Director of Public Health Annual Report 2024-25
Communicating Complexity. Living Well: Bradford’s Whole Systems Approach to obesity.

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Introduction

Welcome to my annual report for this year, which focuses on our experience of using a whole system approach to tackling obesity here in Bradford. When I had been here in post for 6 months I was asked if I had managed to reduce obesity yet. My response was that if I had, everybody would be talking about it. Obesity is a global public health issue with several countries seeing prevalence doubling or tripling over the last 30 years and reversing that trend is something we are all trying to achieve, with limited success. In addition to increasing levels of obesity overall there has been a significant increase in the most deprived communities, leading to a widening gap between the most and least deprived areas. This means that with the high levels of poverty and deprivation in the district, obesity has a bigger impact in Bradford.

Even though the need to reduce obesity is universally accepted, government policy often takes a fragmented approach that focuses on individual behaviour and choice - after all, all we need to do is Eat Less and Move More, right? In reality, it is much easier to create a narrative that is about people making bad choices and not taking responsibility for their own health than it is to take the cross-cutting population level approach that evidence tells us is needed.

That is why, as a public health team, we decided to be brave and develop a whole system approach to reducing obesity, which we call Living Well. We will share what we have done, what our successes and challenges have been and our learning from the journey we have been on. The work is still ongoing and we definitely have more to do but I am proud of how far we have come. This a jointly funded and delivered programme between our integrated care board and Bradford Council. It has been a truly joint venture that has required commitment, persistence and hard work and I should end by thanking, in particular, ICB and Council programme leads, the public health team and of course our portfolio holder for Living Well: Councillor Sue Duffy.

Sarah Muckle

Director of Public Health

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Introduction: health and wellbeing in Bradford districts

On average, Bradford tends to see poorer health and wellbeing outcomes compared to the rest of the country. Health and wellbeing outcomes are also not distributed evenly across the district, with big inequalities between areas within Bradford district [see Appendix A for further details]. The causes of health inequalities are varied, complex, and inter-related. We know that the drivers of obesity are the same drivers as for many other long-term conditions. Therefore, by focusing our collective efforts on reducing the rate of obesity, we will also be encouraging positive wellbeing and an improved healthy life expectancy overall.

Our Living Well programme, established in 2017 and now embedded in the district’s partnerships, aims to address the causes of ill-health and poor wellbeing, with a particular focus on healthy weight, in a range of ways: through working with individuals, communities and systems. To do this, we must find ways of communicating complex concepts with a wide range of people the help them identify ways to influence and make positive changes within their own parts of the system.

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What influences health?

Research shows that a huge range of factors affect people’s health and wellbeing, and their health-related behaviour. These factors are highly interlinked and can’t be considered in isolation. Individual personal factors include knowledge, skills, beliefs, habits, and attitudes. A “personal responsibility” view implies that we are all in control of our health-related behaviours, and able to choose to modify these to live a healthier life. However, personal responsibility alone can’t explain the rapid rise in overweight and obesity which has occurred across the world over the last four decades, and now affects almost two in three adults and one in three children in Europe (1).

We don’t live our lives in isolation. Diverse factors around us, often termed the Wider Determinants of Health, influence our health and wellbeing in a complex system of cause, effect, and interactions. The Wider Determinants of Health include things like what social support people have in place, what is typical within families and communities (sometimes termed “social norms”), and what access people have to different options and opportunities. These are heavily influenced by our work, how much money we have to buy different foods, how much time and resource we have for cooking, the quality of the housing we live in, and our access to different forms of exercise such as parks, green spaces, safe walking and cycling routes, and sports. These, in turn, are in large part controlled by local and national public policy: the laws and decisions made by governments which impact on health, education, the economy and the built environment.

