Consultation outcome

Updating the GBSF: equalities assessment

Updated 9 August 2021

Introduction

This paper examines the impact of the policy to update the nutrition standards in the government buying standards for food and catering services (GBSF) with protected characteristics. This is in accordance with our duties under the Equality Act 2010.

Under the Equality Act 2010 (the Act), the Department for Health and Social Care (DHSC), as a public authority, is legally obliged to give due regard to the public sector equality duty when making policy decisions. The public sector equality duty is also known as the general equality duty.

DHSC, as a public authority must, in the exercise of its functions, have due regard to the need to:

(a) eliminate unlawful discrimination, harassment and victimisation and other conduct prohibited by the Act

(b) advance equality of opportunity between people who share a protected characteristic and those who do not

(c) foster good relations between people who share a protected characteristic and those who do not

The public sector equality duty covers consideration of the following protected characteristics:

• age
• disability
• gender reassignment
• pregnancy and maternity
• race
• religion and belief
• sex
• sexual orientation

Marriage and civil partnership is a protected characteristic under (a) above.

Background

In 2011 the government introduced the government buying standards for food and catering services (GBSF) as a means of meeting the Greening Government Commitments when buying and providing food and catering services.

All central government departments and their agencies are required to comply with the GBSF, as well as prisons, the armed forces, and the NHS. Trusts with retail units also need to comply.^{[footnote 1]} Schools must follow the school food standards legislation but may also choose to use the GBSF too. The wider public sector is encouraged to apply these standards, including to food and drink offered in vending machines (for example, in leisure centres). Overall policy responsibility for the GBSF rests with the Department for Environment, Food and Rural Affairs (Defra). DHSC, taking into account advice from Public Health England (PHE), has responsibility for the nutrition standards within the GBSF. Compliance with GBSF standards is mandatory for UK government departments as well as NHS England hospitals under the terms of the NHS Standard Contract. Nutrition is a devolved policy, and it is the decision for the devolved administrations whether or not they choose to follow the GBSF within their government buildings.

It is essential that public food procurement, including the GBSF, is underpinned by evidence-based dietary recommendations^{[footnote 2]} so that the government can lead by example to ensure a healthy food environment for the public who live and work within the public sector.

Childhood obesity: a plan for action, chapter 2 announced the government would consult on updating the nutrition standards in the GBSF. The aim of the policy is to ensure healthier food and drink options are available across the public sector. Since the nutrition standards of GBSF were last set, the Scientific Advisory Committee on Nutrition (SACN) has published recommendations on both sugar and fibre intakes and sugar-sweetened drinks consumption be reduced. These recommendations were subsequently accepted by government and included in government dietary recommendations. Core dietary messages and tools have been updated to reflect this.

As part of the DHSC vision document prevention is better than cure, published on 5 November 2018, the government recommitted to the work set out in chapter 2 of the childhood obesity plan and highlighted that the workplace is a great setting for encouraging healthy lifestyles – including on eating healthily.

DHSC consulted on this proposal from May 2019 to August 2019. Following consultation, the government has decided to update the nutrition standards in the GBSF.

This document is intended to be read in conjunction with the consultation response, which sets out more detailed information about the policy objectives. The policies are not designed to increase disadvantage between individuals or groups, particularly those that share protected characteristics as set out in the Equality Act 2010. They are intended to encourage a positive effect on the wider food environment and therefore a positive impact across the population. We have considered whether there are any unintended consequences and how we can mitigate any disadvantages as well as to comply with the public sector equality duty. The following section will examine the impact of the policies in the plan on various groups sharing protected characteristics.

Consultation feedback

The consultation sought views on whether this proposal would be likely to have an impact on people on the basis of a number of protected characteristics.

Respondents could select as many characteristics as they believe applied. Distribution of the selected characteristics is as follows:

Age:

• yes: 57 respondents
• no: 55 respondents

Sex:

• yes: 21 respondents
• no: 89 respondents

Race:

• yes: 33 respondents
• no: 78 respondents

Religion:

• yes: 27 respondents
• no: 82 respondents

Sexual orientation:

• yes: 5 respondents
• no: 105 respondents

Pregnancy and maternity:

• yes: 50 respondents
• no: 61 respondents

Disability:

• yes: 37 respondents
• no: 73 respondents

Gender reassignment:

• yes: 4 respondents
• no: 106 respondents

Marriage or civil partnership:

• yes: 5 respondents
• no: 104 respondents

There were 40 respondents who provided a justification to explain their answer in a free-text box. Free-text answers were analysed to infer whether the respondent believed the policy would have a positive or negative effect on the particular characteristic.

