look at America because of the Make America Healthy Again movement. And sort of regardless of the politics—and there's so much sort of controversy and difference of opinion with the Trump administration and the links with the MAHA movement over there—what has been interesting is an essentially very Americanised food system that is built on essentially an ultra-processed heavy diet that we have adopted here in the UK, being transformed to prioritise and reframe the food agenda in such a profound way. Whether you agree with it or not is kind of not the point I'm making, it's more that you can see that transformation of framing, you can see a political prioritisation, which I still believe is possible in the UK.

Because we know from public opinion research that actually the public is very much in favour of government doing more on food and health policy. They want government to make it easy for them to be able to enjoy a nourishing diet, and for food that is good for us to be made more affordable and available. We know that very strongly. So the public is primed, it's almost like the politics needs to be made to happen.

And there are lots of reasons why the politics are very difficult, which we worked on with Nourishing Britain to interview politicians about exactly that. And they're totally understandable, related partly to the history of our British culture regarding food and wanting to be seen as being "down with the people"—politicians sort of use food as a tool to do that. And it's something even politicians are slightly confused about, which I think is a really interesting point.

And also the fact that I guess we're sort of looking for an identity that potentially Britain doesn't have, and I don't think has had. I've been sent literature from the 19th century that talks about Britain's food culture as being still sub-optimal compared to other countries! So I don't think it's... I think we have to be forward-looking and thinking about what it is that we would want as a forward-looking British food culture—one that sort of supports and nourishes people properly.

[25:38] Hugo Harper: Yeah, like the... I mean, the politicians are in a bit of a bind. If you stop someone on the street and ask them, "What do you need to do to sort out healthy eating or obesity?", they normally give you two answers: education and physical activity. Those two things are well-evidenced to not sufficiently improve the issue. But then, you know, you're the politician, you're appealing to voters, right? And so if that's the understanding around this, then you can kind of see how you can get trapped in this cycle.

Also, you know, the benefits are in the future. You know that weight loss takes a long time, and to reach a new weight equilibrium... and so like, you're talking about benefits probably after your term in parliament, you know, when you really see the sort of benefits for it. So it's understandable, but the thing that we should be really clear on is like: consistently for years, if you poll people, they're positive on this stuff. And so this idea that people sort of revolt... you know, there's a very vocal minority that sort of, you know...

[26:37] Joe Owen: "Nanny state."

[26:38] Hugo Harper: Yeah, exactly! And so, you know, you ask actual people about this, particularly if you frame it properly... You know, if you're like, "Do you think they should take away your burgers?" You know, there's a lot of silly framing that goes on that sort of provocates outrage on it. But if you give people—particularly if you give them a bit of time, you know, there are things like citizens' juries, deliberative forums where you kind of let people sit with something for a bit—and then you get responses from people that look a lot more like what the like evidence-based community would suggest. So it's both that there's an initial like a real desire to improve on this, and that when people are given the time and the information to kind of engage properly, they tend to sort of be pretty positively aligned to what like expert opinion on this stuff would be.

[27:24] Joe Owen: Hugo, do you agree on GLP-1s then?

[27:26] Hugo Harper: Yeah, and the evidence does, right? As soon as people come off these drugs, they start putting the weight back on. And so that's sort of proof of Dolly's point, right? You remove the drugs, you're back in the same environment, you go back to the same weight. You know, it takes a little while for people to do it. And so then to have those like health benefits sustained, you need to then be on the drugs forever. And then you need to be paying for the drugs forever.

So, you know, it's no solution for a large portion of the population. Definitely get access to these drugs for the people who need it now. You know, the current rollout on the NHS is pretty slow. We'd want to see that sort of probably expanded to... you know, originally it was down for 3.4 million people, now it's 1.6 over 12 years. We'd love to see that in more like 5 years rather than 12. So it's not that like GLP-1s are bad—they're a great treatment for people who really need it. It's no way to treat a population-wide issue, yeah.

[28:19] Joe Owen: No taking foot off the gas.

I said we'd come back to the food industry, and I wanted to ask you first, Dolly, about... when you talked of your three reasons why previous action had failed, one of them was that it was voluntary in nature and therefore the sort of system didn't adjust, and the other was that things sort of gradually get watered down over time in response to lobbying. Do you think the food industry is sort of friend or foe of the government on this? Is this like government is scared to face down these vested interests? Is it that it's bad policy? How confrontational do you think that relationship should be?

[29:01] Dr Dolly van Tulleken: Well, it's a hard... So from a government perspective, what we discovered with our interviews with politicians over the last 30 years about why it's so hard to act on this, and understanding the difficulty when it comes to engaging with business, is that sort of government as an institution overall has a mixed relationship with business, where it's sort of partly championing it—massively championing it—and partly having to regulate it. And that can be quite a tension.

And we were showing examples of where that plays out even in individual careers. So you have someone like Jeremy Hunt who had been the longest-serving Health Secretary—at one point he talked about regretting not doing more on childhood obesity—but as Chancellor he was celebrating PepsiCo UK's largest expansion in the UK in 25 years. And so you can have that tension playing out even in individual careers.

My own position in terms of whether, you know, the food industry is a sort of friend or foe, I tried to essentially create a framework to try and answer that question last year with a report I did called Net Drain or Net Gain?, which I did with the Food, Farming and Countryside Commission. And the idea was that we don't have a way to assess companies—individual companies—for whether they are sort of net drains or net gains on society, the economy, our health, the planet overall.

And what could be the sort of way to do that so that we would get almost a holistic idea? Because yes, they'll tell the story that they provide jobs and they've got these factories and they're really big contributors to GVA and all of this kind of stuff on the economy front—you'll hear that narrative very strongly, and they often host events in parliament celebrating their economic and social contributions. And at the same time, you've got academics and researchers and campaigners who are talking about the harms that they're causing—whether that's the false economy in the food system, about the externalities in terms of the health problems that they're creating, environmental damage, welfare issues, animal welfare issues, you name it.

