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Associations between exposure to takeaway food outlets, takeaway food consumption, and body weight in Cambridgeshire, UK: population based, cross sectional study

BMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g1464 (Published 13 March 2014) Cite this as: BMJ 2014;348:g1464

Re: Associations between exposure to takeaway food outlets, takeaway food consumption, and body weight in Cambridgeshire, UK: population based, cross sectional study

It makes intuitive sense that an increased number of takeaway outlets would result in more people accessing these outlets. Takeaway outlets are also more likely to produce and sell foods considered to be less healthy and less likely to contain components of a healthy balanced diet (1). For example, takeaway foods are thought to be high in calories and contain high levels of fats, trans fatty acids, salt and carbohydrates and the Food Standards Agency in Scotland is in the process of researching this (2). It also makes intuitive sense that consuming more of these types of foods would result in an increase in BMI or overweight and obesity. However, due to the study design these results cannot prove a causal link between an increased prevalence of takeaway outlets and increased food consumption and this was duly acknowledged by the authors.

Due to the sheer complexity of overweight and obesity there are a number of potential confounders which have not been considered. These include the types of food consumed, calorie content and ethnicity with the latter being a surprising omission due to the proximity of Cambridge to London. Also, it seems quite arbitrary why some takeaway food outlets were used and not others. The popularity of Chinese and Indian takeaway food outlets in the UK has not been assessed in this study and these foods could arguably be less nutritious than other food outlets included in this study. The 1 mile radius used in this paper may also not be a useful distance to accurately assess access to outlets due to the availability of delivery services and the increasing popularity of websites offering online ordering options. Food affordability is also a factor which can influence purchasing patterns and it has been well documented that takeaway outlets are often cheaper than healthier alternatives (3).

A crucial area that this research does not discuss is the association between social norms and obesity. Living in an area and having regular exposure to takeaway outlets on a daily basis will result in these food outlets becoming the norm. This is similar to regular exposure to smoking, drugs and alcohol. Regular exposure to these outlets results in them becoming more acceptable and less shocking. In populations where this is the norm people are more likely to adopt these behaviours themselves (4, 5). In fact, in some communities if you actively go against these norms you may risk being stigmatised. As has been described in many studies before this, these risk factors are often seen in more deprived areas (6). However, this study is unlikely to be able to fully demonstrate this as it was based in a more affluent area.

The complexity of overweight and obesity has been acknowledged and demonstrated in research such as the obesity system map in the Foresight report (7). While it makes sense that regular exposure to takeaway foods and outlets would affect food choices and potentially result in an increased consumption, nobody forces us to eat junk food. A number of fast food outlets also offer healthy alternatives and an increasing number are now displaying nutritional information on their menus. Ultimately, your risk of obesity can be influenced by the choices you make. You choose where and what you eat. Exposure to food outlets alone is unlikely to explain the increase in overweight and obesity and the cause is likely to involve a combination of several factors such as lifestyle, diet, activity, deprivation and cultural and social norms that are contributing to the nation’s growing waistlines. The food environment may well be an additional factor but it is unlikely to be the only contributing factor.

1.Food Standards Agency in Scotland. The eatwell plate. http://www.food.gov.uk/scotland/scotnut/eatwellplate
2.Food Standards Agency in Scotland. Food Standards Agency in Scotland Evidence-Gathering Programmes. http://www.food.gov.uk/science/research/devolvedadmins/scotlandresearch/...
3.NHS Choices. Healthier takeaways. http://www.nhs.uk/Livewell/men1839/Pages/Dodgytakeaways.aspx
4.Robinson E, Thomas J, Aveyard P, Higgs S. What Everyone Else Is Eating: A Systematic Review and Meta-Analysis of the Effect of Informational Eating Norms on Eating Behavior. J Acad Nut Diet 2014;114:414-29.
5.Hruschka DJ, Brewis AA, Wutich A, Morin B. Shared Norms and Their Explanation for the Social Clustering of Obesity. Am J Public Health, 2011;101(Suppl 1):S295–300.
6.Miura K, Giskes K, Turrell G. Socio-economic differences in takeaway food consumption among adults. Public Health Nutr 2012;15:218-26.
7.Foresight. Tackling obesities: Future choices – project report. 2nd edition. London: Foresight, Government Office for Science, 2007. http://www.bis.gov.uk/assets/foresight/docs/obesity/17.pdf

Competing interests: No competing interests

25 March 2014
Louise Flanagan
Specialty Registrar in Public Health
C Albert Yeung, Consultant in Dental Public Health
NHS Lanarkshire
Kirklands, Fallside Road, Bothwell, G71 8BB
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