Dietary related diseases are a major cause of morbidity and premature mortality in Sandwell, one of the most deprived populations in England( 1 ). An estimated 28·7 % of the adult population is obese, significantly higher than both the average for England (24·1 %) and the level reported in local authorities of a similar economic structure (24·1 %)( 2 ). About 40 % of year 6 children were obese or overweight in 2012( 3 ). While early mortality rates from CVD ( < 75 years) have declined markedly since 1995, they remain significantly higher than the national( 2 ). Sandwell is in the bottom 10 % of local authorities for deaths from heart disease, which are 50 % higher than neighbouring Dudley( Reference Sandwell 4 ).
While there has been some recent debate about the health impact of SFA( Reference Lawrence 5 , Reference Wise 6 ) and the adverse consequences of replacing SFA with carbohydrates( Reference Lawrence 5 ), there is evidence that total fat and SFA in particular are implicated in obesity and CVD( Reference Salter 7 – Reference Baum, Kris-Etherton and Willett 9 ).
Excessive salt is an important factor in hypertension( 10 ), and there are recommendations nationally to reduce the salt content of food eaten outside the home to achieve a safe level of intake( 10 – Reference Taylor, Ashton and Moxham 12 ). Small-scale sampling of takeaway foods in Sandwell in 2010 found high levels of total fat, SFA and salt( Reference Sandwell 13 ).
Obesity and overweight are increasingly being considered in terms of the wider environmental context of the places in which people live and work, as well as factors acting at the individual level such as attitudes, behaviours and beliefs. While there is an established literature on the lack of access in deprived communities to retail fresh fruits and vegetables (food deserts), there is growing concern over the association between the fast food landscape and obesity( Reference Rudge, Suglani and Jenkinson 14 ). Sandwell has been actively considering the impact of communities living in ‘fat swamps’ (areas with large numbers of outlets selling readily accessible, cheap, energy-dense pre-prepared food) as well as food deserts. Nowhere in Sandwell is more than a very short walk from one or more hot food takeaways( Reference Rudge, Suglani and Jenkinson 14 ), and there is a significant association between such close residential proximity and deprivation. The density of outlets increases with deprivation effectively doubling the probability of a proximate outlet, and also increasing the choice and diversity of fast foods available( Reference Rudge, Suglani and Jenkinson 14 ). In addition, there is some, albeit modest, evidence that increased density of takeaways is associated with increased consumption of takeaway foods and levels of obesity( Reference Burgoine, Forouhi and Griffin 15 ).
Sandwell is clearly close to some level of market saturation. This presents a public health challenge in terms of promoting healthy diets, and also introduces the prospect of businesses turning to cheaper and more hazardous ingredients, as operating margins shrink. In particular, there is concern about the health effects of the cheaper, more stable, low maintenance trans-fatty acids (TFA) in food manufacture( Reference Willet 8 , Reference Laake, Pedersen and Selmer 16 – 18 ). There are calls for a ban on TFA particularly in schools( 19 ), advice implemented internationally( Reference Lichtenstein 20 , 21 ). While their use is being actively managed and reduced in large-scale manufacturers, little work has been conducted on the extent of use in small-scale hot food takeaways, potentially a major source of exposure in Sandwell.
During 2013–4 the then Sandwell Primary Care Trust commissioned the purchase of over 250 takeaway food items, and their analysis for total fat, saturated and unsaturated fats, TFA and salt. The present paper reports the results of those analyses, data interpretation and recommendations for intervention.
Methods and procedures
Literature review
A literature review was conducted on recommended standards and exposures for fats (including TFA) and salt, and the levels reported in takeaway food products. For details of the search strategies, inclusion and exclusion criteria and decisions, and data extraction tables, see online Supplementary material.