So I wanted to sort of pose the question of: what's true? You know, if you were to kind of assess them as a whole, what is true? And I think it's a really important lens. We would love that framework to be applied to start assessing individual companies, but there were key pieces of information we don't even have. For example, the proportion of ultra-processed food that one given company makes and sells, or even the profits derived from unhealthy ultra-processed food—we don't have that information.

So there was a lot of kind of going, "We actually need..." which essentially is some of the stuff that Nesta is calling for in terms of that transparency around reporting and being able to create targets around. We are missing a lot of that transparency in order to make that assessment.

So I kind of approach companies as trying to move away from talking about "the food industry" as this big, homogeneous group of businesses, because there is so much diversity. And we have to have food businesses operating! We have to have businesses producing food, manufacturing food, making food, distributing food—we absolutely need that infrastructure. So we need to have a very clear distinction about going: these are the kind of ways that we're going to think about the food businesses we want as part of the solution, and these are the sort of businesses and the operations and incentives we need to move away from. And I think until we have that very clear distinction between the kind of businesses that are sort of net gain versus net drain, we're going to find it really hard to move away from that narrative that sort of essentially people that sound anti-all food businesses versus one saying we have to have and support food businesses in the first place.

[22:30] Hugo Harper: Yeah, like, food isn't smoking. Right, food isn't bad. We don't want the amount of food to be zero! And in a way, the food industry's been sort of a victim of its own success, right? They were given the remit to make food plentiful, make it cheap, make it not go off or make you sick, and they smashed it! Right? And it's caused this other problem.

And so, you know, we'd be very against like, you know, painting people as like amoral, evil... You know, that stuff's not helpful. It's just people are playing to the incentives that they're given into the system that they're given, and government controls those regulatory incentives.

And so like, we at Nesta, we're in this really fortunate position because we're an endowed charity, we can partner with some of these businesses to see if we can get them to make some more progress. That gives us a much better understanding of the business, it causes some direct impact, but because we do that on a voluntary basis, no money's changing hands, right? There's not that conflict of interest that you often get with like academic work funded by industry, or, you know, consultancies that rely on a large portion of their business coming from large food manufacturers or that sort of stuff.

So you also don't want to be in a position where you're saying like, "We can't ever engage with you on anything," because food is complicated, and so otherwise you'll come up with solutions that like sound plausible, but actually fall down for a number of technical reasons.

So the way we talk about it is like: you want government to set an ambition, and you don't want that watered down. Right, that's based on like public health values, what it means for productivity, all that. And then once you've got your target, once you've got your impact goal, then you can have conversations about how best to hit it—you know, what industry thinks are the most promising ideas, what things actually won't really work for practical reasons, or what solutions would be required to unblock stuff. But what you really don't want is the like... having people involved in the process of what should the target be or when should it be hit by, because based on current incentives, that will be water down the target, push it out further, let's do less, you know... And so it's a really tricky balance.

[34:36] Joe Owen: And there are trade-offs, right? In that, I'm sure some of the conversations government is having with supermarkets at the moment is with one hat on in the health department, conversations around obesity and the food environment; but in the Treasury, they're also saying, "How can we keep prices as low as possible?" And the supermarkets might say, "Well, the people from government I spoke to yesterday were telling me things that it might cost me a little bit to adjust to in the short term, and you're telling me currently that I need to..." So some of this is about supermarkets, I suppose, or large retailers and the food industry, having sort of the different heads of the snake of government saying different things to them at different times, and then saying, "What do you actually want?"

I want to conclude on a positive note, though, and I want to come back to the point that you made earlier, Hugo, around the Healthy Food Standard. So the mandatory reporting, the mandatory targets, is a bit of work that we at Nesta have been doing—well, we worked on, and we sort of, I think we like to think we inspired it! We did inspire it. And it was announced in the 10-year plan for health by the Secretary of State last summer. So where are we at? Is this a big moment of hope? Do we think it's all changing, or is it going the way of previous attempts?

[35:56] Hugo Harper: Well, as you mentioned, it was announced about a year ago, right? And currently, no visible progress on it. You know, talking about that there should be a consultation soon on the... whether that consultation covers just the reporting bit, whether it covers target the targets of it, when it would be suggested that those might be implemented by—that's all uncertain currently.

You know, what we would be pushing for is mandatory reporting as soon as possible. A number of organisations already voluntarily publish this information. We know from our work with people that this is data that is often held, and so this is something that should be doable. Problem is, you know, anything at the scale of a national retailer, you get to big numbers. So, you know, is a million pounds a lot? Well, not if you're Tesco! You know, and so it can be tricky when you're having these arguments about what are the costs to business.

So, but it's plausible that a consultation comes out tomorrow, right? Depending on when this is going live! Plausibly a consultation's already come out. And so there's absolutely definitely still time to make this work this parliament. So in terms of like the hope for this, we should be pushing this. This is the number one thing, right?

Even if we're wrong by double... you know, if it's not 20%, if it's 10%; if it's not 20%, if it's 5%; if it was 2%, that's still huge! You know, the numbers here are massive, particularly for the costs. The estimate that we've got is that this would be about 0.1% of revenue for these for these big retailers—which is a big number, but also a tiny number.

So we should be optimistic about this, but we need to see action soon, because otherwise you time out about these things. You know, government gets less ambitious generally at the end of parliament, they sort of... you don't want these things going on to the next parliament. And we've had a change in Health Secretary, right? Political instability, that's generally not good for progress on things. And so we have cause to be optimistic we can still make this huge impact happen, but we need to see action pretty soon.

[37:54] Joe Owen: So we've got a big policy, the government's game for it, it's still doable this parliament, and if so, the benefits could be enormous over the long run in comparison to lots of previous policies that we've tried. So that is a reason to be hopeful.

Dolly, there will be lots of people who worked in the food environment space for a long time who have seen various commitments get watered down. How do you stay motivated and hopeful working in this space, and what can an individual listening to this do who thinks changing the food environment is a thing they care deeply about? What can they do to to make it happen?