Of the 40 respondents, 9 respondents suggested that age and pregnancy and maternity were the characteristics deemed most likely to benefit from the policy. Respondents felt that the policy was important to help educate and improve children’s food choices and that the policy would have a greater long-term impact on children than it would on adults. Respondents highlighted, supporting evidence that young people tend to have lower intakes of fruit, vegetables, fibre and higher intakes of sugar, soft drinks and confectionary or savoury snacks than older people and for pregnant women the policy could improve overall diet and that it would benefit both mother and child.

Of the 40 respondents, 10 respondents believed there would be a negative effect on disabilities. Respondents expressed the view that people that required full allergen information would be disadvantaged and highlighted that people with gastroenterological conditions needed to follow a low-residue diet that includes low-fibre foods. Respondents felt that having a disability could affect diet and food choices due to restricted income and limited mobility. Respondents felt that people living with dysphagia need to be provided with calories in ways which they could consume them and this may mean they would not be able to adopt to the new standards and that those with learning difficulties, such as, the condition Autistic Spectrum Disorder, would not be able to comprehend why they were unable to have the food choices that they wanted.

Of the 40 respondents, 6 respondents highlighted that the policy would have a negative effect on older people as they may be vulnerable and may not necessarily be able to choose food for themselves, elderly people are more likely to struggle to change their eating habits, have different taste buds and have more food intolerances or digestive issues.

Of the 40 respondents, 4 respondents believed it would have a negative effect for those in religious groups due to restrictive diet requirements, and that this will make it more difficult for them to find the food that meets their needs. Some respondents that answered the question on the protected characteristics on race also expressed these views.

Of the 40 respondents, 3 respondents believed it would have a positive effect for those in different ethnicities and that the standards would help to reduce health inequalities by improving access to healthier food choices. They also expressed the view that there is evidence of a correlation between many health inequalities and race. Respondents highlighted that those in Black and Asian ethnic groups are more likely to lead unhealthy lifestyles that could lead to being overweight and living with obesity.

Each of these comments are addressed in their respective section in the equalities assessment.

Respondents were also asked whether this proposal would help achieve any of the following aims:

• eliminating discrimination, harassment, victimisation and any other conduct that is prohibited by or under the Equality Act 2010: 13 respondents

• advancing equality of opportunity between persons who share a relevant protected characteristic and persons who do not share it: 18 respondents

• fostering good relations between persons who share a relevant protected characteristic and persons who do not share it: 17 respondents

• not answered: 113 respondents

Respondents could provide free-text responses to justify their answer. Some respondents highlighted that the policy will not change existing discrimination. One respondent said that to achieve the aims of these proposals, there would be a requirement for all caterers to be trained on health, ethnicity, religious and philosophical belief in meeting dietary needs.

Assessment against protected characteristics

The primary objective of updating the GBSF is to shift the balance towards healthier products and maximise the availability of those products to help consumers make healthier choices in the public sector. As a result, the policy aims to lead to a reduction in the public’s overconsumption of high fat, sugar and salt (HFSS) products that are linked with excess sugar and calorie intake and over time, weight gain and obesity. The policy is specifically targeted at the public who live, visit and work within the public sector. It is expected to have an effect on the wider food environment and therefore a positive impact across the population.

Age

Obesity prevalence

Obesity prevalence is different across age groups. PHE analysis of National Child Measurement Programme (NCMP) data shows that obesity prevalence increases in children in England as they progress through primary school. 1 in 10 children in reception and around 1 in 5 children in year 6 is obese.^{[footnote 3]}

In adults, 2019 results from the Health Survey for England showed that 64% of adults were classified as overweight or obese. Obesity and overweight rates went up with age but decreased in the oldest age groups. Obesity ranged from 14% of men aged 16 to 24 to a peak of 32% of men aged 45 to 54, and the equivalent range for women was from 12% aged 16 to 24 to 33% aged 55 to 64. This decreased to 26% of both men and women aged 75+.

Impact of GBSF policy

The policy aims to ensure healthier food and drink options are available across the public sector and to maximise the availability of healthier products that are offered, to make it easier for people to make healthier choices when buying products from canteens and restaurants. We believe that the policy will affect adults more than children as adults are more likely to be in places where GBSF complies. Schools must follow the school food standards legislation.

