Oxford Public Health Magazine Issue 3 by Oxford Public Health

The Magazine of the Oxford Public Health Global Network

February 2016

A recipe for obesity prevention in children?

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The beauty of the Oxford Public Health Global Consultancy Network is that we connect and match organisations with consultants in all sectors worldwide, while providing opportunities to consultants at any level, ranging from new graduates to experienced professionals… and it’s free to join! 3

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Eat less, move more, and manage stress… is it that simple to maintain a healthy weight?

In this issue, we hear insights from the presidents of the American College of Lifestyle Medicine and European Society of Lifestyle Medicine. Keeping with the comparison across both sides of the Atlantic, we also learn about how work with youth may inspire healthy lifestyles, including an organization set up by Dr Mehmet Oz of The Dr Oz Show.

It is never too late to reap the rewards of a healthy lifestyle, but once obese, it can be challenging to return to and sustain an optimal weight. On a population level, the global obesity crisis is a ‘wicked problem’ that has multiple potential causes, in turn demanding multi-sectorial solutions.

We then hear about what cities can do to promote health and wellbeing amongst its population, as well as the role of design in health.

In this special issue of the Oxford Public Health Magazine, we highlight the role of a healthy start in life, preventing the development of obesity in children. These early years represent a critical period of physical and emotional development that are vital in setting the foundations for learning and maintaining healthy lifestyles.

Dr. Andrew Marshall writes about how child health professionals can be part of the solution, including recommendations directly from the Royal College of Paediatrics and Child Health. Dr Adam Briggs shares his experience in combining research and public health practice to target obesity prevention in both children and adults, covering the launch of a free drop-in health improvement advice centre based at Oxford University Hospitals NHS Foundation Trust.

In England, with an imminent national childhood obesity strategy, Public Health England recently published several presentation slide sets offering the facts and figures about obesity, the costs, the benefits of investing and the potential routes to action. A new smart phone app has been developed to allow parents and children to scan the barcodes on food packaging at home and at the shops to see the number of sugar cubes in everyday food and drink. The UK’s Faculty of Public Health has published a toolkit to assist local strategies for tackling obesity.

With our interest in promoting public health careers, we end by interviewing Sir Rory Collins, Head of the Nuffield Department of Population Health at Oxford University, on his career in research into the prevention and treatment of chronic non-communicable diseases.

In this issue... Dr. David L. Katz

American College of Lifestyle Medicine

Dr. Michael Sagner

European Society of Lifestyle Medicine

Dr. Phillip Blanc

HealthCorps

Fran Bury

The Winch

Ian Brooke

Oxford City Council

Gayle Souter-Brown

Greenstone Design UK Ltd

Dr. Andrew S J Marshall

Oxford University Hospitals NHS Foundation Trust

Dr. Adam Briggs

Oxford University

Sir Rory Collins

Oxford University

Book Review: “Global Population Health and Well-Being in the 21st Century” (Springer Publishing, New York, 2016) Author: George R Lueddeke PhD A must read for public health, clinical, and social care students, teachers, and practitioners alike, including case studies to provide a thorough and up-to-date account of the past, present, and future of global public health. Dr Lueddeke effectively highlights the ingenuity gap between today’s wicked problems and their potential solutions, with a timely emphasis on the concepts of ‘planetary health’ and ‘integrative ecological public health’. Following on from the four “waves” of public health interventions in developed nations, including water/ sanitation (first), medical and scientific breakthroughs (second), the welfare state and social security (third), and the current focus on systems thinking, risk factors, and lifestyle (fourth), there is now an emerging need for the “Fifth Wave” interventions that require complex adaptive systems thinking. Dr Lueddeke presents a manifesto for collective public health action through the ‘One Health’ movement, recognising the inter-dependencies in the health of people, other animals and the environment we live in. One of the main aims of the book is to support the implementation of the UN 2030 Agenda for Sustainable Development, including the 17 Sustainable Development Goals (SDGs). This book describes part of the solution being the development of an effective public health workforce through innovations in education and training, offering a proposal for Centers of One Health Excellence (COHE) worldwide. Our mission at Oxford Public Health is aligned closely with many of the compelling concepts in this very informative and ground-breaking read. 6

Dr. David L. Katz

Dr. Katz is the founding director of Yale University’s Yale-Griffin Prevention Research Center, and current President of the American College of Lifestyle Medicine. Recognized globally for expertise in nutrition, weight management and the prevention of chronic disease, he has a social media following of well over half a million. In 2015, Dr. Katz established the True Health Initiative to help convert what we know about lifestyle as medicine into what we do about it, in the service of adding years to lives and life to years around the globe.

“Since we CAN use lifestyle as medicine; since we CAN prevent some 80% of all chronic disease; since we CAN rally around fundamental, actionable, time-honored, evidence-based, consensus-supported truths about healthy living- why wouldn’t we? The fate of populations and the planet are at stake. The future we bequeath to our children and our grandchildren- is at stake.”

What is the burden of childhood obesity across the US and globally? How bad is the problem?

Obesity, in adults and kids alike, is, of course, almost entirely preventable with knowledge long and readily at our disposal. Better use of feet and forks- eating well, being active- is enough to prevent all but quite rare cases of obesity. More importantly, this same lifestylebased approach to health is known to have the potential to prevent up to 80% of all major chronic disease. Nothing for which a Nobel Prize in medicine has ever been awarded can rival this.

While it tells us something to say that one in three kids in the US is overweight or obese, and that numbers are high and rising in much of the world- it doesn’t tell us nearly enough. More important is this: a generation ago, type 2 diabetes was a disease essentially exclusive to overweight adults. In fact, it was called ‘adult onset’ diabetes to distinguish it from type 1, or ‘juvenile onset’ diabetes. Now, it is diagnosed routinely in children, and this is driven by epidemic childhood obesity, poor diet, and inadequate physical activity in our kids. There are ever more cardiac risk factors documented in ever younger people; ever more fatty liver disease; and even a rising incidence of stroke.

Which specific lifestyle changes have the most impact for children? For children and adults alike, the top three priorities are avoiding toxins like tobacco, excess alcohol, and drugs; eating an optimal diet of wholesome foods, mostly plants, in a sensible combination; and being physically active as a matter of routine. Other high-impact priorities include: adequate sleep; managing stress; and respecting the importance of relationships. Love and friendship contribute importantly to our health.

The Centers for Disease Control and Prevention (CDC) projects that should current trends persist, by mid 21st century, 40% of American adults will be diabetics- and those adults in 2050 are both today’s kids, and kids yet to be born. We are doing nothing less, with business as usual, than bequeathing a blighted future to the next generation.

What are the evidence-based successful interventions for ensuring healthy lifestyle change in children?

I don’t think we can overstate the toll of childhood obesity as kids succumb, globally and en masse, to what were once chronic diseases that occurred at or after midlife- and were already bad enough at that!

We have many sources of evidence to show what healthy living can do- for kids, as for adults. We have many fewer examples of long-term change at the community level. But we do have some. Here in the U.S., Shape up Somerville is a good example of the possible. In Europe, a study called EPODE is another. If we build the right programs, policies, and practicesresults, do indeed, come.