Takeaway food sampling and analysis
Sandwell Metropolitan Borough Council (MBC) provided details of all hot food takeaways in the borough, and a dedicated officer to purchase the samples. A sampling framework was agreed to by Sandwell MBC, Primary Care Trust and Worcestershire Scientific Services. Sampling targeted independent retailers to include at least one in each ward, products previously sampled in published surveys from Sandwell and other local authorities in England and Northern Ireland to enable comparisons, and foodstuffs considered by Sandwell MBC as vulnerable to substitution and representative of local demand (see Table 1).
Table 1 Sampling framework
TFA, trans-fatty acids.
Standards
There have been multiple methods used to develop nutrient recommendations and guidelines and these vary between, and sometimes, within countries( Reference Aranceta and Perez-Rodrigo 22 ). In the UK, Guideline Daily Amount (GDA) for women, men and children have been established for energy and seven other main nutrients — protein, carbohydrate, sugars, fat, SFA, fibre and salt. Although currently being replaced by reference intakes, at the time of this research GDAs were widely used by the industry with evidence that they were familiar to, and approved by, consumers, and encouraged healthy choices( 23 ). GDA for total fat, SFA and salt were used as an acceptable exposure limit. In the absence of a GDA for TFA, a limit was derived from the literature.
The 2007 review( 18 )of the Scientific Advisory Committee on Nutrition (SACN) considered the evidence regarding the health effects of TFA, and advised that average TFA intake should not exceed 2 % of food energy, equivalent to approximately 4·8 g/d. SACN also considered that further reductions could impact on attempts to reduce dietary SFA and on the consumption of animal products( 18 ). However, while only an estimated 3 % of the general adult population consume more than 2 % food energy as TFA( Reference Henderson, Gregory and Irving 24 ), that figure rises to 9 % of males and 6 % of females in the low income cohort( Reference Nelson, Erens and Bates 25 ), which has implications for Sandwell's large deprived population. A meta-analysis study has suggested that a 1 % decrease in energy from TFA would deliver a 12·5 % decrease in the risk of CHD( Reference Oomen, Ocké and Feskens 26 ). Reducing food energy as TFA to below 1 % for everyone in the UK requires an average decrease of 0·6 %, and it would reduce CHD risk by 5·0–7·5 %( 18 ). Given these factors, an acceptable limit of 1 % (2·4 g/d) was derived for this study, a level recommended by the American Heart Association( Reference Lichtenstein and Appel 27 ). This review was unable to identify an appropriate limit for children.
Results
The literature searches identified 130 references. Reviews of titles and abstracts, examination of citation lists, references provided by experts, and exclusion of duplicates resulted in the inclusion of thirty-four papers which were retrieved and reviewed together with two local authority reports. Table 2 summarises levels of fat reported in takeaway foods (where reported in g). Results were published for a range of takeaway products sampled in the UK, Ireland, the USA, and Australia. While there is some consistency in the products sampled, there is considerable variability in methods with different definitions of takeaway, metrics used, components tested, and populations assessed. This precludes meta-analysis but there are useful outcomes in terms of the impact of this sector on exposure and the relative position of Sandwell.
Table 2 Levels of fat (g) in takeaway foods reported in the literature
TFA, trans-fatty acids.
Only one paper recommending dietary standards for takeaways was identified, suggesting that a single meal should not exceed 30 % of the GDA for any given component( Reference Wellard, Glasson and Chapman 28 ). There is sparse data on the frequency takeaways are consumed. One US study reported young people using fast food outlets three to four times a week( Reference Larson, Neumark-Sztainer and Laska 29 ); another found 30 % of the sample consuming fast food on a typical day( Reference Bowman, Gortmaker and Ebbeling 30 ). A UK study reported 10 % of surveyed children using takeaways daily and over 50 % twice or more a week( Reference Patterson, Risby and Chan 31 ).
food samples were purchased and analysed including forty-seven portions of rice, thirty-six portions of fries, thirty-four fish, twenty-eight pizzas, twenty-five sweet and sour chicken, twenty-five battered products, twenty-three lamb jalfrezis, fourteen kebabs, and nine saveloys.
