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DURHAM UNIVERSITY (Anonymous) Candidate No: Z0970909

QUEENS CAMPUS
SMPH PGT PROGRAMMES Submission Date: 7/4/17
WRITTEN ASSIGNMENT Title of Assignment: Assignment 2 (Policy brief + Essay)
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Module Name: The Dynamics of Evidence Informed Policy

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1
 The use of evidence in development of the 20%
sugar reduction policy, to address childhood
obesity in the UK
Childhood obesity is a growing
threat to public health.
The UK government developed a
sugar reduction policy to
address it (as part of a complex
intervention).
The use of evidence in this
policy process was not straight
forward and open to bias.
The definition of evidence, its
selection and interpretation
shaped policy development.
The problem
The 21st century faces a worldwide obesity
epidemic, amongst adults and children (1).
Childhood obesity is diagnosed by a body
mass index above the 98th growth percentile
(2). It is a complex issue with an array of
drivers, including, behaviour, environment and
culture (3).
In the UK, nearly 1/3 of children (2-15yrs) are
obese or overweight (3). This is associated
with serious long-term health risks and
economic consequences for the UK.
The policy
In 2016, the UK government published
Childhood Obesity a plan for action to
combat childhood obesity (3).
As part of a larger initiative, this plan contained
a commitment to reduce sugar content of
selected food and drinks by 20% by 2020 (3) .
Reformulation will be led by Public Health
England, across nine food categories,
reflecting the largest contributors to childrens
sugar intake (3). All sectors of the food
industry are targeted.
Reformulation will be achieved through
reduction of sugar levels in products, reducing
portion size or shifting purchasing towards
lower sugar alternatives (3).
These measurements will be reviewed by
Public Health England biannually to track
progress (3).
The use of evidence
1 To set the agenda
There are varying theories on the cause of the
obesity epidemic, the dilemma is deciding
which theory to focus upon (3). A series of
recently published reports represent a theory
shift towards targeting the (obesogenic) food
environment, rather than the individual (5-7).
Only quantitative evidence produced by
scientific experts is used to frame the obesity
issue (3). This indicates an evidence
hierarchy, in which objectivity is promoted
(despite inherent researcher subjectivity) (8).
This evidence is presented in an argument to
appeal to public interest (3).
2
2 To design policy implementation
The obesogenic theory of childhood obesity
shapes policy design, so industry is held
responsible (3).
Previous policies - the Public Health
Responsibility Deal (RD) and Salt Reduction
Programme were key learning tools for
policy design (9,10).
Stakeholder engagement was conducted with
industry and NGOs to co-produce the policy
(11); this may improve its feasibility but could
prioritise industry views, and limit policy scope
(12).
Control of policy implementation is conceded
to industry, without strong incentives or
sanctions for non-compliance (3,13). This
design ignores criticisms of previous policy
and aspects of the stakeholder analysis
(11,14,15).
3 To evaluate policy
Evidence criteria for evaluation is relevant and
quantifiable so progress is simple to track (3).
Evaluation is based purely on quantitative
data, so is overly simplistic and ignores
contextual factors (3).
Although the policy was published in 2016, the
baseline for evidence of sugar reduction is
2015 (3). This represents the interest of
industry.
Conclusion/Recommendations
Evidence was used variably in the sugar
reduction policy; its definition appears
malleable.
Evidence is used to inform policy, but
decisions are based upon politics, judgement
and debate.
Policy is not necessarily formed by the
evidence available but the evidence selected
and how this is interpreted to fit the policy
agenda, and balance external influences.
Thus political judgement is an evidence base
in its own right; a challenge to navigate when
designing policy.
References
1. WHO. 2016. Obesity and overweight: fact sheet
[Online]. World Health Organisation. Available from:
www.who.int/mediacentre/factsheets/fs311/en/.[Accessed
3/4/17]
2. Knai C, Petticrew M, Mays N. 2016. The
childhood obesity strategy.
3. Government 2016. Childhood Obesity - a plan
for action. London: HM Government
4. Lang T, Rayner G. 2007. Overcoming policy
cacophony on obesity: an ecological public health
framework for policymakers. Obesity Reviews, 8(s1):165-
81.
5. Swanton K. 2008. Healthy Weight, Healthy
Lives: A toolkit for developing local strategies. London:
National Heart Forum.
6. Marmot M. 2010. The Marmot Review final
report: Fair society, healthy lives. London: UCL.
7. B Butland, S Jebb, P Kopelman, K McPherson,
S Thomas, J Mardell, et al. 2007. Tackling obesities:
future choices. Project report. Foresight. London;
Government Office for Science.
8. Goldernberg M. 2006. On evidence and
evidence-based medicine: Lessons from the philosophy of
science. Social Science and Medicine;62(11):262132.
9. DoF. Public Health Responsibility Deal.
https://responsibilitydeal.dg.gov.uk.
10. Tedstone A, Targett V and Allen R. 2015.
Sugar reduction: The evidence for action (Annexe 5 Food
Supply) London: Public Health England
11. Tedstone A, Owtram G, Targett V, Pyne V, Allen
R, Bathrellou K, et al. 2017. Sugar Reduction and Wider
Reformulation Programme: Stakeholder engagement -
May 2016 to March 2017. London: Public Health England.
12. Panjwani C, Caraher M. 2014. The Public
Health Responsibility Deal: Brokering a deal for public
health, but on whose terms? Health Policy. 114(2):163-73.
13. Tedstone A, Targett V, Owtram G, Pyne V, Allen
R, Bathrellou K, et al. 2017. Sugar Reduction: Achieving
the 20% - A technical report outlining progress to date,
guidelines for industry, 2015 baseline levels in key foods
and next steps. London: Public Health England.
14. Parliament. 2016. Government Response to the
House of Commons Health Select Committee report on
Childhood obesity brave and bold action, First Report of
Session 2015-16. In: Health Do, editor..
15. Durand MA, Petticrew M, Goulding L, Eastmure
E, Knai C, Mays N.2015. An evaluation of the Public
Health Responsibility Deal: Informants' experiences and
views of the development, implementation and
achievements of a pledge-based, public-private
partnership to improve population health in England.
Health Policy. 119(11):1506-14.
3
The use of evidence in development of the 20% sugar reduction policy to
address childhood obesity in the United Kingdom