[08:31] Dr Dolly van Tulleken: Yeah, it's a really good question, and we've talked about this a lot because I think any... if you work in a space where you're trying to change a system, and especially one as complex and huge as the food system, you do risk burnout and sort of having these huge dips of hopelessness and feeling like you're never going to get anywhere.

So one, it's really important that we sort of celebrate those wins as we talked about earlier. I think also creating a community where there are genuine, supportive relationships between people working, campaigning, researching together in this space is really important. And we're very lucky in this agenda that there are people who have stayed around for a long time, and there are really wonderful working relationships between people, and I think that you sort of need that on a day-to-day basis as well.

And the reason that I'm hopeful, in addition to sort of just finding it fascinating and I've also committed to dedicating my life to this, so I'm not going to be going anywhere! Is that there's a real shift in the last few years that the understanding—partly with research that I've focused on around why we've had so many years of government policy that hasn't worked—towards really trying to mobilise everyday people to become aware of the problems, become aware of the drivers of our unhealthy food system, and to be able to become active, become vocal, become part of it.

And part of that is the Citizens' Assemblies work, there's been really interesting stuff done, and the Food, Farming and Countryside Commission is still working on that and trying to enable people, members of the public, citizens of the UK, to become active and speak out about their own experiences, which I think is one way to do it.

There are also lots of organisations in the food and health policy space who provide ways that people can become active. So whether that's Bite Back, that as a young person you can become an activist through their programme, and you get training and you can work with trying to change stuff in your schools, in your communities—so they have an entire way for young people from the ages of 14 years old to become active. There are other organisations like Sustain that will have automated letters that you can send to your local Members of Parliament, and that can be a really... if you are absolutely time-poor, but really wanting to provide some way to say that you're interested in this agenda and want to have it as a higher priority on policy makers' agendas, then sending an email or a message to your elected Member of Parliament is a really good way to do that. So there are lots of organisations set up to try and activate, so getting involved in those main ones in this space is a great way to start.

[41:14] Joe Owen: Great. And if you want to spend time with people who care about this, you can come to some Nesta events!

[41:19] Dr Dolly van Tulleken: Exactly!

[41:20] Joe Owen: Dolly, Hugo, thank you so much.

[41:22] Dr Dolly van Tulleken: Thank you.

[41:23] Joe Owen: If you enjoyed this episode, please do like, share and subscribe wherever you get your podcasts. As a reminder, Nesta is a research and innovation foundation. We design, test and scale solutions to society's biggest challenges. We are funded by a charitable endowment, and we are politically neutral. If you'd like to find out more, please go to nesta.org.uk.

[00:00] Hugo Harper: The scale of the problem is huge. Most people in the UK, most adults, are living with excess weight. About 30% of people, so 1 in 3, are living with obesity. And that's doubled since the 90s, so it hasn't always been this way. It's a relatively new problem. The costs are huge. There is no bigger public health issue at the moment in the UK than obesity.

[00:25] Dr Dolly van Tulleken: If you're looking at a country like the UK, we are one of the largest consumers of unhealthy high fat, salt, sugar, ultra-processed food in the world. Even when you look at our near European neighbours, we have quite a different diet to countries like France and Italy that are so close geographically. We're much more like America when it comes to the food that we consume, and that's because the food that surrounds us in the places that we operate in—whether it's schools, hospitals, the high street, supermarkets—the majority of food that's in those places tends to be unhealthy.

[01:04] Joe Owen: Hi and welcome to The Policy Fix by Nesta, the research and innovation foundation. I am Joe Owen. Every episode, we take a policy problem and look at how to fix it. If you like this episode, please do like, share and subscribe wherever you get your podcasts.

For decades, UK governments of all stripes have correctly identified obesity as a major public health problem. There have been policies, plans and programmes, but the upshot: obesity in the UK has doubled in the last 30 years, and now nearly 1 in 3 adults live with obesity. The impact for our health service, for our economy and for our public finances is brutal.

So why haven't any of these worked to date? What have we been getting wrong, and how can this administration do things differently? Joining me today are two people who have thought and written about this topic a lot. We have got Dr Dolly van Tulleken, who is a health and obesity policy expert, and Hugo Harper, who is the Director of our Healthy Life Mission, which aims to halve obesity by 2030.

Dolly, Hugo, welcome. Hugo, can you tell us a bit more about the scale of the obesity problem in the UK? How does it compare to other health problems?

[02:17] Hugo Harper: The scale of the problem is huge. Most people in the UK, most adults, are living with excess weight. About 30% of people, so 1 in 3, are living with obesity. And that's doubled since the 90s, so it hasn't always been this way. It's a relatively new problem.

The costs are huge, you know, by rough calculations, £126 billion per year. That's made up of a couple of different things. That's not just the sort of direct costs to the NHS or the loss in productivity from the workforce, but that's also the sort of value government puts on people being unwell. You know, we should place a value on people's suffering if they're sick, and so that includes that. And so there is no bigger public health issue at the moment in the UK than obesity.

[03:08] Joe Owen: And the health impacts for individuals—like musculoskeletal issues—there's a whole range, right?

[03:14] Hugo Harper: Yeah, exactly. It's associated with loads and loads of stuff. So, some is sort of more obvious: musculoskeletal disorders, diabetes (you have these really clear links between), certain types of cancers you see associations with. There's some stuff which feels a little bit more bidirectional around mental health issues—you're not sort of sure which one's causing which, but the associative evidence is massive. And so, you know, if you're looking to improve health more broadly, looking to improve healthy life expectancy, if you're a government looking to close the disparity regionally between healthy life expectancy, you can't not tackle obesity.

[03:50] Joe Owen: Dolly, it's like really easy to reach for the mental model for obesity that it's like about individual choices, and the fix is for the individual to eat less or exercise more. Why is that wrong?

