THE OUT-OF-HOME FOOD ENVIRONMENT REPORT OF A WHO REGIONAL OFFICE FOR EUROPE AND PUBLIC HEALTH ENGLAND EXPERT MEETING, 10 JUNE 2021
THE OUT-OF-HOME FOOD ENVIRONMENT REPORT OF A WHO REGIONAL OFFICE FOR EUROPE AND PUBLIC HEALTH ENGLAND EXPERT MEETING, 10 JUNE 2021 Abstract The WHO European Office for the Prevention and Control of Noncommunicable Diseases (NCD Office) is engaging in several initiatives to address healthy and sustainable food environments, guided by experts from across the Region. This report sets out the presentations and discussions that took place at an expert meeting on the out-of-home food environment, held virtually on 10 June 2021 and co-hosted by Public Health England. Member States presented snapshots of their experiences, policy and data in the out-of-home food sector, and addressed two key areas in detail: portion size and food delivery apps. Keywords Out-of-home food environment Portion sizes Meal delivery apps WHO European Region Noncommunicable diseases Document number: WHO/EURO:2022-5714-45479-65098 © World Health Organization 2022 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY- NC-SA 3.0 IGO; https://creativecommons.org/licenses/ by-ncsa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. If you create a translation of this work, you should add the following disclaimer along with the suggested citation: “This translation was not created by the World Health Organization (WHO). WHO is not responsible for the content or accuracy of this translation. The original English edition shall be the binding and authentic edition: The out-of-home food environment: report of a WHO Regional Office for Europe and Public Health England expert meeting, 10 June 2021. Copenhagen: WHO Regional Office for Europe; 2022”. Any mediation relating to disputes arising under the licence shall be conducted in accordance with the mediation rules of the World Intellectual Property Organization (http://www.wipo.int/amc/en/mediation/rules/). Suggested citation. The out-of-home food environment: report of a WHO Regional Office for Europe and Public Health England expert meeting, 10 June 2021. Copenhagen: WHO Regional Office for Europe; 2022. Licence: CC BY-NC-SA 3.0 IGO. Cataloguing-in-Publication (CIP) data. CIP data are available at http://apps.who.int/iris. Sales, rights and licensing. To purchase WHO publications, see http://apps.who.int/bookorders. To submit requests for commercial use and queries on rights and licensing, see http:// www.who.int/about/licensing. Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables, figures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright holder. The risk of claims resulting from infringement of any third party-owned component in the work rests solely with the user. General disclaimers. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. This publication contains the report of a WHO Regional Office for Europe and Public Health England expert meeting, 10 June 2021 and does not necessarily represent the decisions or policies of WHO. iii Contents Acknowledgements iv Abbreviations iv Executive summary v 1. Importance of the out-of-home food environment 1 2. Digital food environments: food delivery apps 4 3. OOH portion size 6 4. Member State experiences of the OOH sector 8 4.1 Consultation on the OOH food environment 8 4.2 National insights from the expert meeting 9 5. Next steps 14 References 15 Annex 1. Meeting participants 17 iv Acknowledgements The WHO Regional Office for Europe thanks all representatives of Member States and experts who gave presentations and comments at the meeting. Thanks also go to Public Health England for co- hosting the meeting. We are also grateful to the rapporteur, Katy Cooper, for writing this meeting report and to Holly Rippin and Kremlin Wickramasinghe for reviewing it. Abbreviations NCD noncommunicable disease OOH out-of-home SMEs small and medium-sized enterprises v Executive summary This report summarizes an online expert meeting held on 10 June 2021 on the out-of-home (OOH) food sector. It was hosted by the WHO European Office for the Prevention and Control of Noncommunicable Diseases (NCD Office) and co-hosted by Public Health England. The meeting followed a short consultation process with Member States to gain an initial understanding of the experiences, interests and challenges faced in data gathering and policy development in the OOH food environment. After opening presentations by the WHO Regional Office for Europe, representatives from six Member States (France, the Netherlands, Norway, the Russian Federation, Spain and the United Kingdom) presented and discussed their experiences, policy and data on the OOH sector and related health policies. This work is part of the Regional Office’s wider emphasis of on developing healthy and sustainable food environments across the WHO European Region. The key messages were as follows. • Presentations by all six Member States noted a lack of available data and the inadequacy of existing data. Information is lacking on the structure and use of the OOH food environment as a whole, on portion size and on the nutritional composition of the OOH foods offered. • There is a very substantial difference in portion size between the meal and snack options offered in retailers such as supermarkets and those offered in the OOH sector; consequently, the latter contain more energy, sugar and salt. Calorie-reduction efforts in England (United Kingdom) were presented: these aim to reduce portion size and encourage reformulation. • Food delivery apps are an increasingly prevalent way for consumers to access OOH food and their use has risen significantly during the COVID-19 pandemic. The WHO NCD Office and Kingston University London are collaborating on a data collection initiative that uses machine learning and natural language processing. The aim is to gain a better understanding of the restaurant and menu options and promotions offered through the major apps. The planned next steps are to convene a group of Member States from the WHO European Region to share policy and innovation, and to establish a new network on sugar and calorie reduction that will be chaired by Public Health England.
