investigating a ‘glasgow exploring the nutritional effect ... · pupils, and with which school...

BRIEFING PAPER

September 2010

Investigating a ‘Glasgow Effect’: why do equally

deprived UK cities experience different

health outcomes?

FINDINGS SERIES25

June 2012

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Exploring the Nutritional

Quality of ‘Out of School’

Foods Popular with

School Pupils

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KEY FINDINGSThis report summarises a range of analyses undertaken to investigate the so-called ‘Glasgow Effect’, a term used in recent years to describe the higher levels of mortality and poor health experienced in Glasgow over and above that explained by its socio-economic profile.

The aims of the research were to establish whether there is evidence of such an ‘effect’, even when comparing Glasgow to its two most similar and comparable UK cities: Liverpool and Manchester.

The analyses were based on the creation of a three-city deprivation index, and the calculation of a series of standardised mortality ratios (SMRs) for Glasgow relative to Liverpool and Manchester. A range of historical census and mortality data were also analysed.

The results showed that the current deprivation profiles of Glasgow, Liverpool and Manchester are almost identical.

Despite this, premature deaths in Glasgow for the period 2003-2007 were more than 30% higher than in Liverpool and Manchester, with all deaths around 15% higher.

This ‘excess’ mortality was seen across virtually the whole population: all ages (except the very young), both males and females, in deprived and non-deprived neighbourhoods.

For premature mortality, SMRs tended to be higher for the more deprived areas (particularly among males), and around a half of ‘excess’ deaths under 65 were directly related to alcohol and drugs.

Analyses of historical data suggest it is unlikely that the deprivation profile of Glasgow has changed significantly relative to Liverpool and Manchester in recent decades; however, the mortality gap appears to have widened in the last 30 years, indicating that the ‘effect’ may be a relatively recent phenomenon.

The results emphasise that while deprivation is a fundamental determinant of health and, therefore, an important driver of mortality, it is only one part of a complex picture. As currently measured, deprivation does not explain the higher levels of mortality experienced by Glasgow in relation to two very similar UK cities. Additional explanations are required.

This research, in particular the creation of the small area based three-city deprivation measure, has allowed identification of communities in Glasgow which, although almost identical to similar sized areas in Liverpool and Manchester in terms of their socio-economic characteristics, have significantly poorer health outcomes. These will now be the focus for a second, qualitative, phase of research.

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KACKNOWLEDGEMENTS

Thanks are due to a number of people and organisations who made this research

study possible:

The Scottish Collaboration for Public Health Research and Policy (SCPHRP) jointly

funded the study, along with the Glasgow Centre for Population Health (GCPH).

The Research Steering Group provided sustained advice and input from conception

to completion of the study and its write up. Five group members led the data

collection in each study area. Membership of the group comprised:

● Paul Birkin, Team Leader, Environmental Health and Trading Standards, Glasgow

City Council● Helen Clark, Quality Improvement Offi cer, Education Services, Glasgow

City Council● Fiona Crawford, Public Health Programme Manager, GCPH● Anne Ellaway, Programme Lead, Neighbourhoods and Health, MRC/CSO Social

and Public Health Sciences Unit (SPHSU), Glasgow● Helena Hailstone, Project Manager, Cordia (Services) LLP● Dionne Mackison, Public Health Nutritionist, University of Stirling● Kelda McLean, Research Coordinator/Administrator, GCPH● John Mooney, Career Development Fellow, SCPHRP

Professor Martin Caraher, City University, London, and Professor Annie Anderson,

University of Dundee, provided expert advice and support.

The following nutrition students from Queen Margaret University, Edinburgh, gave

up a day of their time to assist with data collection and provided invaluable help:

● Sarah Archibald● Alicia Bryce● Grace McLean● Kirsty Murdoch● Angelica Quatela● Desiree Schliemann● Karen Whiteford

Susie Palmer, formerly of Glasgow City Council, also helped with the fi eldwork.

Glasgow Scientifi c Services undertook the purchasing and nutritional analysis of

samples.