How important are healthy lifestyle changes in preventing obesity and promoting healthy development in early life and children? 7

Have there been any interventions to date that do NOT work?

many industries profit from pretending that there is constant confusion about healthy eating and living- it just isn’t so. The world’s experts agree on the fundamentals. The fundamentals rest on a vast foundation of evidence. The idea here is that you simply cannot get ‘there’ from here until you acknowledge you know where ‘there’ is. With regard to healthy living, we do- and an unprecedented coalition of global authorities is coming together to say so.

I think it’s fair to say that nothing to date has ‘worked’ well enough, since the overall global epidemiology is deteriorating. We have ever more obesity and preventable chronic disease, rather than less. So we know what to dobut are not doing it. So far, the forces of profit over public health are winning. It’s high time to fix that.

Are healthy lifestyle changes purely the result of the child's or their parents' behaviours?

What’s planned over the next 5 years? ACLM will grow, and reach ever more people. It will develop state-of-the-art educational programming, and link valued credentialing to it. And, it will advocate actively for reimbursement reform so that the practice of lifestyle medicine is remunerated routinely, as it so clearly deserves. As a result, the ranks of those practicing- and benefiting from- lifestyle medicine will grow enormously.

The short answer to this is that the choices any of us makes are subordinate to the choices we have! Social factors and environmental factors are important determinants of our behavioral choices. To account for rampant obesity and chronic disease, we have NO- zeroevidence that the average level of personal responsibility has declined. We have abundant evidence, in contrast, that environments have changed; that our daily routines have changed. This is not complicated.

The True Health Initiative will do nothing less than end the era of diet fads; get-healthy-quick nonsense; and the appearance of confusion about the fundamentals of healthy living. This global effort will combine voices into a signal that rises about our cultural noise, to rally people to basic, actionable truths about healthy living- including healthy eating. As a result, our massive allocation of societal resources to bickering and debating what we already know will end- and instead, these resources will be directed to putting what we know to good use. As a consequence of this, a bounty of years will be added to lives, and a bounty of life to years, for millions upon millions around the globe. Some 80% of chronic disease and premature death is preventable using knowledge we already have- the THI will make sure everyone knows that we know what we know, so that luminous promise is realized.

What are the American College of Lifestyle Medicine (ACLM) and your Initiative doing to help? ACLM (www.lifestylemedicine.org) is all about advancing applications of lifestyle as medicine in every way possible. A major emphasis is raising awareness among health care professionals, and raising standards of practice. To advance this mission, the College is developing curricula and credentialing programs, and disseminating best practices. The True Health Initiative (www.truehealthinitiative.org) is all about showing and convincing the world that while

Dr. Michael Sagner

Dr. Sagner is the current president of the European Society of Lifestyle Medicine in Paris, France, and a member of the European Union Platform for Action on Diet, Physical Activity and Health. Michael Sagner is the editor in chief of the peerreviewed Elsevier journal Lifestyle Medicine – Research, Prevention and Treatment of Chronic Diseases.

“We welcome all health professionals who are interested in research, prevention or treatment of lifestylerelated chronic diseases to visit the Society’s website at http://eu-lifestylemedicine.org”

What is the burden of childhood obesity across Europe? Lifestyle-related chronic diseases are now the leading cause of death and disability, not only in Europe but across the globe. Obesity is often a gateway disease to chronic diseases. It is estimated that in Europe the prevalence of overweight (including obesity) is 16-22% - of which, the prevalence of obesity is 4-6%. This translates into about 11.8 – 16.3 million children as overweight and obese, of which 2.9 – 4.4 million children are obese. Overweight as the childhood equivalent is defined as a body mass index (BMI) of 25 or above (age and gender adjusted) and obese as the childhood equivalent of having a BMI of 30 and above (age and gender adjusted).

Childhood obesity is difficult to treat, most obese children are likely to remain obese as adults. A complicating factor is that obesity is not only excess body fat but often leads to alterations in metabolism and also psychology which makes it even more difficult to lose weight later in life. Obese children often enter adulthood with a high risk for chronic diseases, thus the prevention of overweight and obesity in childhood has to be a top priority.

How important are healthy lifestyle changes? A healthy lifestyle is the most important step to prevent childhood obesity. This is more complex than many stakeholders have previously thought. Lifestyle behaviors

Chronic lifestyle-related diseases (non-communicable diseases) are now the leading cause of death and disability on the planet. To reverse this trend, the underlying mechanisms of these diseases such as chronic systemic inflammation and the underlying causes such as nutrition and physical activity have to be addressed. Lifestyle Medicine is an emerging field in medicine that is dedicated to research, prevention and treatment of chronic lifestyle-related diseases. Lifestyle Medicine draws on systems biology, public health and clinical medicine, and considers complex interactions within the human body in light of a patient's lifestyle, genomics and environment. The European Society of Lifestyle Medicine (http://eu-lifestylemedicine.org/) is the world’s leading scientific organization dedicated to interdisciplinary approaches to chronic lifestyle-related diseases. The new journal 9 ‘Lifestyle Medicine: Research, Prevention and Treatment of Chronic Diseases’ will highlight the latest research and facilitate advancements in the field.

such as nutrition and physical activity cannot be seen as individual factors, there is a complex interaction with the patient’s psychology, belief system, the environment, social community and the culture in which the person tends to live.

Many things that have been tried did not work, as reflected by the statistics on childhood obesity. A reductionist approach singling out factors such as nutrition or physical activity seems to be rather ineffective. It is important to take the complex interactions of nutrition, physical activity, psychology, the environment and social factors into account – the whole lifestyle has to be addressed.

A healthy lifestyle to prevent obesity includes healthy eating patterns (both quality and quantity of food intake as well as timing) and should include regular physical activity and stress management techniques, especially when children are born into a high-stress environment such as found in most countries and cities in the modern world.

Are healthy lifestyle changes purely the result of the child's or their parents' behaviours? Lifestyles are influences by a complex interaction of factors, the parents’ behavior play a key role, of course, because in the early stages of life children will imitate what they see their parents doing. But the environment plays a crucial role as well. Growing up in an urban and high-stress environment that take promotes physical inactivity is an example of a more distal risk factor for childhood obesity. Addressing these complex issues will be key to tackle the global obesity crisis. We have to build environments where living a healthy and active lifestyle is the easy choice for all children.

Which specific lifestyle changes have the most impact for children? It is important to take the psychology of children into account. Children are not small adults, they have different needs and susceptibilities. ‘Nudging’ them into healthy lifestyle behaviors such is better than forcing them onto the children. An important aspect is to reduce sedentary time. Today, sitting in front of a computer or TV (in addition to sitting at school, most of the time) makes up a large part of a child’s daily (in)activity and has been shown to be a risk factor for chronic diseases and obesity.

Congratulations on establishing the European Society of Lifestyle Medicine (ESLM). What is ESLM doing to help?

What are the evidence-based successful interventions for ensuring healthy lifestyle change in children?

Establishing ESLM was a group initiative of clinicians, researchers and other health professionals across Europe in an effort to advance research, prevention and treatment of lifestyle-related chronic disease.

Interesting observations have been made in the ‘Blue Zones’ project. There are several regions on the planet where people tend to live to very old age in good health. At the same time there seem to be very few overweight children. Very likely this is due to a healthy lifestyle with a strong commitment from the whole community. It has shown the value of providing children with a culture that promotes healthy lifestyle behaviors including daily physical activity, a plant-based diet as the basis and low-stress phases throughout the day as well as strong social support.