Feedback from the consultation suggested that some respondents were concerned for the potential negative impact it would have on older people. Specifically, respondents highlighted older people being vulnerable due to not necessarily being able to choose for themselves, having a lower BMI, a desire to eat less, more food intolerances or digestive issues. Whilst the policy must be followed in the case of patients who are ‘nutritionally well’ and in the provision of staff food and hydration, it is important to note that clinical need for those patients who are ‘nutritionally vulnerable’ must be the first priority. Risk assessments should be carried out to ascertain where exceptions to the GBSF guidelines are acceptable, and whether the use of the British Dietary Association guidelines are more appropriate.

The benefits from the policy arise mostly as health benefits at older ages. For example, around 44% of the incidence of diabetes, 23% of heart disease and between 7% and 41% of certain cancers (breast, colon and endometrial) are attributable to excess body fat.^{[footnote 4]} These conditions all increase with age. The individuals affected by the policy today (including children) will benefit if they can maintain a lower weight as a result of the interventions in place. This is especially important as we know that overweight or obese children are far more likely to go on to become obese adults,^{[footnote 5]} with a higher risk of developing life-threatening conditions such as some forms of cancer, type 2 diabetes, heart disease^{[footnote 6]} and liver disease.^{[footnote 7]}

This policy will have an effect across different age groups in public sector workplaces such as central government, hospitals as well as prisons and the armed forces therefore will not discriminate between age groups. The policy will affect adults more than children as adults will be in places where GBSF complies. We do not foresee any group being disadvantaged by age.

Overall, we expect the policy to have a neutral impact with regards to age as it will impact across all age groups.

Sex

Obesity prevalence

There are also differences in obesity prevalence depending on sex. The Health Survey for England 2019 reports that almost 7 out of 10 men (68%) and almost 6 out of 10 women are overweight or obese (60%). This includes 27% of men and 29% of women in England who are obese.

The National Diet and Nutrition Survey (NDNS) also includes extensive information on diet, nutrient intakes for men and women in different age groups. This data highlights some differences between men and women in the proportion meeting diet and nutrition recommendations. Although these differences are generally small, there is some evidence that a higher proportion of girls aged 11 to 18 years and women aged 19 to 64 years and 65 years and over, fail to meet some micronutrient recommendations than do boys and men in the same age groups. In particular, the NDNS data shows that the proportion of women of childbearing age meeting recommendations for iron and folate is lower than for men as the recommendations for women are higher reflecting higher physiological requirements. The only clear differences between men and women are for iron and folate.

Impact of GBSF policy

Some consultation respondents suggested that the policy could impact sexes differently. Some respondents suggested women are more affected by body image and marketing leading to a higher prevalence of eating disorders among women, compared with men.

The policy could affect women differently due the food and drinks choices that they make and how they are influenced. It has been reported that women tend to be more invested in food-related issues, have better knowledge of food and nutrition, are more prone to go on a diet, and are more likely to perceive themselves as needing to lose weight.^{[footnote 8], [footnote 9], [footnote 10]} GBSF could make women more receptive to the healthier food on offer in restaurant and canteens and reduce their overconsumption of HFSS products that are linked with excess sugar and calorie intake and over time, weight gain and obesity.

Women and men have different needs when it comes to food and drink this is due to physiological differences. Men on average have a greater body size than females and therefore have higher energy requirements meaning their food consumption and nutrient intake is generally higher. Men and women also have different requirements for certain micronutrients (notably iron and folate).

The policy has the potential to support healthier choices for the population who visit hospitals, work in government buildings, those serving time in prison and in the armed forces. Therefore, we expect the policy not to discriminate against men or women.

The policy aims to help provide healthy diets for adults by ensuring healthier food and drink options are available across the public sector workforce such as the government and NHS. There are some variations in general nutritional needs between men and women, however we expect the policy will benefit all individuals regardless of sex.

Race

Obesity prevalence

Differences in weight between racial groups arise due to various factors such as environmental factors, health behaviours, socio-economic status and access to healthcare.^{[footnote 11], [footnote 12]}. The reasons for differences in obesity prevalence across ethnicities are various and it is difficult to state how different groups will benefit from the policies. The fact that ethnic differences persist even when controlling for deprivation and controlling for interaction suggests that cultural and genetic differences within some ethnic minority groups may account for the increased likelihood of children from these groups becoming obese or overweight.^{[footnote 13], [footnote 14], [footnote 15], [footnote 16], [footnote 17], [footnote 18],}

People from different ethnic groups have different levels of risk to develop conditions associated with obesity and being overweight. For the same level of BMI, people of African ethnicity appear to carry less fat and people of Asian ethnicity generally have a higher percentage of body fat than people of the same age and gender.^{[footnote 19], [footnote 17], [footnote 20],} HG Some ethnic minority groups (especially those of Asian descent) are at risk of type 2 diabetes and cardiovascular disease at a lower BMI than other groups.^{[footnote 20]} The proposed policies are targeted at adults (and children) from all ethnicities and are therefore expected to have a positive effect on all ethnic groups.