1 THE OUT-OF-HOME FOOD ENVIRONMENT 1. Importance of the out-of- home food environment The context for this meeting on the out-of-home (OOH) food environment was introduced by Carina Ferreira-Borges and Kremlin Wickramasinghe (NCD Office) and Alison Tedstone (Public Health England,1 co-host of the meeting). All WHO Member States have agreed to targets on obesity (Box 1) but, as the WHO Regional Office for Europe’s noncommunicable disease (NCD) surveillance shows, no country in the WHO European Region is on track to meet these targets. Addressing poor diet is crucial to tackling NCDs (a priority of the European Programme of Work: United Action for Better Health in Europe (1), and the food system was a particular focus in the United Nations Food Systems Summit in September 2021 (2). OBESITY TARGETS In 2012 WHO Member States agreed six global targets to improve maternal, infant and young child nutrition, including no increase in childhood overweight by 2025 from 2010 levels (3). In 2013 WHO Member States adopted nine voluntary global targets to tackle NCDs, including halting the rise in obesity for all population groups by 2025 from 2010 levels (4). Member States are aware that the challenges of the burgeoning OOH food sector (Box 2) are an important area for action, but requested in-depth discussions to better define and understand these challenges and to learn from other countries’ approaches. In response, planning for this expert meeting began in 2019 but was delayed by the COVID-19 pandemic. The link between obesity and severe COVID-19 outcomes throughout the pandemic highlighted even more clearly the need for action on healthy diets. THE OOH SECTOR The OOH sector includes all food and beverage outlets where food and drink can be purchased and consumed outside the home, either on or off the premises. The sector can be accessed in both the physical and digital arenas. Examples of OOH outlets include: • restaurants, cafés and bars; • takeaways, and fast-food and street-food outlets; • outlets in public transport stations; • outlets in hospitality businesses (gyms, sports centres and hotels) and in entertainment and attraction venues (cinemas, theatres, arenas and theme parks); 1 In October 2021, after this meeting was held, the diet, physical activity and obesity function of Public Health England was transferred to the Office of Health Improvement and Disparities. BOX 2. BOX 1. 2 REPORT OF A WHO REGIONAL OFFICE FOR EUROPE AND PUBLIC HEALTH ENGLAND EXPERT MEETING BOX 2. CONT • food to go from supermarkets, convenience stores, department stores and shopping centres; • contract catering, such as workplace canteens, university/college/further education centre canteens, event catering and hospital visitor canteens; and • any of the above listed on food delivery apps. Public Health England provided an overview of the United Kingdom’s OOH sector, which has been rapidly expanding in recent years but with relatively little corresponding policy action. The Government of the United Kingdom has been collecting data on this sector for about five years (most recently with Kantar Out-of-Home Panel (5)),2 but many data gaps remain. • Around 25% of calories are consumed outside the home, with over half of the expenditure on purchases from large chains. The OOH sector in Great Britain (the part of the United Kingdom made up of England, Scotland and Wales) was worth £52.7 billion prior to the COVID-19 pandemic, with 98.5% of consumers eating out at least once a year. • A fall in the OOH market precipitated by the pandemic was countered by a rapid expansion of food delivery services, driven in large part by aggregators such as Deliveroo (see section 2). OOH delivery accounted for 41% of total OOH expenditure in the summer of 2020, and in October 2020 over half of consumers said that they would continue to use these delivery services at least as much in the future. • OOH deliveries are shifting away from delivery of larger main meals only to include smaller meals, snacks and drinks, which are likely to be of higher caloric value than the equivalent homemade or retail-sourced products. • Competition in the OOH sector has increased the amount of promotion and marketing. Since portion size is much larger than for products sold by retailers (see section 3), growth in this sector is expected to lead to higher overall calorie consumption. This has implications for weight gain, overweight and obesity, and related NCDs. Using policy to manage the OOH sector is proving to be challenging because the industry is less willing to engage with policy-makers compared with retailers and manufacturers. A common narrative is that OOH eating is a treat – but it has become a more commonplace activity for many people. Guidance has been set on sugar and calorie reduction for retailers, manufacturers and the OOH sector; however, because portion sizes are so much bigger than for equivalent products sold by retailers (section 3), there is a very long way to go before the targets are reached. Calorie labelling will be required at the point of purchase for OOH chains with more than 250 employees in England by April 2022. 2 Kantar Worldpanel, Out of Home, Total Market, 52 week ending February 2020 versus February 2019 (5); Kantar Worldpanel, 52 week ending 27 December 2020 versus 29 December 2019 (6); and Kantar LinkQ Wave 4, September 2020 – Agree with statement “I will continue to buy delivery more or the same”, % share of consumers (7). COVID-19 has taught us that our diet is not only affecting our NCD risk; it is affecting our infectious disease risk. Obesity is very clearly linked to hospital admissions and severe COVID-19 consequences. Alison Tedstone, Public Health England 3 THE OUT-OF-HOME FOOD ENVIRONMENT The OOH sector is very broad and intersects with other areas that were not covered in detail in the meeting, including food procurement and food waste (which would be useful topics for future WHO Regional Office for Europe meetings), as well as with other aspects of the Regional Office’s work, such as the European Marketing Network (8). Good data is essential for policy action. However, although data on and sales, consumption and nutritional composition data are being gathered through a range of methods (from Kantar WorldpanelOnline (6), web scraping and sometimes from companies themselves), there are still many gaps. Overall, lack of data (on the structure of the OOH sector, nutrition, food composition and portion size) was an important spur to action and discussion point in the meeting. 