Linked to the wider determinants of health is the market for food: the availability of food within travelling distance, how this food is advertised and sold, how it is made, and what ingredients go into it. These factors, which alongside industries selling other commodities related to health are sometimes known as the Commercial Determinants of Health (CDoH), are again influenced by national policy, advertising law, local planning decisions, national planning legislation, and the industry itself. Generally, the CDoH refers to private companies, whether large or small, which can affect health. Companies may promote or harm health, or, more commonly, do a mixture of the two. The food industry is essential: it supports the population with access to affordable, nutritious food. However, it also sells us poor quality food, often made using cheaper ingredients and processes. Depending on where we live and what we can afford, the availability of good quality food, or any food at all, may not be guaranteed.

In 2018, over 100 partners working in Bradford joined together to map out these factors, to help everyone involved in the health and wellbeing of Bradford’s population to understand the complex nature of the systems leading to growing rates of overweight and obesity. The map that was created helps to show the range of influences on health-related behaviour, how they link together, and how they influence each other. This helps policy makers to make better decisions about where to place finite resources, looking for places in the system they can intervene to make it easier for people to make healthy choices. Much of the system is beyond local control, and relies on national, or even international policy to make changes. However, there are many points within the map below where we can make a difference locally, through planning, policy, and education. The map also helps to identify the possible consequences of actions taken in the system which might not be immediately obvious. For example, improving access to technology might have both positive effects (e.g. ability to buy cheaper fresh food online, access to recipes and information) and negative effects (more screen time, negative media influences).

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How can we help people to change their behaviour?

There are many theories of behaviour change (2). Most of these rely on an individual’s own motivation and willpower. However, as discussed above, there are a large number of influences on our behaviour, many of which are outside our control; particularly for people already dealing with other stressors such as poverty and poor health. Living Well favours the COM-B model of behaviour change (3), which includes contextual and environmental factors in addition to individual ones, and offers ideas for different ways of addressing these factors. At its core, the COM-B model focuses on:

• Capability: “the individual's psychological and physical capacity to engage in the activity concerned. It includes having the necessary knowledge and skills.”
• Opportunity: “all the factors that lie outside the individual that make the behaviour possible or prompt it”
• Motivation: “all those brain processes that energize and direct behaviour, not just goals and conscious decision-making. It includes habitual processes, emotional responding, as well as analytical decision-making”
• Behaviour: the actions or activities that a person hopes to change

Reproduced from: (3)

This model and recent research tells us that to help people change their behaviour, we need to move away from traditional approaches to health improvement which focus on changing an individual’s knowledge and attitudes, and towards policies which make healthier choices more accessible, appealing, and easy (4). This approach takes account of not only the “capability” aspect, which is addressed by traditional health education models, but also the “opportunity” and “motivation” sections of the COM-B model. The approach is also good in that it doesn’t rely on individuals having the money, time, and ability to make difficult changes to their lives, and so can help to reduce inequalities.

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Why a Whole Systems Approach?

These two principles: that health is influenced by a huge range of factors; and that for people to make meaningful, lasting changes to their behaviour we must make those behaviours easy to achieve, underpin the Living Well approach. Living Well is a Whole Systems Approach, with the primary outcome being the reduction in the rate of obesity, understanding that working towards this objective for the population of Bradford will also improve health and wellbeing more generally. A whole-systems approach is a collective effort and is the responsibility of everyone with any influence over local policy and action.

Systems thinking is defined and advocated by the UK government as a tool for complex problems and systems (5):

A system is a set of elements or parts interconnected in such a way that they produce their own pattern of behaviour over time. Systems thinking is a framework for seeing the interconnections in a system and a discipline for seeing and understanding the whole system; the ‘structures’ that underlie complex situations. It is a collection of tools and approaches that help support us in thinking systemically about our work. Systems thinking is particularly powerful when applied to complex systems. By creating simple models of complex systems, systems thinking can be a useful building block towards understanding and visualising data flows within a system.

A complex system is one with many interconnected parts, which develops organically with no central control, in which it is impossible to accurately predict the outcome of a change to any individual part of the system. This also means that it is impossible to change the outcome in a predictable way by changing one part of the system. There are many examples of complex systems in nature: the weather, the human brain, and the behaviour of large groups of people, such as cities.