[04:03] Dr Dolly van Tulleken: We all like to think that we have got lots of free will, and very little influences our decision-making other than ourselves and our own decisions. It can be very hard to understand and see the drivers of our choices, and probably quite hard for a lot of us to let go of the idea that we're not necessarily in control of all the decisions that we make—or at least not in control enough that you can shape them in such a profound way.

And I try and reframe it so it's positive in a way: that we want to create a condition that makes you the most free to do what you want to do, that provides you with the biggest freedom to live the most fulfilling, happiest life, enable you to thrive. And part of that is being free from negative influences and harmful influences.

So trying to reframe it in a positive way, rather than saying actually there's all this stuff that shapes our decision-making—such as a really unhealthy food environment that we live in depending on where you are, what postcode you live in, your background. These things are all dictating the kind of decisions that are available to us. Rather than sort of feeling like we don't have that kind of power, being able to look around us and going: how can we create conditions that enable us to be the most free that we possibly can and want to be, and to be free from negative influences, is the kind of thinking that we would ideally move towards.

[05:34] Joe Owen: And what do we mean by "food environment"?

[05:36] Dr Dolly van Tulleken: So in terms of the food environment, essentially what surrounds us shapes us. So in terms of the kind of food that we have available, if you're looking at a country like the UK, we are one of the largest consumers of unhealthy high fat, salt, sugar, ultra-processed food in the world. Even when you look at our near European neighbours, we have quite a different diet to countries like France and Italy that are so close geographically. We're much more like America when it comes to the food that we consume. And that's because the food that surrounds us in the places that we operate in—whether it's schools, hospitals, the high street, supermarkets—the majority of food that's in those places tend to be unhealthy ultra-processed food options. And so that means that those are the decisions that we are offered, and therefore having to make as a result of that.

[06:28] Hugo Harper: Yeah, sometimes when people say "food environment", sometimes people think that you just mean like where shops are. And it's much broader than that. So it's the physical environment, but it's also the information environment (like what advertising you're exposed to), it's a social environment (what's sort of cultural), it's a financial environment (what's kind of cheap). So it's a very broad term. I think Dolly's "what surrounds us shapes us" is a pretty nice way to put it, and it's more like few things don't fit into the sort of food environment rather than it being a very exclusive category.

[06:57] Joe Owen: Let's move on to solutions and what the solution set looks like. But before we do what we should do now, I wanted to understand a little bit more about what we have tried. So Dolly, it's not like this is a problem that hasn't had the attention of government and politicians for the last however many decades. What have they tried, and why has it failed?

[07:21] Dr Dolly van Tulleken: They've tried a lot. You can't say that politicians and policy makers in government have not tried to do stuff about obesity and our food and health issue as an agenda for literally the last three decades. We've had efforts by the government, and you could even say that there's a whole host of policies that are even earlier than that. But the early 90s marked the first time that government for England introduced obesity reduction targets. So for that, essentially we can look at that obesity reduction target as the marking point of starting with their efforts to tackle obesity.

And in the last 30 years, between the early 90s and to very recent years, we've had almost 700 individual government policies to tackle obesity, and in that includes the reduction in health inequalities as well. And yet we haven't seen a reduction in obesity or the related health inequalities in that time.

And there are kind of three key reasons for why those many hundreds of government policies proposed haven't necessarily worked.

One is that the ideas have tended to focus on trying to get people to change their own behaviour, without doing what we've been talking about of concentrating on the food environment that's around people and making that as healthy as possible so that people basically don't really have to think about what they're doing. It's just the easiest, most affordable, most accessible thing to do is to eat and enjoy a healthy diet.

The second is that policies have tended to be voluntary. So even when they're proposed and even when they even go through implementation and are introduced, they tend to be voluntary, so there aren't really consequences on the responsible sectors—whether that's the food industry or schools or whoever's supposed to be doing the policy and enacting the policy—there aren't really consequences for not. And unsurprisingly, that means that you tend to have very low effective uptake and delivery of that. And those kind of policies, especially when they're voluntary, don't tend to have clear follow-ups or evaluation, so it's actually really hard to know if anything was ever done as a result of them.

And then finally, the implementation problem with government policy. And this is not just an issue related to obesity policy, this is a kind of government problem and how to solve it I guess is the big unanswered question. But essentially most policies that are proposed by government don't go through the full implementation process. So you get so many hundreds of policies proposed by government that never really get fully implemented, or they'll experience a weakening, a delay... and we may talk about some in more detail regarding this agenda, but the common story is that policies are either weakened, delayed, scrapped, introduced and then scrapped, or they're never introduced in the first place. But it's not all defeatist—we have had some good success stories when it comes to this agenda in more recent years.

[10:20] Hugo Harper: Yeah, because sometimes if you just hear the first bit and you say like, "Wait, so government have tried 700 things, therefore this must be impossible and you can't do anything about it." That's not real—like, they've announced 700 things. Most of them didn't really happen, and if they did, they were a watered-down version. So it's just, you know... I think we share this view of like: there's a lot of reason to be hopeful about this. The reason we're both really passionate about the area is like you should be able to have this massive progress on it. It's not like it's impossible. And you could feel like that if you just sort of look at some of the headlines on it—like we've been trying this for a very long time and it's gone, if anything, the wrong way. And so it's both true that we should be sort of critical of what's happened in the past, but also optimistic for the future.

[11:07] Joe Owen: I thought we could drill down into the advertising restrictions as a sort of case study. So those have been one of the recent big announcements. Why have they not worked, or are they working?

[11:21] Hugo Harper: Well, so full evaluation, like don't know if they're working yet, haven't seen it. And one of the big recent announcements—well, I thought initially they were happening in 2016, and then that got pulled back, and then in 2018 they were formally announced, and then eight years later they're actually coming in. So I mean that's one of the really big lessons here. You know, if you care about childhood obesity, well someone's gone from 0 to 8 in that time. You know, they've started and finished primary school. So this delay is really problematic, particularly if you care about children.