4 REPORT OF A WHO REGIONAL OFFICE FOR EUROPE AND PUBLIC HEALTH ENGLAND EXPERT MEETING 2. Digital food environments: food delivery apps Digital food environments are online settings in which service and information flows influence food and nutrition choices and activities (9). They include social media, digital food marketing, online food retail and, increasingly, food delivery apps. The already rapid growth of these food delivery apps has been accelerated by the COVID-19 pandemic, which advanced consumer adoption of delivery services by two to three years. The food delivered by these services tends to be less healthy and in larger portion sizes than food prepared in the home and is promoted by large marketing budgets. OOH delivery also encourages sedentary behaviour as people do not need to leave home to get the food. Preliminary studies on food delivery apps suggest that expansion of the apps led to an expansion of the geographical area within which digital platforms can deliver. However, better data and new data collection tools are needed to inform policy and direct future research. As part of efforts to address this gap, the WHO NCD Office is collaborating with Kingston University London on a data collection initiative, initially in the United Kingdom but with plans to expand to other countries. The initiative aims to build an open and secure data bank for data on the digital food environment. Kingston University London presented the findings of an initial joint feasibility study with the NCD Office. As part of the study, three datasets were collected on the food offerings of two of the major aggregators (Just Eat and Deliveroo), with machine learning and natural language processing used to analyse the data. Data were collected on: • restaurants: 27 000 restaurants were included in the United Kingdom and 4700 in Spain; • menus: 5 million menu items from the restaurants were included in the United Kingdom and 400 000 items in Spain; and • restaurant promotions: the study focused on online offers by restaurants in London over a weekend as offered through a selected aggregator. Food delivery through apps is available throughout the United Kingdom, with most restaurants in London, followed by Leeds, Manchester and Liverpool. The research focuses on restaurant chains because it is easier to gather their nutrition information; Subway is the chain with the most restaurants included in the aggregator. The collected data enables hygiene ratings to be categorized. The study also monitors children’s meals/offers and alcohol-delivery services provided through the apps. The discussion highlighted discrepancies on branded product recipes between different countries. For example, the sugar content in a particular brand of soft drink (often included as part of deliveries through apps) can vary significantly between countries. This demonstrates that there is scope to improve formulation of these products and, therefore, the powerful potential of the collected data to inspire policy action by government. 5 THE OUT-OF-HOME FOOD ENVIRONMENT Gathering data on the different recipes for food products is one of the aims of the Kingston University London research, but language challenges must be overcome if the calculations made through machine learning are to be accurate between countries. The Regional Office is working on other complementary projects and recently launched the Global Sodium Benchmark to demonstrate differences in recipes for the same product between different regions and countries (10). A further ongoing initiative is comparing vegan burgers between different restaurants across cities in five countries. In combination, all of these areas of research are starting to build a more nuanced picture of the OOH sector. 6 REPORT OF A WHO REGIONAL OFFICE FOR EUROPE AND PUBLIC HEALTH ENGLAND EXPERT MEETING 3. OOH portion size Public Health England presented information on the portion size of OOH food offerings, the work of the Government of the United Kingdom on calorie reduction related to portion size, and how data can be used to bring about change in England. However, collecting adequate data on OOH portion sizes remains a key challenge for the United Kingdom and other Member States. Portion size is a key policy area because of both the increase in portion size (for example, pizzas have grown in size by 50% since the early 2000s) and substantial difference in portion size between OOH products and the same products offered through retailers. Consequently, the increased portion size has led to an increase in potential calorie and sugar consumption. United Kingdom Government guidelines for sugar and calorie reduction in England (overseen by Public Health England) are not based on the manufacturers’ suggested portion/serving size but on what an individual is actually likely to consume (derived from data gathered from participants in the United Kingdom’s National Diet and Nutrition Survey (11). In 2018 as part of the One You campaign, Public Health England established a rough calorie guideline for companies to suggest to consumers when eating OOH foods of no more than 400 kcal for breakfast and 600 kcal each for lunch and dinner. Calorie guidelines can take two forms: • a maximum guideline (that no product should exceed a set number of calories in a single portion); or • a sales-weighted or simple average (sales-weighted averages look at the volume of sales, but this is more relevant to retailers and is much harder to do in the OOH sector). The two main approaches of the United Kingdom Government’s sugar and calorie-reduction programmes are portion-size reduction and reformulation. Together, these aim to change the standard product, rather than introducing low-sugar or low-calorie alternative products. because the standard product is consumed most often. In this way, these combined approaches will have the greatest impact on population intake. • The sugar reduction programme sought a reduction in sugar levels of 20% by 2020 across a range of products (12). The programme also set calorie-reduction guidelines, including (for example) a maximum per serving of 400 kcal for breakfast cereals and of 175 kcal for yoghurts. These maximums apply to both the retail and OOH sectors (excluding puddings, which were set at 450 kcal for at-home consumption but at 550 kcal for OOH settings, in acknowledgement that in restaurants many puddings are served with cream or other additions). • During the consultation prior to the start of the calorie-reduction programme, it became clear that not all sectors of the food industry (including OOH) would be able to achieve a 20% reduction in calories. Therefore, for most retailer- and manufacturer-branded products, a 10% reduction is required. Guidelines are available for both the maximum per portion and sales-weighted average – the latter allows companies to provide a range of products in their portfolio across a range of calorie levels. The guidance was also adapted to recognize that the OOH sector often offers food in the form of a complete meal rather than as individual foods. 