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Contents A note from the editors
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School Food at Washingborough Academy
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Shame vs support: a discussion of obesity stigma in public health
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Sugar Reduction – The Evidence for Action
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Brighton and Hove Sugar Smart City campaign
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Getting up-to-date with “The eatwell plate”
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Hospital Nutrition: Nottingham University Hospitals
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Detecting and Treating Malnutrition in Older People
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A note from the editors Welcome to the East Midlands edition of PH1! Nutrition is a key public health issue in the UK; dietary risks are the largest contributor to DALYs (10·8%, 95% UI 9·1–12·7), closely followed by tobacco (read more here). In September last year the East Midlands Public Health Registrars spent an interesting two days engrossed in a conference on 'Food and Obesity'. We heard from a range of speakers on topics as varied as school food programmes, weight stigma and PHE’s role in policy development. This sparked an idea for our issue of PH1, which is focused on nutrition. We have drawn on some of our learning from the conference, as well as a range of other people who are currently engaged in topical developments around under- and over-nutrition in the UK, to produce the articles you see here. We hope that you will find them interesting and that one or two might even provoke discussion among trainees elsewhere in the UK. And thanks for reading! Lucy, David, Tiffany and Jilla
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School Food at Washingborough Academy by Lucy Gavens & Rosie Cooper We have all heard in recent years about schools that have introduced growing and cooking into school life in innovative ways. It is thought to be a good way to engage children in what they eat and where food comes from, involving them in food production from a young age. Washingborough Academy is a primary school in Lincolnshire that is passionate about teaching children about healthy food choices and essential life skills such as cooking. It was the first school in the UK to sign up to the Jamie Oliver Foundations Kitchen Garden Club project. As a rural school, it is lucky enough to have space for its own vegetable plots on site. This means that children of all ages from nursery through to age 11 are able to learn about how their food grows and where it is sourced. Further, the school has recently purpose-built a colourful, small person sized cooking classroom for the children to support cookery teaching. Since the start of the academic year, the school has employed its own School Chef who prepares food onsite using fresh, seasonal, local ingredients, with the meals enjoyed by staff and pupils alike. Using local produce improves sustainability and supports children to understand about seasonality. The school communicates regularly with parents about school meals, which has resulted in an increase in school dinner uptake as parents have seen the quality of the food rise. Making the most of produce grown on site, the children are also supported to develop and sell products in a school ‘Snack Shack’. This ‘Snack Shack’ produces healthy snacks to sell for 50p and is run by the children themselves. The children can take the recipes they use home for the family to try, and Washingborough even has its own YouTube channel with the children demonstrating making a range of recipes.
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The school has worked hard to link growing, cooking and the ‘Snack Shack’ enterprise into the curriculum. For example, children record the number of portions sold and how much profit they have made. The school also runs a Farmers Market open to the community, where surplus produce they have grown is sold and other local businesses are also invited to have a stall. Overall, Washingborough Academy’s approach to school food seems to be innovative, engaging both pupils and parents in food education. In 2014, Duncan Selbie praised Washingborough for the ‘enlightened’ way it is teaching pupils about the importance of good diet and exercise.
Food for thought… What innovative growing and cooking programmes are being used in your local schools? What opportunities and challenges can you foresee in implementing an approach similar to Washingborough Academy in your local schools? How can we evaluate and disseminate evidence around the short and longer-term effectiveness of school food initiatives?
Shame vs support: a discussion of obesity stigma in public health by Daniel Flecknoe (with thanks to Dr Judy Swift) An American friend of mine pithily summed up his personal attitude towards weight management in a conversation we had recently. His exact words were, “Being fat sucks, but dieting & going to the gym sucks more”. Hearing this, I was paradoxically reminded of the infamous ‘Size Zero’ maxim, attributed to Kate Moss, that “Nothing tastes as good as skinny feels”. Although these two statements are diametrically opposed in their priorities, they also have something in common. Both encapsulate the idea of making a personal health choice after weighing (pun not intended) the alternatives. But is either of them objectively healthier, or more ethically praiseworthy, than the other? Perhaps it would be reasonable to argue that the healthy option lies somewhere in between the two extremes of obesity fatalism and emaciation chic. “Fat” and “skinny” are both terms with negative connotations in mainstream Western society, and health professionals have a difficult balance to strike between properly informing and educating patients who fall outside of the recommended BMI range, and unhelpfully increasing the levels of weight stigma experienced by those individuals. In an attempt to better understand this debate I sat down for a (fairly) healthy lunch and a chat with Dr Judy Swift, Associate Professor of Behavioural Nutrition at the University of Nottingham. Dr Swift specialises in research investigating how health professionals can communicate more effectively about obesity, in particular childhood obesity. Obesity is, as she puts it, “a complex, valueladen subject” involving a much wider array of root causes than
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the reductionist ‘energy intake > energy expenditure = obesity’ equation would imply. Deprivation [HSCIC, 2014], cultural norms, ethnicity, social networks (although still controversial, there is some evidence that obesity can be contagious [Christakis & Fowler, 2007]), attitudes to food, stress and self-image are all intertwined with our risk of becoming overweight. To further complicate matters, as Dr Swift observes, many people who are overweight (or whose children are overweight) may genuinely not realise that this is the case. Some of those who do realise it may wish, either for their own or their children’s emotional wellbeing, not to label it. Social stigma may function as a barrier to even addressing the problem, in that respect. There is no doubt that people who are overweight in the UK do experience stigma and discrimination, and that both local and national public health policy has sometimes contributed to the prevalence of this phenomenon. This may sometimes be a deliberate, and sometimes an accidental effect. Certainly, various politicians [Martin, 2010; Betts, 2010], bioethicists [Callahan, 2012] and media commentators [Littlejohn, 2010; Liddle, 2013] have suggested that people of a higher weight ought to be ‘shamed’ as a means of encouraging them to slim down. Advocates of deliberate stigmatization tend to justify such tactics by appealing to the common good, the cost to the NHS and neo-liberal ideals of personal responsibility, but it is rare to find them endorsed by health professionals. However, it is also possible to increase the stigma experienced by people of a higher weight, either at a one-to-one or group level, as a by-product of emphasising the seriousness of the problem. The Chief Medical Officer’s recent categorisation of obesity alongside terrorism as a national threat [Lay, 2015], could be said to be a (perhaps unintentional) example of this. It’s hard to see anyone feeling particularly good about being put on the same list as ISIS.