Introduction

The 21st century faces a worldwide obesity epidemic; obesity has more than doubled since 1980, and
this upwards trend affects both adults and children (WHO, 2016) Childhood obesity is diagnosed in
children with a body mass index above the 98th growth percentile (Knai et al., 2016). Due to its
serious long-term health consequences, it is regarded by the World Health Organisation as one of the
most significant global public health threats at present (WHO, 2016).

Within the United Kingdom, childhood obesity affects between 9-11.6% of the population (at reception
age, varying across England, Scotland, Wales and N. Ireland) (Baker, 2017). In 2016, the UK
government released a policy plan aiming to tackle this health crisis, entitled Childhood Obesity a
plan for action (Government, 2016). Alongside other policies, the plan contained a commitment to
reduce the sugar content of selected food and drinks by 20% by 2020, through a centrally led
reformulation programme (ibid).

This policy analysis seeks to explore the use of evidence to develop the sugar reduction policy,
adopting the policy cycle approach to analysis (fig 1) (Coveney, 2010).

Figure 1: Adapted policy cycle (Bridgman and Davis, 2004). The coloured sections represent the structure adopted
in this policy analysis: Green) agenda setting; blue) policy formation and implementation; yellow) policy review. A
linear (cyclical) structure is used for this policy analysis though this would not apply during policy development.

4
The use of evidence to conceptualise the childhood obesity crisis

The conceptualisation of childhood obesity, and its relevance as a major public issue, within
Childhood Obesity a plan of action is important, as is the presentation of evidence to support this
claim; but the abundance of evidence leading up to the formation of this document is equally critical,
so shall be addressed first.