7 THE OUT-OF-HOME FOOD ENVIRONMENT • In the OOH sector, where calorie levels are generally so much higher than in the retail and manufacturer sector, the full 20% reduction in calories is being sought. Even this, however, will not bring the calories in many food offerings down to the recommended One You level of 600 kcal per serving for lunch/dinner. However, this is only the start of the journey because trying to reduce all portions to 600 kcal would probably lead to disengagement of much of the OOH sector. Good data collection is essential to monitor progress and hold businesses to account. Data can demonstrate the need for policy action (for example, by providing evidence on the calories in OOH portions, which remain substantially higher than for in-home consumption). They can also support decisions on appropriate action (such as mandatory targets) and can be used to predict the anticipated and demonstrate the actual impact of different policies on calorie consumption. This type of analysis creates the political will for action among government ministers. Caution was urged for policy-makers in considering portion sizes to avoid reaching a tipping point at which consumers switch to eating two portions. This would actually increase, rather than decrease, calorie consumption. The discussion addressed how the food industry is held to account. Currently, no direct incentives are offered for compliance, but regular monitoring enables the reporting of progress made by individual businesses in their top-selling brands. Such monitoring data clearly indicate which companies have (or have not) responded to the guidelines. There are so many calories all around us... We are nudged into overconsumption very easily Victoria Targett, Public Health England 8 REPORT OF A WHO REGIONAL OFFICE FOR EUROPE AND PUBLIC HEALTH ENGLAND EXPERT MEETING 4. Member State experiences of the OOH sector 4.1 Consultation on the OOH food environment Each participating Member State of the WHO European Region has a different level of understanding of and policy development in the OOH sector. Prior to the meeting, a short consultation to gain an initial understanding of the OOH food environment in selected Member States (France, Spain and the United Kingdom) found the following. • Definitions of OOH food are not consistent across countries: France and Spain include institutional catering, but the United Kingdom does not. • The OOH sector is extensive in all three countries and there is clearly an upward trend (albeit with a decline during the COVID-19 restrictions). The OOH sector accounted for 13.3% of meals consumed in France and for 13.9% by volume and 34.1% of expenditure on food in Spain. Prior to the COVID-19 pandemic, the OOH sector was worth £52.7 billion in Great Britain. • The profile of the sector varies: in France, 49% of OOH meals are from contract catering, followed by takeaways (27%) and restaurants (14%); in Spain, most OOH meals are from bars/cafés (41.4%) and restaurants (29%); and in Great Britain, there is a more even distribution between fast-food restaurants (21%), pubs/bars (14%), full-service restaurants (13%) and bakery/sandwich outlets (11%). • There are differences in the use of OOH foods between different age groups (more are consumed by younger people). • The proportion of small and medium-sized enterprises (SMEs) versus larger chains is very different between countries: in France, 64% of outlets are SMEs; in Spain, 91% of food companies have five or fewer employees; and in Great Britain, spending is evenly split between SMEs and larger chains. • Delivery platforms are here to stay, although the market share of these platforms varies between countries: in 2020 just 1.5% of turnover was occupied by delivery platforms in France compared with 36.2% in Great Britain, where there was a 172% increase in delivery aggregators between 2019 and 2020, driven by the COVID-19 pandemic (data from the pre-meeting survey). Challenges identified in the three countries were primarily related to data, nutrition, food composition and portion size. • France has limited data on the OOH sector as a whole, with a specific lack of nutritional data on OOH foods. • Spain lacks data on food composition and market share within a highly fragmented market. • The United Kingdom lacks nutritional information, with more data needed on the OOH sector (including portion size). This country has the additional challenge of how best to support SMEs in implementing policies. 9 THE OUT-OF-HOME FOOD ENVIRONMENT Topics requested for further discussion in the future include portion size, digital food environments, data collection and reformulation (France), and improving the understanding of the OOH landscape and business models in other countries (United Kingdom). 4.2 National insights from the expert meeting Six Member States (France, the Netherlands, Norway, the Russian Federation, Spain and England (United Kingdom)) presented snapshots of their experiences, policy and data, which provided welcome insight, understanding and illustrations of the different approaches being taken at national level. 4.2.1 France In France, the main policies related to the OOH sector that are directed towards public health are collective catering, voluntary Nutri-Score labelling and food/nutrient standards. Two aspects of work in France on the OOH sector were presented: a recent multistakeholder survey on the OOH environment in institutional and commercial catering (unpublished) and efforts to apply the Nutri- Score to OOH catering (13). The national survey on the French OOH food environment used pre-COVID-19-pandemic data (2014–2015) comparing nutrient content and density across four categories: institutional catering (including schools and workplaces), commercial catering (including restaurants), fast-food catering, and a final “in-home” category including homemade food, industrial products, food from delicatessens and vending machines, and unspecified food items. It looked at individual consumption data and defined OOH as food that is prepared outside the home even if it is eaten at home. In France, institutional catering was the biggest contributor to OOH consumption: 40% of adults and 75% of children and teenagers ate meals in these settings at least once a week, and the meals accounted for 10% of food consumed (8% of energy intake) for adults and up to 20% of food consumed (15% of energy intake) for children and teenagers. Meals in these settings were more consistent with national guidelines compared with other OOH categories in the survey, and typically included fruit, vegetables and water, with less alcohol and fewer sugary drinks consumed than in other settings. In