Impact of GBSF policy

Some consultation respondents suggested that the updates to the GBSF would have a positive effect as well as a negative effect under the protected characteristic of race. Respondents believed it would have a positive effect for those in different ethnicities and that the standards would help to reduce health inequalities by improving access to healthier food choices. Respondents also highlighted the evidence of a correlation between many health inequalities and race. Respondents also suggesting it would have a negative effect on some religious groups who have restrictive diet requirements. The updated nutrition standards for GBSF should not restrict the offering of certain diets, for example vegetarian, or those that follow religious specific diets, but improve the nutrition in the food provided.

The policy is to be implemented in a way that does not differentiate by race. However, some ethnic groups experience higher obesity prevalence and therefore the potential for a reduction in obesity may be higher.

Overall, we expect the policy to have a neutral impact with regards to race.

Religion and belief

Four respondents believed it would have a negative effect for those in religious groups due to restrictive diet requirements. GBSF should not restrict the offering of certain diets, for example vegetarian, or those that follow religious specific diets, but improves the nutrition in the food provided.

We have considered the impact of the policy on the protected characteristic of religion and belief. There is no evidence to suggest that the policy will have a negative impact on people who share this protected characteristic as compared with people who do not share this protected characteristic.

Sexual orientation

We have considered the impact of the policy on the protected characteristic of sexual orientation. There is no evidence to suggest that the policy will have a negative impact on people who share this protected characteristic as compared with people who do not share this protected characteristic.

Pregnancy and maternity

Obesity prevalence

Women who are obese when they become pregnant have increased risks to their own and their babies’ health. They are more likely to experience complications in labour^{[footnote 21]} and their children have increased risks of obesity in childhood and adulthood, and other health conditions later in life including heart disease, diabetes, and asthma.^{[footnote 22], [footnote 23], [footnote 24], [footnote 25],} Maternal obesity is also associated with an increased risk of infant mortality.^{[footnote 26]} HG

Although maternal obesity rates are not routinely monitored in England, we do know that obesity in pregnant women has increased, which is likely to increase the risks passed on to children. Between 1989 and 2007, maternal obesity (the proportion of pregnant women with a BMI greater than 30) doubled from 7.6% to 15.6%.^{[footnote 27]} In 2014, PHE analysis found that almost 60% of all women of childbearing age in England were either overweight or obese and therefore they and their children are at greater risk during and after the pregnancy.

Impact of GBSF policy

Some consultation respondents suggested breastfeeding mothers and those that are pregnant will have different dietary and nutritional requirements and may not be able to purchase the food and drink options they need such as healthy fat and nutritious fruit, dairy products and fibre rich food.

The National Institute for Health and Care Excellence (NICE) recommends that pregnant women should not alter their calorie intake during the first 6 months of pregnancy and only slightly increase calorie intake in the final 3 months (and then only by around 200 calories per day).^{[footnote 28]}

The policy aims to ensure healthier food and drink options are available across the public sector and to maximise the availability of healthier products that are offered, to make it easier for people, including pregnant women, to make healthier choices when buying products from canteens and restaurants.

The policy has the potential to support healthier choices for the population who visit hospitals, work in government buildings, those serving time in prison and in the armed forces. It would have an effect on the wider food environment and would affect the eating behaviour of all age groups, including women at childbearing age.

Therefore, we expect the policy to have a positive impact on maternal obesity rates, and a knock-on positive impact on the associated risks with maternal obesity.

Disability

Obesity prevalence

Analysis by PHE suggests children with disabilities are more likely to be obese than those without disabilities. This difference increases with age. Analysis of combined data from the Health Survey for England 2006 to 2010 shows that children with a limiting long-term illness are approximately 35% more likely to be obese than children without a limiting long-term illness. Overweight and obesity in children and young people has also been linked to a range of disabling conditions, including learning disabilities, physical activity limitations, spina bifida as well as audio-visual impairments.^{[footnote 29]} Disabled children are therefore at greater risk of developing obesity-associated conditions as adults, such as type 2 diabetes.