And then, is it working? Well, there are big old loopholes in it. So you know, when you hear the government has banned junk food advertising on TV and online, that sounds really good! Right, that'll have a massive impact. But there are like quite a few ways around it. Dolly, I don't know if you want to give some sort of examples of it?

[12:13] Dr Dolly van Tulleken: Oh god, it always makes me slightly depressed thinking about the examples of what you can get away with! But one of the exemptions that was talked about quite a lot—and I understand was pushed back against by the food industry and potentially the advertising industry as well to make sure that this was kept out—was brand advertising. So you can still, even if you don't show, for example, a Dairy Milk—if you don't show the actual chocolate bar, you can still talk about Dairy Milk. And as we know, you don't really need to say that much other than Dairy Milk to know what we're talking about!

So those kind of examples of going the real specifics when it comes to policy and regulation, especially in law, can be absolutely critical for what that means. Because people assume if you're talking about, "Yeah, you know, junk food advertising ban," we'll see no junk food adverts. It's like, no, there are lots of nuances to that.

But again, it's a huge step forward, and the fact that, you know, if you're in this space, we've been waiting essentially a decade for this to happen. So that has to be celebrated because when you do understand how difficult policy changes are to make, the wins are really, really important to celebrate and understand what we can learn from that. And make sure that there isn't a kind of sense for policy makers who are juggling so many different areas, that there's an idea of always striving for perfection that they're just going to be criticised for whatever they do. Because you get this sense of going, "Well why do anything if even when we try and get something done and we do achieve something, you've got a whole load of people going 'It's not good enough, you know, we need to do better.'"

So I think it's a really important message for people outside of government policy making to send to policy makers to go: we understand the realities of trying to make change on any agenda, this one being so difficult because there are so many political and policy barriers, and commercial barriers to making change happen, that we do need to celebrate the wins when they happen. But it can be hard when you see the exemptions!

[14:04] Hugo Harper: Yeah, it's really tricky. So to put some numbers on it: we think that of advertising spend on food and drink, we think plausibly the regulations capture about 8% of it. But when you then drill down to all the ways people could like easily divert—so you know, with the Dairy Milk example, you do that just like "Cadbury's" or something like that, or you move to outdoor advertising which is not covered by the regulations—we think that the real impact and reduction is probably more like 1%.

Now, 1% of the total advertising spend in the UK on food advertising spend in the UK is still a big number. And so this is the public health problem: any improvement in a way should be celebrated because it applies to so many people. But is it proportionate to the scale of the challenge? No.

[14:50] Joe Owen: I want to come back a bit later on to what is driving this sort of the concessions and the sort of watering down, and in particular the relationship with industry. But I wanted to pick up on the point of optimism in that, like, you know, there are good things that can happen. And this obviously isn't just a UK problem, and as we've said, it's not a new problem. So we have got some evidence about what interventions might actually work. I know, Hugo, you and the team here spend a lot of time with that evidence to try and understand what the option set looks like for ministers who are serious. What did it tell you?

[15:28] Hugo Harper: You need to do something that meaningfully changes the incentives for big food business. That's sort of the top line, right? It's great to do stuff on education and information—like, directionally it's nice, but it's completely insufficient for real change in this.

And so, the things that we've been looking at, the things that we talk about... you might have heard some of the government announcements around mandatory reporting, mandatory targets. The mandatory targets is the big thing. So you can't have something that's voluntary—you know, as we've discussed, that tends to not work. You could have something that's a tax as a type of regulation. You could ban a bunch of stuff. You could tell people, "You need to hit this target, we don't care how you get there."

But the key thing is you need something that incentivises meaningful change for big food businesses, which is a move away from providing information to individuals and telling them to just "be better". People are trying!

And so the main thing that we're excited about at the moment is the government's announcement of the Healthy Food Standard. And so that includes both mandatory reporting and then mandatory targets for large food businesses. And so if you can get even relatively small changes... like, there's no reason anybody should know this, but there's like this scale called the Nutrient Profiling Model, and you can do a version of it where it goes from 0 to 100. 0 is really bad, 100 is really good. If you move from a score of 66 out of it (which happens to be where most the average supermarket is at the moment) to about 69 on it, that would have an impact equivalent to reducing obesity by a fifth. So a massive impact!

So you can have these small changes... these small changes, rather, can have these massive impacts because you're targeting such a large proportion of food that is consumed by such a large proportion of people. And so then you can have these sort of potentially transformational improvements if you do the stuff that's well-evidenced and proportionate. So, you know, there have been 700 things, but none of them have been nearly the sort of scale of that. And so you need something that is that sort of scale if you want to make meaningful changes.

Sugar tax is a great example of something that is like conceptually the exact right sort of thing, but it only applied to fizzy drinks! So fizzy drinks are just not that much of the diet. So you have these amazing improvements, you know: massive reduction in sugar content (something like 40%), improvement in like volume sales for it (so businesses were fine), and then people were saying, "Well, how come obesity hasn't dropped?" Because fizzy drinks aren't most of the diet! You know, you just need something that applies to lots of stuff.

And that's some of the issue with the like more positive side as well: increasing fruit and veg—great thing to do, you know! But like, you would have to have a huge relative increase in the consumption of fruit and veg to move the dial nationally on obesity. And so, you know, if some schools are getting some fruit and veg for free, that is a positive thing, but it's totally insufficient to the scale of the challenge.

[18:19] Joe Owen: And so your theory is if most meals that people consume are not a lot—you know, 50-odd calories lower over a sustained period—you see huge change.

[18:30] Hugo Harper: Way less than that. Right, so if you were to see a 216-calorie reduction on average for people living with excess weight—so that's about a bottle of Coke every day—that's about an 8.5% reduction. So that would halve obesity rates nationally. So this is what we're sort of talking about in terms of like: if you have those changes across a large portion of your diet, you know, little changes across lots of things, you don't really notice it.

