01 May 2020
Our response to the House of Commons EFRA Select Committee inquiry into food availability during the COVID-19 pandemic.
1. Have the measures announced by the Government to mitigate the disruptions to the food supply chain caused by the pandemic been proportionate, effective and timely?
Government communications have been lacking and disruptive
At a basic level, we agree with Professor Tim Lang and colleagues that the government’s communications have been weak, and that in some cases their failure to issue clear and reassuring guidance to the public and leaving much of the work to supermarkets has actually exacerbated the problem of panic buying and stockpiling. This in turn has made it harder for the population as a whole to access food. Professor Lang identifies a “a dangerous tendency to blame consumer behaviour not shape it.” He states that without further advice or steps taken by government, people’s decision to stockpile is actually a rational response.
The IGD have reported survey data on 20th April that indicates 64% of the public claim to have stockpiled or bought extra food items. This has increased since the previous week (56%) and follows the extension of the lockdown. 48% say they plan to stockpile, up from 42% the previous week. For people living hand-to-mouth, stockpiling has not been an option so the negative impact of limited supermarket goods will be most acutely felt by the most vulnerable. The Independent Food Aid Network (IFAN), which works with more than 250 food banks all over the UK, remarks that in a direct response to stockpiling, donations to food banks have declined.
The decision to shut down the out-of-home food sector so suddenly did not appear to take account of the important role it played in people’s food needs. Pre-lockdown, approximately 30% of meals were being eaten out of the home. Without proper communications or provision for alternatives, disruption was inevitable.
Concerns about the food packs provided by government
Although we appreciate that the government has had to act quickly, the emergency ration packs organised for vulnerable people self-isolating have been lacking. The government outsources the provision of these packs to two companies that have been relatively inflexible on their contents, providing an identical pack to every one of the approximate 200,000 individuals (at time of writing) who have signed up.
The BDA’s work with Public Health England to influence the content of these packs has resulted in limited changes to the nutrient content. While we understand the need to use long-life and easily stored foods, we perceive cost to have been a contributory factor in deciding the contents. Dietetic advice regarding key nutrition issues such as suitability for older people, patients with renal disease and patients with cancer, have not been fully realised, in part because of the inability to customise packs. For example, the inclusion of a high proportion of tomato based tinned foods results in a high potassium content, rendering many items in the pack unsuitable for people living with renal disease.
The take up of these packs has thus far been below expectations. It is possible that people are accessing food sufficiently from other sources, however, other potential reasons include a lack of awareness of their existence, or of personal eligibility. We have been made aware of inconsistencies in the way in which patients are informed of their shielding status, leaving some unable to access and receive their emergency pack.
Ministers should explain how all four nations of the UK are monitoring uptake of emergency food packs and ensuring vulnerable patients are aware of their eligibility. What feedback is being gathered to evaluate the acceptance and suitability of the pack to allow further improvement?
Lacking a comprehensive food strategy or a resilient food system
Although we accept that this crisis will inevitably cause the postponement of the development of the National Food Strategy, the government’s failure to produce and implement one much sooner means the UK still has no specific plan to increase resilience within the food chain. With the transition period of the UKs exit from the EU still due to take place at the end of 2020, this constitutes a serious issue. This pandemic has further evidenced how reliant upon other nations the UK is for food, and how easily and rapidly disruption can begin to have a negative impact.
The crisis has also exposed some of the inflexibilities in our food system preventing any rapid change of use, resulting in food shortages and significant food waste. A specific example is the widely reported disposing of produce at dairy farms as the swift closure of cafés and restaurants resulted in reduced orders, whilst at the same time supermarket shelves rapidly emptied.
Ministers must consider how the system can respond more rapidly to shocks.
2. Are the Government and food industry doing enough to support people to access sufficient healthy food; and are any groups not having their needs met? If not, what further steps should the Government and food industry take?
Food inequalities issues coming home to roost
In terms of accessing healthy food, COVID-19 has exacerbated the preexisting problems of food poverty and food inequality in the UK. It is already well established that people facing financial pressures have poorer quality diets and are more likely to experience food access issues such as living within a “food desert”. Before this crisis hundreds of thousands of people were accessing food banks regularly, and millions more were food insecure as outlined in our food poverty policy statement .
The Food Foundation has found as many as three million people are going hungry as a result of COVID-19. The government has taken some positive steps to address this, such as increasing Universal Credit payments. However, this is insufficient to solve the wider societal problems of food insecurity such as food access, food deserts or poor housing. These additional hardships faced by vulnerable people make it nigh on impossible for them to consume a healthy diet.