institutional catering settings, for meals of the same size, nutrient intake by adults was lower in lipids, saturated fat and sugars than in commercial and fast-food settings, and the nutrient density of meals for children tended to be higher in fibre and lower in salt than in all the other settings. The survey also found that frequent consumers of institutional food had the same overall nutrient intake as those who did not use institutional catering, but that the food contributors were different: for example, sugar came from sources such as fruit compote among those who ate in institutions and from sweet drinks among those who did not. Commercial catering accounted for a lower proportion of the diet, but was associated with the consumption of three times as much alcohol than at home for adults; typical food groups included hot drinks, pies, sandwiches and soft drinks. The quality of the nutrient content fell between the levels of fast-food and institutional catering; for example, meals consumed by adults had a higher lipid density compared with institutional catering but was lower in sugar compared with fast-food catering. As with institutional catering, the overall nutrient intake was the same for frequent consumers and non-consumers of commercial catering, but with different foods contributors: carbohydrates mainly came from bread for non-consumers and from sandwiches and pizza for frequent consumers. 10 REPORT OF A WHO REGIONAL OFFICE FOR EUROPE AND PUBLIC HEALTH ENGLAND EXPERT MEETING Fast food has poorer nutritional quality than commercial and institutional catering, but visits to fast- food outlets have doubled since 2006. In 2014–2015 20% of adults and 18% of teenagers consumed food from these outlets at least weekly. France is also taking on the challenge of testing the feasibility and effectiveness of implementing the Nutri-Score in OOH food settings (13). The French Ministry of Health launched calls for projects in 2019 and 2020 to test the feasibility and impact of adapting the Nutri-Score to collective catering. One of its aims was to develop a standardized methodology and tools to calculate a Nutri-Score from the nutritional composition of a range of foods based on the list of ingredients and taking account of how this changes during cooking. Partners in institutional catering environments received funding in 2019 and partners in commercial catering and digital apps in 2020. Results of these studies were delayed by the COVID-19 pandemic but are expected to be published shortly. In developing the methodology, the aim was to avoid giving too much responsibility to OOH food producers (so they should not receive a greater burden than food manufacturers) and to keep the requirements simple to enable small producers to engage in the process. European Union regulations allow manufacturers to calculate the nutritional composition of food from the known/average values of the ingredients in the national French ANSES-CIQUAL food composition database (14), and the same approach is being taken for the OOH sector. Beyond partners identified through the Ministry’s call, McDonald’s in France has announced that it will be using the Nutri-Score on its foods. This suggests that applying the Nutri-Score is feasible. Challenges related to with this approach are that cooks often have significant leeway in terms of the amount of fat and salt added, so these may vary between and within establishments and dishes. In addition, the Nutri-Score does not fully reflect the impact of portion size, which varies significantly, so a quantitative element could potentially be incorporated. 4.2.2 The Netherlands In the Netherlands, work on the OOH sector has just begun, driven by the Department of Health’s National Prevention Agreement 2019–2040 (which includes overweight and obesity) (15) and a new National System for Food Product Improvement 2022–2030 (under development). The National System is introducing Nutri-Score this year; it will set stepwise criteria by product group and establish a monitoring framework and an incentive structure. Criteria are being developed for various subgroups of processed foods: for example, within a specific food group, 25% of each manufacturer’s products must be in the lowest sodium category (with equivalent criteria for saturated fat and for sugar). Over time, the Government of the Netherlands will reduce the proportion so eventually only 10% of products in each category will be in the least-healthy group. Portion and package sizes are now also being addressed, as well as unhealthy nutrients. However, data gathering remains particularly challenging. • Limited data quality means that only limited information is available on OOH meal composition compared with the equivalent retail products. • Use of the Nutri-Score to help to score the overall nutrient profile is being considered, along with the practicality of recipe reconstruction. For example, what recipe should be chosen as an OOH pizza recipe is being considered, and whether this recipe could be applied to all pizzas, with individual elements (such as the tomato sauce or dough) being reformulated. 11 THE OUT-OF-HOME FOOD ENVIRONMENT • An inventory of semi-finished products (that is, half-made products bought by restaurants) is being planned, along with an inventory of recipes used for and nutrients and portion sizes of foods sold in fast-food chains. • Collecting data on portion and package size is also a challenge because, although it is mandatory to include the net content on labels, this may not reflect either the package or portion size. Furthermore, even when the advised portion size is included on the packaging (which is not mandatory), this may be defined by the producer and be much less than the amount that people are likely to consume in practice. A preliminary study comparing pizzas from supermarkets and food-service companies found that supermarket pizzas tend to be significantly smaller, and have less variation in size, than equivalent pizzas from food-service companies. This study could be extended to compare energy content and other nutrients such as salt. 4.2.3 Norway In Norway, the main framework for action to address overconsumption of saturated fat, salt and sugar and low intake of fruit, vegetables, wholegrain and fish is within the National Action Plan for a Healthier Diet (16), which has a particular emphasis on breaking the link between social inequality, risk factors and disease (including obesity and hypertension). The Norwegian presentation focused on collaboration with the food and drink industry, which was first established as a high-level group in 2014, initiated by the minister for health. The group set concrete goals to reduce the consumption of unhealthy nutrients and increase the intake of healthy nutrients and fish. A letter of intent with industry was recently re-signed and now includes goals on front-of-pack labelling (the voluntary Nordic Keyhole system (17)). The Government of Norway is responsible for monitoring progress. The agreement is loosely connected to voluntary guidelines established by the industry to restrict unhealthy food marketing to children, which have twice been evaluated by the Government. There are also other recommendations to the OOH sector, notably around nutrition in the public procurement of food products and meals. 