ESLM has two priorities: First, education and training for health professionals. In collaboration with other international scientific organizations ESLM will be launching a peer-reviewed journal soon that will provide a platform for all healthcare professionals involved in chronic diseases. ESLM will start offering postgraduate university training and CME courses. Second, ESLM supports research to improve our understanding of lifestyle-related diseases and advance treatment and prevention of chronic diseases. ESLM aims to connect researchers and facilitate interdisciplinary research activities to advance our understanding of chronic diseases and the role lifestyle factors play in the pathogenesis and prevention of these diseases, not only in Europe but across the globe in collaboration with the Lifestyle Medicine Alliance.

Have there been any interventions to date that do NOT work?

Dr. Phillip Blanc

A graduate of Rutgers University (Bachelor of Arts), Robert Wood Johnson Medical School (Doctor of Medicine), and Harvard University (Master of Public Health), Dr. Blanc trained for four years as an Emergency Medicine resident at The Mount Sinai Medical Center, and then for two years as a Public Health/ Preventive Medicine resident at the New York City Department of Health and Mental Hygiene. He currently serves as Vice President of Research and Health Science Communication for HealthCorps. Outside of the office, Dr. Blanc enjoys épée fencing, playing electric bass guitar for church, and spending time with his wife, Ursula.

“Whether it’s at the grassroots or policy level, it’s reassuring to know that HealthCorps is working to impact as many U.S. teens as possible before they embark on their respective life paths after high school. ”

What's HealthCorps all about? What's your mission?

these health pillars to others using a “train-the-trainer” model (e.g., school-based personnel can then teach our health-related foci to students in their schools sans the expense of having a full-time Coordinator at the school).

Our mission is “to unleash the power of America’s youth so they can live productive lives.” To achieve this, we equip teenagers across the country with practical, lifeaffirming tools related to nutrition, physical activity, and mental resilience.

In addition to HCU, another means by which HealthCorps aims to reach critical mass is through its advocacy at the policy level, working to influence change on such federal education laws as the Elementary and Secondary Education Act (ESEA), to make health-related activities such as physical education a more significant part of school curricula nationally.

What types of activities does HealthCorps get involved in? HealthCorps aims to impact teen health in a number of ways. One way is through its programs, the main two being its “Living Labs” and “HealthCorps University” (HCU) programs. Our Living Labs represent the core of HealthCorps: high schools in which we embed recent college graduates to teach our unique health and wellness curriculum, HealthCorps and You, to disadvantaged students across America. Our curriculum focuses on three main pillars of health: nutrition, physical activity, and mental resilience. Along with these classroom-based lessons, our health champions/instructors, called Coordinators, reinforce healthy principles to students outside of the classroom through food demonstration activities (“Café O’ Yeas”), after-school cooking clubs, and health fairs. In order to cultivate a health and wellness culture in the school community, Coordinators also develop wellness councils, through which engaged school staff can also help target collective health goals for the school.

Whether it’s at the grassroots or policy level, it’s reassuring to know that HealthCorps is working to impact as many U.S. teens as possible before they embark on their respective life paths after high school.

Who founded HealthCorps? HealthCorps was founded by heart surgeon and Emmy® Award-winning television personality, Dr. Mehmet Oz and his wife, Lisa, in 2003.

What inspired the Founders of HealthCorps to take action and establish the organization? I think it was likely a culmination of events that led to the creation of HealthCorps. For instance, while at the macro level, nationally we were seeing a rise in childhood obesity, at the clinical level, Dr. Oz describes performing “life-saving” surgery on patients in their 20s—a demographic which, prior to the obesity epidemic, was apparently not as prevalent on heart surgeons’ operating tables.

Currently, Living Labs are present in 44 schools across 10 U.S. states and the District of Columbia. In order to reach critical mass (e.g., affecting one in five American teens), HealthCorps has also developed HealthCorps University (HCU) which instructs and certifies external entities (e.g., outside corporations, school districts, community organizations, etc.) so that they can teach 12

How did you get involved?

(MPH) degree, I gained some basic understanding of public health-related concepts, such as epidemiology and biostatistics. After medical school, I trained in Emergency Medicine at The Mount Sinai Medical Center in New York City, as well as Public Health/ Preventive Medicine at the New York City Department of Health and Mental Hygiene. While the former has helped me recognize the grave consequences of obesity up close at the individual patient level, the latter has helped me appreciate the impact of policy changes at the population level. I also honed my survey design and analytical skills, and developed my interest in Health Communication while training in Public Health/Preventive Medicine.

After appearing on Dr. Ozâ&#x20AC;&#x2122;s show as a guest expert, working for HealthCorps represented a nice melding of my background and interests in public health and media.

What are your roles and responsibilities? At HealthCorps, I oversee our research department, which entails guiding the onboarding of new research projects, as well as securing funding opportunities for the department. Additionally, I communicate our research findings internally and externally.

What are your top tips for anyone considering a similar career pathway?

What did you have to study and gain training in, in order to prepare you for your current role?

Two things come to mind. I was fortunate enough to know that I was interested in pursuing public health years in advance of applying to public health degree programs. This gave me some time to pursue opportunities in public health prior to submitting my applications, which may have been instrumental in demonstrating to admissions staff that my interest in public health was genuine. The takeaway here is that the earlier you know that you are interested in a particular field, you can make great use of that time by building experience in that field.

In order to prepare for my current role, I studied public health at Harvard University in between my third and fourth years of medical school at Robert Wood Johnson Medical School. While earning a Maser of Public Health

Dr. Mehmet Oz with Dr. Phillip Blanc.

Courtesy of The Dr. Oz Show

The second point relates to this first point: consider pursuing as many experience-oriented learning opportunities as possible. Whether it’s an unpaid volunteer experience or a paid internship in the field, having such experiences can both inform the direction you take with regard to your future career, as well as help increase your chances of acceptance to graduate/ professional school. When you do this, remember: it’s okay to have experiences that either affirm—or disaffirm—your original career interest; both types of feedback from your experiences are valuable.

Pastor Joel says, “Every setback is a setup for a comeback.” So just at the time that you’re ready to give up, explore this possibility: if you hang in there, your breakthrough may be just around the corner. Meanwhile, in her Harvard commencement address a few years back, Ms. Winfrey declared: "there is no such thing as failure. Failure is just life trying to move us in another direction…. learn from every mistake because every experience, encounter, and particularly your mistakes are there to teach you and force you into being more who you are.” Therefore, be hopeful, keep going, and be a stonecutter:

Any final words?

“I would go and look at a stonecutter hammering away at his rock perhaps a hundred times without as much as a crack showing in it. Yet at the hundred and first blow it would split in two, and I knew it was not that blow that did it, but all that had gone before together.”

Persistence pays off. Not every career path will have been paved before you embark on your journey—in fact, like pioneers have done in other industries and fields, you might be the one creating the path in your chosen field. Especially when you have to chart your own way, you can expect that challenges will follow. However, not all challenges spell complete defeat. I like how minister, Joel Osteen, and media mogul, Oprah Winfrey, frame failure.

–Jacob A. Riis, The Making of an American For more information on how you can support our work at HealthCorps, please visit us online at: https://www.healthcorps.org/donate/.

Rooftop garden in Brooklyn, New York.