UN rapporteur on poverty Professor Philip Alston, who wrote a damning 2018 report on poverty and food insecurity in the UK, has been scathing about our COVID-19 response. He states “my thoughts of course hark back to the sense of how utterly hypocritical it is now to abandon ‘austerity’ with such alacrity, after all the harm and misery caused to individuals and the fatal weakening of the community’s capacity to cope and respond over the past 10 years.”
Food banks and similar organisations are an unfortunate but vital facet of the UK food system. The current crisis has forced many to shut, or to adapt to home-delivery models, to try and protect their staff whilst continuing to support people. Usage has increased with the Trussell Trust reporting an 81% increase on this time last year.
Government should explain what plans they have to comprehensively fill the gaps that necessitate the existence of food banks. They must explain what steps they will take to prevent further families and individuals experiencing food insecurity during and after the COVID-19 crisis.
Issues for older and other more vulnerable people
Our members have serious concerns that many older and more vulnerable people are struggling to access a healthy diet due to COVID-19. Malnutrition is already prevalent within the UK population, with nearly three million people, mostly older and the vast majority in their own homes, at risk from malnutrition in normal circumstances. Reduced access and increased social isolation are almost certain to escalate this situation. Our failure to take stronger more decisive action in previous years to deal with the issue of malnutrition in our communities now presents further nutritional risk during the pandemic.
It is also important to note that what constitutes a healthy diet varies for different groups and individuals. For those with low appetites, or those requiring modified textured diets, the risk of malnutrition is heightened and consumption of nutrient dense foods is particularly important. Accessing foods with such specific qualities has been made more difficult.
Where measures have been brought in to assist the most vulnerable, they have been piecemeal. Supermarkets have taken their own steps to introduce restricted opening hours for vulnerable customers, but definitions of who qualifies differ even from branch to branch. A number of organisations, including the BDA, have introduced standardised letters for patients with less visible vulnerabilities, not necessarily included in the shielding categories, to use to gain access, but these have not always been successful.
One particular area of concern is the rationing of delivery slots by supermarkets, which may be the primary way for those shielding to access food. Although retailers have made efforts to prioritise vulnerable people, there remains insufficient delivery capacity overall. Despite supermarkets being informed of vulnerable groups to prioritise, there are still significant numbers unable to secure slots. We also know that official “vulnerable” lists are incomplete, with people needing to self-report to GPs to be designated as high-risk individuals in terms of COVID-19.
Other groups requiring specific food items include patients with coeliac disease, food allergies and food intolerances. The reduced availability of specialist food products such as gluten-free foods or specific brands of acceptable items, could have an impact on long term health and compliance with necessary diets.
Government should develop more robust systems for identifying individuals, particularly those who are shielding (whether identified officially or not) to aid businesses to provide household delivery of foods e.g. supermarkets, delivery companies etc.
Mental Health Conditions
For people with mental health conditions, social isolation and reduced access to support services is already presenting further challenges. Our members working in mental health services report that for those with an eating disorder this is a particularly difficult time. Whereas other people can adjust to alternative food ingredients, flavours or brands, those with specific eating habits often struggle to make these adaptations. The introduction of supermarket rules such as “you touch it you buy it” adds further negative connotations to food where checking food labels for ingredients or best before and use by dates is a necessity. Beat Eating Disorders have reported a 35% increase in calls to their services.
Our members supporting people living with a mental health condition also report people with agoraphobic or anxiety type presentations, are struggling to obtain food due to not wanting to leave their homes, or mix with people who may pass on infection; this has impacted upon their accessibility to food.
Schools had and continue to play a vital role in supporting the nutrition of many school children, providing meals both during and outwith term times. However, we are concerned about the uptake of free school meal entitlements Unfortunately, we know a very small number of vulnerable children are attending school despite places being available for them Schools across the UK have taken different approaches to how support is offered to families. In England some received vouchers, others cash transfers whilst others have access to packed lunches or food in school buildings. Media reports highlight families are unable to spend their food vouchers for a variety of reasons.
Our members supporting families also share a more general concern that children may be less flexible around what they eat, in terms of aforementioned food swaps and adaptations. This is particularly relevant for children diagnosed as being on the autistic spectrum.
Our members have reported a significant impact on the catering industry, which is particularly concerning for those provide for care homes and sheltered accommodation. Members report a reduction in factory production due to potential staff absence and increased consumer demand. Chilled ranges have been rationalised to streamline ordering and deliveries, reduce wastage and ensure the products in highest demand are available. Introducing social distancing in factories and catering facilities presents challenges in production and has resulted in labour intensive recipes being altered and the introduction of simpler recipes and menus.
