The struggle to eat healthily on a low income
By Annie Seeley and Tim Lobstein from the Food Commission

Introduction

Cookery features abound in the media and certainly, in terms of choice and quality, the food available to families on middle and higher incomes is beyond the dreams of previous generations. At the same time, we are more aware than ever before that “we are what we eat”, and we are also more anxious about the adverse impact on health of a poor diet coupled with physical inactivity. There is particular concern about rising levels of childhood obesity due to children eating too much fat, sugar and salt, combined with them taking too little exercise. Children in families on low incomes are known to be at increased risk of obesity, ill health and reduced life expectancy compared to children in more affluent homes. Some commentators are concerned that the long-term rise in life expectancy in Britain may stall or decline as a result of these trends. At the very least, any consequent increase in ill health would place an unwelcome extra burden on an already hard-pressed NHS.

Worries about diet strike at the heart of how we live now: they require us to consider the drawbacks as well as the benefits of living in a land of plenty, one in which we are all – children and adults alike - apt to be targeted by the pervasive marketing of less healthy foods by powerful corporate interests.

NCH’s Research

This is the broader policy context against which NCH decided to research the diets of children and families living on low incomes in the UK today. NCH’s charitable aim is “to improve the quality of life of the most vulnerable children” and we believe these children’s views and those of their parents should inform the current debate about what we do eat and what we should eat.

NCH carried out similar research in 1991 and a key issue for this project was to examine what has changed over the intervening twelve years, especially given this Government’s very welcome commitment to end child poverty by 2020.

The Food Commission carried out the research for NCH in 2003. Its three elements were:
• A questionnaire survey of 55 families living on low incomes across Great Britain. The sample was drawn from NCH family support and community projects and almost one in two respondents were lone parents and two in five lived in the countryside. The sample was overwhelmingly White British in ethnic origin. Three in five of the sample was on Income Support and two in five were employed but on a low income.
• Two focus groups with families on low incomes, in an urban and a rural area.
• A regional survey of the costs of eating healthily and less healthily. NCH staff and volunteers carried out forty shopping basket surveys across the UK. The basket of foods included ‘healthy’ and ‘unhealthy’ versions of basic items. An additional range of goods was included which could contribute to the ‘5-a-day’ fruit and vegetable intake recommended for health.

The Research Findings

Parents struggled to find enough money to always put food on the table for all the family
• Almost half the parents (46%) in the survey had gone short of food during the previous twelve months to meet the needs of someone else in their family.
• Over a third (36%) said they had gone without food in the last month so that others in the family could eat.
• One in five (20%) families said they didn’t have enough money for food; a further two in five (40%) said they only just had enough money for food.
• Of those families on Income Support (32 respondents), five said they had been so desperate for money they had considered doing something illegal.

When asked what parents had been so desperate to buy they had considered doing something illegal responses included:
“Food and clothes”, Laura, mother of one in Wales
“To feed my child”, Eileen, mother of three in the North East
“I am on benefits and sometimes find it hard,” Jane, mother of one in the North East
“My children are looked after very well, fed and clean and clothed. If I leave anyone out it’s me”, Cathy, mother of four in the South East

The diets eaten by many children in these families were nutritionally poor
• Only a minority of children in the survey ate vegetables regularly; more than a quarter (28%) never ate green vegetables or salad.
• Most children ate fruit but a quarter (25%) ate fruit only occasionally and a further one in ten never ate fruit.
• In contrast, nine in ten of the children ate sweets and chocolate; almost one in five (17%) ate them every day.
• More than four in five of the children (82%) drank sugary drinks; half of them (50%) drank them most days.
• More than nine in ten children ate crisps (93%); more than two in five (43%) ate them most days.

“All the good food is too expensive so I buy cheap brands”, Rebecca, mother of one in the North East
“The children have two packets of crisps a day, one with their lunch and one with their dinner”, Louise, mother of two in the South East

Parents’ diets were similarly nutritionally poor
• Only half the parents in the survey (50%) ate green vegetables or salads most days; a quarter (25%) never ate them at all.
• Just over two in five (44%) of the parents ate fruit most days; just under a quarter (23%) never ate fruit.
• More than half (55%) of the parents ate sweets or chocolate; approaching one in five (17%) ate them most days.
• Nearly four in five (79%) parents ate crisps; more than a quarter (27%) ate them most days.
• Seven in ten of the parents (70%) drank sugary fizzy drinks; more than two in five (42%) drank them most days.