Courtesy of HealthCorps

Fran Bury

Fran Bury is the Chief Operating Officer of the Winch. Prior to this she worked in a think tank, a private sector consulting firm and two local authorities. She is a Director of the campaigning organisation We Own It, and her nonwork related interests include environmental sustainability, music and public health. She has two degrees from Oxford University.

What has youth work got to do with public health? To start with, we provide a safe space for young people – this alone can deliver significant improvements in wellbeing, especially where there is high fear of crime or bullying. Combined with sports activities, arts projects, informal discussion groups and mentoring, it can be truly transformative.

I work for a local children and young people’s charity based in Camden, London. We work with young people “from cradle to career”, as well as their parents, schools and council services, to break down the barriers built by poverty and disadvantage and to ensure every child we work with has the chance to thrive.

Secondly, we believe our work, which is proactive and starts during the most formative early years, will deliver long lasting physical, psychological and socio-economic benefits. Whether we are supporting parents to manage their children’s behaviour more effectively, providing safe play space for children who would otherwise be stuck indoors or enabling young women to feel confident enough to discuss contraception with their partners, we are helping to lay the foundations for a happier and healthier population of adults.

On the face of it, the work of local children’s charities like ours may appear to have little connection with the world of public health. However a great deal of research has shown just how important the first years of life are for a wide range of outcomes, including those relating to health. Whether it is establishing good dental hygiene, feeling confident undertaking exercise or understanding how to eat healthily, the earlier we reach people, the stronger the foundations for the future.

Thirdly, we are able to reach people that statutory services often struggle to engage. Our services are open to all, and are seen as non-judgemental, supportive and above all, welcoming. As a result, the parents, teenagers and young adults who are often considered to be “hard to reach” are prepared to engage with our services, meaning we are able to support them, provide information and sometimes, from this position of trust, link them to statutory services.

I know that my organisation is delivering public health outcomes every day. And I have also come to suspect that the two fields have more in common than you might expect – and could learn a lot from each other. Let me give you four examples, which could have happened on a typical day in our organisation. A group of parents meet a local dentist and find out how to care for their babies’ teeth. Five children and their coach take the bus to their weekly under 10s football match, and return exhausted but triumphant. A teenager at risk of sexual exploitation finds someone to confide in over a hot chocolate. And a young father hears he has secured a job which will enable him to move out of his damp and overcrowded hostel accommodation.

So, what might youth workers and public health professionals be able to learn from one another? We certainly share a number of challenges, and it seems likely that shared thinking could deliver more creative and effective solutions to them. The first that come to mind is the difficulty in proving causality. Both youth work and health promotion operate in real world contexts in which it is impossible to control for all the social and environmental factors which could influence outcomes.

Each one of these is contributing to important health and wellbeing measures likely to be of interest to our public health colleagues. And they illustrate some of the important ways in which youth work affects population health and wellbeing. 18

At the time of writing, an important project, established to help youth charities improve the rigour of their evaluations, is considering dropping the requirement for randomized controlled trials (RCTs) to be undertaken, in recognition that in this context they may not be suitable, or even useful. What are the tools already used by youth work and public health professionals which might be shared and adopted to overcome this challenge? The second similarity is related to this; at their heart, these two professions are both interested in the mechanisms by which behaviour can be influenced and changed. Although they approach this challenge from different angles – I suspect my youth worker colleagues would see public health campaigns, which aim to promote specific actions or behaviours, as paternalistic, and quite different from their attempts to empower young people to make their own choices in life – the challenge remains, how to sufficiently engage and interest other people that they are willing to modify their behaviour. What insights might youth workers have into motivation and perseverance or indeed confidence and optimism which could be used to improve smoking cessation services, for example? The Winch

Credit: Sabine Thoele

“So, what might youth workers and public health professionals be able to learn from one another?” Finally, and sadly, our two fields share a common challenge in rapidly decreasing funding, and a sense that our work is seen as “nice to have” rather than essential by governments seeking to find even greater savings from already reduced budgets. In particular, we both are affected by the inadequate funding for mental health services, particularly for young people. These challenges won't go away - but they also present us with an opportunity. In North Camden, we are beginning to develop an innovative collaboration between residents, charities and statutory organisations – including our local public health team - to produce a fundamental shift in the way that we do things in order to improve outcomes for children and young people. It is in the early stages, and we are still discovering how it might work in practice, but we have a hunch that by pooling our data, aligning our priorities and building a culture of collaboration and trust, we will be able to do more for our children, and it may even cost us less. You can find out more about the Winch’s work at thewinch.org and about the North Camden Children’s Zone at greatplacetogrowup.squarespace.com/.

The Winch

Credit: Sabine Thoele

The Global Health Network aims to accelerate and streamline research. It is an innovative digital platform facilitating collaboration and resource sharing in global health. The Global Health Network has a steering committee comprised of:  Trudie Lang (University of Oxford)  Kevin Marsh (KEMRI-Wellcome Programme, Kenya)  Rosanna Peeling (London School of Hygiene and Tropical Medicine)  David Lalloo (Liverpool School of Tropical Medicine)  Tumani Corrah (MRC The Gambia)  Patricia J Garcia (Universidad Peruana Cayetano Heredia Peru)  Arthur Thomas (Oxford Internet Institute) Research Tools  Free, certified eLearning course  International regulatory information database  Site-Finder, a collaboration-finding tool for linking research sites and studies seeking sites  Professional Membership Scheme for tracking continued professional development  Process map to guide the set up of research studies Member areas Over 20 open-access, interlinked communities of practice containing:  Discussion groups and blogs  Up-to-date global health research news, events, and conference information  Grants and funding information from major global funders  ‘Ask an Expert’ and ‘Ask the Author’ panels  Information about scholarships and competitions from many sources  Guidance articles  Downloadable tools and resources Topics  Disease specific information portals, covering topics such as malaria, HIV and Influenza.

www.TheGlobalHealthNetwork.org 20

Ian Brooke

Ian Brooke is the Head of Community Services at Oxford City Council, Vice Chair of the National Chief Culture and Leisure Officers Association (CLOA) and a board member of the Oxfordshire Sports Partnership. Ian is currently working on a national health commissioning project and on a health inequalities commission in Oxfordshire.

In this article Ian argues that the answer is motivation and that local authorities must better use their assets to get residents motivated. Ian shares the work his team are doing to reduce obesity and simplifies what is often viewed as the highly complex challenge of tackling obesity.

Is obesity understood?

Addictive computer games, mobile phones, an enormous fast food industry – all of which are incredibly well marketed, children spending far less time playing outdoors and financial barriers. So, how do you motivate families and children to be active, especially when breaking the shackles of obesity takes such an overwhelming effort?

What better way to test this than ask a child, so I asked my six year old how can people stop becoming fat? “Don’t eat too many burgers, but if you do then exercise. And don’t eat too much cake, but if you do then eat lots of healthy things a well” So far so good…

I’ll summarise a few of things we have done in Oxford that I believe have helped to motivate children and families to establish active lifestyles.

“If you want to be fat you can be, but its better to be fit and healthy as it lets you live longer” Gold star Jude! This highly non-scientific sample reinforces my view its far from rocket science, don’t eat more calories than you burn off. Therefore, why is obesity spiralling out of control?

Step 1—Make the most of what you’ve got

It comes down to motivation – so the challenge in common with most behaviour change is how to make someone want to eat healthier and be more active.