If I say "no more biscuits at 4pm for you", you'll revolt against it, you know, you don't get the fun things! So when we talk about it, we talk about making food healthier rather than necessarily healthy, because we don't like this binary distinction of like "good food" and "bad food". You know, like, it's fine to have cake on your birthday; it's not fine to have cake for breakfast every day! There's somewhere in the middle you get to a sensible consumption of it.

And there's lots and lots of different foods, so you don't want to be prescriptive with it, but you want to be pragmatic and quantitative and say like: these changes that are required, if spread out, shouldn't feel painful, shouldn't remove the joy from food, shouldn't make it impossible for business.

[19:44] Joe Owen: Yeah, that all makes total sense. I guess the skeptic listening or watching this might say, Dolly, like: why does the food environment matter now? We've got GLP-1s.

[19:53] Dr Dolly van Tulleken: Oh, it's a very good question! And, you know, one that is very high up on the media and public and government agenda at the moment with this.

There are very various sort of reasons why not, some very practical ones like the cost, which right now would be absolutely insane and completely impossible for government to fund, so that sort of feels like a very real reason why that's not the solution as of yet.

I love Sir Michael Marmot talking about: why do we treat people and then send them back to the conditions that made them sick in the first place? And I feel like that couldn't be more relevant when it comes to thinking about GLP-1s. We absolutely shouldn't be treating people for a condition that essentially was the result of the food environment around them, without changing that food environment. The idea that we would treat people and then send them back to the exact conditions that made them sick...

And you know, I'm in touch with a group of clinicians and I hear very disturbing stories about people who are taking GLP-1s with private prescriptions and eating a diet that is meaning that they are in an incredibly nutritionally poor situation, and not getting kind of proper guidance and support along the way. And that sort of feels like it represents the fact that we're essentially providing this treatment, but then putting people in exactly the same food environment that made them sick in the first place.

So I feel like it absolutely has to go hand-in-hand. Also, to prevent people from needing treatment, you also still need to absolutely transform the food context that people operate in. And as Hugo said, that's everything from the literal food that is available to the way that we advertise it and the way that we talk about it, think about it, the information around it. And that essentially is a cultural transformation.

And I think that a cultural transformation is the way that we should be thinking about it from a policy perspective, because to understand behaviour and understand what makes it easy for people to do a certain thing, we often talk about as being culture. We'll say that, you know, Japanese, Italian, French food behaviours are related to their culture, and we'll say, "Oh, that's just culture, you'll never get it." There are so many excellent examples, including in our country, related to smoking—the fact that we went from essentially a smoking culture to a non-smoking culture that was completely related to policy change.

And another example that I often go to to demonstrate that, when we talk about the Dutch as being cyclists and we just think "Oh, that's the way that culture has always been"—that was a huge policy change over a 10-year period that essentially resulted in huge investment in the infrastructure that has resulted in a cycling culture, but that wasn't necessarily always the case.

So I think we have to believe in the possibility that Britain can have this nourishing food culture and an incredible food system that supports good health and sustainability and all of the other factors that we would be interested in—equity, justice, you name it. We have to believe in that cultural transformation, but in order to do it properly, we have to think of it in that way: that it's a multi-pronged approach.

[23:09] Joe Owen: And where does it come from? How do you drive that? Is that a... it needs political leadership in order to do it? Is it that the politics will always be following the culture and therefore there are things outside of government that need to happen? What are the ingredients of the sort of successful cultural change, do you think?

[23:26] Dr Dolly van Tulleken: Well, I mean, I can't help but look at America because of the Make America Healthy Again movement. And sort of regardless of the politics—and there's so much sort of controversy and difference of opinion with the Trump administration and the links with the MAHA movement over there—what has been interesting is an essentially very Americanised food system that is built on essentially an ultra-processed heavy diet that we have adopted here in the UK, being transformed to prioritise and reframe the food agenda in such a profound way. Whether you agree with it or not is kind of not the point I'm making, it's more that you can see that transformation of framing, you can see a political prioritisation, which I still believe is possible in the UK.

Because we know from public opinion research that actually the public is very much in favour of government doing more on food and health policy. They want government to make it easy for them to be able to enjoy a nourishing diet, and for food that is good for us to be made more affordable and available. We know that very strongly. So the public is primed, it's almost like the politics needs to be made to happen.

And there are lots of reasons why the politics are very difficult, which we worked on with Nourishing Britain to interview politicians about exactly that. And they're totally understandable, related partly to the history of our British culture regarding food and wanting to be seen as being "down with the people"—politicians sort of use food as a tool to do that. And it's something even politicians are slightly confused about, which I think is a really interesting point.

And also the fact that I guess we're sort of looking for an identity that potentially Britain doesn't have, and I don't think has had. I've been sent literature from the 19th century that talks about Britain's food culture as being still sub-optimal compared to other countries! So I don't think it's... I think we have to be forward-looking and thinking about what it is that we would want as a forward-looking British food culture—one that sort of supports and nourishes people properly.

[25:38] Hugo Harper: Yeah, like the... I mean, the politicians are in a bit of a bind. If you stop someone on the street and ask them, "What do you need to do to sort out healthy eating or obesity?", they normally give you two answers: education and physical activity. Those two things are well-evidenced to not sufficiently improve the issue. But then, you know, you're the politician, you're appealing to voters, right? And so if that's the understanding around this, then you can kind of see how you can get trapped in this cycle.

Also, you know, the benefits are in the future. You know that weight loss takes a long time, and to reach a new weight equilibrium... and so like, you're talking about benefits probably after your term in parliament, you know, when you really see the sort of benefits for it. So it's understandable, but the thing that we should be really clear on is like: consistently for years, if you poll people, they're positive on this stuff. And so this idea that people sort of revolt... you know, there's a very vocal minority that sort of, you know...

[26:37] Joe Owen: "Nanny state."

