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Archive for September, 2017

By Prof John Middleton, FPH President

John Middleton 2 web

August was a stock-take month for me. I held several meetings which all pointed to the need for public health and the woeful neglect of public health expertise by local, national and international policy makers.

Early in August we held a productive session of the Global Violence Prevention Special Interest Group which resolved to look at training tools for work in conflict and post-conflict areas – how to make rapid needs assessments, how we build alliances with public health resources in conflict areas and how we make sense of prevention and resolution of conflict through working with political scientists, theologians, international lawyers and aid non-governmental organisations. The work is being led by Daniel Flecknoe and Bayad Nozad. We plan to join up this work with that of Brian McCloskey and David Heymann for Chatham House (Royal Institute of International Affairs) looking at emergency responses in conflict zones. Mark Bellis’s work for the Commonwealth will also play a key part. The FPH statement says our unique role is in preventing violence and building and implementing the evidence base – locally, nationally and internationally. Economic inequality and unequal power-sharing are major causes of violence at local, regional and international level, and major challenges for the public health community, whether in relation to violence, childhood obesity or premature mortality. It is clear to me that FPH can play a greater role in violence prevention by harnessing the disparate skills of our members, from the frontline to high-level international policy – in emergency preparedness, health protection and health services organisation and in public mental health and community development.

In August I also met with David Ross from the armed forces public health services. They clearly have much expertise to contribute – in relation to international conflicts and closer to home. We have resolved to have a meeting with forces colleagues in the new year. The root causes of violent behaviour are also often the root causes of accidental violent injury. This was never more demonstrated than with the Grenfell Tower disaster. I am pleased that we could respond to the terms of reference consultation for the inquiry. Sadly our representations were not heeded and a limited range has been set for the inquiry with a junior minister leading consultation on the implications for social housing and some superficial examination of the causes of the causes. Nevertheless, I am extremely grateful to the FPH members who responded rapidly to our request for help on the Grenfell submission and particularly to Ruth Gelletlie who put together our response on the terms of reference. We received a wealth of material on every aspect from health protection and response, public mental health responses, health inequalities and the London housing market, building design, regulation and controls and social issues regarding migration and homelessness. Ruth and colleagues in the revitalised Housing and Health Special Interest Group will be drawing on this material for our formal submission to the inquiry (and for a listening minister…?)

A sustainability and transformation partnership has announced a £2.7million contract with the private sector for a year’s support for an accountable care organisation. It’s a mind-numbing figure and would buy an awful lot of public health health-care expertise and analysis. We will follow this programme carefully and see what it teaches… and in the meantime, continue our work to rebuild training and capacity in healthcare public health.

As we return from the summer holidays, FPH will once again get into full swing with major policy-planning days. Our workforce strategy is nearing completion and will be formally signed off in November. We are much exercised by the need to build our membership and would urge you to invite all your colleagues to join us – we have a category for virtually everyone working in public health or associated with our work. I will also be involved in the Academy of Medical Royal Colleges planning days. Our policy team priorities on Brexit and public health funding are taking shape. I will be at the Public Health England conference in Warwick at which we will launch the Public Health Prevention Concordat for good mental health. I will also be speaking at MEDACT’s conference in York with the International Physicians for the Prevention of Nuclear War on the theme of the progressive-health movement. I will also be speaking at the Oxford public health registrars symposium on the theme of partnership in public health. I believe there are still places available at all of these meetings.

As the US President flexes his nuclear options, and our government stumbles over complex imponderables of Brexit, it is clear to me we absolutely need a progressive health movement which addresses inequalities in income, in opportunity, in education and environment, which understands and builds new programmes for public mental health and conflict resolution, which stands strongly for non-violent resolution of problems, which looks at the health impacts of all policies and across future generations, and which believes in partnership, in shared benefits and better outcomes for all.

Can I draw your attention to an exciting event coming up which provides a unique opportunity to share learnings about advocacy. Mike Daube, Professor of Health Policy at Curtin University, Perth, Australia, will be delivering the DARE Lecture entitled ‘Not a Spectator Sport: public health advocacy and the commercial determinants of health’ on 27 September in London.