BRIEFING PAPER

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FINDINGS SERIES25

Investigating a ‘Glasgow

Effect’: why do equally deprived

UK cities experience different health outcom

es?

The link between socio-economic circumstances and health is well established. However, the extent to which the poor health profile of Scotland – the nation with the highest mortality rates and lowest life expectancy in western Europe – can be explained in terms of socio-economic factors is less clear. Historically, Scotland’s unenviable position in being what the press has labelled ‘The Sick Man of Europe’ has been attributed almost exclusively to its relatively high levels of socio-economic deprivation, principally in comparison to England and Wales. However, a number of publications over the past five years have highlighted a phenomenon speculatively entitled the ‘Scottish Effect’, a term used to describe the country’s higher levels of morbidity and mortality over and above that explained by deprivation. One such analysis showed this ‘Scottish Effect’ to exist in all geographical regions of Scotland and at all levels of deprivation, but that it was most evident in the most deprived post industrial region of West Central Scotland, with Glasgow at the region’s core. This led to talk of a ‘Glasgow Effect’, a notion reinforced by other recent research showing that mortality in the former industrial areas of West Central Scotland was higher, and was improving more slowly, than in the vast majority of other, similar, post-industrial regions of Europe, including those which currently experience worse socio-economic conditions.

Within a UK context, however, Glasgow is not alone in experiencing relatively high levels of poor health and deprivation. Liverpool and Manchester are two other cities which stand out in this regard, with high levels of poverty and the lowest life expectancy of all cities in England. The approach taken in this project, therefore, was to investigate this ‘Scottish Effect’ or ‘Glasgow Effect’ by looking in detail at the three cities of Liverpool, Manchester and Glasgow, cities which share similar histories of industrialisation and deindustrialisation, and which have high mortality associated with known problems of deprivation. Furthermore, we sought to improve on previous related analyses by employing a more up to date and spatially sensitive measure of deprivation than was previously available to researchersi.

i Previous analyses were based on the Carstairs & Morris index, a composite measure of deprivation calculated from census data. This measure is now out of date (the most recent data being for 2001), but crucially was also calculated for different-sized geographies north and south of the border: the relatively large size of these areas (especially in the two English cities), and the variation in size between the Scottish and English geographies is potentially problematic in measuring the effects of area-based deprivation.

INTRODUCTION

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KKEY MESSAGES

● Poor nutrition and steadily increasing prevalence of obesity in Scottish children

and young people are growing public health concerns.

● Schools have been identifi ed as a key setting to provide and promote healthy

nutrition amongst pupils. Recent policy and legislation has improved the school

lunchtime environment and raised school meal standards.

● Although in recent years primary school meal uptake has increased, secondary

school meal uptake has declined.

● Many secondary pupils who eat out of school at lunch-time buy unhealthy

convenience food of very poor nutritional quality from external outlets that they

can easily access within the lunch-time period.

● Many external outlets offer meal deals and promotions which are attractive to

pupils, and with which school canteens struggle to compete.

● Potential measures that can be taken by school staff to promote healthy

nutrition amongst secondary pupils include: ● Stay-on-site policies for junior secondary pupils (which include the

provision of lunch-time activities). ● Continued education and awareness raising through the Curriculum

for Excellence. ● More effective communication with parents/carers regarding the

importance of healthy eating and greater parental/carer involvement in

school-based healthy eating initiatives. ● Further development of innovative approaches such as the introduction

of food kiosks in school grounds.

● Potential regulatory levers include: ● Fiscal policies which tax unhealthy foods and drinks and subsidise

healthy foods and drinks. ● Utilisation of licensing and planning powers to control number and

concentrations of commercial outlets selling take-away food in

neighbourhoods near schools. ● Strengthening of the role of local authority environmental health

departments in relation to licensing, food safety/hygiene and

nutritional regulation.

● Further collaborative work should also be undertaken with the food industry and

with food outlet staff building on learning gained from previous initiatives

and programmes.