On the other hand, by over-sensitively refraining from public engagement on the subject, or by taking the view that people who are overweight are just helpless victims of “Big Food” (per capita consumption of energy, fats & sugar in the UK has actually declined significantly since the 1970s [BHF, 2012]), are we not – as public health professionals – failing in our duty to inform the public and empower behaviour change? A balance needs to be struck which proportionately identifies and addresses the problem without causing more harm than good. In discussing this question, Dr Swift and I considered the cultural spectrum of views about obesity from stigma to acceptance, from “fat shaming” [Channel 4, 2015] to the “Health At Every Size” movement [HAES, 2015]. She has researched the effects that expressed negative attitudes towards obesity can have on members of the public, and documented the internalised disgust and learned helplessness which shaming messages can create. Dr Swift’s personal position is that there is a connection between weight and health (although the way that the associated risks are usually communicated is overly reductionist), and she firmly endorses the nuanced message that there are things that people can do to be healthier at every size, independent of weight loss. There are intertwined issues of both practicality and ethics for public health professionals to consider here. Deliberately utilising stigma to incentivise weight-loss might “work”, in the sense of achieving certain predefined outcomes, but that would only be making half the case for whether or not we ought to do it [Bayer, 2008]. I am quite happy to accept that there are circumstances in which torture works (i.e. elicits the required information from a reluctant prisoner of war), and this would be a necessary yet insufficient justification for undertaking it. We have a professional responsibility to justify our actions not only on the grounds that they are supported by reasonable evidence of efficacy, but also that they adhere to a well validated framework of medical and social ethics. Of course, if a particular intervention doesn’t work there is no need to proceed to ask the ethical question – it can simply be dismissed. So, does weight stigma ‘work’ in reducing obesity?
The theoretical case for its effectiveness could be made by analogy. Looking at the relative historical successes of campaigns against smoking and drink driving (both of which have utilised the power of social disapproval), it could be argued that if stigma worked there then it should also work for obesity. However, as Dr Swift points out, smoking and drink driving are behaviours, whereas obesity is not. Obesity is the long-term outcome of a complex web of behaviours (some of which are more or less involuntary), and is therefore much less susceptible to the effect of social stigma on individual actions. There is also evidence to suggest that the more stigmatising aspects of at least some anti-smoking campaigns didn’t work very well anyway [Whipple, 2015]. Dr Swift states that while the literature provides us with some evidence that experiencing weight stigma can act a motivator for behaviour change, this is dwarfed by the de-motivational effects which have been documented. Weight stigma can result in unhealthy eating behaviours (e.g. binge eating and increased calorie consumption), reduced physical activity and motivation to exercise, decreased utilization of healthcare services, psychological disorders, poor self-esteem & body image, and stress-induced pathophysiology. As a consequence, Dr Swift strongly prefers an empowerment health promotion model for addressing this issue. The allure of mobilising social disapproval may be better resisted in favour of making healthy life choices more available to low income communities, for example. She advocates promoting positive gain-focussed messages (“Zumba is fun!”) rather than more paternalistic “You can’t eat that” prohibitionism.