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By Dr Jennifer Mindell, Reader in Public Health, Research Department of Epidemiology and Public Health, University College London

Today nearly a third of children aged two to 15 are overweight or obese (1, 2), and younger generations are becoming obese at earlier ages and staying obese for longer. Given the evidence that children and adults’ diet is influenced by advertising, summarised by Adams and colleagues (3), the World Health Organization (WHO) made 12 recommendations in 2010 about marketing food and non-alcoholic drinks to children (4).

However, industry spends 500 times as much on promoting high fat, salt or sugar (HFSS) foods as the WHO spends on promoting healthy diets. For example, food companies in the UK spend one billion pounds on marketing. Not surprisingly to a public health audience, there are marked differences in proportions between constituents of a healthy diet and food advertising (Figure). The ways that marketing can influence behaviour, as well as some examples, were available in the presentation given at the FPH 2017 annual conference session organised by the FPH Health Improvement Committee.

Disproportionate food advertising
Adapted from: www.foodcomm.org.uk/pdfs/Broadcasting_bad_health.pdf

In the UK, legal restrictions on television advertising of HFSS foods to children under 16 focused on preventing screening of such advertisements on children’s channels, and around or during programmes on general channels of particular appeal to children aged 4-15 years. As the Health Improvement Committee had predicted, this had no effect on children’s exposure overall (despite adherence to the restrictions) because of increased HFSS advertising around programmes aimed at a general audience, not covered by these regulations, screened before 9pm (4): larger numbers of children watch these general programmes than watch ‘children’s TV’. Similar restrictions were introduced on 1 July 2017 on advertising HFSS foods to children under 16 via non-broadcast media, including on children’s media and on media where children form more than 25% of the audience. However, the exclusions are many (see examples).

Discussions by about 25 people at the FPH conference session produced the following policy suggestions:
A. Gold standard: Ban advertising of all HFSS products (regardless of to whom, when, where).
B. Banning marketing aimed at or influencing children is a good place to start, if (A) isn’t (yet) politically acceptable. This should be a part safeguarding children.
C. We need to keep reiterating our point that the proportion of the audience who are children is irrelevant:

  • Far more children may watch a generally popular show (eg. X Factor) than children’s TV or TV programmes where children are 25%+ of the audience, so restrictions need to apply based on the number of children exposed as well as the percentage.
  • Advertising aimed overtly at adults also influences children through what adults buy for them, what adults do, and what adults see as the norm.

D. Online material is now more important than TV; even TV is mostly watched on-demand, so the timing of programmes is now largely irrelevant: Should we ignore the watershed?
E. Ban anything aimed at children or young people, eg. toys, cartoon characters, celebrities, that can increase desirability of the associated HFSS products or influence behaviour adversely. The Olympics should not be associated with MacDonalds, Coca Cola, etc.
F. Ban HFSS product displays and marketing at point of sale (PoS) eg. supermarket checkouts, newsagents.
G. Ban displays of HFSS products at children’s height (put on top shelves only?)
H. Ban HFSS displays or marketing posters in shop windows (seen by children as they pass).
I. Ban marketing that displays people eating except when sitting at a table for a meal The benefit of the Mediterranean diet may be partly because of eating slowly at a family meal while talking, etc, instead of eating ‘on the go’, as well as the actual diet itself.
J. Harness the opportunity of controlled environments to change the accepted norms (eg. rules for schools, workplaces, hospitals, prisons).
K. Recognise the time it takes to change social norms and to make regulation socially acceptable; balance this with the size of impact of HFSS products on health and health inequalities.
L. Need for a clear iteration of the harms of HFSS with agreement amongst influential public health bodies, to start influencing the debate.

Other ideas suggested were to ban price-based promotions of HFSS, given that fruit is often more expensive to buy than crisps or chocolate bars. Chile introduced health warnings and standardised packages for HFSS last year; we need to monitor what effects these have. Brexit may yield an opportunity to influence front-of-packaging labelling, for example by portion size rather than per 100g, if EU rules no longer apply. Given most children’s incessant exposure to marketing, schools should be encouraged to teach advertising literacy.

The main conclusions by those attending as that this is a societal responsibility, rather than individuals or their parents being to blame. Population-level initiatives are needed to control commercial activities that are costly to the country both in terms of poor health and regarding healthcare, social care, and economic costs of ill health.