A wealth of primary research has been conducted on childhood obesity, culminated in a wide body of
evidence and general scientific consensus. Despite this, there are varying theories about the cause of
the epidemic, including arguments which hold individual behaviour accountable, those which
emphasise genetic causation, and others focusing on the obesogenic environment (Lang and
Rayner, 2007). Over the past 10 years, a series of influential reports on childhood obesity have been
published Foresight: Tackling Obesities project report, Healthy Weight Healthy Lives toolkit, Fair
Society, Healthy Lives Marmot review predominantly supporting the obesogenic environment theory
(Butland et al., 2007, Swanton, 2008, Marmot, 2010). In addition to consulting this research, the UK
government receives nutritional advice and childhood obesity information from expert panels,
including the Scientific Advisory Committee on Nutrition (SACN) and the Obesity Review Group
(GOV.UK, 2017b, GOV.UK, 2017a) . Consequently, the Childhood Obesity policy agenda was framed
using a mixture of sources; overcoming the conflicting perspectives of these sources is a challenge.

Although the primary research referenced in the sugar reduction policy is strictly quantitative, the
reports and advice-panels consulted are more diverse. Both the Foresight report and Marmot review
include qualitative evidence regarding the causes of childhood obesity development; similarly, the
SACN considers all evidence...at the outset of defining a nutritional issue (SACN, 2012). Despite the
opportunity for qualitative research to provide better illumination of the different theories proposed for
childhood obesity, in Childhood Obesity a plan for action, value is attributed strictly to quantitative
research (Government, 2016). No qualitative research is cited and emphasis is placed on statistics
and figures. Furthermore, despite the broad definition of evidence* provided by the UK Cabinet Office,
only scientific research was used as evidence to conceptualise childhood obesity, indicating an
evidence hierarchy (Government, 2016, Office, 1999). This hierarchy is emphasised by the SACN
whereby only data in peer-reviewed journals or expert reports...and state RCTs [random controlled
trials] is considered; the latter preferred due to the bias of observational studies (SACN, 2012).
Prioritisation of scientific evidence reflects a logical positivist epistemology, in which objectivity is
promoted, however through selection and interpretation of this evidence, biases are implicit
(Goldenberg, 2006). Furthermore, rejection of insufficiently objective evidence obscures the
subjective elements of human inquiry, creating a false reality (which ignores the influence of culture
and context) (Goldenberg, 2006). The significance of this evidence hierarchy stems from the link

------------------------------------------------------------------------------------------------------------------------------------------------------------------

*According to the UK Cabinet Office, evidence is defined as expert knowledge; published research, existing research;
stakeholder consultations; previous policy evaluations; the Internet; outcomes from consultations; costings of policy
options; output from economic and statistical modelling (Office, 1999).

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between power and knowledge; by selecting certain evidence to frame the childhood obesity problem,
the government shapes the policy agenda, and decides upon the truth.

Within the sugar reduction policy, childhood obesity is presented as a complex problem, necessary
to address due to three key issues (Government, 2016). Firstly, through statistics, the impact of
childhood obesity upon health is portrayed, including the likelihood of developing further conditions,
and the increased risk of death (ibid). Secondly, the economic cost to the UK is illustrated, and lastly,
the potential for childhood obesity to exacerbate inequalities is mentioned (ibid). By selecting these
arguments, childhood obesity is portrayed as a national issue, with quantifiable consequences; the
individual psychosocial impacts of childhood obesity are downplayed (ibid). This position likely reflects
the public perspective, as policy operates within the public sphere and so must reflect public debate
and opinion; a barrier to overcome in policy design (Head and Queensland, 2017).

The use of evidence to design policy action and implementation

Translating evidence into policy directly links to how the problem is initially conceptualised. By
presenting childhood obesity as a complex problem within the policy document, the necessity for a
complex solution is implied. The different routes leading towards childhood obesity development
creates a wealth of opportunities for policy intervention (fig 2), however this also creates a slight
policy cacophony; a dilemma for policy makers in which it is difficult to know where best to intervene.