The behaviour of populations and subsequent emergence of obesity is one example of a complex system. A whole systems approach to reducing obesity is therefore essential – changes to individual components of the system will not result in the desired outcomes, we must look at the system as a whole, and work together. The whole systems approach is therefore a partnership of stakeholders, including local communities, who can share understanding, identify opportunities, and agree on actions.

There are many benefits to the Living Well whole systems approach that have been identified since its inception:

• The effect of collective actions is greater than the sum of the individual actions – the approach identifies, implements and aligns actions that have wider impact across the local system
• A systems approach provides value for money – by delivering targeted action collectively the approach is efficient, ensuring focused work with limited duplication, and acting upstream where spending is more cost effective
• The approach reflects the local leadership role of local authorities – it enables reach into local places, working with and through a large range of stakeholders, including communities
• It aligns with a ‘Health in All Policies’ approach – it recognises the range and complexity of causes of obesity, supporting a system-wide approach to understand and address health inequalities
• It maximises all the assets in the local area, including community assets – recognising and identifying local assets can help build on the particular strengths of communities
• The approach supports a community-centred approach to tackling health inequalities – involving local communities, in particular disadvantaged groups, can better reflect the local realities, help improve health and wellbeing and reduce health inequalities
• It develops transferable workforce skills and capacity – the same skills which are used to tackle obesity can be used for other complex issues
• It recognises the potential of all partners to contribute – NHS organisations, local authority departments and the education, business and voluntary sectors all have a significant role to play in improving the population’s health.

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Our strategy

With all this in mind, Living Well’s aim is to make it “easier for everyone, everywhere, everyday to live a healthy and active lifestyle”. Actions can be divided in a number of ways but can be thought of in three levels: individuals and families, communities and organisation, and the physical environment. These are underpinned by supporting projects called “system enablers”, which include overarching food and physical activity strategies, communication with the public, and training of professionals. Each aspect has a crucial role to play in reducing obesity and improving health for the population.

The Living Well approach is organic, responsive, and ever-changing. Evaluation is constant and is done in a number of ways, reflecting the diverse interventions and ways of working of the system. Academics are a key part of the Living Well partnership, undertaking qualitative and quantitative research, and looking at both outcomes and processes. This ensures that the approach can be flexible enough to change where things are not working, build on things that are, and create new initiatives when new evidence comes to light.

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Governance and stakeholder engagement

To be successful as a whole systems approach, it is vital that the initiative is both represented in the rooms and conversations in which decision-making takes place, and that stakeholders are engaged in the work of Living Well itself. Strong, clear governance is therefore essential. An active Living Well Collaborative Network is in place and flourishing. This supports Living Well work and gives members opportunities to share and present information about the organisations and programmes which are delivering Living Well across the system.

Living Well is also an official “enabler” for the local Health and Care Partnership, acting as a supportive underpinning for prevention within each priority of the Partnership. Living Well is represented in each Health and Care Partnership programme to ensure that prevention is at the forefront of every agenda. At regional level, Living Well is also actively represented within West Yorkshire Health and Care Partnership workstreams, including the Improving Population Health Programme, the Prevention Network, the Physical Activity Steering group and the Healthy Weight and Food Resilience group.

Lastly, and perhaps most importantly, partnerships within communities are key to ensuring the success of a whole systems approach. Living Well is aligned to Community Partnership groups: networks of primary care, social care, acute trusts, VCS, community members, and other statutory bodies, providing an opportunity to integrate and promote Living Well with the prevention and health inequalities work that these groups deliver.

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How do we communicate our approach

Whole Systems work is, by definition, complex, and it can be difficult to communicate the scale and interconnectedness of the systems leading to the increase in BMI across populations.

Research shows that there are certain ideas which can be followed to help communicate complexity to a wider audience. Reed et al. identified a framework based on three “principles” and 12 “rules” to follow when defining and communicating complex systems(6). The research was based on clinical systems, but many of their ideas can be translated to population systems work.