Image: http://publications.mcgill.ca/reporter/2011/04/understanding-obesity-seeing-past-the-stigma/
An empowerment model of tackling obesity in the UK could also lead to a bottom-up shift in the cultural norms and obesogenic environment which currently make meaningful change so difficult to achieve. Consumer pressure, from a well-informed population exercising free choice, is a powerful force which can radically change corporate marketing decisions. Regulation, by contrast, is a blunt instrument, especially given the multiplicity of factors which can affect the national prevalence of obesity. The best way for me to lose weight is not necessarily the best way for you to lose weight, nor is it helpful for it to be imposed upon you as if it were. As Dr Swift says, it is vitally important for public health professionals to consider the potential negative health impacts of any obesity strategy in terms of increased stigma before advocating it. The social and psychological consequences of weight stigma are public health problems in their own right. Where stigma is the unintended collateral damage of our actions, that fact needs to be incorporated in both the practical and ethical evaluation of the intervention. It is all too easy to allow the overall goal of improving public health to be lost in a taskfocussed mentality which may then overlook any tangible harm that is being caused by our endeavours. We need to take the good intentions which motivated our action at the strategic level, and re-inject them at the implementation stage, otherwise unintended byproducts of the ‘solution’ may become part of the problem. It’s become a cliché to observe that a century ago the rich were fat and pale while the poor were thin and tanned, and that now it’s the other way around. The genuine historical trends in obesity prevalence which underlie this
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generalisation are associated with corresponding ecological changes in the average daily calorie count and amount of physical activity within different socioeconomic groups. However, life expectancy and health outcomes in general have always been higher for the wealthy in society, regardless of their waistlines, which would tend to suggest that deprivation is the more salient factor [see Table 1]. As a public health community, we should be cautious of obsessively targeting what may only be proxies for deprivation, especially if in the course of doing so we further isolate people who are already among the most vulnerable members of our society. Reflecting upon the two viewpoints which prompted this article, I find that I don’t want to call either Kate Moss or my American friend wrong, ignorant, unhealthy or a bad influence on children, let alone part of a national threat equivalent to international terrorism. I would like to promote a wider range of ideals of beauty that better reflect the diversity of body shapes and skin tones which make up the UK population. I’d also like to (and probably will) talk enthusiastically to my friend about how much I am enjoying cycling to work, and the benefits I am feeling from having lost a few pounds, but really, we all have personal decisions to make about what we want and are able to do about our weight. I would argue that the role of public health is to concentrate less on affecting and limiting what people want to do, and more on expanding and promoting the range of what people, especially those living in deprived communities, can do to improve their health status.
Historical trends in obesity status & health for low and high socioeconomic status groups in the UK [Table 1] Early 1900s
Early 2000s
LOW INCOME Food intake: ↓↓ Widespread calorie deficiency, Food intake: ↑↑ Excess calorie diets high in fats with almost half of poor households estimated & sugars more common in low income families.b a to have less than 80% of their required intake. Energy expenditure: ↑↑ Economy driven by low paid and physically-demanding labouring jobs in manufacturing, mining & agriculture.c Obesity: ↓ Very limited data, but appears to have been unknown in low income groups.
Energy expenditure: ↓↓ Low income occupations mainly sedentary jobs in the service industry.c Low levels of recreational physical activity.d Obesity: ↑ More prevalent in low income groups.f
SMR* for the most deprived areas of the UK – 124.0g SMR* for the most deprived areas of the UK – 121.2g HIGH INCOME Food intake: ↑↑ Calorie surplus, with high Food intake: ≈≈ Balanced diets more easily calorie diets available to wealthy Britons.a available to those with higher incomes.b Energy expenditure: ≈≈ More sedentary occupations for the wealthiest but also more recreational exercise available.e
Energy expenditure: ↑ High levels of recreational physical exertion associated with increasing education & socioeconomic status.d
Obesity: ↑ Very limited data, but appears to have only been prevalent among the wealthy.
Obesity: ↓ Less prevalent in high income groups.f
SMR* for the least deprived areas of the UK – 89.4g
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SMR* for the least deprived areas of the UK – 89.0g
* Standardised Mortality Rate – an age adjusted measurement of comparative death rates. The national death rate for each time period is designated as being 100, meaning that an SMR of >100 indicates an age-adjusted mortality rate which is higher than the national average for the time. (a) Gazeley & Newell, 2015 (b) FPH, 2005 (c) Lindsay, 2003 (d) Farrell et al, 2013
(e) Perry, 2011 (f) NOO, 2012 (g) Gregory, 2009