Table 3 shows the average weight of total fats, saturates, TFA, PUFA:SFA ratio and salt by food product. Levels of total fat, TFA and salt in pizzas bought in Sandwell are broadly similar to the international literature, although they are higher in saturated fat. However, there are some notable exceptions. Total fat in ‘generic meals’ (using pizza and chips as the example) in Sandwell was at the upper extreme of the range reported internationally, and saturated fat was more than double the internationally reported mid range. Fries in Sandwell were lower in total fat and salt (although samples in Sandwell were not salted on purchase), and again higher in saturates. Both sweet and sour chicken and fried rice and chicken tikka masala and rice meals had higher levels of total and saturated fats and salt than those reported in both a 2010 Sandwell study( Reference Sandwell 13 )and a recent English study( 32 ). It was found that 69 % of the products had PUFA:SFA ratios less than 1, and 30 % less than 0·1.
Table 3 Average weight of fat and salt content in takeaway portions (values for example meals derived from individual components) (Mean values and standard deviations)
Seventy-one of the 104 separate analyses exceeded the recommendation that a meal should contain less than 30 % of any GDA( Reference Wellard, Glasson and Chapman 28 ) for at least one measure (Table 4). Pizzas exceeded the recommendation for all measures. Of the thirty-three results below 30 % GDA, seventeen were for TFA and five of the thirteen food groups contained no TFA. Fifty-four of the analyses exceeded 50 % GDA for at least one measure including twenty-one of twenty-six results for SFA. Eighteen results exceeded 100 % of the GDA including 203 % GDA in pizza and chips for women/children (SFA), 173 % GDA in sweet and sour chicken and fried rice for children (salt), and 170 % GDA in fish and chips for women/children (SFA). Fourteen of the thirty-nine results for children exceeded 100 % of the GDA for at least one measure. For 69 % of the samples, seven of the twenty-six salt analyses exceeded the GDA for salt.
Table 4 Proportion of recommended daily intake of fats and salt in takeaway samples
GDA, Guideline Daily Amount.
A surprising finding was that portions of both pizzas and fries purchased in Sandwell were considerably larger than those reported elsewhere including the US, e.g. average Sandwell portion size for pizza of 365 g compared with 94 g( Reference Tyburczy, Mossoba and Rader 33 ) and 102 g( Reference Dunford, Webster and Woodward 34 ), and for fries of 355 g compared with 120 g( Reference Tyburczy, Mossoba and Rader 33 ).
Discussion
An adequate and nutritious diet is essential to a healthy, productive and fulfilling life. This is especially so for children whose physical, intellectual and emotional well-being is inextricably linked to what they eat, how much is consumed and, indeed, to what they can't afford to and so don't eat. Access to a healthy diet is a fundamental right and is predicated by a range of factors including personal knowledge and choice, convenience, availability, quality, cost, and social norms. The evidence is clear that deprivation compounds all these factors with poorer people buying more unhealthy foods with fewer healthy components while being exposed to circumstances that make such ‘choices’ inevitable( Reference Rudge, Suglani and Jenkinson 14 ). The consequences of this unfortunate situation are manifest in Sandwell with its burden of obesity and CVD. Perversely, Sandwell has become simultaneously both a food desert and a fat swamp. Virtually the entire population of Sandwell lives a short walk from at least one takeaway. Consequently, the quality of these foods is of real significance for the health of the people of Sandwell. The present study has found high levels of exposure to fats including SFA and salt in takeaway foods. More than half the samples exceeded at least one GDA (or Acceptable Daily Intake) for fat, SFA or salt with a pizza-and-chips meal exceeding the recommended levels for all measures. The great majority of the foods provided more than 50 % of a GDA in a single meal, and over 80 % of that for SFA, which is of particular concern.