[26:38] Hugo Harper: Yeah, exactly! And so, you know, you ask actual people about this, particularly if you frame it properly... You know, if you're like, "Do you think they should take away your burgers?" You know, there's a lot of silly framing that goes on that sort of provocates outrage on it. But if you give people—particularly if you give them a bit of time, you know, there are things like citizens' juries, deliberative forums where you kind of let people sit with something for a bit—and then you get responses from people that look a lot more like what the like evidence-based community would suggest. So it's both that there's an initial like a real desire to improve on this, and that when people are given the time and the information to kind of engage properly, they tend to sort of be pretty positively aligned to what like expert opinion on this stuff would be.

[27:24] Joe Owen: Hugo, do you agree on GLP-1s then?

[27:26] Hugo Harper: Yeah, and the evidence does, right? As soon as people come off these drugs, they start putting the weight back on. And so that's sort of proof of Dolly's point, right? You remove the drugs, you're back in the same environment, you go back to the same weight. You know, it takes a little while for people to do it. And so then to have those like health benefits sustained, you need to then be on the drugs forever. And then you need to be paying for the drugs forever.

So, you know, it's no solution for a large portion of the population. Definitely get access to these drugs for the people who need it now. You know, the current rollout on the NHS is pretty slow. We'd want to see that sort of probably expanded to... you know, originally it was down for 3.4 million people, now it's 1.6 over 12 years. We'd love to see that in more like 5 years rather than 12. So it's not that like GLP-1s are bad—they're a great treatment for people who really need it. It's no way to treat a population-wide issue, yeah.

[28:19] Joe Owen: No taking foot off the gas.

I said we'd come back to the food industry, and I wanted to ask you first, Dolly, about... when you talked of your three reasons why previous action had failed, one of them was that it was voluntary in nature and therefore the sort of system didn't adjust, and the other was that things sort of gradually get watered down over time in response to lobbying. Do you think the food industry is sort of friend or foe of the government on this? Is this like government is scared to face down these vested interests? Is it that it's bad policy? How confrontational do you think that relationship should be?

[29:01] Dr Dolly van Tulleken: Well, it's a hard... So from a government perspective, what we discovered with our interviews with politicians over the last 30 years about why it's so hard to act on this, and understanding the difficulty when it comes to engaging with business, is that sort of government as an institution overall has a mixed relationship with business, where it's sort of partly championing it—massively championing it—and partly having to regulate it. And that can be quite a tension.

And we were showing examples of where that plays out even in individual careers. So you have someone like Jeremy Hunt who had been the longest-serving Health Secretary—at one point he talked about regretting not doing more on childhood obesity—but as Chancellor he was celebrating PepsiCo UK's largest expansion in the UK in 25 years. And so you can have that tension playing out even in individual careers.

My own position in terms of whether, you know, the food industry is a sort of friend or foe, I tried to essentially create a framework to try and answer that question last year with a report I did called Net Drain or Net Gain?, which I did with the Food, Farming and Countryside Commission. And the idea was that we don't have a way to assess companies—individual companies—for whether they are sort of net drains or net gains on society, the economy, our health, the planet overall.

And what could be the sort of way to do that so that we would get almost a holistic idea? Because yes, they'll tell the story that they provide jobs and they've got these factories and they're really big contributors to GVA and all of this kind of stuff on the economy front—you'll hear that narrative very strongly, and they often host events in parliament celebrating their economic and social contributions. And at the same time, you've got academics and researchers and campaigners who are talking about the harms that they're causing—whether that's the false economy in the food system, about the externalities in terms of the health problems that they're creating, environmental damage, welfare issues, animal welfare issues, you name it.

So I wanted to sort of pose the question of: what's true? You know, if you were to kind of assess them as a whole, what is true? And I think it's a really important lens. We would love that framework to be applied to start assessing individual companies, but there were key pieces of information we don't even have. For example, the proportion of ultra-processed food that one given company makes and sells, or even the profits derived from unhealthy ultra-processed food—we don't have that information.

So there was a lot of kind of going, "We actually need..." which essentially is some of the stuff that Nesta is calling for in terms of that transparency around reporting and being able to create targets around. We are missing a lot of that transparency in order to make that assessment.

So I kind of approach companies as trying to move away from talking about "the food industry" as this big, homogeneous group of businesses, because there is so much diversity. And we have to have food businesses operating! We have to have businesses producing food, manufacturing food, making food, distributing food—we absolutely need that infrastructure. So we need to have a very clear distinction about going: these are the kind of ways that we're going to think about the food businesses we want as part of the solution, and these are the sort of businesses and the operations and incentives we need to move away from. And I think until we have that very clear distinction between the kind of businesses that are sort of net gain versus net drain, we're going to find it really hard to move away from that narrative that sort of essentially people that sound anti-all food businesses versus one saying we have to have and support food businesses in the first place.

[22:30] Hugo Harper: Yeah, like, food isn't smoking. Right, food isn't bad. We don't want the amount of food to be zero! And in a way, the food industry's been sort of a victim of its own success, right? They were given the remit to make food plentiful, make it cheap, make it not go off or make you sick, and they smashed it! Right? And it's caused this other problem.

And so, you know, we'd be very against like, you know, painting people as like amoral, evil... You know, that stuff's not helpful. It's just people are playing to the incentives that they're given into the system that they're given, and government controls those regulatory incentives.

And so like, we at Nesta, we're in this really fortunate position because we're an endowed charity, we can partner with some of these businesses to see if we can get them to make some more progress. That gives us a much better understanding of the business, it causes some direct impact, but because we do that on a voluntary basis, no money's changing hands, right? There's not that conflict of interest that you often get with like academic work funded by industry, or, you know, consultancies that rely on a large portion of their business coming from large food manufacturers or that sort of stuff.

So you also don't want to be in a position where you're saying like, "We can't ever engage with you on anything," because food is complicated, and so otherwise you'll come up with solutions that like sound plausible, but actually fall down for a number of technical reasons.

So the way we talk about it is like: you want government to set an ambition, and you don't want that watered down. Right, that's based on like public health values, what it means for productivity, all that. And then once you've got your target, once you've got your impact goal, then you can have conversations about how best to hit it—you know, what industry thinks are the most promising ideas, what things actually won't really work for practical reasons, or what solutions would be required to unblock stuff. But what you really don't want is the like... having people involved in the process of what should the target be or when should it be hit by, because based on current incentives, that will be water down the target, push it out further, let's do less, you know... And so it's a really tricky balance.