References Many thanks to Dr Judy Swift for giving me the benefit of her time and expertise in arranging my thoughts on this matter. Only statements or opinions which I have directly attributed to Dr Swift are necessarily hers. All other suggestions, musings and mistakes are my responsibility. Bayer R (2008) Stigma and the ethics of public health: Not can we but should we? Social Science & Medicine. 67 (3), pp.463–72. Betts M (2010) Doctors 'should tell overweight patients that they are fat'. Herald Sun [Online]. Accessed at http://www.heraldsun.com.au/archive/news/doctors-should-tell-overweight-patients-that-they-arefat/story-e6frf7l6-1225898699043 on 04/01/2016. British Heart Foundation (2012) Coronary heart disease statistics: A compendium of health statistics [2012 edition]. British Heart Foundation, London. Callahan D (2013) Obesity: Chasing an Elusive Epidemic. Hastings Center Report. 43 (1), pp. 34–40. Channel 4 (2015) 'Fat shaming' cards 'handed' to commuters on Tube. Channel 4 News [Online]. Accessed at http://www.channel4.com/news/fat-shaming-cards-handed-to-commuters-on-tube on 04/01/2016. Christakis NA & Fowler JH (2007) The Spread of Obesity in a Large Social Network over 32 Years. New England Journal of Medicine. 357, pp.370-79. Faculty of Public Health (2005) Food Poverty and Health: Briefing Statement. [Online] Accessed at http://www.fph.org.uk/uploads/bs_food_poverty.pdf on 15/01/2016. Farrell L, Hollingsworth B, Propper C & Shields MA (2013) The Socioeconomic Gradient in Physical Inactivity in England. Centre for Market & Public Organisation, Working Paper No. 13/311. [Online] Accessed at http://www.bristol.ac.uk/media-library/sites/cmpo/migrated/documents/wp311.pdf on 15/01/2016. Gazeley I & Newell A (2015) Urban Working-Class Food Consumption and Nutrition in Britain in 1904. The Economic History Review. [Online] Accessed at http://onlinelibrary.wiley.com/doi/10.1111/ehr.12065/pdf on 15/01/2016. Gregory I (2009) Comparisons between geographies of mortality and deprivation from the 1900s and 2001: spatial analysis of census and mortality statistics. BMJ. [Online] Accessed at http://www.bmj.com/content/339/bmj.b3454 on 15/01/2016. HAES (2015) Healthy At Every Size [Website]. Accessed at http://www.haescommunity.org/ on 04/01/2016. Health & Social Care Information Centre (2014) National Child Measurement Programme - England, 2013-14. [Online resource] Accessed at http://www.hscic.gov.uk/catalogue/PUB16070 on 22/12/2015. Lay K (2015) Obesity as dangerous as terror threat, warns medical chief. The Times [Online]. Accessed at http://www.thetimes.co.uk/tto/health/news/article4638602.ece on 04/01/2015. Liddle R (2013) If we don't stigmatise fat people, there'll be lots more of them. The Spectator [Online]. Accessed at http://www.spectator.co.uk/2013/10/if-we-stop-stigmatising-fat-people-well-have-lots-more-ofthem/ on 04/01/2016. Lindsay C (2003) A century of labour market change: 1900 to 2000 (Special Feature). Labour Market Trends. March 2003, pp.133-44. Littlejohn R (2010) Obese? Big-boned? No, just fat. Daily Mail [Online]. Accessed at http://www.dailymail.co.uk/debate/article-1298826/LITTLEJOHN-Obese-Big-boned-No-just-fat.html on 04/01/2016. Martin D (2010) Obese? Just call them fat: Plain-speaking doctors will jolt people into losing weight, says minister. Daily Mail [Online]. Accessed at http://www.dailymail.co.uk/news/article-1298394/Calloverweight-people-fat-instead-obese-says-health-minister.html#ixzz3wH8AoATo on 04/01/2016. National Obesity Observatory (2012) Adult Obesity and Socioeconomic Status: NOO data factsheet. [Online] Accessed at http://www.noo.org.uk/uploads/doc/vid_16966_AdultSocioeconSep2012.pdf on 15/01/2016. Perry A (2011) Victorian Sport: Playing by the Rules. BBC History. [Online] Accessed at http://www.bbc.co.uk/history/british/victorians/sport_01.shtml on 15/01/2016. Whipple T (2015) Demonising smokers just makes them want to light up. The Times [Online]. Accessed at http://www.thetimes.co.uk/tto/science/article4603124.ece on 04/01/2016.
Sugar Reduction: The Evidence for Action by Lucy Gavens & Rosie Cooper “We are eating too much sugar and it is bad for our health.� Excessive consumption of high sugar food and drink can lead to weight gain and related health problems, as well as tooth decay. Levels of overweight and obesity among adults and children have increased rapidly in England in recent decades, making it a high priority for public health.
Higher sugar foods and drinks are more likely to be on promotion, which is likely to influence purchasing in all socio-demographic groups. Research suggests that price increases (e.g. through taxation) can influence purchasing of sugar sweetened drinks and other high sugar products, at least in the short-term.
PHE have, together with other partners, reviewed the evidence-base on actions to reduce sugar consumption. The review considers the need for action (i.e. the amount of sugar consumed and sources of dietary sugar) and then identifies multisectorial interventions that could be implemented to reduce sugar intake. These fall broadly into three categories: the environment that influences our food choices, our food supply, and knowledge, training, and local action.
Recommendations:
A summary of evidence and key recommendations for each area and our reflections on those key recommendations are presented here.
1. The number and type of price promotions in all retail outlets including supermarkets and convenience stores and the out of home sector (including restaurants, cafes and takeaways) should be reduced and rebalanced. 2. Opportunities to market and advertise high sugar food and drink products to children and adults across all media including digital platforms and through sponsorship should be significantly reduced. 3. A clear definition for high sugar foods should be developed to aid with actions 1 and 2 above.
Influencers People are exposed to a high volume of marketing and advertising through a range of media (e.g. TV, radio, billboards and online). Research shows that food preference, choice and purchasing are influenced by all forms of marketing in both children and adults. Further, food price promotions are common in England, encouraging us to buy roughly 20% more than we would if products were not on promotion.