References:

1. Fuller E, Mindell J, Prior G (Eds). Health Survey for England trend tables 2015. Leeds: NHS Digital, 2016.
2. Childhood obesity: a plan for action. London, 2017. https://www.gov.uk/government/publications/childhood-obesity-a-plan-for-action/childhood-obesity-a-plan-for-action
3. Adams J, Tyrrell R, Adamson AJ, White M. Effects of restrictions on television food advertising to children on exposure to advertisements for ‘less healthy’ foods: repeat cross-sectional study. Plos One. 2012;7(2):e31578.
4. World Health Organization. Set of recommendations on the foods and non-alcoholic beverages to children. Geneva: WHO, 2010.

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By Claire Beynon MFPH

BACP Travelling Fellowship
Every two years the Faculty of Public Health (FPH) awards a BACP travelling fellowship to assist members of FPH in training to undertake educational travel. This fund was established in 1994, using funds donated by the British Association of Community Physicians (BACP) on its dissolution.

At the FPH Conference in Telford in June I was delighted to receive the travelling fellowship funding based on my application to travel to Japan to experience its culture and make observations about why its levels of childhood obesity were so much lower than those in the UK, and to present my public health work at a conference in Japan.

Observations on Childhood Obesity in Japan
Before I left for Japan I read many articles that explored the differences between childhood obesity rates in the USA and Japan. Their focus was on lifestyle factors including diet and physical activity.

Whilst in Japan I met with several academics who specialised in obesity, physical activity and diet. They were all most welcoming and shared their research and experiences readily.

The key points they raised were:

  • Younger children spend less time in school. As age increases so does the length of the school day. This gives more free time for outdoor play.
  • 90% of children walk to school daily.
  • Children do three hours of physical activity each week in school time.
  • There are no cleaners in Japanese schools; part of a child’s everyday activities includes cleaning their own school – children are active when cleaning.
  • Schools often have before-school sports clubs as well as after-school sports clubs.
  • Between each lesson there is a five-minute break to allow children to run around in the play area. This is in addition to morning break, lunch and afternoon break.
  • There are multiple opportunities in school for competitive sports, with regular competitions and celebrations. Children spend time practising for these with friends.
  • Children have three hot meals a day at breakfast, lunch time and in the evening.
  • Children serve each other a cooked meal at lunch time and sit and eat this hot meal together.

Further Observations
Whilst travelling in Japan I observed a number of additional environmental factors that tip the balance in favour of walking and cycling:

  • Priority is given to the pedestrian, then cyclist, then the motor vehicle. Encouraging walking and cycling. By giving priority to more vulnerable road users speed of motor vehicles is also decreased.
  • Cyclists and pedestrians share the pavement area, which is often separated from the road with a barrier and/or low-level bushes. This makes for a safer cycling experience than the UK where cycle lanes are often shared with buses.
  • There were a number of covered shopping areas, which were accessible only to cyclists and pedestrians and proved very popular thoroughfares.

    Shopping area in Japan

    Covered shopping area where pedestrians and cyclists share space

  • There was consistent and regular signage for cyclists and pedestrians, including details of directions and distances to the nearest public transport options.
Example of road, cycling and walking space in Tokyo

Example of road, cycling and walking space in Tokyo

• The number of employed people working on any urban street was much higher than the UK, with police highly visible, construction staff, cleaners, car park attendants and others all adding to the sense that the street was a safe place.

 

Policeman on the street in Japan

Presence on streets of local police make a space feel safe

• Public art installations make walking and cycling spaces more interesting and appealing.

Street art in Japan

Example of simple art installation

We know from the 2007 Foresight Report that obesity is a complex issue with multiple factors influencing obesity levels in adults and children. My own research looking at the risk factors for obesity in children in Wales using Welsh Health Survey data showed a reduced risk of obesity for children who met the one-hour physical activity guideline.

 

The new experiences and culture that I have experienced from this educational trip make me more determined than ever to tackle childhood obesity in Wales. I am looking forward to being involved in the drafting of an obesity strategy for Wales as part of my placement with the Welsh Government and will share my experiences with other registrars and colleagues at every opportunity.

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