[34:36] Joe Owen: And there are trade-offs, right? In that, I'm sure some of the conversations government is having with supermarkets at the moment is with one hat on in the health department, conversations around obesity and the food environment; but in the Treasury, they're also saying, "How can we keep prices as low as possible?" And the supermarkets might say, "Well, the people from government I spoke to yesterday were telling me things that it might cost me a little bit to adjust to in the short term, and you're telling me currently that I need to..." So some of this is about supermarkets, I suppose, or large retailers and the food industry, having sort of the different heads of the snake of government saying different things to them at different times, and then saying, "What do you actually want?"

I want to conclude on a positive note, though, and I want to come back to the point that you made earlier, Hugo, around the Healthy Food Standard. So the mandatory reporting, the mandatory targets, is a bit of work that we at Nesta have been doing—well, we worked on, and we sort of, I think we like to think we inspired it! We did inspire it. And it was announced in the 10-year plan for health by the Secretary of State last summer. So where are we at? Is this a big moment of hope? Do we think it's all changing, or is it going the way of previous attempts?

[35:56] Hugo Harper: Well, as you mentioned, it was announced about a year ago, right? And currently, no visible progress on it. You know, talking about that there should be a consultation soon on the... whether that consultation covers just the reporting bit, whether it covers target the targets of it, when it would be suggested that those might be implemented by—that's all uncertain currently.

You know, what we would be pushing for is mandatory reporting as soon as possible. A number of organisations already voluntarily publish this information. We know from our work with people that this is data that is often held, and so this is something that should be doable. Problem is, you know, anything at the scale of a national retailer, you get to big numbers. So, you know, is a million pounds a lot? Well, not if you're Tesco! You know, and so it can be tricky when you're having these arguments about what are the costs to business.

So, but it's plausible that a consultation comes out tomorrow, right? Depending on when this is going live! Plausibly a consultation's already come out. And so there's absolutely definitely still time to make this work this parliament. So in terms of like the hope for this, we should be pushing this. This is the number one thing, right?

Even if we're wrong by double... you know, if it's not 20%, if it's 10%; if it's not 20%, if it's 5%; if it was 2%, that's still huge! You know, the numbers here are massive, particularly for the costs. The estimate that we've got is that this would be about 0.1% of revenue for these for these big retailers—which is a big number, but also a tiny number.

So we should be optimistic about this, but we need to see action soon, because otherwise you time out about these things. You know, government gets less ambitious generally at the end of parliament, they sort of... you don't want these things going on to the next parliament. And we've had a change in Health Secretary, right? Political instability, that's generally not good for progress on things. And so we have cause to be optimistic we can still make this huge impact happen, but we need to see action pretty soon.

[37:54] Joe Owen: So we've got a big policy, the government's game for it, it's still doable this parliament, and if so, the benefits could be enormous over the long run in comparison to lots of previous policies that we've tried. So that is a reason to be hopeful.

Dolly, there will be lots of people who worked in the food environment space for a long time who have seen various commitments get watered down. How do you stay motivated and hopeful working in this space, and what can an individual listening to this do who thinks changing the food environment is a thing they care deeply about? What can they do to to make it happen?

[08:31] Dr Dolly van Tulleken: Yeah, it's a really good question, and we've talked about this a lot because I think any... if you work in a space where you're trying to change a system, and especially one as complex and huge as the food system, you do risk burnout and sort of having these huge dips of hopelessness and feeling like you're never going to get anywhere.

So one, it's really important that we sort of celebrate those wins as we talked about earlier. I think also creating a community where there are genuine, supportive relationships between people working, campaigning, researching together in this space is really important. And we're very lucky in this agenda that there are people who have stayed around for a long time, and there are really wonderful working relationships between people, and I think that you sort of need that on a day-to-day basis as well.

And the reason that I'm hopeful, in addition to sort of just finding it fascinating and I've also committed to dedicating my life to this, so I'm not going to be going anywhere! Is that there's a real shift in the last few years that the understanding—partly with research that I've focused on around why we've had so many years of government policy that hasn't worked—towards really trying to mobilise everyday people to become aware of the problems, become aware of the drivers of our unhealthy food system, and to be able to become active, become vocal, become part of it.

And part of that is the Citizens' Assemblies work, there's been really interesting stuff done, and the Food, Farming and Countryside Commission is still working on that and trying to enable people, members of the public, citizens of the UK, to become active and speak out about their own experiences, which I think is one way to do it.

There are also lots of organisations in the food and health policy space who provide ways that people can become active. So whether that's Bite Back, that as a young person you can become an activist through their programme, and you get training and you can work with trying to change stuff in your schools, in your communities—so they have an entire way for young people from the ages of 14 years old to become active. There are other organisations like Sustain that will have automated letters that you can send to your local Members of Parliament, and that can be a really... if you are absolutely time-poor, but really wanting to provide some way to say that you're interested in this agenda and want to have it as a higher priority on policy makers' agendas, then sending an email or a message to your elected Member of Parliament is a really good way to do that. So there are lots of organisations set up to try and activate, so getting involved in those main ones in this space is a great way to start.

[41:14] Joe Owen: Great. And if you want to spend time with people who care about this, you can come to some Nesta events!

[41:19] Dr Dolly van Tulleken: Exactly!

[41:20] Joe Owen: Dolly, Hugo, thank you so much.

[41:22] Dr Dolly van Tulleken: Thank you.

[41:23] Joe Owen: If you enjoyed this episode, please do like, share and subscribe wherever you get your podcasts. As a reminder, Nesta is a research and innovation foundation. We design, test and scale solutions to society's biggest challenges. We are funded by a charitable endowment, and we are politically neutral. If you'd like to find out more, please go to nesta.org.uk.