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Food supply Evidence suggests that we can change how much sugar the population consumes by lowering the sugar content of food and drink in shops, restaurants and institutions, particularly if accompanied by changes in portion size. By making lower sugar products more available, this may result in a population level shift in the level of sugar consumption. Such actions are therefore unlikely to widen health inequalities and indeed may reduce them.
4. A broad, structured and transparently monitored programme of gradual sugar reduction in everyday food and drink products should be introduced, combined with reductions in portion size. 5. A price increase of a minimum of 10-20% on high sugar products through the use of a tax or levy such as on full sugar soft drinks, should be introduced. 6. Government buying standards for food and catering services (GBSF) should be adopted, implemented and monitored across the public sector. Knowledge, training and local action There is currently no routinely available accredited training in diet and health for people who have the opportunity to influence food choices. Within their review, PHE have developed a competency framework for people working in the catering, fitness and leisure sectors, and it is hoped that relevant knowledge and improvements in diet will increase if training such as this is delivered widely alongside the development and adoption of accredited training.
7. Ensure that accredited training in diet and health is routinely delivered to all of those who have opportunities to influence food choices in the catering, fitness and leisure sectors and others within local authorities. 8. Continue to raise awareness of concerns around sugar levels in the diet to the public as well as health professionals, employers, the food industry etc., encourage action to reduce intakes and provide practical steps to help people lower their own and their families sugar intake.
Our reflections
We are heartened to see that these recommendations are targeted towards population level policies, which should facilitate all socio-demographic groups in England to reduce their sugar intake. We also fully acknowledge the important role that different types of media have in influencing dietary choice and education and feel we should maximise media opportunities to share healthy eating messages in new and innovative ways. Finally, continuing to raise awareness of the role of sugar in our diets, and supporting people to make informed choices around sugar consumption, is an important responsibility for public health.
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SugarSmartCity by David Johns We caught up for an interview with Katie Cumming, a Public Health Consultant from Brighton and Hove City Council to discuss the recent Sugar Smart City launch that attracted much media attention. Could you provide us with an introduction to yourself and how you got involved in the ‘Sugar Smart City’ initiative?
My name is Katie, I am a consultant in public health at Bright and Hove City Council. Working with a small team back in June [2015], we began planning a local public health debate. Over the years we have held several public health debates on topics such as infant feeding, alcohol and smoke free spaces, long before national legislation was put in place. We decided we wished to hold a public debate on food and at the same time, the SACN report came out with strong findings and recommendations regarding sugar intake. Given the timing of the report and recommendations [to reduce sugar intake to 5% of energy intake], we decided we would like to ask people in the City firstly whether and secondly how they thought we should be taking action on sugar. We were interested in opening the debate to as wide an audience as possible to gauge opinion but also raise awareness about sugar intake. Back at the beginning of October we launched the Sugar Smart City survey. This launched as an online and paper based survey.
‘Sugar Smart City’ was launched at a time when sugar was making the headlines with the government and PHE coming under increasing pressure to release a delayed report on methods to reduce sugar intake, was this timing deliberate? Originally, we thought we would time the debate to fit in with the PHE sugar smart campaign which was then planned for October. Then of course while we were making our preparations for the debate, PHE cancelled its campaign. That seemed a bit
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disappointing at the time but little did we know that the issue of sugar would gain much more publicity with the controversy around the delayed PHE report. It was interesting timing for us. Who were you targeting and looking to engage in your debate? We planned to engage residents generally in the debate but also wanted to specifically talk to schools: teachers, parents and pupils themselves; and food outlets in the discussion about sugar. We just wanted to again raise awareness of the sugar issue and raise awareness amongst them of the general work we were trying to do to improve the healthiness of the choices that were variable in the city when people were eating out. So our key audiences were residents, food outlets and schools.
Jamie Oliver was also campaigning for sugar reduction and specifically, a sugar sweetened beverage tax, at the same time. How did he become involved in the Brighton Sugar Smart City project and what resulted from that link? A couple of months, maybe 6 weeks prior to the launch, we decided to get in contact with the Jamie Oliver team. It was just prior to the Jamie’s sugar rush TV programme that came out but there had been a bit of publicity about that and we thought if the Jamie team were interested that would be great. We didn’t really know what to expect. Luckily, they were interested and we linked up with the Jamie Oliver food foundation. They were primarily campaigning around actions on a sugar tax and we were promoting a number of actions that our key audiences might choose to take up.