4.2.4 The Russian Federation The Russian Federal Nutrition Institute stated that activities are ongoing and preliminary results would be available in the near future. 4.2.5 Spain In Spain, the main policies related to the OOH sector that are directed towards public health are voluntary reformulation and food offer improvement, a co-regulatory code to reduce marketing to children, and regional nutritional recommendations in school settings. The Spanish presentation described the available data sources, relevant public health policies and the challenges being faced. National-level food consumption data, both inside and outside the home, are published quarterly by the Ministry of Agriculture, and an annual report is published (18). The Ministry of Agriculture studies food consumption using data from Kantar WorldpanelOnline and Kantar LinkQ (6,7). In relation to OOH food consumption, information is collected from 10 500 Spanish nationals aged 12 REPORT OF A WHO REGIONAL OFFICE FOR EUROPE AND PUBLIC HEALTH ENGLAND EXPERT MEETING 15–70 years through a smartphone app, with 3000 people giving detailed information on all consumed products. In 2019 almost 14% of the total food consumption was OOH; this accounted for 34% of the total food expenditure, of which 70% of the volume and almost 40% of the cost were for beverages. The most popular OOH foods were vegetables, meat and bread, and the most popular drinks were beer, water and soft drinks. Bars/cafés (41.4%) and restaurants (29%) had the largest market shares. Over 250 000 companies are operating in this fragmented sector, with almost 70% of companies having one or two employees. Comparison of the third quarter of 2019 data with the third quarter of 2020 (after the biggest impacts of COVID-19 pandemic had subsided) revealed that OOH food consumption per person had fallen by 28%. There are three main public health policies of relevance to OOH food consumption. • The Collaboration plan for the improvement of food and beverage composition and other measures 2020 introduced voluntary commitments for manufacturers, retailers and the OOH sector (19). The plan aims to improve the composition of products (own brands and distribution brands) through agreements with the manufacturing and retail sector. These include increasing the offer of healthier foods on menus through reformulated products and recipes through agreements with social catering, modern restaurant and vending sector and to encourage collaboration between all companies, large and small. The commitments were formalized in 2019 in agreements with different parts of the manufacturing, retailer and OOH sector. In the OOH sector, commitments have been made by 53 companies in the catering sector, 52 in the restaurant sector and 63 in the vending sector (20). • A time frame was set for the end of 2020 and a final evaluation is ongoing, with data collected by questionnaire and some follow-up checks. For each sector, average nutrient contents will be determined, an overall assessment of compliance will be carried out (using a 2016 baseline) and progress by establishments/vending companies towards reaching the targets will be quantified. • The Co-regulation Code for the Food and Beverages Marketing aimed at Children (the PAOS Code) was established in 2005 (21). It comprises a set of ethical rules to guide member companies in the development, execution and dissemination of food and beverage advertising to children. The Spanish Food Safety and Nutrition Agency is currently modifying the PAOS Code to reinforce the protection of children from advertising for unhealthy food, in line with the European Union Audiovisual Media Services Directive (22), including nutritional criteria for the restriction of advertising for children. • In 2010 non-mandatory national nutrition recommendations for school canteens were set out, but not all Spanish regions have developed regulations to meet these recommendations. To facilitate this, the National Plan for Official Control of the Food Chain 2021–2025 includes a new programme that aims to promote food in schools that meets nutrition requirements for school meals and vending (23). The programme describes procedures for monitoring and control of compliance with nutrition criteria; schools will be inspected by regional authorities. Continuing work on the OOH sector as part of policy for healthy and sustainable food environments is a priority. However, notable challenges are related to data collection (including on food composition, cooking techniques and portion size) and the fragmented nature of the sector. It is important to collaborate with stakeholders on nutritional data gathering and to raise consumer awareness and understanding. 13 THE OUT-OF-HOME FOOD ENVIRONMENT 4.2.6 England (United Kingdom) The main policies related to the OOH sector and directed towards public health are voluntary reduction and reformulation programmes (for calories, salt and sugar (24)), OOH calorie labelling on menus for larger businesses and the One You information campaign (2018) (25). Health is a devolved issue in the United Kingdom, so the presentations focused primarily on efforts being made to address England’s OOH food environment; however, the devolved nations are also working on this sector. Legislation to mandate calorie labelling on OOH menus was introduced by the Parliament of the United Kingdom in May 2021 and is due to come into force in April 2022. This reflects an increasing public demand for OOH calorie labelling, with consumers believing that food in restaurants should be treated the same way as pre-packaged food. In all, 80% of consumers wanted this information to be provided and 60% said they would be more inclined to eat in establishments that provide this information. The legislation on labelling will also apply to food delivery aggregators and franchises. As OOH food contains on average twice as many calories