Principle 1: Act scientifically and pragmatically

Rule 1: Understand the problem and opportunities

Living Well was initially conceived in 2015 and formally established in 2017, and has grown and changed in the time since. The approach was based on local data showing the rise in overweight and obesity among both children and adults, and research evidence showing that one-to-one interventions weren’t sufficient to address the problem. The necessity and opportunity for a coordinated approach to obesity was clear, and Living Well was born.

Rule 2: Identify, test and iteratively develop potential solutions

Living Well is a partnership approach and has been developed collaboratively. A wide range of solutions have been and continue to be delivered, spanning a range of different targets. These grow and develop iteratively, and are tested for effectiveness along the way. For example, the Reducing Inequalities in Communities work led by the clinical commissioning group (CCG; now integrated care board, or ICB) was a test bed in which we could pilot and evaluate the Living Well schools programme, learning from this to develop a whole-district approach to supporting schools.

Rule 3: Assess whether improvement is achieved, and capture and share learning

Academic colleagues are key partners within the Living Well collaborative. We work to evaluate both individual interventions, and the Living Well process as a whole. This is challenging, however, as evaluation of a whole systems approach is as complex as the approach itself. Novel ways of evaluation are used, in addition to the evaluation of individual interventions. For example, Ripple Effect Mapping has been used to evaluate the impact of less tangible inputs and outcomes, such as partnerships, workshops, and relationships. These activities are invaluable, but not often measured. Learning from this type of evaluation can help to identify valuable work, and to plan for future activities.

Rule 4: Invest in continual improvement

As a partnership, we are constantly striving to develop the Living Well approach. This is iterative, building on previous success and learning from initiatives which haven’t had the impact we were hoping for. For example, the Living Well Children and Families service was a major development using investment from the Office for Health Improvement and Disparities (OHID). The service was developed using the latest evidence and advice from academic colleagues and has grown rapidly, now delivering family interventions for children living outside a healthy weight across the district.

Principle 2: Embrace complexity

Rule 5: Understand practices and processes of care

For wellbeing, including overweight and obesity, the concept of “care” is broader than for many clinical topics. Care can include self-care, nutrition and exercise, in addition to physical and mental health care. It is critical to the success of Living Well that we understand how people live, and the challenges they face in their daily lives. The systems mapping work has been vital to our understanding of this, and the Communities strand of work allows us to explore in detail the diverse experiences of the different communities within the district.

Rule 6: Understand the types and sources of variation

Wellbeing, overweight and obesity are strongly related to inequalities. As a core part of the work we do, we work to understand the geographical, socioeconomic, ethnic, and cultural differences in outcomes for people in the district. This means that we can target interventions more effectively, and make sure that they are accessible to the people who need them most.

Rule 7: Identify systemic issues

A major piece of work for Living Well was developing the systems map for obesity. This has been invaluable, as it helps the partnership to identify the different causes of overweight and obesity, to see how they link together, interact with and reinforce each other, and ultimately to identify areas for intervention which are most likely to create positive change. This also helps our wider partners to understand their own role in helping people to maintain healthy behaviours, particularly those working in fields which are, at first glance, unrelated to health and wellbeing.

Rule 8: Seek political, strategic and financial alignment

One of the key aspects of Living Well is that it has very senior support across the different organisations responsible for health and wellbeing in Bradford district. Living Well is owned by Bradford’s Health and Wellbeing Board – the most senior strategic local forum responsible for health and wellbeing, which brings together leaders from a large range of organisations including the local authority, health settings, the voluntary and community sector, faith settings, the business world, and academic institutions. The Living Well steering group is chaired by a dedicated portfolio holder for Living Well, ensuring strong political representation. Funding is distributed, with partners dedicating their own budgets towards the principles of Living Well, dedicated external funding from OHID, and committed Public Health funding.

Principle 3: Engage and empower

Rule 9: Actively engage those responsible for and affected by change

The purpose of Living Well is to create a partnership and a network of individuals with the power to make changes for the district, across a wide range of organisation and departments. In this way, representation from across the systems map is guaranteed, and each individual can see how they fit into the solution. Furthermore, the Living Well Communities strand of work devolves power back to the communities we serve, through funding, collaboration and engagement. This ensures that traditionally underserved and underrepresented communities have their voices heard and that we “do with” rather than “do to”.