Figure 2: Critical opportunities for intervention across the life-course. Different intervention points offer alternative types of
intervention e.g. metabolic plasticity or behaviour change (Butland et al., 2007)

6
As aforementioned, Childhood Obesity a plan for action is shaped by previous childhood obesity
research however this research is heavily biased towards the causes of childhood obesity, rather than
strategies for prevention or treatment (Butland et al., 2007). Previous policies serve as invaluable
evidence but the majority have not been widely replicated, delivered on an adequate scale, or been
subject to long-term evaluation (ibid). Nevertheless, in their absence, policy directed at other health
issues can be used. Consequently, both the Public Health Responsibility Deal (RD) and Salt
Reduction Programme were used a key learning tools in the sugar reduction policy development
(Musingarimi, 2008, DoF, Tedstone et al., 2015b). Failure of previous consumer-targeted policies to
curb the childhood obesity epidemic has directed more recent policies towards altering the
obesogenic environment, including the RD and salt reduction schemes.

This new perspective on policy intervention represents a paradigm shift, on which Childhood Obesity
a plan for action was based (Lang and Rayner 2007). This paradigm shift is also reflected in
childhood obesity reports published prior to the policy document. For instance, in the Marmot Review,
emphasis is placed upon the effectiveness of an upstream approach to tackling childhood obesity,
and attempts to prevent ill health by working across sectors (Marmot, 2010). Thus, Childhood Obesity
a plan for action contains a breadth of policies, including the sugar reduction initiative, in which
responsibility lies with the food and drinks industry. According to the policy document, universal
[changes] that do not rely on individual behaviour change are a successful way of improving diets,
citing previous reformulation schemes and reiterating the paradigm shift towards a market-based
approach (ibid). Sugar reduction was chosen to fit this approach due to a wealth of evidence
promoting this intervention published in 2015 (Tedstone et al., 2015a).

In a stakeholder analysis document, accompanying Childhood Obesity a plan for action, discourse
between non-governmental organisations (NGOs) and industry is revealed (Tedstone et al., 2017a).
These stakeholders were consulted by Public Health England (PHE) to develop the approach to the
sugar reduction programme. Notably the Food Standards Agency (FSA) were absent, despite their
knowledge and expertise in working with industry to achieve voluntary agreements (including their
involvement in the salt reduction scheme). Nevertheless, this signifies an attempt at co-production of
the policy (Bettencourt, Ostrom et al, 2002). Unlike the conceptualisation of the childhood obesity
problem, where evidence was largely restricted to quantitative data, design of the policy included
professional field experience as an evidence base, showing the diverse and contestable nature of
evidence (Head and Queensland, 2017).

Engaging businesses in the design of policy implementation can improve its feasibility, and ensure
business investment more effectively than excluding industry from the process, however co-
production does complicate policy creation (Boyle and Harris, 2009). Co-production may prioritise
industry views and provide the opportunity for industry to influence health policy or limit its scope
(Hawkes and Buse, 2011) (Panjwani and Caraher, 2014). Forging public-private partnerships and
delegating responsibility may also strengthen businesses by increasing their reputation while failing to
positive influence health outcomes (Boyle and Harris, 2009)

7
The finalised approach to sugar reduction detailed in Sugar Reduction Achieving the 20% is slightly
unclear. Sugar reduction is targeted across a range of products within nine food categories. It is
stated that these categories were chosen to reflect the largest contributors to childrens sugar intake,
but no supporting evidence is provided or reference for this claim. Notably, although the plan is aimed
at food and drink, only food categories are included.

The sugar reduction policy references previous policies so recognises the wider policy context, but
this is not fully realised in its design. The Public Health Responsibility Deal (RD) is mentioned as a
key learning tool however criticisms of the RD appear to have been ignored (Durand et al., 2015). For
instance, the 20% sugar reduction policy is designed to be achieved by businesses, adhering to
guidelines of action set by Public Health England; the policy states that if sufficient process has not
been made by 2020 then alternative levers need to be used (Tedstone et al., 2017b). This lack of
commitment to alternative actions should the policy fail, and the absence of strong sanctions to drive
compliance, is precisely what researchers have previously criticised about the RD (Panjwani and
Caraher, 2014, Durand et al., 2015). Although the sugar reduction policy is not defined as a voluntary
measure, by conceding control to individual businesses and monitoring progress instead of
addressing failures, there is still low incentive for businesses to comply, particularly as the policy
conflicts with business interests; This has repeatedly shown to be ineffective, and a challenge for
policy-makers to overcome (Knai et al., 2016). Contrastively, the firm and decisive leadership
instrumental in the success of the salt reformulation programme, on which the policy was also
based, has been ignored (Parliament, 2016). In the stakeholder analysis document, a strong aversion
for out-of-home food businesses to comply was observed, yet this evidence was not integrated into
policy design either (Tedstone et al., 2017a). This reflects the selective nature of evidence informed
policy, and the role (and difficulty) of political judgment as an evidence base in the policy-making
process (Goldenberg, 2006).