as the retail equivalent, the aim of labelling is to drive reformulation and help people make more informed choices. The legislation will apply to large companies (over 250 employees) and focus on food for immediate consumption – either eaten on- site or as a takeaway requiring no further preparation. The information must: • be presented at the point of choice for consumers (that is, on the restaurant’s display or menu, including delivery app menus); • include reference to portion size (for example, calories per scoop of ice cream); and • state that adults “need around 2000 kcal a day”. Some exceptions are made for alcoholic drinks, prepacked food items (which already include calorie labelling), and temporary/ad hoc menu items that make use of leftovers to avoid food waste. The rationale for action on reformulation is that changes in food composition have a direct impact on what people consume and do not rely on changing individual behaviour. Consumers are not necessarily aware that OOH food may contain significantly more calories than equivalent food prepared at home. The calorie-reduction ambitions established in 2020 need to be more stringent for the OOH sector because it has much further to go than the retail and manufacturing sectors to reduce calories in everyday foods. Such health-by-stealth strategies for everyday food can also help to reduce health inequalities as lower-income groups (particularly children in these groups (26)) often live with more excess weight and are at greater risk of obesity. There also tend to be more fast-food outlets in deprived areas, which are often small businesses. The mixture of independent businesses and national chains is a challenge, and there is a clear opportunity for large companies to take a leadership role. There needs to be a change of mindset for [OOH] businesses to recognize their societal role in this space. Sam Montel, Public Health England 14 REPORT OF A WHO REGIONAL OFFICE FOR EUROPE AND PUBLIC HEALTH ENGLAND EXPERT MEETING 5. Next steps In closing, Kremlin Wickramasinghe noted the need for further topic-focused discussions on OOH food, which the WHO NCD Office hopes to take forward. He commented that the NCD Office had been considering the potential of developing a Nutri-Score for the OOH sector but had thought this would be many years down the line – so it has been gratifying to hear that change is coming more rapidly than anticipated. The next step will be for WHO to convene a meeting for a wider group of Member States to share their thoughts on key policy areas and innovations. Change is taking place at very different rates in different countries and hearing from a wide range of Member States will help WHO to clarify its approach. Kremlin Wickramasinghe also announced that the Government of the United Kingdom has offered to chair a new network on sugar and calorie reduction. This will be an opportunity for Member States to learn from each other about action on sugar and launch a new dialogue on the way forward. 15 THE OUT-OF-HOME FOOD ENVIRONMENT References 1. European programme of work 2020–2025: united action for better health. Copenhagen: WHO Regional Office for Europe; 2021 (https://apps.who.int/iris/handle/10665/339209, accessed 21 February 2022). 2. Food Systems Summit 2021, New York, 23 September 2021. New York: United Nations; 2021 (https://www.un.org/en/ food-systems-summit, accessed 21 February 2022). 3. Comprehensive implementation plan on maternal, infant and young child nutrition. Geneva: World Health Organization; 2012 (https://apps.who.int/iris/handle/10665/113048, accessed 21 February 2022). 4. Global action plan for the prevention and control of noncommunicable disease 2013–2020. Geneva: World Health Organization; 2013 (https://apps.who.int/iris/handle/10665/94384, accessed 21 February 2022). 5. Out-of-Home Panel. In: Kantar [website]. London: Kantar; 2022 (https://www.kantar.com/uki/expertise/consumer- shopper-retail/consumer-panels/out-of-home-panel, accessed 21 February 2022). 6. WorldpanelOnline [online data repository]. London: Kantar; 2022 (https://eu.worldpanelonline.com/Commissioning/ SPages/login.aspx?ReturnUrl=%2fCommissioning%2fPages%2fHome.aspx, accessed 21 February 2022). 7. Consumer & shopper attitudes & trends. In Kantar [website]. London: Kantar; 2022 (https://www.kantar.com/uki/ expertise/consumer-shopper-retail/consumer-landscape/consumer-and-shopper-attitudes-and-trends, accessed 28 February 2022). 8. Reducing marketing pressure on children [website]. Copenhagen: WHO Regional Office for Europe; 2022 (https://www. euro.who.int/en/health-topics/disease-prevention/nutrition/policy/member-states-action-networks/reducing-marketing- pressure-on-children, accessed 21 February 2022). 9. Digital food environments: factsheet. Copenhagen: WHO Regional Office for Europe; 2021 (https://apps.who.int/iris/ handle/10665/342072, accessed 21 February 2022). 10. WHO global sodium benchmarks for different food categories. Geneva: World Health Organization; 2021 (https://apps. who.int/iris/handle/10665/341081, accessed 21 February 2022). 11. National diet and nutrition survey. London: Public Health England; 2021 (https://www.gov.uk/government/collections/ national-diet-and-nutrition-survey, accessed 21 February 2022). 12. Sugar reduction: progress report, 2015 to 2019. London: Public Health England; 2020 (https://www.gov.uk/government/ publications/sugar-reduction-report-on-progress-between-2015-and-2019, accessed 21 February 2022). 13. Nutri-Score et restauration collective et commerciale: résultats des appels à projets de recherche-intervention 2019–2020 [Nutri-Score and collective and commercial catering: results of calls for research-intervention projects 2019–2020]. Paris: Ministère des Solidarités et de la Santé; 2021 (https://solidarites-sante.gouv.fr/actualites/actualites-du-ministere/ article/nutri-score-et-restauration-commerciale-nouvel-appel-a-projets-de-recherche, accessed 21 February 2022) (in French). 14. CIQUAL: French food composition table. In: ANSES [website]. Paris: French Agency for Food, Environmental and Occupational Health & Safety; 2022 (https://ciqual.anses.fr/, accessed 21 February 2022). 15. National prevention agreement. Amsterdam: Government of the Netherlands; 2019 (https://www.government.nl/ documents/reports/2019/06/30/the-national-prevention-agreement, accessed 21 February 2022). 16. Norwegian National Action Plan for a Healthier Diet – an outline. Oslo: Ministry of Health and Care Services; 2017 (https://www.regjeringen.no/contentassets/fab53cd681b247bfa8c03a3767c75e66/norwegian_national_action_plan_ for_a_healthier_diet_an_outline.pdf, accessed 21 February 2022). 