The Oxford City Council invested in transforming the city’s play areas from dull, uninspiring areas, to exciting, fun spaces helping children develop a love of the outdoors and being active.

Before I attempt to answer this let’s remember what we’re up against.

This led to a significant increase in usage and satisfaction with our parks. I believe this is the most cost effective investment a Council or Health Service can make to tackle obesity as it provides a free, safe and family friendly environment for activity. We also invested in tennis courts, multi-use games areas, sports pavilions and installed outdoor gyms. So, while the kids are enjoying zooming down a zip wire in a Narnian themed play area (this is the theme of the play area at Bury Knowle Park) they are becoming motivated to try tennis, football, basketball, or one of the range of activities we provide that will hopefully lead to them enjoying activity and building exercise into their lifestyles. We have also ensured that our leisure centres are appealing. We closed three costly old leisure centres and invested the money this saved into improving the remaining ones. The income from the centres now covers the costs, 96% of users are at least satisfied and usage has increased by 50% over the past six years with far greater increases in our target groups such as young people.

Step 2â&#x20AC;&#x201D;Communicate whatâ&#x20AC;&#x2122;s available Perhaps the most important part of communication is having a clear agreed plan in the first place; Oxfordâ&#x20AC;&#x2122;s plan is our Leisure & Wellbeing Strategy. A key part of the strategy was creating and communicating a joined up leisure offer, the offer is anywhere people can be active ranging from; parks, rivers, roads, leisure centres, schools, community centres and church halls. Our development teams and partners are excellent at creating and managing accessible activity pathways. We adapt communication channels for the audience; a good example is we created an app called Bungee that shows young people all actives that are near them at any location in the County and how to get there. The app also contains health and safeguarding information. By making the most of what Oxford has and effectively communicating a joined up leisure offer we have increased adult participation with over 15,000 more people taking part in regular activity than six year ago.

Gayle Souter-Brown

Gayle is a PhD candidate. She is a practising salutogenic landscape and urban design consultant, the managing director of Greenstone Design UK Ltd, is author of the seminal text Landscape and Urban Design for Health and Well-Being and works globally.

Health and Well-Being: Is the hype worth the money? As we look to tackle the childhood obesity crisis the World Health Organisation says we need to think innovatively and explore multi-disciplinary solutions. Active, healthy lifestyles have been key components of the public health mantra for the past 10 years. In UK schools we saw playground seating removed as head teachers tried anything they could think of to get children moving. Unfortunately for the children the approach added to their stress and did nothing for their BMI. What is being found to work in the fight against obesity is the introduction of nature connections. Shade trees, fruit trees, shrubs and herbaceous planting that attract birds and insect life, diminish stress and encourage children to engage and explore. When stress levels are reduced through environmental design interventions children, like their adult counterparts, are more likely to want to spend time in the environment. Whether gardening, walking, playing, running or cycling, active healthy lifestyles can be encouraged and enabled through environmental design. Health and well-being is the focus of an international marketing craze. Well-being is the latest must-have commodity. Newly-launched bars, restaurants, luxury hotels and apartments tout their ability to enhance well-being. What was once known as a beauty salon now sells ‘wellbeing’. Exclusive housing estates offer ‘healthy lifestyles’ replete with parkland, walkways, lakes and ponds as part of their sales package. Previously the design and marketing hype sold us ‘atmosphere,’ now we are sold the concept of health and well-being. So where are the health providers in this mix? What do policy makers make of it? While public health professionals are waking up to the idea, marketers and business managers are up and running. The question becomes, is there anything behind the marketing hype and can we as public health professionals learn from it? That well-being is able to be bought and sold is an interesting concept. Well-being as a commodity appeared relatively recently in the media.

When the global financial crisis hit, communities struggled to pay their bills; individual and public health and well-being suffered. Businesses struggled to entice people to spend their money with them. While public health initiatives focussed on reducing obesity, smoking and suicide, a new ‘drug’ was needed to inject some life into the economy. Well-being as a commodity was born. Research interest in nature and general greenspace for health has been growing steadily. Roger Ulrich was the first to note that healing times may be reduced when patients have a green view1. Since Ulrich’s early work many other research projects have followed. Architecture recognises the potential health impacts of design2. In education, interest in wellbeing is mounting as organisations become aware that there is more to success than can be measured by Treasury targets3. As we strive as communities to achieve more with less we are looking for value added, cost effective options. We need to improve public health and well-being to do so. “Schools cannot achieve their primary mission of education if students and staff are not healthy and fit physically, mentally, and socially”.4 Linkages between health, wellbeing and environment are now well established.5, 6 Much of the research to date is correlative. However, while researchers investigate the efficacy and dose response of nature, smart marketing money isn’t waiting for the longitudinal data. The accountants and bankers agree that the hype is real; there is sufficient evidence to justify the business case. Business owners have decided we know enough to act. Landowners, developers and business owners are investing in nature to heighten a sense of well-being. Fake grass, real grass, trees, living walls, pots of herbs, potted fruit trees, hanging baskets and trailing vines are increasingly seen in places where marketers want people to spend time, and so money. Commercial pockets of urban greening are appearing in piecemeal fashion on footpaths, on rooftops and in courtyards in cities everywhere. 23

Airports have realised that stress levels are reduced and so people spend more money in the retail outlets where there are real trees, water and the sights and sounds of nature. Corporate employers notice increased worker productivity where they have access to green views or attractive outdoor space. Big money is being spent on staff greenspace-for-wellbeing initiatives by premium employers like Google, Microsoft and Price Waterhouse Coopers. Luxurious workspaces buy more than just staff loyalty. The return on their investment is paying off. Investing in greenspace sends signals to the marketplace that well-being is important.

It is now firmly based on business case return-on-investment success. What can we learn from this? I believe there are 3 points to note.

Greenspace as a luxury commodity is nothing new. For 100s of years wealthy people have benefited from leafy parks and gardens. Conversely, people in poorer neighborhoods often lack nature connections in the form of trees, flowers, birds and butterflies and their poor health statistics reflect this.

If we are to effectively meet the obesity challenge we need to think innovatively and work collaboratively. We need to be mindful of costs and benefits of prevention and treatment options. We need to agree the adequacy of the science and accept commercial reality. Public health, education and social housing policy makers and service providers, take note. We have enough information to act.

The relationship between trees and health was investigated by Donovan.7 He found strong evidence that a nature connection, in the form of trees, and the animals – birds, bugs and microbiota that live on them, have a measureable effect on human health. “Historically access to nature was an intrinsic part of daily life. Where modern society has moved away from nature we have seen a decline in public health and an increased need for healing gardens. Today we need nature experiences more than ever to balance the negative effects of the hard-edged built environment coupled with fast-paced information-overloaded lifestyles.”8 The city of Portland, Oregon noted that where urban street trees were planted, housing sale times were reduced, sale price was increased, pedestrian activity increased, health active lifestyles were fostered and local businesses prospered. It was found that the urban nature connection provided by the street trees add $1.1 billion to Portland’s property value, or $45 million per year, on an on-going basis. Annual maintenance costs of $4.6 million are a small fraction of the trees’ value. As an investment of just $89 / tree, the return is significant. The hype may initially have been based on the hypothesis that green space is good for us, that nature is naturally healing.