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Healthy school food policy is recognised as important in promoting children and

young people’s nutritional health.1 The school lunchtime environment and school

meal standards have improved through policy and legislation.2,3 Concerted efforts

have also been made to provide healthy foods and drinks and promote their uptake

by primary and secondary pupils through a number of school-based programmes

and initiatives and through the Scottish Curriculum for Excellence.4,5,6,7

Although there are signs of success in relation to increased school meal uptake in

primary school, uptake of secondary school meals is declining8 and in many urban

areas, secondary school pupils can be observed purchasing lunchtime food and

drinks from external outlets situated near schools.6 Building on previous research

and evaluation facilitated by GCPH in collaboration with Glasgow City Council and

the Scottish Centre for Social Research,9 this study aimed to assess the quality of

popular foods purchased by pupils from outlets in study areas near fi ve Glasgow

secondary schools against Scottish nutrient standards for school lunches.10 These

standards were introduced following the passage of the Schools (Health Promotion

and Nutrition) (Scotland) Act 2007.3

The principal research question was:

How does the quality of popular foods purchased by secondary school pupils

from outlets near Glasgow secondary schools compare with mandatory nutrient

standards set for food and drinks provided by schools in Scotland?

Objectives were as follows:● To describe numbers and type of commercial outlets near fi ve Glasgow

secondary schools● To identify outlets popular with pupils and observe pupil purchasing behaviour● To purchase and analyse a sample of popular savoury food items to compare

nutritional quality against Scottish nutrient standards for school lunches

K

K

INTRODUCTION

RESEARCH AIM AND OBJECTIVES

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The research was undertaken as a collaboration between: GCPH; the Scottish

Collaboration for Public Health Research and Policy (SCPHRP); the MRC/CSO Social

and Public Health Sciences Unit, Glasgow (MRCSPHSU); the University of Stirling;

and Glasgow City Council (GCC). Funding for the study was provided by GCPH and

SCPHRP and each partner contributed resource in kind in the form of individual staff

time and organisational support as required. A member of the GCPH team fulfi lled

the role of administrator/research co-ordinator for the duration of the study.

A research steering group was established which included key investigators from

the above organisations along with representatives from GCC’s Environmental

Health Department, GCC Education Services and Cordia (Services) LLP (the

organisation responsible for delivery of school-based food and drinks in Glasgow

schools). GCC’s Director of Education and NHS Greater Glasgow & Clyde’s Director of

Public Health were briefed regarding the research. Two experts in the fi eld, Professor

Martin Caraher (City University, London) and Professor Annie Anderson (University

of Dundee) acted as external advisors to the research study.

One of the purposes of this study was to test how feasible it would be to collect

data on the food purchasing behaviour of secondary school pupils who eat out of

school at lunchtime. The study used mixed methods, described below, to address

research objectives. Prior to undertaking the research, ethical approval for the

study was obtained from the University of Glasgow College of Social Sciences Ethics

Committee for Non-Clinical Research Involving Human Subjects.

Study area selection

Study areas were selected around fi ve secondary schools in Glasgow each based

on an approximate radius of 10 minutes walk from the school gate. Each study

area represented a different geographic area of the city, a contrasting physical

and socio-demographic environment, and a variable pupil population in terms of

school roll, and socio-economic characteristics (represented by free school meal

(FSM) entitlement). School rolls in the fi ve pilot secondary schools varied, the

smallest school roll was 600 and the largest 1300. Figure 1 shows the range of FSM

entitlement across the fi ve pilot secondary schools which varied from 12.2% to

42.2%. Average FSM entitlement in Glasgow secondary schools is 30%, double that

for Scottish secondary schools which is 14.4%.8

KAPPROACH AND METHOD


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Figure 1 FSM Entitlement in Pilot Secondary SchoolsSource: School Meals in Scotland, 2010 8

A snapshot of local school meal data supplied by Cordia in October 2011, shown

below in Figure 2 illustrate that school meal uptake in the pilot schools, whether free

or paid for, was very low.