SFA are associated with factors that predispose people to CVD, although the evidence of a direct relationship is currently challenged( Reference Wise 6 ). However, there is biological plausibility for an effect, and given the clear evidence that a balanced diet protects health, it is important that populations follow at least the current recommended intake of fats. The GDA is not a target for consumption, and so its use is a relatively conservative approach, and replacing SFA with PUFA will reduce risks. The PUFA:SFA ratios reported demonstrate that the present consumption of takeaway foods in Sandwell is incompatible with that substitution.
The levels of salt are of even more concern. Salt consumption has a profound effect on hypertension and the risk of CVD. A recent well- conducted systematic review highlighted the power of this relationship, and recommended a target reduction in salt intake to 3 g/d, the 2025 target level set by the National Institute for Health and Clinical Excellence for the UK( 35 ). GDA is currently 6 and 4 g for adults and children respectively( 36 ). Seven of the thirteen food groups sampled exceeded this target. This result becomes extreme, given that fries were not salted on purchase and were part of three of the four combination meals purchased for this study,.
There were some remarkable results reported with single meals containing over 100 % GDA, including 203 % and 170 % GDA of SFA, and 173 % GDA of salt, given the evidence that young people routinely eat takeaway foods several times a week( Reference Larson, Neumark-Sztainer and Laska 29 – Reference Patterson, Risby and Chan 31 ); that the fourteen of the thirty-nine results for children exceeded 100 % of the GDA for at least one measure in a single visit is indeed a serious public health threat.
The results for TFA appear at first sight to be reassuring in that zero levels were reported in five food groups, and only nine of the twenty-six analyses exceeded 30 % GDA. But high levels of TFA were found in pizza-and-fish-and-chips meals, and TFA is a chemical to be scrupulously avoided. The overwhelming consensus in the literature is that TFA are linked with poor health outcomes, and their levels should indeed be reduced; several papers call for a ban on TFA, and the US Center for Disease Control has recommended the removal of TFA from school meals( 19 ); the advice should be successfully implemented in earnest by municipalities internationally( Reference Lichtenstein 20 , 21 ).
While it is evident that the food industry has responded to these concerns by reducing the use of TFA, it is also clear from the analysis of foods in Sandwell that a real exposure hazard remains. The Sandwell results are especially important as they relate to the smaller independent outlets rather than the large chains which have been able to reduce TFA use without commercial disadvantage. It is also a sobering reality that the young and the deprived are more likely to use fast food takeaways, a disproportionately large community in Sandwell. Experience from New York has demonstrated the impact a municipal ban on TFA in major chains can have on levels of exposure( Reference Angell, Cobb and Curtis 37 ). This is a limited option for Sandwell given that its market is dominated by small independent businesses as opposed to the major chains, the limited powers an English Council has to legislate in this area, and the potential access to takeaways in the four bordering Councils.
It is entirely legitimate for Councils to consider those powers they have (for e.g. planning and licensing) to enforce a TFA reduction, to lobby the Government on delegating powers to local authorities to respond to local public health issues, and collaborate with neighbouring councils on a regional approach to ensure that businesses in one area are not prejudiced by initiatives in another.