Firstly, policy needs to acknowledge the very real human need for nature connections for health and well-being. Secondly, practitioners have another drug option in their medical bags, one without nasty side-effects and with an affordable price tag. Thirdly, health equity can be improved across population groups through the addition of appropriate planting around where people live, work, play, and go to school.

References 1. Ulrich, R. (1984 ). View through a window may influence recovery from surgery. Science, Apr 27;224(4647):420-1. 2. Blair L. Sadler, L. L. (2011). Fable Hospital 2.0: The Business Case for Building Better Health Care Facilities. Hastings Center Report . 3. OECD. (2015, August). Better Life Initiative: Measuring WellBeing and Progress. Retrieved 2015, from OECD: http:// www.oecd.org/statistics/better-life-initiative.htm 4. NASBE. (2000). Fit, Healthy, and Ready to Learn: Part 1: Physical Activity, Healthy Eating, and Tobacco-Use Preventio. Alexandria, VA.: National Association of State Boards of Education. 5. Fuller, R. A., Bush, R., Lin, B., Gaston, K., & Shanahan, D. (2014). Opportunity or Orientation? Who Uses Urban Parks and Why. PLOS l One, e87422. doi:10.1371/journal.pone.0087422. 6. LNE. (2015). Environment and Health. Retrieved 2015, from Leefmilieu, Natuur en Energie, LNE: http://www.lne.be/en/ environment-and-health 7. Donovan. (2013). The Relationship Between Trees and Health. American Journal of Preventitive Medicine, 44(2):139-145. 8. Souter-Brown. (2014). Landscape and Urban Design for Health and Well-Being: Using Healing, Sensory and Therapeutic Gardens. London: Routledge.

Credit: Gayle Souter-Brown

Dr. Andrew S J Marshall

Paediatric Registrar with an Interest in Public Health, Oxford University Hospitals NHS Foundation Trust. With many thanks for reviewing this article, to Dr. Taffy Makaya, Consultant Paediatric Endocrinologist, and Ms. Kate King-Hicks, Public Health England South East

The Role of Child Health Professionals in Tackling the Obesity Crisis “Change will not come if we wait for some other person, or if we wait for some other time. We are the ones we’ve been waiting for. We are the change that we seek.” – Barack Obama

The Big Issue The growing pandemic of a ‘Western diet’, with its consequential obesity and high blood pressure, now supersedes smoking as the leading risk factor for preventable death globally. Although the mortality associated with both smoking and the Western diet occurs primarily in adults, these habits often commence – and carry significant morbidity – in childhood. Amongst early teenagers in different world regions, 12-21% of boys and 4-14% of girls smoke tobacco, and 5-30% of children are overweight. It therefore behoves all child health professionals to engage in the struggle against these scourges of the modern era.

Working with Children Healthcare professionals, when learning to work with children and young people, must develop a range of specific skills: from listening to an infant’s heart mid-scream; to dodging the daily missiles of vomit, urine, and liquid faeces; to engaging with the monosyllabic teenager. More importantly, we learn how to examine the wider determinants of health and wellbeing, including the family, antenatal, perinatal and early life history, and by exploring the child’s social circumstances. Thinking through the life-course, many professionals working with children and families would routinely discuss pre-conception health, parental smoking, breastfeeding, vaccination, growth and development, behaviour, education, sex, drugs, and mental health. So, amidst the other challenges, most of us take pride in caring for children in a holistic way, and opportunistically offering pertinent advice.

Secondary Care Those working in hospitals review the weight of almost every child they see, placing them in a key position to detect overweight and obesity. What happens next appears to be highly variable. There may be an attitude of ‘this is a primary care problem’ or ‘where’s the evidence for how to treat childhood obesity?’, or the professional may feel they lack the time, experience or energy to delve into the complex underlying reasons for the child becoming overweight. There may be no clear pathway for referring on such children, and those working in hospital may not be up-to-date with the ever-changing patchwork of local services which could provide more specific support and follow-up. Healthcare workers in secondary care are not the only ones who seem unsure what to do next: parents merely informed of their child’s overweight may be distressed, offended or in denial, before even beginning to discuss how to tackle the problem. The UK’s National Child Measurement Programme was primarily established for population surveillance, identifying overweight children. Its guidelines suggest informing parents of results and offering advice, though this is not mandated and there is no standardised management or follow-up plan. The patient pathways and networks we have established for other chronic (but less common) diseases, such as asthma or diabetes, appear lacking.

Guidance We should be thankful for, if not overwhelmed by, a smorgasbord of NICE guidance on obesity, aimed at a range of healthcare professionals who work with children. Unfortunately, given the prevalence of this condition, it would seem unlikely that every child is being followed up and treated per protocol. Hospital paediatricians also have UKbased guidelines, which focus on detecting rare causes of secondary obesity and managing the uncommon 25

Therefore professionals working with children and young people should not only play a key role in educating patients and families regarding detecting and managing overweight and obesity. We should optimise our opportunities to prevent obesity – particularly in the first ‘1001 days’ (www.1001criticaldays.co.uk) – through advice on feeding, parenting strategies, exercise, sedentary activities, etc. We should practise having these conversations, and educate ourselves on resources for parental advice. We should enhance and expand the collaborations between our primary-, secondary- and community-based services.

Local Initiatives

consequences such as paediatric type 2 diabetes. So whilst our role in secondary and tertiary prevention is essential and relatively clear-cut, our role in primary prevention may be less obvious, often getting lost amidst the pressures of acute paediatrics. Leading by example for the UK at least, the Royal College of Paediatrics and Child Health has chosen obesity as one of its key areas of public health work, spanning a broad range of projects (see supplementary RCPCH section on next page).

National Strategies

At Oxford University Hospitals, a ‘Health Improvement Advice Centre’ was recently established, where children and families (as well as adult patients, visitors and staff) can drop-in or be referred for brief advice, covering a range of lifestyle issues, and signposting to community services. We hope this approach will encourage hospital-based professionals, before referring patients, to raise issues of diet and overweight, and stress their importance. Healthcare professionals may also gain confidence in offering their own brief advice, along the lines of ‘Making Every Contact Count’, with direct signposting to community services when appropriate. Most professionals working with children and young people have been trained to advocate against smoking. They may even have been involved in pushing for legislation against passive smoking. Similarly, we should advocate for antiobesogenic societal change through our interactions with friends, colleagues, local services, schools, the media, MPs and government. There is no NICE guideline for implementing societal change, but we’ve done it before – can’t we follow the same blueprint? “You never change things by fighting the existing reality. To change something, build a new model that makes the existing model obsolete.” – Richard Buckminster Fuller

Tackling the smoking pandemic over the last six decades has required a multi-pronged approach including: developing an extensive evidence base; public health media campaigns; taxation; and legislation to restrict both advertising and passive smoking. The ‘Western diet’ could be regarded as a similarly addictive and culturally-ingrained ‘bad habit’. Just as the culture of smoking has moved away from ‘a sophisticated norm’ in many countries, we surely now need to shift our societies’ current dietary norms towards new horizons. Of course, there are differences between these habits – smoking needs to be actively taken up and costs money, whereas eating unhealthily may have been life-long and is often the cheaper option. However, the solutions may still be similar – education can reduce smoking commencement and improve parents’ food choices for their children, whilst taxation could be used to encourage both smoking cessation and the avoidance of unhealthy food. A UK Childhood Obesity Strategy is much awaited in this regard. To combat bad dietary habits on a national and international scale, it seems likely that a multi-faceted approach, as has been deployed in the world’s war on tobacco, is now warranted. 26