Rule 10: Facilitate dialogue

Our Living Well Communications and Living Well Communities strands both aim to facilitate dialogue with those people we serve in our communities, and with our partners. This reciprocity is critical to our success.

Rule 11: Build a culture of willingness to learn and freedom to act

Within organisational structures with strict governance, freedom to act can be challenging, as action takes time and needs to be balanced against the needs of individual organisations and the partnership. However, in building a strong, well-respected, evidence-based approach, we have built trust in the process, which brings with it a freedom to innovate and develop the systems. This is supported by a strong culture of evaluation, ensuring that we recognise innovations that are going well, and those which need modifying.

Rule 12: Provide headroom, resources, training and support

The Living Well website hosts numerous resources, including communications materials, case studies, links to support, and personalised information. There is also a Workforce section, detailing training courses available to professionals in the district. Training is a key “enabler” of the Living Well programme, disseminating the knowledge and skills needed to the wider workforce.

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What have we learned

Population increase in obesity and overweight is a complex issue, which cannot be solved through individual services or programmes. Systems-level working across organisational boundaries is needed to tackle the myriad interconnected causes of poor and unequal health and wellbeing. This is difficult, taking time, resources, communication skills, and sensitivity. Within a complex system many stakeholders have a role to play, without always recognising their potential contribution. A key goal of Living Well is to support partners to recognise their role in the system, and to generate support from across the range of actors, embedding the approach across all policies and organisations.

• Communication of the complexity of the issues has been one of the biggest challenges to date. This is critical in bringing partners together. Following the principles above helps to navigate some of this, and helps to create partnerships using a common narrative and approach.
• It is vital to set a clear, simple vision, with measurable outcomes. This enables all partners and stakeholders working in the system to work towards a common goal, and to measure progress against that goal. Such outcomes may not be traditional outcomes such as might be seen in an analysis of a single intervention. Rather, they may also be outputs, process outcomes, or measures of the broader impact of our work. Creativity, time, and an understanding of the system is needed to identify suitable measures of success.
• Sitting underneath this overarching vision, breaking the systems work down into clearly defined areas, each with a lead owning the remit, means that the work is manageable. As the issue of obesity is so wide-reaching, it can be daunting, but by breaking it down into manageable topics, it becomes easier to target and prioritise our collective efforts.
• Strong governance is really important, ensuring that the breadth of work being done is understood by all partners working together. This helps to link up pieces of work, share learning, avoid duplication, and align workstreams. It also makes sure that everyone involved understands the processes by which work is approved and monitored, so that feedback and support can be given to each of the workstreams.
• Living Well has its own dedicated elected member portfolio holder, who chairs the Living Well Steering Group. This reports directly to Health and Wellbeing Board. This is another factor which is crucial to its success: only with buy-in at the most senior levels will such a model gain traction across the whole system.
• Actions and changes within the system are different and varied depending on stakeholders’ interests and what they want to achieve. Different organisations have multiple perspectives and different agendas, with different sources of knowledge. This multiplicity of approach can be both a challenge, and a source of great strength for systems working.
• Adaptability is a vital attribute of systems working. The approach must be strong enough to secure a shared vision of the desired outcomes, while remaining flexible enough to respond to challenges, changes in the working context, and new information and evidence.
• Many of the challenges we are seeking to address are long-term, well-established issues, which will take time and a consistent approach. For example, the food system is influenced by poverty, commercial enterprise, national and international policy, and culture, all of which are ingrained in our society. While changing these may seem like an impossible task, it is only through small incremental steps and the organised efforts of society that will we succeed.

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Recommendations

1. Living Well is not the only systems-working programme in Bradford District. I recommend that partners align cross-system work programmes in order to learn from each other, coordinate communications messages, and gather insights and feedback from local communities.
2. Co-production and engagement is critical to the success of this work. I recommend that within Living Well, we capitalise on the developing Living Well Communities and Living Well Schools work strands, so that we can tailor our communications even more closely to the needs, understanding, and interests of our diverse communities.
3. During periods of political and social change, maintaining strong partnerships can be challenging. Over the coming year, we must redouble our efforts as a system to focus on the causes of ill health and inequalities, and to enable people to make choices which allow them to live healthier, happier lives.