17. The Keyhole – for healthier food. Trondheim: Norsk helsenett; 2022 (https://www.helsenorge.no/en/kosthold-og-ernaring/ keyhole-healthy-food/, accessed 21 February 2022). 18. Fondo Español de Garantía Agraria [Spanish Agrarian Guarantee Fund] [website]. Madrid: Spanish Agricultural Guarantee Fund; 2022 (https://www.fega.gob.es/en/PwfGcp/en/el_fega/mision/index.jsp, accessed 28 February 2022). 19. Plan de colaboración para la mejora de la composición de los alimentos y bebidas y otras medidas 2020 [Collaboration plan for the improvement of food and beverage composition and other measures 2020]. Madrid: Spanish Agency for Food Safety and Nutrition; 2020 (https://www.aesan.gob.es/AECOSAN/web/nutricion/seccion/plan_colaboracion.htm, accessed 21 February 2022) (in Spanish). 20. Evalución intermedia de los acuerdos de reducción del Plan de colaboración para la mejora del a composición de los alimentos y bebidas y otras medidas 2020 [Intermediate evaluation of the Collaboration plan for the improvement of food and beverage composition and other measures 2020]. Madrid: Spanish Agency for Food Safety and Nutrition; 2020 (https://www.aesan.gob.es/AECOSAN/docs/documentos/nutricion/Informe_Plan.pdf, accessed 21 February 2022) (in Spanish). 16 REPORT OF A WHO REGIONAL OFFICE FOR EUROPE AND PUBLIC HEALTH ENGLAND EXPERT MEETING 21. Publicidad de alimentos y bebidas dirigida a menores: Código PAOS [Co-regulation code for food and beverage marketing aimed at children: the PAOS Code]. Madrid: Spanish Agency for Food Safety and Nutrition; 2020 (https://www.aesan.gob.es/AECOSAN/ web/nutricion/seccion/marketing_y_publicidad_dirigida_a_menores.htm, accessed 21 February 2022) (in Spanish). 22. Directive (EU) 2018/1808 of the European Parliament and of the Council of 14 November 2018 amending Directive 2010/13/EU on the coordination of certain provisions laid down by law, regulation or administrative action in Member States concerning the provision of audiovisual media services (Audiovisual Media Services Directive) in view of changing market realities (PE/33/2018/ REV/1). OJ. 2018;L 303:69–92 (https://eur-lex.europa.eu/eli/dir/2018/1808/oj, accessed 21 February 2022). 23. Plan Nacional de Control Oficial de la Cadena Alimentaria (PNCOCA) [National plan for official control of the food chain 2021–2025, programme 16]. Madrid: Spanish Agency for Food Safety and Nutrition; 2020 (https://www.aesan.gob.es/AECOSAN/ web/seguridad_alimentaria/seccion/pncoca.htm#:~:text=El%20Plan%20Nacional%20de%20Control,de%20venta%20al%20 consumidor%20final, accessed 28 February 2022) (in Spanish). 24. Sugar reduction and wider reformulation [website]. London: Public Health England; 2020 (https://www.gov.uk/government/ collections/sugar-reduction, accessed 21 February 2022). 25. One You: a step towards better health and more sustainable services. London: UK Health Security Agency; 2016 (https://ukhsa. blog.gov.uk/2016/03/07/one-you-a-step-towards-better-health-and-more-sustainable-services/, accessed 21 February 2022). 26. Time to solve childhood obesity: an independent report by the Chief Medical Officer, 2019. London: Department of Health and Social Care; 2019 (https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/837907/ cmo-special-report-childhood-obesity-october-2019.pdf, accessed 21 February 2022). 17 THE OUT-OF-HOME FOOD ENVIRONMENT Annex 1. Meeting participants MEMBER STATES France Roxane Berjaoui Carine Dubuisson Sandrine Carrillo The Netherlands Liesbeth Temme Norway Professor Haakon Eduard Meyer Arnhild Haga Rimestad Russian Federation Dinara Mukaneeva Vladislav Vlasov Spain Maria José Yusta United Kingdom Scott Mahony Tom Wood EXPERTS Université Paris Chantal Julia RIVM: National Institute for Public Health and the Environment Marieke Hendriksen University of Oslo Lene Frost Andersen Kingston University Jaywardana Weerasinghe 18 REPORT OF A WHO REGIONAL OFFICE FOR EUROPE AND PUBLIC HEALTH ENGLAND EXPERT MEETING Safefood Charmaine McGowan Joana Silva, Chief Specialist in Nutrition Public Health England, United Kingdom Tazeem Bhatia Sam Montel Jo Nicholas Emma Peacock Victoria Targett Alison Tedstone Michelle Young Scottish Government Colin Baird Food Standards Agency Northern Ireland Fionnuala Close Public Health Division, Welsh Government Alison Black University of Cambridge Gareth Hollands Spanish Agency for Food Safety and Nutrition Maria José Yusta London School of Hygiene and Tropical Medicine Pauline Scheelbeek Food Standards Scotland Alana McDonald, Senior Public Health Nutrition Advisor Agencia Española de Seguridad Alimentaria y Nutrición (AESAN), Spain Almudena Rollan, Advisory Member Enrique Gutiérrez, Technical Officer Teresa Robledo, Technical Adviser National Research Centre for Preventive Medicine, Ministry of Health, Russian Federation Marina Popovich Spanish Agency for Food Safety and Nutrition Carmen Villar, head of service 19 THE OUT-OF-HOME FOOD ENVIRONMENT WHO WHO Regional Office for Europe Chizuru Nishida, Coordinator Jodie Anne Littlewood, Programme Assistant WHO European Office for Prevention and Control of Noncommunicable Diseases Carina Ferriera Borges, Head Kremlin Wickramasinghe, Acting Programme Manager, Nutrition, Physical Activity and Obesity Holly Rippin, Consultant Afton Halloran, Consultant Dodkhudo Tuychiev, Programme Assistant WHO Regional Office for South-East Asia Angela Padmini, Regional Adviser, Nutrition and Health for Development Katy Cooper, Rapporteur World Health Organization Regional Office for Europe UN City, Marmorvej 51, DK-2100, Copenhagen Ø, Denmark Tel.: +45 45 33 70 00 Fax: +45 45 33 70 01 Email: eurocontact@who.int Website: www.euro.who.int WHO/EURO:2022-5714-45479-65098 The WHO Regional Office for Europe The World Health Organization (WHO) is a specialized agency of the United Nations created in 1948 with the primary responsibility for international health matters and public health. The WHO Regional Office for Europe is one of six regional offices throughout the world, each with its own programme geared to the particular health conditions of the countries it serves. Member States Albania Andorra Armenia Austria Azerbaijan Belarus Belgium Bosnia and Herzegovina Bulgaria Croatia Cyprus Czechia Denmark Estonia Finland France Georgia Germany Greece Hungary Iceland Ireland Israel Italy Kazakhstan Kyrgyzstan Latvia Lithuania Luxembourg Malta Monaco Montenegro Netherlands North Macedonia Norway Poland Portugal Republic of Moldova Romania Russian Federation San Marino Serbia Slovakia Slovenia Spain Sweden Switzerland Tajikistan Türkiye Turkmenistan Ukraine United Kingdom Uzbekistan