Tackling childhood obesity The Royal College of Paediatrics and Child Health (RCPCH) has for many years now, campaigned to reduce rates of childhood obesity in the UK. We have:    

Held an obesity summit to inform the Government’s childhood obesity strategy (2015) Given evidence at the Health Select Committee’s inquiry into childhood obesity (2015) Held a series of round table events at party conferences (2013) Led a campaign on obesity on behalf of the Academy of Medical Royal Colleges (2013)

At a time when around one in five 5 year olds and one in three in 10 year olds are overweight or obese 1 in the UK and half of seven year olds are not meeting the Chief Medical Officer’s target of at least an hour of physical activity a day2, this multi-factorial problem demands a range of solutions involving every sector of society, private as well as public. To tackle childhood obesity in the UK, the RCPCH has made a series of recommendations. These include: 1. Supporting mothers to breastfeed by providing education and information for parents, and by providing training for health professionals. 2. The Government should strengthen the health visiting programme and work with local authorities to provide adequate health visiting services to support parents in providing healthy nutrition and activity for their children. 3. Public Health England should extend the National Child Measurement Programme to include measurements in children between Reception and Year 6. 4. Public Health England should improve the current National Child Measuring Programme to provide more detailed and motivational feedback to parents, including notification of data to GPs. 5. The Government should make Personal, Social, Health Education a statutory subject in all schools.. 6. A duty should be piloted on all sugary soft drinks, increasing the price by at least 20%. 7. A ban on advertising of foods, high in saturated fats, sugar and salt before 9pm and an agreement from commercial broadcasters that they will not allow these foods to be advertised on internet ‘on-demand’ services. 8. Public Health England should undertake an audit of local authority licensing and catering arrangements with the intention of developing formal recommendations on reducing the proximity of fast food outlets to schools, colleges, leisure centres and other places where children gather. Lauren Snaith, Senior Media and Campaigns Officer, Royal College of Paediatrics and Child Health 1. 2.

Health and Social Care Information Centre (2014) Statistics on Obesity, Physical Activity and Diet: England 2014 HSCIC Griffiths LJ, Cortina Borja M, Sera F, et al. (2013) How active are our children? Findings from the Millennium Cohort Study. BMJ Open 2013; 3:e002893. doi:10.1136/bmjopen-2013-002893

Dr. Adam Briggs

Adam Briggs is in the second year of a Wellcome Trust funded clinical DPhil at Oxford University, comparing the cost-effectiveness of different public health policies affecting diet and physical activity. He initially studied Natural Sciences at Cambridge University before going to read Medicine at Oxford and eventually specialising in public health. His broader research interest include the interactions between nutrition, non-communicable disease, and sustainability, and the role of using price changes to change peoples eating habits. He has two years left on the public health training scheme as a specialty registrar when he finishes his DPhil.

Thinking about obesity Public Health Research & Practice Recently I have been lucky enough both to work at Oxford University Hospitals NHS Foundation Trust (OUH), and to start a DPhil in Population Health. Both posts aim to improve obesity, and non-communicable diseases more broadly. And both look to achieve this in different ways. Between 2013 and 2014 I had one of my Public Health specialty registrar placements at OUH. I worked with the trust management, its occupational health and wellbeing department, Oxfordshire County Council (OCC), and other public health registrars to set up a new public health strategy. We wanted to make the most of 12,000 members of staff and over 1 million patient contacts every year, not to mention all the visitors, to improve health and prevent disease among the population of Oxfordshire. It is estimated that of the 660,000 people living in the county, over 26,000 have a diagnosis of diabetes, 20% of adults are obese, and 40% of adults aren’t getting enough physical activity. We aimed to tackle these issues and more by incorporating health improvement and disease prevention into the day-to-day running of the organisation. To do this, the strategy initially focused on three broad areas: promoting healthy lifestyles, developing a healthy environment, and embedding population health approaches within the organisation (the 2014 strategy can be found here: http://www.ouh.nhs.uk/about/trustboard/2014/march/ documents/TB2014.38PublicHealthStrategy.pdf). One of our initiatives is the Here for Health Centre, based in the Trust’s outpatient department. This is a health improvement and advice drop-in service for staff, patients, and visitors aimed at not only reducing obesity, but at reducing the burden of preventable disease more broadly. At the centre, individuals can:    

The centre is staffed by two health improvement specialists who use motivational interviewing and behaviour change techniques to support and engage individuals in healthy living. A range of topics are covered, including smoking cessation, weight management, reducing drinking, eating healthily, becoming active, emotional well-being, dental health, and sexual health. The Centre also forms part of several integrated clinical care pathways including hypertension and liver services. Centre staff will visit referred patients on the wards, run pop up clinics throughout the trust, and link with community services and providers. We have been delighted by how well the centre has been received. Over 1500 individuals were seen in its first ten months of operation (weight management and risk factors for obesity were commonly discussed issues), and soon after OUH agreed substantive funding for the staff posts. Paramount to its success has been the enthusiasm, energy, and expertise of the two full-time members of staff. They have persuaded, cajoled, and educated colleagues both within and outside OUH into working with them to make disease prevention a key part of the organisation’s day-to-day activity. Furthermore, the Trust management and senior clinical staff have created an environment whereby the Centre, and the public health strategy more widely, can flourish and become an integral part of the trust’s identity. Those of us who set it up went to countless meetings, searched for funding, gave out fruit at football matches, and organised teaching but at no point did we encounter anything but positive and supportive responses from colleagues.

access brief chronic disease risk assessments; find information on healthy living; complete an action plan consisting of health behaviour change goals; and receive referrals/signposting to community services for on-going support. 29

The Here for Health Centre at Oxford University Hospitals NHS Foundation Trust

Following OUH I went to the British Heart Foundation Centre on Population Approaches for Non-Communicable Disease Prevention at Oxford University to start three years out of my public health training to do a DPhil. The aim of the DPhil is to develop a computer model that can compare the cost-effectiveness of different public health approaches to improving obesity and associated illnesses â&#x20AC;&#x201C; particularly approaches aimed at diet and physical activity that can benefit children and adults alike. Examples of interventions are reformulating food to have less salt, saturated fat, and sugar, or giving local residents free access to leisure centres. The hope is that this will be of use to local and national public health decision-makers when choosing where to invest their increasingly constrained budgets. I am half way through the project so donâ&#x20AC;&#x2122;t yet have any data to share, however it has highlighted some of the major challenges of public health economic research.

Public health interventions are more difficult, however. It can be impossible to trial some interventions, such as reformulating food to be healthier, and benefits such as reducing the risk of heart disease are often small at the individual level and manifest far away into the future. Also, there is a question over whether a QALY is the best measure of benefit. If a council decides to build a new park rather than an industrial estate, is the only important outcome what happens to levels of heart disease, or are social wellbeing, happiness, the effect on jobs, and social cohesion as important? Although not directly relevant to my DPhil question, I have found these important issues to think about when considering the evidence underlying public health policy. One research project that I have been able to complete since starting my DPhil has been a piece of work led by Public Health England. We used data from the Global Burden of Disease project to estimate the burden of disease in England by region and by deprivation quintile, and to quantify the relative attributable risk from major environmental, biological, and behavioural risk factors (the open access article can be found here: http://www.thelancet.com/journals/lancet/article/ PIIS0140-6736%2815%2900195-6/fulltext).