It is true that Sandwell, as several other UK Councils, has used its planning and licensing powers to restrict the siting of takeaways in the vicinity of schools. While this sends out a very powerful political statement, it is doubtful whether such restrictions will have an impact on obesity especially in an environment where there are so many other available takeaway options. Such readily accessible and cheap foods is inevitably attractive to deprived communities, given that food prices increased 12 % in real terms between 2008 and 2012, while median incomes in the most deprived decile fell 12 % between 2002 and 2011( 38 ). Analysis of the cost of ‘more healthy’ and ‘less healthy’ foods over a very similar period (2002–12) found that the former were consistently more expensive, and that this gap had widened with healthier foods being almost three times more expensive by 2012( Reference Jones, Conklin and Suhrcke 39 ). For poorer social groups avoiding the expense of cooking entirely is a cost effective way of sourcing energy. These are the same populations experiencing high levels of unemployment and limited opportunities to develop businesses. There are, clearly, strong political, social and economic reasons for not considering a blanket restriction on takeaways given the role such businesses play in entry-level employment and business opportunities for disadvantaged communities( Reference Neckerman 40 ). In addition to the composition of takeaways, another major concern for Sandwell is the apparent supersizing of portions in the independent sector, presumably in response to intense market competition. A surprising finding was that portions of both pizzas and fries purchased in Sandwell were considerably larger than those reported elsewhere including some American research( Reference Tyburczy, Mossoba and Rader 33 ). Rather than trying to ban such foods, a more realistic and effective intervention is to challenge and change what's on offer, how much is on offer, and how it's been prepared. As Neckerman put it in a recent BMJ Editorial, ‘change the menu not the venue’( Reference Neckerman 40 ).
Trading Standards and Environmental Health, with responsibilities to enforce food standards and safety legislation including labelling and composition, have critical roles in ensuring that health and nutrition claims comply with current legislation, and promote government food policy across the industry. It is necessary for the government and the local authorities to encourage and enable businesses to use healthier ingredients and techniques. This ‘non-regulatory’ work is just as important as regulatory interventions, if not more so, given the potential for the major improvements over and above mere compliance with the law to make meaningful changes in the Sandwell community consumption pattern.
Previous work in Sandwell demonstrated the value of targeting food safety interventions on an area basis, rather than through a simple individual business risk assessment. This approach delivered statistically significantly improved food hygiene scores during its implementation from 2008–10( Reference Sandwell 41 ). There may be some value in adopting the same approach to improving the dietary quality of fast food takeaways in Sandwell and elsewhere.
In summary, people in Sandwell are exposed to large portion sizes and high levels of fats and salt in takeaway foods, with levels in some foods having increased further since 2010. They have limited options to break out of this highly compromising environment due to high levels of deprivation, limited transport options and the dubious distinction of living simultaneously in a ‘swamp’ of unhealthy, readily accessible and cheap takeaways, and a ‘desert’ of healthy options. A package of interventions is required including: the use of local planning and regulatory powers; undertaking environmental and educational interventions targeting consumers and businesses; addressing portion sizes( Reference Vermeer, Steenhuis and Poelman 42 ); stimulating demand for healthier products; framing school food procurement policies; adapting the roles of Council enforcement officers to persuade the industry to promote healthy food preparation techniques; and launching a local social marketing campaign( 43 ).
Strengths and limitations of study
The present investigation effectively utilized the skills and resources of the key public health agencies and professional groups. It targeted the independent retail sector, the largest source of takeaway foods in Sandwell, subject to intense economic pressure and competition. Sampling covered each ward in the Borough.
Testing for fraudulent substitution of products revealed very little information and weakened the reliability of the limited sampling resource. The discretion of local enforcement officers in determining representative products was partially subjective, and led to a disproportionate sampling of some products at the expense of others (this is reflected in some of the large standard deviations reported in Table 3).
Supplementary material
To view supplementary material for this article, please visit http://dx.doi.org/10.1017/S0007114515001063
Acknowledgements
This research received no specific grant from any funding agency, commercial or not-for-profit sectors.
Paul Hancock, Worcestershire Scientific Services, provided technical expertise on sampling methods and managed sample analysis.
Richard Norton, Sandwell MBC, provided data on location of takeaway food businesses and a dedicated staff member to purchase, store and transport food samples.
Contribution of authors were as follows: P. S. managed the programme of work including the development of sampling and analytical protocols, supervised the data analysis, interpreted results and led on early drafts of the paper; A. S. conducted the data analysis; J. M. secured funding from Sandwell Primary Care Trust and contributed to the design and management of the programme. All authors read and commented on drafts of the paper.
None of the authors has any conflicts of interest to declare.