In adults, there is a 2-way relationship between obesity and disability – that is, disabled adults are more likely to be at risk of obesity, while obese adults may develop complications leading to disabilities because of being obese.^{[footnote 30]} Analysis of NHSD primary care data showed that disabled people have substantially higher rates of conditions with being overweight such as diabetes, heart failure and strokes.^{[footnote 31]}

Impact on GBSF policy

Feedback from the consultation suggested that some respondents were concerned for the potential negative impact on people with certain disabilities, such as dysphagia, who would need to be provided with calories in ways which they can consume them and this may mean they would not be able to adapt to the new standards. Similarly, some respondents were concerned for those with gastroenterological conditions who need to follow a low-residue diet that includes low-fibre foods. By ensuring healthier food and drink options are available across the public sector, in line with government population dietary advice, the policy aims to reduce the prevalence of obesity which may therefore reduce the incidence of associated health risks in child and adulthood, including many gastrointestinal diseases. The policy provides restrictions to specific food categories. However, a small percentage of non-healthy food and drink products are expected to still be accessible and sold in canteens and restaurants. It is therefore not expected that the policy will result in any significant inconvenience for people with gastroenterological conditions and dysphagia.

Not directly linked to obesity, phenylketonuria (PKU) is a rare but potentially serious inherited disorder. Persons with PKU are intolerant to aspartame, an ingredient in food and drink which delivers a sweet taste with lower or no sugar content. Many of the products in scope of the proposed proposals are already being challenged to reformulate their products through PHE’s sugar and calorie reduction programmes. Replacing sugar with artificial sweeteners is only one way for business to achieve this policy. For the GBSF beverage nutrition standard the objective is to ensure healthier products are available, and therefore less sugar sweetened beverage products. The new proposal in the standard aligns with an existing requirement for NHS trusts to ensure that sales of sugar-sweetened beverages (SSBs) account for no more than 10% by volume in litres of all beverages which it sells in any contract year.^{[footnote 1]} This could potentially increase the amount of beverages on offer that include artificial sweeteners, such as aspartame. However, NHS trusts are permitted to sell sugared beverages and we would expect a range of products to be sold in addition to the 10% of SSBs allowed by the new standard. GBSF is intended to ensure greater access to healthier options by increasing the healthier alternatives available, but it does not preclude the sale of sugared beverages as it is understood that some medical conditions such as PKU require consumption of these products.

We have considered the impact of the policy on disabled people. This policy ensures healthier food and drink options are available across the public sector estate including the NHS, central government, as well as prisons and the armed forces. Therefore, we expect that both disabled and non-disabled individuals who use these facilities are expected to benefit.

Overall, we expect the policy to have a neutral impact with regards to disability.

Gender reassignment

We have considered the impact of the policy on the protected characteristic of gender reassignment. There is no evidence to suggest that the policy will have a negative impact on people who share this protected characteristic as compared with people who do not share this protected characteristic.

Marriage and civil partnership

We have considered the impact of the policy on the protected characteristic of marriage and civil partnership. There is no evidence to suggest that the policy will have a negative impact on people who share this protected characteristic as compared with people who do not share this protected characteristic.

Summary of the effects of the policy on people with protected characteristics

Age: neutral or positive

This policy will likely have a more of an impact on adults than children as the environments they effect, public sector workplaces such as government, hospitals as well as prisons and the armed forces, would typically be used by adults more than children. Schools must follow their own nutrition standards through the school foods standard legislation, therefore this policy will not discriminate between age groups.

Sex: neutral

The policy ensures healthier food and drink options are available across the public sector and to maximise the availability of healthier products that are offered. The policy will benefit all individuals regardless of sex.

Race: neutral or positive

Some ethnicities have a higher prevalence of obesity and therefore the potential for health benefits due to weight reduction is larger. However, the policy does not specifically target people of any ethnicity.

Religion and belief: neutral

Sexual orientation: neutral

Pregnancy and maternity: neutral or positive

The policy ensures healthier food and drink options are available across the public sector and to maximise the availability of healthier products that are offered. We expect the policy will have a positive impact for pregnant or breastfeeding women, increasing the availability of healthier food and drinks.

Disability: neutral

There is a link between obesity and disability. Reducing obesity results in health benefits for people with this protected characteristic.

Gender reassignment: neutral

Marriage and civil partnership: neutral

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