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Appendix A: Overview of health-related risk factors in Bradford district

Life expectancy and healthy life expectancy

One major driver of inequalities and poor health outcomes is poverty. In Bradford, there are almost twice the proportion of children who are living in poverty than in England on average, with nearly one in three children (28.9%) in Bradford living in poverty, compared to 15.3% in England. This again varies by ward, with over half of all children living in Manningham (51.7%) living in poverty, compared to 3.3% of those living in Ilkley.

Overall, life expectancy for women tends to be slightly higher than that of men, with a girl born today in Bradford expected to live to 81.5 years on average, and a boy born today expected to live to 77.3 years. This is lower than the average life expectancy for England as a whole, where an average baby girl would expect to live to 83.1 years and an average baby boy to 79.4 years. Adults in Bradford are more likely to die prematurely (under the age of 75 years) from respiratory (lung) disease, cardiovascular disease (heart disease and stroke), and cancer, than in the rest of the country, on average.

Within Bradford, there are inequalities between different parts of the district. There is a gap of 10.1 years for women between the ward with the lowest life expectancy (77.1 years, Manningham) and the ward with the highest life expectancy (87.2 years, Wharfedale). For men, there is a gap of 10.8 years between the ward with the lowest life expectancy (72.1 years, Manningham) and the ward with the highest life expectancy (82.9 years, Wharfedale).

For healthy life expectancy, which is the length of time people in our district live without physical or mental ill health, this difference is even greater, with a difference of over 20 years for both men and women between the wards with the longest and the shortest healthy life expectancy.

Life expectancy at birth for women in Bradford District, by Ward. Reproduced by permission of Ordnance Survey on behalf of HMSO © Crown copyright and database right 2024

Life expectancy at birth for men in Bradford District, by Ward. Reproduced by permission of Ordnance Survey on behalf of HMSO © Crown copyright and database right 2024

Overweight and obesity

Childhood weight data shows that in reception classes at age 4 or 5 years, children in Bradford are similarly likely to be classed as “overweight” as children in England, at 22.3% in Bradford compared to 22.1% in England. However, by year 6, the difference has increased, with 40.9% of children in Bradford “overweight” and 26.7% classed as “obese”, compared to 36.6% classed as “overweight” and 22.5% classed as “obese” in England at the same age. There are again differences between wards, with for example almost half of children in Keighley Central classed as “overweight” in year 6, compared to only one in five children in Ilkley.

Prevalence of overweight (including obesity) – Reception Ward distribution. 3 years data combined 2020-21 – 2022-23

Prevalence of overweight (including obesity) – Year 6 Ward distribution. 3 years data combined 2020-21 – 2022-23

Adults in Bradford are slightly less likely to be recorded as living with obesity than those in England on average (8.5% compared to 9.7%). However, again we see inequalities across the district, with 3.6% of adults in Wharfedale living with obesity, compared to 9.9% in Manningham ward.

Smoking

Smoking is a major risk factor for poor health, leading to an increased risk of heart disease, stroke, lung disease, many cancers, and more. The numbers of people recorded by their GP as being a current smoker has been falling in recent years. However, Bradford still has a significantly higher proportion of people who smoke compared to the rest of the country on average, at 17.9% in Bradford compared to 14.7% in England. Again, this varies across the district, with 6.8% of people in Keighley West recorded as being a current smoker, compared to 38.2% of those in Bingley Rural.

Physical activity

Physical activity is an important component of both physical and mental health and wellbeing. It can support healthy development for children and young people, prevent illness such as heart disease, stroke and cancer, and improve mental wellbeing (7).

In Bradford, fewer children and adults are physically active, compared to the rest of the country (8). In 2022/23, 28.8% of all adults in Bradford were described as physically inactive, compared to only 22.6% of those in England on average. For children and young people, only 37.7% described themselves as physically active in Bradford, compared to 47% of children and young people across England.