Figure 2 School Meal Uptake in Pilot Secondary Schools Source: Cordia Data, October 2011

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* Pupil Numbers = School Roll x Attendance % (December 2010)

School

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Data collection

Building on previous research exploring the density of food outlets around Glasgow

secondary schools,11 the external commercial food environment in the study areas

was mapped using GIS software and GCC’s database which records the name, type

and location of all commercial outlets selling food and drinks in Glasgow.

Between 10am and 2pm, on a designated school day in September 2011, 15

researchers (two to four per study area) visited each of the fi ve study areas to

observe pupil purchasing patterns. Using an observational checklist (drawing on

methodologies developed in similar research elsewhere),12,13 researchers gathered

data regarding the characteristics of commercial food outlets that were observed

as popular with pupils. In addition to the use of the checklist for data collection and

where possible, researchers questioned shopkeepers and outlet staff regarding

items sold and what was perceived as popular with pupils. Researchers carried an

information leafl et explaining the purpose of the research which was distributed

to shopkeepers/store managers in outlets visited in the morning, prior to the data

collection. A separate pupil information leafl et was also carried by researchers for

issue to any pupil who became aware that s/he was being observed and asked for

information.

Through observation, researchers identifi ed and listed what they considered were

popular savoury food items purchased by secondary pupils in each of the fi ve study

areas, during the lunch-time break of each study area school. The research team

then met to discuss and agree the number and type of food items to be sampled in

each area. In collaboration with environmental health colleagues, sampling offi cers

subsequently purchased 50 pre-agreed items, recording the outlet from which

purchased, study area and cost of each item. Nutritional analysis of these items was

conducted by Glasgow Scientifi c Services to compare the quality of key nutrients

with Scottish nutrient standards for school lunches.

There was marked variation in numbers of outlets identifi ed within a 10 minute walk

from each school, ranging from fi ve in the area with the lowest number present to

thirty in the area with the highest. Concentrations of outlets were identifi ed near

schools in three out of the fi ve study areas, often on busy roads. Observational

fi eldwork revealed the presence of additional outlets which were not identifi ed

through the mapping exercise.

KRESULTS


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Outlets present were heterogeneous and included chip shops, kebab shops,

convenience stores, newsagents, bakeries, vans, cafés, pizzerias, sandwich shops

and supermarkets. There was a diversity of internal environments and items on

sale. As the photographs below illustrate, some outlets were observed to be using

targeted marketing strategies to encourage pupils to buy food and drinks including

lunchtime offers, meal deals, price promotions etc.

Observers noted a brisk exodus out of school by pupils when the school lunchtime

bell rang as there was a relatively short 40 minute lunch break. Long queues of

pupils quickly formed at popular outlets – there was some evidence of particular

age/gender groups favouring certain outlets. There was a very rapid turnover in

relation to items purchased.

The most popular purchases contained chips often with bread rolls, curry sauce,

gravy, cheese, fi sh etc. Other popular food items were sausage rolls, pizza, pot

noodles, beef burger/cheese burger, rolls and sausage and doner kebabs. The price

of purchases varied: excluding meal deals and bakery goods, the cheapest savoury

item was a sausage roll costing 64 pence and the most expensive was chips and

a pizza slice costing £2.50. Many pupils augmented their main purchase with

additional items such as sugary drinks, chocolate, crisps, and sweets.

Nutritional Analysis

Nutritional analysis of the 50 purchased items was conducted by laboratory staff.

Of the 50 purchases, four were ‘meal deal’ options (i.e. they included a carbonated

drink and/or confectionary/bakery goods), one item was a commonly purchased

home-baked item (a sweet doughnut type cake known as a yum-yum). These four

atypical items were excluded from the main analysis and results for the remaining

45 samples are presented below. A number of very similar items (such as chips

and curry sauce) were purchased from different outlets in order to compare their

nutritional content.

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Items were analysed for energy, fat, saturated fat and salt content and compared

with the Scottish Nutrient Standard for Schools.10 There was marked variation across

all parameters as can be seen in Figures 3 to 5.