The use of evidence to evaluate the policy

As the finalised sugar reduction policy was published in March 2017, it is too soon to evaluate its
implementation and effectiveness. Nevertheless, the proposed methods of evaluation stated within
the policy document, and the use of evidence in this process can be explored.

Within Childhood Obesity a plan of action, it is stated that progress will be measured on the basis
of reductions in the sales weighted average sugar content per 100 grams, reductions in portion size
so that these contain less sugar, or a clear sales shift towards lower sugar alternatives (Government,
2016). Although allowing flexibility (of measurements) between business hinders accountability, the
criteria are clear, relevant and quantifiable, so progress is simple to track. These measurements are
intended to be collected and shared frequently (through PHE interim reports every 6 months)
improving the transparency of the policy, and richness of the evaluation.

Despite its merits, basing evaluation of the policy purely on quantitative data is overly simplistic, and
restricts how comprehensive policy analysis can be. As sugar reduction is part of the larger complex
intervention proposed in Childhood Obesity a plan for action, evaluation requires contextual

8
evidence about the mechanisms of the policy (as well as progress on set sugar-content and health
outcomes) (Petticrew et al., 2013) For instance, although reducing food product size is one method of
reducing sugar content, this is not synonymous with reducing portion size. If a business maintains the
original size of a food product, but increases the stated portions served by that product, then this may
not discourage the consumer from eating according to the original portion size. By not refining the
definition of portion size, this measurement can be manipulated and, in the absence of further data,
undetectably. Clearly, the selection of evidence in the evaluation of the sugar reduction policy is
critical, and unless alternative quantitative data is collected, or supplemented by rich qualitative data
(e.g. exploring the link between portion size and product consumption), it may yield unreliable results.

Although the policy was written in 2016, in order to recognise previous efforts by businesses to
reduce the sugar content of their products, the baseline year from which analysis is conducted is 2015
(Tedstone et al., 2017b). This decision clearly represents the interests of industry, and restricts the
scope of the policy. This ignores criticisms of the RD for allowing businesses to exaggerate their
achievements (MacGregor et al., 2015)

Conclusion

Evidence is used in policy development to improve efficiency and effectiveness, but rather than
deduction by empirical analysis, policy emerges from the interaction between politics, judgement and
debate (Head and Queensland, 2017). Hence evidence informs rather than determines policy. The
level of influence varies between policies, depending on the policy maker perspective; HM
Government has an extreme position on this point, urging rather than wait for further evidence to
follow from international experience, the Government [should] be bold in implementing [the sugar
reduction] policy (Parliament, 2016). Furthermore, the policy process is not informed by the evidence
available, but the evidence selected, and how this evidence is interpreted to fit the policy agenda.
Consequently, political judgement is an evidence base in its own right; navigating this judgement
presents a policy dilemma, particularly once taking into account the clashing perspectives of experts
in different fields. Interpretation of evidence must also acknowledge external policy influences, such
as key barriers to implementation - in the case of childhood obesity, this involves reversing the social
norm. In conclusion, incorporating evidence into policy is not a straight forward process, and is very
open to bias.

9
References

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BOYLE, D. & HARRIS, M. 2009. The Challenge of Co-production: How equal partnerships between
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evaluation of the Public Health Responsibility Deal: Informants experiences and views of the
development, implementation and achievements of a pledge-based, publicprivate
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GOLDENBERG, M. 2006. On evidence and evidence-based medicine: Lessons from the philosophy
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11