Physical Activity in Bradford, Yorkshire and the Humber, and England; 2022/23.

Nutrition

According to the World Health Organisation: “Nutrition is a critical part of health and development. Better nutrition is related to improved infant, child and maternal health, stronger immune systems, safer pregnancy and childbirth, lower risk of non-communicable diseases (such as diabetes and cardiovascular disease), and longevity.”

In the UK, the Office for Health Improvement and Disparities (OHID) recommends that people follow the Eatwell Guide for a healthy diet. Principles are:

• Fruit and vegetables: eat at least 5 portions of a variety of fruit and vegetables every day.
• Potatoes, bread, rice, pasta, and other starchy carbohydrates: choose wholegrain or higher fibre versions with less added fat, salt and sugar.
• Beans, pulses, fish, eggs, meat, and other proteins: eat more beans and pulses, 2 portions of sustainably sourced fish per week, one of which is oily. Eat less red and processed meat.
• Dairy and alternatives: Choose lower fat and lower sugar options.
• Oils and spreads: choose unsaturated oils and use in small amounts.

Unfortunately, for a multitude of reasons, many people in England find it difficult to follow these guidelines and aren’t able to maintain a balanced diet. In 2022/23, only 31% of adults in England were able to eat five or more portions of fruit and vegetables per day. This had fallen from 34.9% in 2020/21.

Each year, the UK conducts a survey of adult’s dietary habits. The latest available survey (9) is from 2020, describing the impact which the covid-19 pandemic had on people’s diets. The survey found that no age groups were eating the recommended amount of fruit and vegetables, fibre, or oily fish, on average. However, consumption of saturated fat and sugar exceeded recommendations.

Financially, in the 2020 survey, 17% of those responding said that they were “just about getting by”, while another 5% said that they were “finding it quite difficult or very difficult”. This was more common among families with children.

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References

1. A 2022 update on the epidemiology of obesity and a call to action: as its twin COVID-19 pandemic appears to be receding, the obesity and dysmetabolism pandemic continues to rage on. Boutari C, Mantzoros CS. 155217, s.l.: Metabolism., 2022, Vol. 133. doi: 10.1016/j.
2. Theories of behaviour and behaviour change across the social and behavioural sciences: a scoping review. Davis R, Campbell R, Hildon Z, Hobbs L, Michie S. (3): 323-44., s.l.: Health Psychol Rev., 2015, Vol. 9. doi: 10.1080/17437199.2014.941722. Epub 2014 Aug 8. PMID: 2510.
3. The behaviour change wheel: A new method for characterising and designing behaviour change interventions. . Michie, S., van Stralen, M.M. & West, R. 42, s.l.: Implementation Sci, 2011, Vol. 6. https://doi.org/10.1186/1748-5908-6-42.
4. Determinants of behaviour and their efficacy as targets of behavioural change interventions. Albarracín, D., Fayaz-Farkhad, B. & Granados Samayoa, J.A. 377–392, s.l. : Nat Rev Psychol, 2024, Vol. 3.
5. Government Office for Science. Guidance: Introduction to systems thinking for civil servants. gov.uk. [Online] 12 January 2023. [Cited: 11 September 2024.] .
6. Simple rules for evidence translation in complex systems: A qualitative study. Reed, J.E., Howe, C., Doyle, C. et al. 92, s.l. : BMC Med, 2018, Vol. 16. .
7. Fact sheet: physical activity. World Health Organisation. [Online] 26 June 2024. [Cited: 11 September 2024.]
8. Office for Health Improvement and Disparities. Fingertips: Public Health Profiles. fingertips.phe. [Online] 2024. [Cited: 11 September 2024.]
9. Public Health England and Food Standards Agency. National Diet and Nutrition Survey: Diet, nutrition and physical activity in 2020. A follow up study during COVID-19 (PDF). gov.uk. [Online] September 2021. [Cited: 11 September 2024.]