Figure 3 Displays the energy content of samples which varied from 131 - 1323

Kilocalories (Kcal).

Figure 3 Energy Content per Savoury Food Item (KCalories)

As can be seen in Figures 4 and 5 overleaf, fat and saturated fat content was similarly

variable, ranging from 2 - 80g and 1-30g respectively while salt content varied from

0.4 - 4.5g.

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Figure 4 Fat and Saturated Fat Content of Savoury Food Items

Figure 5 Salt Content per Savoury Food Item

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NSS for sat fat = 8g

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Approximately half of the samples exceeded recommended energy levels; over a

half exceeded recommended fat and saturated fat levels; and over a third exceeded

recommended salt levels. Thirty seven of the 45 savoury food items sampled did

not comply with one or more of the nutrient standards for fat, saturated fat and salt.

Given the fact that a number of pupils were observed augmenting savoury food

items with sweetened carbonated drinks, crisps, and confectionery, it is likely that

their lunchtime energy, fat and salt consumption will be greater than that revealed

by the nutritional analysis. With the exception of a portion of lentil soup and a roll

that contained lettuce, there was no inclusion of vegetables or salad in any of the

samples analysed.

This study highlighted a stark contrast between the nutritional quality of the food

available within school and that commonly sold by external commercial outlets near

schools. Findings indicate that many pupils who eat out of school at lunch-time buy

unhealthy, convenience food of poor nutritional quality. A number of outlets selling

food in the study areas appear to be offering meal deals and promotions to pupils

with which school canteens struggle to compete. Previous evaluations of school

lunchtime stay-on-site policies and programmes have highlighted staff and parental

concerns regarding the presence of commercial outlets in the vicinity of schools

and their patronage by pupils who leave school at lunchtime.6,14 These concerns

relate not only to the consumption of unhealthy food and drinks but also to fears

regarding road safety, bullying, truancy, stranger danger etc. Findings from this

study provide further evidence justifying professional and parental/carer concerns

regarding the adverse impacts on pupils’ health and well-being of leaving school at

lunchtime.

Over recent years, a number of policies and plans have been published, driven by

converging policy agendas aiming to address both the poor nutrition in many

population groups in Scotland and the steadily increasing prevalence of obesity

in children and adults.15,16,17 The most recent Scottish Government publication in

this regard, ‘Preventing Overweight and Obesity in Scotland: A route map towards

healthy weight’ sets out plans and actions to prevent obesity at a population level.18

KCONCLUSIONS


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Specifi c measures that are recommended in the school setting include:

● Supporting schools to make remaining in school for lunch more attractive to

secondary school pupils through a range of innovative approaches.

● Exploring measures to restrict access by children to nutritionally inappropriate

meals and high energy and energy-dense foods from businesses located in the

vicinity of schools.18

In relation to measures that can be taken within school, school lunchtime stay-

on-site policies for junior secondary pupils have now been implemented by

more than half of Glasgow’s 30 secondary schools, following an initial pilot and

evaluation. Follow up research conducted in 2011 to explore facilitators and barriers

to sustaining these stay-on-site policies concluded they offer a very promising

way forward for school-based promotion of healthy eating.14 The provision of

lunchtime activities was found to be one of the factors leading to success due to

their popularity with pupils who enjoyed participating in these activities with their

friends. It was recommended that the provision of lunchtime activities should

be sustained in future stay-on-site policies. However, despite largely positive

feedback from younger secondary pupils regarding their experience of staying

in school for lunch it was clear that many of them intended to leave the school

premises at lunchtime to buy lunch off-site when they progressed to their second

year. The research concluded that more work needed to be done on managing

pupils’ expectations, assumptions and priorities in relation to healthy eating.

Communication with parents/carers and greater parental involvement in school-

based healthy eating initiatives and policies were identifi ed as important.

An additional approach to encourage pupils to stay on site at lunchtime has recently

been introduced by Cordia, Glasgow City Council’s school meals provider. Cordia

has established food kiosks in the grounds of two Glasgow secondary schools.19

These kiosks sell a range of hot and cold foods and drinks and provide pupils with

an alternative to eating in the school canteen. Initial feedback from pupils and

uptake of foods and drinks from these kiosks appears very promising.