“I don’t have breakfast or lunch. Yesterday I had a couple of pieces of Kit Kat during the day. I usually have about six or more coffees a day with two teaspoons of sugar. I don’t eat veg usually; the last time I had them was at Christmas. I can’t remember when I last had fruit – I don’t really eat it”, Sarah, mother of two in the North East
“I drink a lot of coke and so do my children. I buy three big bottles a week – I got them on special, three bottles at £1 each. I have about a litre to 1.5 litres a day. The children probably have one or two glasses a day”, Louise, mother of two in the South East

Food marketing to children influenced the foods these children wanted to eat, generally for the worse in nutritional terms
• Four out of five (80%) of the parents said their children were encouraged to ask for certain foods by television advertising, packaging and free toys.
• Three out of four (74%) of parents said their children pestered them to buy products when they were out shopping.
• More than nine out of ten parents (93%) said their children pestered them to buy products that were within children’s reach in shops.
• Four out of five (80%) of the foods children asked for were high in saturated fat, sugar and/or salt.

“I buy these items for my child as (otherwise) she will have a temper tantrum and scream. It is easier to give in to her, for a peaceful life”, Jane, mother of five in Wales
“When I take them shopping they are always asking for the foods that have cartoon characters on the packaging”, Jane, mother of three in the North East
“Sweets are always by the checkout: that should be banned full stop. It’s so difficult because you are sorting out the shopping and having to pay so you say go on and have it then, just to keep them quiet”, Louise, mother of two in the South East

Lack of money sometimes made it impossible for these parents to provide their children with a nutritious diet
• In the survey the average amount spent on food per person was £16.07 a week, or just £2.29 a day.
• Families in the survey with one or more employed adults and two children spent an average £50.71 on food each week. In comparison, the minimum amount needed to provide such a family with a low cost but adequate diet has been calculated as £62.84.
• More than two in five of parents said they were behind with paying bills.
• Of the families on Income Support, the likelihood of being in debt increased with the time spent being dependent on benefits.
• More than a quarter of parents (29%) said they weren’t able to give their children the food they would have liked. Of these parents, almost half (45%) said the reason was that they couldn’t afford it.
• The parents were asked what foods they would buy if they had an extra £10 a week for food for their children. Four out of five (81%) said they would buy their children healthy food, most frequently fruit, vegetables and unprocessed meat.

“I often don’t have enough money for food – the first thing you do is to pay off the debts and then see how much money you have left for nappies and food”, Jane, mother of three in the North East
“I can’t buy my children fruit and vegetables. When I go to pick up the children from their Nana’s on a Wednesday she has a fruit bowl and I will pinch bananas, apples or oranges from it”, Sarah, mother of two in the North East
“I wish I had a garden here. If I did I would grow my own food and save money. I would grow sprouts and carrots”, Isla, mother of one in the North East

For some, having to travel to go shopping added significantly to costs and limited families’ access to fresh fruit and vegetables in rural areas
• Almost half the parents (45%) shopped for food once a week or less frequently; one in three (33%) shopped between two and three times a week.
• More than half (57%) the parents living in rural areas went shopping for food once a week or less frequently compared with fewer than two in five (38%) of those living in urban areas.
• More than three in four (77%) shopped at a big supermarket; more than one in five (22%) shopped at small supermarkets.
• More than two thirds of the parents (70%) had to travel more than half a mile to do most of their food shopping; more than one in three (35%) had to travel more than two miles.
• About half the parents reported the cost of their journey. Of this group the average journey cost was £3.71. Compared to the average weekly spend on food, this represents an extra 23% on top of the cost of their shopping.

“It was very hard living in the countryside because as well as having to buy the shopping I would have to pay for a bus ride there and a taxi back. I had to get the taxi back because the buses don’t run that often. This would add an extra £6 onto the shopping and meant I went less often and had £6 less to spend on food”, Louise, mother of two in a rural area in the South East
“The shop where I do my main shopping is ten miles away. That’s the nearest big supermarket, it’s too far to go more than once a week. My local shop doesn’t have many different fruit and vegetables; what it does sell isn’t very nice and is too expensive and not fresh enough”, Hannah, mother of one in a rural area in the South East

It costs significantly more to eat healthily than less healthily across the UK
The shopping basket survey component of this research project found that:
• Healthier versions of basic foods are harder to find in local shops compared to less healthy foods.
• Healthier foods typically cost 15% more than less healthy versions.
• In all regions it is harder to access the healthier versions of food items.
• When available, a significantly higher price premium is paid for healthier food in the Midlands (29%), North East (22%) and South East (21%), compared to the South West (4%), North West (7%) and Northern Ireland (14%).
• It’s harder to find healthier foods in rural areas compared to urban areas.
• Fruit and vegetables present a particular problem: it is harder to find products to meet your recommended ‘5-a day’ if you live in rural areas. When available, ‘5-a-day’ items were typically 38% more expensive in rural areas compared to urban ones.