The National Institute for Health and Care Excellence (NICE) has been producing guidance on what the NHS should and shouldnâ&#x20AC;&#x2122;t fund for years, and in 2005 it started publishing public health guidance. NICE makes recommendations based on estimates of how much an intervention or treatment costs, and the expected health benefit, measured in Quality Adjusted Life Years (QALYs, a measure of both the length and the quality of life gained with the new treatment). If a new intervention offers good value for money (a low cost per QALY gained), then NICE may recommend that the NHS pays for the intervention to be provided. This works particularly well for disease treatments like drugs or surgery as the immediate patient benefit can be readily determined from clinical trials.

The Global Burden of Disease project is an enormously ambitious collaboration run by the Institute of Health Metrics and Evaluation, University of Washington, of over 1,000 academics from over 100 countries. It aims to produce comparable estimates of the causes and disease risk factors across the world. The results are often used to inform national and international health policy. A key strength of the project is that the relative contribution to population ill health is comparable 30

This free online tool allows users to explore and compare all the data used to generate the results in the paper. You can change the deprivation level, year, sex, cause, risk, and region, and view results in absolute numbers, rates, and percentages to suit your own needs. I can highly recommend exploring for yourself by visiting: http://www.healthdata.org/data-visualization/ gbd-compare/england.

across diseases and risk factors, making it possible to rank results and make prioritisation decisions. Headline results that we published for England were: 

Life expectancy is improving but large inequalities remain. For example, in 2013, men in the most deprived area of the country could expect to live 8.2 years less than those in the least deprived area, a difference in life expectancy that has remained unchanged since 1990.



Premature mortality rates fell by 41% between 1990 and 2013, but the burden of disability remained the same. As a result, disability and multi-morbidity are becoming increasingly important problems.



Finally, poor diet and tobacco consumption are the leading causes of disability, each accounting for about 10% of the total burden of disease in England.

These three projects have given me some experience of the theory and practice of how to prevent ill health in both local and national settings. Please do use the Global Burden of Disease visualisation tool and I hope you can drop in on the staff at the Here for Health Centre when you’re next passing by. And of course, hopefully there’ll be some results from the DPhil to share in about 18 months’ time! For anyone who may be interested in a similar career path, mixing both public health practice and research, the obvious remains true – ‘extras’ on the CV such as posters, presentations, publications, and teaching will always help to get the jobs and fellowships – but they’re not the be all and end all. I would say that a genuine interest in research is essential - you’ll struggle to get through three years of a PhD without being properly enthusiastic about the topic. And a mentor can be really useful; someone you can talk to about working in research and public health practice can really help set out some of the challenges (and the rewards), guide you to the different funding opportunities, and offer some ‘been there, done that’ advice for when things go wrong.

The work is the first time a comprehensive estimate of the burden of disease and its causes in England has been made by region and deprivation quintile. The results made national news and I am currently using them to inform part of the Chief Medical Officer’s Annual Surveillance Report on the State of the Public’s Health. One of the most useful ways that our results can help inform policy is through their local dissemination via an online visualised tool developed by Public Health England and the Institute for Health Metrics and Evaluation (University of Washington).

31 Credit: Institute for Health Metrics and Evaluation (IHME). GBD Compare - Public Health England. Seattle, WA: IHME, University of Washington, 2015. Available from: http://vizhub.healthdata.org/gbd-compare/england. (Accessed January 24, 2016).

Sir Rory Collins

Sir Rory Collins studied Medicine at St Thomas’s Hospital Medical School, London University (1974-1980), and Statistics at George Washington University (1976-7) and at Oxford University (1982-3). In 1985 he became co-director, with Professor Sir Richard Peto, of the University of Oxford's Clinical Trial Service Unit & Epidemiological Studies Unit (CTSU). In 1996, he was appointed Professor of Medicine and Epidemiology at Oxford, supported by the British Heart Foundation. He became Principal Investigator and Chief Executive of the UK Biobank prospective study of 500,000 people in September 2005. From July 2013, he became the Head of the Nuffield Department of Population Health at Oxford University. His work has been in the establishment of large-scale epidemiological studies of the causes, prevention and treatment of heart attacks, other vascular disease, and cancer. He was knighted in 2011 for his services to science.

A career in research into the prevention and treatment of non-communicable disease What inspired you to pursue a career in public health and research?

What has been the focus of your research? The main focus of my work over the past 30 years has been in the establishment of large-scale randomised trials of the treatment and prevention of cardiovascular disease. Initially with the “ISIS” series of trials in the emergency treatment of heart attacks, demonstrating that simple low-cost treatments that open up blocked coronary arteries supplying blood to the heart muscle (e.g. with infusions of “thrombolytic” agents like streptokinase or tissue plasminogen activator) and that help to keep them open (e.g. with antiplatelet drugs like aspirin and anticoagulant drugs like heparin) can more than halve the risk of death after a heart attack. Subsequently, we demonstrated the safety and efficacy of long-term treatment in people at increased risk of heart attacks and strokes with antiplatelet drugs and drugs (such as “statins”) to lower blood cholesterol levels.

I've always been interested in the potential of combining mathematics and medicine, and transferred from medical school in London to University in the USA to do a BSc in statistics before returning to finish my medical school training, even though the “powers-thatbe” at my medical school were not at all enthusiastic, asking essentially “what was the point of statistics in medicine … things have moved on quite a way since then!

Why did you decide to specialise in the establishment of largescale epidemiological studies of the causes, prevention and treatment of heart attacks, other vascular disease, and cancer?

What is the secret of your success?

When I was in the USA, I helped to pay my fees by working in a statistics unit running NIH trials and was attracted by the idea of not just generating hypotheses but also of testing them using randomised trials. After I had completed my medical house jobs, I came to Oxford to do research into the emergency treatment of heart attacks. That work led to the series of “ISIS” trials which demonstrated the value of doing much larger randomised trials than had been customary. The success of that approach hooked me on the concept of large-scale trials, often setting out to test hypotheses that emerged from observational epidemiology (e.g. related to blood pressure and blood cholesterol).

Persistence.

What have been your most memorable moments throughout your career? Seeing the results of the ISIS-2 trial for the first time. It showed that a 1 hour infusion of streptokinase reduced mortality during a heart attack by a quarter, that 1 month of low-dose daily aspirin reduced mortality by a quarter, and that the combination halved mortality.

Until then people with heart attacks were given analgesia to reduce their pain and watched in case they had heart rhythm irregularities. The ISIS-2 results changed things, initiating the modern era of much more effective treatment for heart attacks.

Have you seen or been involved in leading innovation in public health and academia? The idea of doing much larger studies of the causes and treatment of disease in order to get appropriately reliable results comes from my colleague, Richard Peto. I feel that my role has been in helping to demonstrate that he was right by making such studies work and generating results that improve patient care and public health.

What advice would you give to those aspiring to take on leadership roles in academic public health? Focus on doing research that really matters rather than on trying to become a â&#x20AC;&#x153;leaderâ&#x20AC;?

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