There are a number of potential regulatory levers outwith the school setting that

could help restrict exposure to unhealthy foods and drinks. Evidence is growing

that health-related food taxes can improve health, particularly if accompanied by

subsidies on healthy foods.20,21 Sales tax on sugared drinks, sweets and snacks has

been introduced in the US, Australia and in several European countries. 22 In the UK

there have been calls to consider the introduction of taxes on unhealthy food and

drinks to help tackle growing obesity levels.23 Modelling studies predict that a

20% tax on sugary drinks in the US would reduce the overall prevalence of obesity

by 3.5%.24

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An increasing number of local authorities in the UK and further afi eld are testing out

the use of licensing and planning powers in an attempt to restrict the number and

concentration of commercial outlets selling unhealthy food in local neighbourhoods

and near schools.25,26 There is potential for these measures to be employed by

national and local government in Scotland, building on current developments such

as licensing of alcohol outlets and through more explicit public health input into

local development plans. In addition, consideration could be given to strengthening

the role of local authority environmental health departments to equip them with

greater powers in relation to food safety and hygiene and to include nutritional

assessment/regulation within their remit.

As well as regulatory levers, collaborations with the commercial/business sector

should be developed. Scotland’s National Food and Drinks Policy, launched in

2009, aims to “ensure that the Scottish Government’s focus in relation to food and

drink, and in particular our work with Scotland’s food and drink industry, addresses

quality, health and wellbeing, and environmental sustainability, recognising the

need for access and affordability at the same time.” 27 There is potential to learn

from and extend initiatives such as the Scottish Grocers’ Federation’s Healthy

Living Programme which encourages convenience stores to develop and promote

healthier products in local stores28 and Consumer Focus Scotland’s Healthy Living

Award, which works with the catering sector in Scotland to encourage changes to

catering practices and ingredients.29

To conclude, if healthy eating amongst secondary school pupils during the school

day is to become more widespread, a range of factors and infl uences need to be

considered and addressed. Schools cannot tackle this alone and it will not happen

overnight but progress in this arena will yield enormous dividends in relation to the

future nutritional health and wellbeing of our children and young people.


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1. Shepherd J, Garcia J, Oliver S, Harden A, Rees R, Brunton G, Oakley A. Barriers to, and Facilitators of the Health of Young People: A systematic review of evidence on young people’s views and on interventions in mental health, physical activity and healthy eating. Volume 2:

Complete Report. London: EPPI-Centre, Social Science Research Unit, Institute of

Education, University of London, 2002.

2. Scottish Executive’s Expert Panel on School Meals. Hungry for Success: A Whole School Approach to School Meals in Scotland. Edinburgh: HMSO, 2003.

3. Scottish Parliament. Schools (Nutrition and Health promotion) (Scotland) Act. Edinburgh:

HMSO, 2007.

4. Glasgow Centre for Population Health. Healthy Food Provision and Promotion in Primary School: What impact is it having on food choices? Glasgow: GCPH, 2007.

5. Glasgow Centre for Population Health. Healthy food provision and promotion in primary and secondary school: impacts in school and beyond. Glasgow: GCPH, 2007.

6. Glasgow Centre for Population Health. Evaluating the impact of ‘The Big Eat In’ Secondary School Pilot. Briefi ng Paper Findings Series No 27. Glasgow: GCPH, 2011.

7. Education Scotland Website. http://www.educationscotland.gov.uk. Accessed May 2012.

8. Scottish Government. School Meals in Scotland. Edinburgh: Scottish Government, 2009.

9. Scottish Centre for Social Research. Evaluating the Impact of the ‘Big Eat In’ – Final Report. Glasgow: GCPH, 2011.

10. Scottish Parliament. The Nutritional Requirements for Food and Drink in Schools (Scotland) Regulations 2008. Edinburgh: HMSO, 2008.