The diets of children and families on low incomes today do not show substantial improvements compared to those found in 1991
Comparing the findings of the 2003 survey with those from the survey in 1991:
• 40% of children in our 1991 survey ate green vegetables or salad most days compared to 35% in the 2003 research.
• The proportion of children eating fruit most days increased from 51% in 1991 to 65% in 2003.
• However, those who were eating neither fruit nor green vegetables most days increased from 24% in 1991 to 31% in 2003.
• The proportion of parents eating green vegetables or salads most days rose from 44% in 1991 to 51% in 2003, but the proportion who ate no fruit or green vegetables most days increased from 32% in 1991 to 37% in 2003.
Note: The survey samples in 1991 and 2003 were different in some respects, for example there were more employed participants in the more recent survey compared to the earlier one. For this reason these comparisons should be viewed as indicative, not conclusive.

Discussion and Conclusions

This study gives substance to the concerns being voiced about public health trends in the UK today. The fifty-five families that took part in NCH’s questionnaire survey comprise only a small sample, but there is no reason to suppose their diets are significantly better or worse than those of families on low incomes as a whole. There are some, for example asylum seeking and refugee families who may be even more vulnerable than those in this survey - who at least were in touch with support services such as those offered by NCH.

The research reported here suggests that a number of structural, economic and cultural factors come together to adversely affect the diets of children of families on low incomes. Some of the parents in the survey, for example, were dealing with serious difficulties such as mental health problems and domestic violence. Providing a consistently nutritious diet for themselves and their children was not always a high priority in these circumstances.

There were examples in the survey of parents saying they lacked basic cooking skills and it may well be that changes to the school curriculum, the increased availability and consumption of ready made meals and time pressures for parents are making it harder for young people to acquire cooking skills, compared to, say, twenty years ago. However, the study also found instances of parents displaying resourcefulness in making a little money go a long way. For example, one mother explained:

“I try to cook everything from scratch. If I notice there’s mince going cheap I will buy it to cook in the slow cooker – it doesn’t use much gas. Then I put batches in the freezer and if I’ve got enough money for some puff pastry I can make a beef and onion pie.”

This research suggests the difficulties families on low incomes face in providing healthy diets for their children are compounded by the fact that children’s food preferences are influenced by the marketing of less healthy foods and the linking of such products with celebrities and cartoon characters to increase their appeal. It is true that many parents struggle to support their children in resisting the allure of such foods and in developing a taste for healthier fare, particularly for fruit and vegetables, regardless of income. However, if you are on a very restricted budget you cannot afford to spend scarce funds on foods that your children may not eat or that may not fill them up. It makes much more sense, in this situation, to spend what relatively little you have on food that your children are virtually guaranteed to eat and that are unlikely to leave them still hungry at the end of a meal.

For families on low incomes living in isolated rural areas the relative lack of availability, the poor quality and the high cost of fresh fruit and vegetables undermine still further their efforts to provide a nutritionally sound diet for their children. If you can only afford to travel to a supermarket once a week or less often it becomes very hard to provide fresh fruit and vegetables on a daily basis: in the survey, the cost of travelling to go shopping comprised, on average, almost a quarter of the shopping bill for the families in the survey – a really significant proportion.

But the issue that emerges from this study as the overwhelming reason for the poor diets of these children and their families is that of low income. Despite the up-rating of existing benefits such as Income Support and the introduction of new benefits such as Family Tax Credit in recent years, some parents still do not have the funds to provide themselves and their children with a nutritionally adequate diet. In this regard it is significant that the research found that, on average, the families in the survey were simply not spending enough on food to enable them to eat healthily.

The focus groups with parents confirm the findings of previous research in suggesting that a major reason for this is that the food budget is one of the few “flexible” budgets for families on low incomes: if there are debts, for example, then the food budget suffers. It seems the old image of some parents going without so their children can eat relatively well is not just historical; it remains a reality in the UK today. This is frankly shocking in our prosperous society in the twenty first century.

It is disappointing that a comparison of the findings of this survey with those of a similar study carried out by NCH in 1991 suggests that the diets of children and families on low incomes have not clearly improved over the last twelve years. A third of children in families on low incomes in the 2003 survey were eating neither fruit nor vegetables most days and this suggests that a small but significant group of children and families in the UK may be experiencing real “food exclusion”. NCH believes the level of inequality between the diets of these children and the diets of children in affluent families is grotesque and unacceptable.