So, for residents, it was about being more sugar aware and sugar smart and for the food outlets there were a range of measures we were recommending they might consider; one of which was taking up a voluntary sugar levy. We promoted this last action with the Jamie Oliver foundation. However, there were other measures such as always having water available; looking at ingredients to reduce sugar in recipes; and labelling and promotions to help sugar smart decisions. For schools the recommendations were things like if they might consider a sugar smart snack policy and again, linking with the Jamie Oliver team, there were opportunities for schools to take up programmes focused around growing, preparing and cooking food. Were there other stakeholders that you engaged before launching this work? Absolutely, one of our key local partners and one that we work with on a number of issues is Brighton and Hove Food Partnership. They work on a range of issues from providing our weight management services to working on food poverty in the area. We also worked closely with the schools on the public health schools programme; the oral health team; and other areas within the local authority. You describe the Sugar Smart City programme as primarily a debate on the issue; however, much of the media attention talked about it as if it was an actionable strategy. Could you provide a bit of clarity on this issue? It was a combination really. We realise a lot of the media attention was on measures such as a sugar tax and that certainly wasn’t something that, as a city council, we were in a position to enforce or tell businesses to implement. Initially it was about raising people’s awareness of sugar reduction and gauging people’s interest in taking action while at the same time stating to bring in some measures such as starting to sign up outlets to sugar smart commitments, signing schools up to various
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interventions/actions around sugar. We knew that for us it wasn’t an option to enforce a 10p levy, the first step had to be about engaging people. Do you have any initial results of your survey that you are able to share with us? What was interesting was the results of the debate did show that over 80% of the respondents were concerned about sugar in food and drink and, for the majority, over 70%, their concern had increased in recent years. Again, over 80% did suggest that action should be taken to reduce sugar intake and that we should be prioritising young children and teenagers in that action. Going on through the different types of actions: 80% agreed or strongly agreed that food outlets should be making healthier options more available and more attractive 80% said schools or academies should be taking action to reduce sugary drinks 77% thought there should be fewer sugary drinks and snacks available in facilities like leisure centres. 72% said there should be stricter rules in primary schools to limit high sugar items in lunch boxes and snacks. For us this was also about getting the mandate to go ahead and bring in further measures; which felt like an important step. As well as the survey, we had events for young people, staff and parents with a panel of experts; various focus groups and smaller group discussions with families and food business owners that raised some interesting qualitative findings.
It became clear over the course of the debate that the issues raised were things that people felt strongly about. It also became clear there was an issue about having freedom of choice as well. What are the next steps? Following the results of the survey we are developing more of the detail around our action plan. Obviously, some of it is already underway with schools having sugar smart assemblies, outlets making sugar smart commitments and starting work on vending machines and with supermarkets and other key players. We realise that this isn’t stuff that changes overnight. One of the key areas of the Sugar Smart City Programme was around addressing vending machines in local authority buildings and increasing the number of healthy options. With public health being integrated within local authority, have there been any quick wins in this area? That is absolutely one of our main objectives and sugar smart vending is something we are committed to in local authority, particularly health related, buildings such as leisure centres. However, it is not proving to be a quick win. There are several pilot machines locally that have been trying healthier vending but it is a challenge and one that we are keen to learn from other areas that have had success in making changes in this area. Since your launch, PHE have released their evidence review. How will this impact your plans? We were happy that PHE released that evidence review and made their recommendations around advertising, marketing and promotion. Personally, we have to have those kind of actions from a government point of view to make a difference on sugar but also fat, salt and other factors that really influence the quality of the food we eat and the amount of calories we are taking in. It is a complex area and not something that one individual action is going to address what we are facing in even the diet component alone in childhood obesity. As such, there have to be a number of actions both locally and nationally including with the food industry if we are really going to see a difference.
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PHE highlighted a lack of evidence of interventions in a UK context. Do you have plans to evaluate and feedback into the national picture? After the results of the survey and now we have that mandate to go ahead on various actions, part of the development of our action plan has got to be working out how we are going to monitor and evaluate not only those actions but also work out how we should be, to the best we can, evaluating any impact in the longer term. Compared to many other places in the UK, the Child Measurement Programme stats are better [with regards prevalence of overweight and obesity] than many other areas of the UK. That being said we do have 1 in 4 children leaving primary school overweight or obese which is not good at all. We will be watching these kinds of longer term outcomes closely as well as dental caries. If we can we would really like to be monitoring the impact on patterns of behaviour across the city. We know it’s challenging and not the easiest thing to evaluate, particularly with diet but we are interested to feedback what we can back into the national picture including the strengths and weaknesses of what we are trying to do.
Many programmes centred on a community approach have faced challenges with sustainability, is this something you are looking at? We are in the early stages of planning at the moment but sustainability has got to be one of the key influences determining how we do this. While it makes sense for public health to drive this for now, our work with the Brighton Food partnership and other organisations mean that we hope other stakeholders will take up the sugar smart commitments and that it won’t just remain nested in public health. It is not about short term action but about long term behaviour change and obviously that is much easier in an environment that supports it. Are there any lessons for other local authorities based on the work you have done so far? In terms of a debate, I think it is good to raise awareness of an issue and get people talking about it. I think this is an important first step.
Food for thought… On what public health topics would your area benefit from open, public debate? Are ‘celebrity’ partnerships always a success? Should the public health community engage more with ‘big names’ to promote public health? How do we monitor and evaluate the impact of complex, system wide approaches to obesity?
It has been an interesting experience working with the Jamie Oliver team and they weren’t quite sure about it to begin with and why we were launching a debate and not just implementing measures but I think they have seen that it was the time for people to talk about it locally and nationally.