11. Ellaway A, MacDonald L, Lamb K, Day P, Thornton L, Pearce J. Do obesity-promoting food environments cluster around socially disadvantaged schools in Glasgow, Scotland? Submitted for publication, February 2012.

12. Saelens BE, Gland K, Sallis FJ, Frank LD. Nutrition Environment Measures Study in

Restaurants (NEMS-R). American Journal of Preventive Medicine 2007;32(4):273-281.

13. Lloyd S, Madelin T, Caraher M. The School Foodshed: A Report on schools and fast food outlets in Tower Hamlets. City University, London. Unpublished report, 2009.

14. Glasgow Centre for Population Health. Are school lunchtime stay-on-site policies sustainable? A follow-up study. Briefi ng Paper Findings Series No 33. Glasgow: GCPH,

2012.

15. Scottish Executive. Eating for Health: Meeting the Challenge. Edinburgh: Scottish

Executive, 2004.

KREFERENCES

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16. Scottish Government. Healthy Eating, Active Living: An action plan to improve diet, increase physical activity and tackle obesity (2008-2011). Edinburgh: Scottish

Government, 2008.

17. ScotPHO. Obesity in Scotland. An epidemiology briefi ng. Edinburgh: ScotPHO, 2007.

18. Scottish Government. Preventing Overweight and Obesity in Scotland. A Route Map towards Healthy Weight. Edinburgh: Scottish Government, 2010.

19. Cordia Website. http://www.cordia.co.uk/News/Press-Releases/CORDIA-SPRINGS-INTO-

ACTION-FOLLOWING-THE-HOLIDAY-B.aspx. Accessed May 2012.

20. Scottish Collaboration for Public Health Research and Policy. Policy Interventions to Tackle the Obesogenic Environment. Focusing on adults of working age in Scotland. Edinburgh: Scottish Collaboration for Public Health Research and Policy, 2011.

21. Mytton O, Clarke D, Rayner M. Taxing unhealthy food and drinks to improve health.

British Medical Journal 2012;344:1-7.

22. Andreyeva T, Long MW, Brownell KD. The impact of food prices on consumption: a

systematic review of research on the price elasticity of demand for food. American Journal of Public Health 2010;100:216-22.

23. Guardian Website. UK could introduce ‘fat tax’, says David Cameron. http://www.

guardian.co.uk/politics/2011/oct/04/uk-obesity-tax-david-cameron. Accessed May 2012.

24. Hall KD, Sacks G, Chandramohan D, Chow CC, Wang YC, Gortmaker SL, Swinburn BA.

Quantifi cation of the effect of energy imbalance on bodyweight. Lancet

2011;378:826-37.

25. Mitchell C, Cowburn G, Foster C. Assessing the options to use the regulatory environment to promote local physical activity and healthy eating. London: National Heart Forum, 2010.

26. New York Times Website. In South Los Angeles, New Fast-Food Spots get a ‘No, Thanks.’ http://www.nytimes.com/2011/01/16/us/16fastfood.html. Accessed May 2012.

27. Scottish Government. Recipe for Success – Scotland’s National Food and Drink Policy. Edinburgh: Scottish Government, 2009.

28. Scottish Grocers Federation Website. http://www.scottishshop.org.uk. Accessed May

2012.

29. Healthy Living Award Website. http://www.healthylivingaward.co.uk. Accessed May

2012.

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David WalshGlasgow Centre for Population HealthHouse 6, 94 Elmbank StreetGlasgow G2 4DL

Tel: +44 (0)141 287 6742Email: [email protected]

Web: www.gcph.co.uk

CONTACT

Glasgow G2 4DL

Tel: +44 (0)141 287 6742Email: [email protected]

Web: www.gcph.co.uk

35

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Fiona CrawfordPublic Health Programme Manager

Glasgow Centre for Population Health

House 6

94 Elmbank Street

Glasgow G2 4DL

Tel: 0141 287 6959

Email: fi [email protected]

Web: www.gcph.co.uk

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