A factor that needs to be taken into account in understanding this apparently poor progress since 1991 is the difference in the trends in the costs of eating healthily and less healthily over recent years. The table below shows that while the cost of a healthy shopping basket decreased between 2001 and 2003, overall the premium paid for a healthy compared to a less healthy shopping basket has increased since 1988, from a fifth (20%) to more than a third (35%). The cost of a healthy shopping basket has also increased by about half (49%) in the same period, while that for a less healthy shopping basket has increased by only a third (33%). In other words, the gap between the costs of eating healthily and less healthily has increased over the last fifteen years – roughly a generation - making healthy eating less attractive and affordable for families on low incomes than when today’s parents were children.

Comparison with previous shopping basket surveys
Average shopping basket Price
1988 1995 2001 2003
Unhealthy 8.88 10.02 12.74 11.83
Healthy 10.70 13.98 18.01 15.96
Premium 20% 40% 41% 35%
Unhealthy basket price compared to 1988 +13% +43% +33%
Healthy basket price compared to 1988 +31% +68% +49%

It seems this negative trend, and perhaps others such as the prevalence of the marketing of unhealthy foods, have more than outweighed the positive impact of the measures this Government has taken to increase the real incomes of the least well off families and to encourage healthy eating, for example, the promotion of breakfast clubs and the provision of free fruit in schools. Welcome though such initiatives are they are too limited and patchy to impact on the range of factors responsible for the poor diets of children living in families on low incomes. In 2003 the Department of Health spent £17 million on the provision of free fruit in English schools, compared to the £252 million spent by the food industry on advertising fast food, pre-sugared breakfast cereal, confectionary, savoury snacks and fizzy drinks on television.

It is clear to NCH that Government policies need to be much more ambitious, coherent and far-reaching if they are to succeed in enabling parents on low incomes and their children to eat consistently well – something we believe should be a basic human right in the UK today. Unless this happens we believe the Government’s policies of improving public health and of ending child poverty are both set to fail.

Recommendations

Action is needed nationally, regionally and locally to tackle the combination of factors responsible for the unhealthy diets of many children living in families on low incomes today. In most respects we know the policies that are required: all that is missing is the political will and public support to implement them. Specifically:

• The Government must develop a national strategy and action plan for ending food poverty as central components of its drives to improve public health and end child poverty.

• Social security benefits, including income support, should contain an explicit food element. For families this should be set in line with an objective assessment of how much it costs to provide a nutritionally adequate diet for parents and children. We support the Zaccheus 2000 call for Minimum Income Standards to be incorporated into the setting of income support and the minimum wage.

• The ability of children to eat healthily and well should be part of the basket of measures used to track the Government’s progress in ending child poverty.

• The Government should reform the Social Fund so most loans to pay for essential items are replaced with grants: at present the repayment of debts significantly reduces the food budgets of many families on low incomes.

• The Government should develop measures for increasing the access to healthy and affordable food of children and families on low incomes, especially those living in the countryside, as part of its broader strategy for tackling poverty and social exclusion. Free or subsidised transport schemes to supermarkets are shown to be helpful: many more are needed.

• Within the Children Bill now going through Parliament, one of the five outcomes to which all children’s services are required to work in England is that of “being healthy”. Government guidance must explain that “being healthy” includes “eating healthily” and detail what this must mean in practice.

• All children’s services in local areas should be required to promote healthy eating and their performance in this regard must be measured through the integrated inspection framework that the Government is currently developing.

• The National Service Framework for children’s health (The “Children’s NSF”) that the Government is developing in England must include one or more specific standards about children’s healthy eating. It must place specific duties on Primary Care Trusts (PCTs) and others to take action to promote this in local areas, particularly for children living in families on low incomes.

• The Government’s Healthy Start Scheme that gives extra money to pregnant women and to mothers of children in their first year of life to help them eat healthily should be up-rated to better reflect the extra costs of eating well, and extended to all mothers of under-5s.

• The food manufacturers and retailers should work with the Food Standards Agency to:
1. Reduce the levels of salt, sugar and fat in foods aimed at children
2. Improve food labelling so children and families can make informed choices about the foods they purchase and eat
3. Remove snacks and sweets from supermarket checkouts
4. Use sponsorship and repeat promotions only for healthier foods.

? The Food Standards Agency is due to publish best practice with regard to these initiatives in March 2005. If the food industry and retailers do not comply with these measures within a further two years the Government should take steps to regulate.

• The Government should review its current initiatives aimed at promoting healthy eating among children, including breakfast clubs and fruit in school. More funding should be invested in those proven to be most effective.

• The secondary school curriculum should be reviewed to ensure that children are given adequate opportunities to learn basic cooking skills.

• Schools should give a consistent healthy eating message with only healthy foods promoted on school premises. Water should be freely available and vending machines should provide only healthy foods and drinks.