It has been reported to us that in more than one hospital trust, a move to a single week menu cycle, means hospitals and wards can no longer tailor their offering. While this is understandable and the menu is nutritionally adequate, this is a drastic change and has implications for patients, especially those in long term care such as patients with mental health problems:
- Reduced higher energy options for patients at risk of malnutrition,
- Increased menu repetition risks menu fatigue,
- Menu not designed locally to meet local needs/preferences.
- Unfamiliar food items or meals
This impact on catering is also affecting NHS staff. 24/7 provision of healthy food options to hospital and care staff is already inconstant, and has worsened as a result of the pandemic. The currently unpublished Hospital Food Review undertaken by Phil Shelley had identified many of these issues.
We ask ministers to bring forward the publication of the Hospital Food Review as quickly as possible so that service can act upon their recommendations as far as is possible during the current crisis
3. What further impacts could the current pandemic have on the food supply chain, or individual elements of it, in the short to medium-term and what steps do industry, consumers and the Government need to take to mitigate them?
Importance of planning to support for the significant and growing number of people who are recovering post-COVID.
Access to food for provision of nutritionally adequate diets and the prevention of malnutrition will be vital in people’s recovery from COVID-19. Whilst the acute phase of incidence may be reducing, the pandemic has the ability to place additional strain on services supporting vulnerable people in the community. This is likely to be exacerbated by the fact that discharge from hospital for patients treated for COVID 19 is often rushed and often without a nutritional assessment prior to returning home.
Research has identified that in ordinary times nutrition related problems are common for patients discharged from ICU, and they are at increased risk of nutritional problems in the long term. In practical terms patients post discharge from ICU can have problems on returning home with activities of daily living including shopping. Recommendations by the European Society for Clinical Nutrition and Metabolism (ESPEN) identifies potential risk of dysphagia (difficulty swallowing) following treatment in ICU, requiring modified food textures for a prolonged period after discharge, as well as loss of skeletal muscle mass and muscle function being a major problem for those leaving ICU. Evidence is emerging about the impact of COVID 19 on appetite not least because of sensory impairment of smell and taste, all of which increases the risk of reduced food intake and potential malnutrition.
Although some of these issues may be improved by Oral Nutritional Supplements and other prescribed nutritional products, using normal food in most cases (a “Food First approach”) is preferable, and should be supported by community health and social services, including assessment, advice, and where required training, from dietitians. For some patients the expectation to source and prepare an appropriate diet to recover, including fortifying foods, is unrealistic without practical assistance. There may also be a greater demand for food products used to increase nutrient density such as protein powders, milk powders etc.
In addition to translating the science of nutrition into practical messages tailored to their audience, dietitians also have the skills to help build people’s resilience, as well as signpost them to further support They have a critical role to play in the UK response to nutritional support in the treatment of patients with COVID-19 and their recovery, including access to an appropriate diet on returning to their community.
Government must recognise the increased need in community health and social care services for the monitoring of patients both with and at risk of malnutrition following treatment for COVID-19, and the additional pressures that may place on our food system.
 A. Julian (2018) available at: https://spiral.imperial.ac.uk/handle/10044/1/78487
4. How effectively has the Government worked with businesses and NGOs to share information on disruptions to the supply chain and other problems, and to develop and implement solutions?
Government should more proactively involve dietitians in decision making process, given their unique expertise in nutrition and health conditions.
Dietetic expertise has been underutilised in aspects of nutritional advice and action at a national level. Dietitians are clinical nutrition experts who also interpret their scientific knowledge to advice and application of practical effective action. This underutilisation reflects a general lack of recognition and inclusion for smaller organisations and professions in not only the government’s response to food supply, but also in health and social care staffing, concerning PPE and other important developments from COVID-19.
It should be recognised that at a community level dietitian have an important role to play in supporting people to eat a nutritionally appropriate and adequate diet in their recovery from COVID-19, and/or their ongoing management of existing health conditions. This is particularly important for those individuals who are shielding. Eating well as part of recovery or to support management of a long-term health condition goes beyond just the practical elements of shopping, cooking and eating but the importance of food on wellbeing and as a social activity.
Dietitians, particularly those working in the community are skilled in partnership working across all sectors, public, private and third (voluntary) sector contributing to schemes supporting food provision, such as the community food partnership operating in Greenwich.
About Dietitians and the BDA
The BDA are the trade union and professional body representing the UK’s dietetic profession. We are one of the oldest and most experienced nutrition organisations in the world, having been first founded in 1936. We are submitting a response on behalf of our members to ensure their experience of tackling COVID-19 and expertise in diet and nutrition is considered as part of the inquiry.
Dietitians are the clinical nutrition experts, and the only nutrition professionals regulated by law. Dietitians use the most up-to-date public health and scientific research on food, health and disease which they translate into practical and individualised advice. They work with people with chronic and acute health problems as well as supporting overall public health.