Acknowledgements: Many thanks to Dr Katie Cumming for giving me the benefit of her time and expertise on this topic. More details on the sugar smart city debate can be found here: https://www.brighton-hove.gov.uk/content/health/healthylifestyle/sugar-smart-city-what-do-you-think More information on the NHS Change for Life Sugar Smart campaign can be found here: https://www.nhs.uk/change4life-beta/campaigns/sugarsmart/home
Getting up-to-date with “The eatwell plate” by Catherine John A “national food guide” has now been with us in one form or another for over 20 years and, perhaps surprisingly, has changed little in that time. Following the target-heavy Health of the Nation White Paper in 1992, the government’s Nutrition Task Force aimed to produce a userfriendly illustration of “an agreed core structure of food groupings” to improve public awareness of the optimal balanced diet. Pyramids, triangles, circles and rainbows were all given consideration but research with key target groups showed that a tilted plate yielded better understanding and recall, and so in 1994 the “Balance of Good Health” was born.[1] Other countries chose different routes: a pyramid is used the US, a rainbow in Canada and the familiar plate in Australia. Back in the UK, a review in 2003 found that whilst a tilted plate remained the most relevant and popular format, the image could be “more appealing”. Moreover, consumers found some elements of the labelling confusing and wanted to see a wider range of foods that were “recognisable” and “real”.[1] The eatwell plate was the result, and remains in use some 12 years on. Yet evidence from the National Diet and Nutrition Survey (NDNS) shows that the majority of the population struggle to achieve the ideal balanced diet. Amongst adults of working age, less than a third consume five portions of fruit and vegetable per day, and amongst teenagers the proportion is alarmingly low at 10%.[2] Recent interest in the role of sugar in our diet also has implications for the plate. The founders of the “Paleo Diet” ruffled PHE’s feathers in late 2014 by taking to social media to suggest that the eatwell plate was contributing to the burden of obesity by endorsing meals largely composed of highsugar, highly-processed foods depicted on the plate. While PHE
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rapidly quashed this suggestion, the inclusion of fizzy drinks, confectionery – and indeed fruit juices – on the plate is clearly a contentious issue. Moreover, it is out of step with last summer’s SACN report which found that our daily intake of “free sugars” should be considerably reduced.[3] The time is ripe, then, for the plate to be refreshed. Following the release of the SACN report in draft format in autumn 2014, PHE established an external reference group to oversee the challenge of translating a raft of increasingly complex dietary recommendations to a simple and eye-catching image which both represents the diversity of foods consumed the UK and remains realistic and accessible to the average consumer. This has included modelling work using a range of approaches – including substituting foods to move from current dietary intakes (according to the NDNS) towards the recommendations, and converting menus such as FSA Scotland’s eatwell week and PHE’s Healthier and More Sustainable Catering menus into a single plate.[4] Stakeholder consultation and consumer research has also been undertaken, with the first phase of research looking at understanding of the current plate and options for change. The new plate is expected early this year, along with the national childhood obesity strategy and a refreshed 5 A Day.
References Public Health England (2014). External Reference Group – eatwell plate background. Available from: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/4 46650/eatwell_Background_Paper_FINAL_updated.pdf Public Health England (2014). National Diet and Nutrition Survey: Results from Years 1-4 (combined) of the Rolling Programme (2008/2009 – 2011/12) Executive summary. [Online] Available from: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/3 10997/NDNS_Y1_to_4_UK_report_Executive_summary.pdf Scientific Advisory Committee on Nutrition (2015). Carbohydrates and Health. [Online] Available from: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/4 45503/SACN_Carbohydrates_and_Health.pdf Public Health England (2015). External reference group: eatwell plate modelling outcome paper. [Online] Available from: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/4 37134/ERG_eatwell_modelling_outcome_paper_final.pdf
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Hospital Nutrition: Nottingham University Hospitals by Tiffany Burch Two years ago I went through a 40 hour labour to finally give birth to my beautiful baby boy. After such a strenuous task I was absolutely ravenous, but I was so sad and disappointed when I was given a meal that, frankly, my dog would not have consumed. My plate contained slimy and congealed turkey with over-boiled carrots, boxed mash potatoes and a side of the world’s most horrific sausage. Unfortunately, there were no other options that were any more palatable. I was required to stay in hospital for a week and only ever provided this sort of meal. Unfortunately, I know I am not alone with my terrible hospital food experience. Most items on offer in the canteen were similarly disgusting and very expensive. Thankfully a large grocery store was minutes away so my husband brought me grapes and cashews. The memory of my hospital food has not left me, and I dread ever going into that hospital again. I wondered how patients staying longer than a week can cope with such culinary offerings. Luckily Nottingham University Hospitals (not my hospital) are acutely aware that food and nutrition are key to the health and wellbeing of patients, staff and visitors! The Dietetics and Nutrition team employs Nicola Strawther, a Chief Dietetic Technician, who works tirelessly to ensure the food available is both enjoyable and healthy. As part of NUH’s efforts to ensure patients are not having negative hospital food experiences, Nicola works as part of a multidisciplinary team for hospital nutrition including: dietetics, catering,
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practice development nurses, language therapists and patients. When Nicola and I sat down to chat, I was very impressed to hear they have multiple menus and patients have CHOICES! My mind was blown. The menus planned by NUH start with the Eat Well plate and are then tailored to the specific nutritional requirements of each patient. For example, the Eat Well plate is not suitable for renal patients. Other patients will require more fat and sugar to increase protein and calories, and others will just not be interested in anything other than chicken nuggets and chips. Thanks to NUH’s electronic ordering system, patients are allowed control of the size of portions they receive. This helps ensure less waste and patients are satiated. As taste did not seem to be a consideration of the food on offer at my hospital, I asked Nicola what NUH does to ensure the food is yummy. Nicola and her team organise monthly food tasting sessions with patients, catering, nurses and contract mangers on hand. Based on patient and staff feedback, specific foods are chosen to be reviewed each month. The portion sizes, taste, nutritional content and appearance are all critiqued. From these sessions recipes may be changed or food may be removed from the menus. The tasting sessions allow for her team to engage with patients and staff, and these sessions also help maintain NUH’s requirements for the Soil Association’s Food for Life Gold Catering Mark.
NUH is one of only 30 hospitals across the country to have a Food for Life catering mark, and one of five hospitals with the Gold level. The Catering Mark provides an independent endorsement that food providers are taking steps to improve the food they serve, using fresh ingredients which are free from trans-fats and harmful additives, and better for animal welfare. Despite having an exemplary menu made with fresh local ingredients, many times staff pressures on the wards mean meal provision and services are not to the standard Nicola and her team expect. To help engage nurses on the wards, Nicola’s team conduct meal observations to determine how best to improve meal times. Special events such as multi-professional nutrition days aim to improve communication between staff groups, increase staff confidence to manage the care of patients with special diets and improve patients’ experiences while in hospital. In light of the sugar tax debate and my general impression that hospital retail is mostly junk food, I asked Nicola what she and her team are doing around this topic. Nicola works closely with the food retail provider to ensure a suitable selection of healthy options while also reducing the number of unhealthy options. Efforts so far have included reducing the number of biscuits and cakes and offering fruit with the meal deals. According to Nicola, getting the balance of healthy food versus junk is tricky. She is keen for the hospital to provide a good example for patients and staff, but it also
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does not want staff, patients and visitors to be disgruntled by the food choices available. Vending machines present a specific challenge as night staff have few food choices after NUH’s restaurants and shops have closed. While working nights, many staff want high calorie foods to get them through their shift. To help discourage poor dietary consumption by staff, the Health and Wellbeing team at NUH are working to educate staff on weight and diet. Nicola and her team are working very hard to improve the food experience of NUH’s patients and staff, and they are doing a fantastic job of health promotion in the hospital setting. I can only hope my local hospital soon becomes more like NUH!
Acknowledgement: With thanks to Nicola Strawther for sharing her time and knowledge of this topic.
Food for thought… Do you know what your local hospital is doing to improve and/or maintain high nutritional standards?
What could local authorities learn from NUH and other hospital trusts about nutritional provision for staff in their own buildings (e.g. vending machines, catering etc )?
Detecting and Treating Malnutrition in Older People by Rosie Cooper & Lucy Gavens Malnutrition is “a state in which a deficiency of nutrients such as energy, protein, vitamins and minerals causes measurable adverse effects on body composition, function (including social and psychosocial) and clinical outcome” (NICE, 2012). Approximately one third of patients admitted to acute care and 35% of individuals admitted to care homes will be malnourished or at risk of becoming malnourished (NHS, England). Contrary to popular belief, malnutrition is largely preventable and treatable and is not an inevitable consequence of the ageing process (Wilson, 2013). Malnutrition is caused by a range of factors including lack of food accessibility or affordability, difficulties in cooking, social isolation, and ill health (including both physical and mental ill health). A rapid review of evidence and guidelines for malnutrition among older people has identified a range of recommendations that can be used to support a reduction in malnourishment in this population. These recommendations address both clinical and community settings, although given the transient nature of older people’s care, it is recommended that a holistic approach be used to detect and treat malnutrition across all settings.
Key recommendations are:
Awareness of malnutrition and how to prevent it should be raised, including among older people, family and friends, carers, health care professionals, and the wider public. Care professionals in all care settings should be appropriately trained on nutrition care. The Malnutrition Universal Screening Tool should be used to detect individuals at risk of becoming malnourished. Local and community planning should incorporate access to nutritional food. Malnutrition should be addressed using an intersectoral approach and communication between health care professionals should be comprehensive and consistent.
Food for thought…
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What is the prevalence of malnutrition in your local population? Are there high-risk groups to be aware of? Can people with a BMI >25 also be malnourished? If so, how do we address this? What are the implications for population level approaches to addressing obesity, for people who are malnourished?
Thank you for reading!
http://food.ndtv.com/photos/funny-food-puns-youll-love-17744/slide/1
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