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Archive for the ‘Chronic Disease’ Category

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

The government is proposing to ban the sale of diesel and petrol vehicles from 2040, to address air pollution in the UK that regularly breaches health-based EU regulations.

There are three main ways to improve UK air quality: reducing emissions from vehicles; driving less; and dealing with other sources of air pollution. The government’s preferred approach seems to be ‘business as usual, but less pollution from existing travel patterns’. Yet, even with this route, they are not committing to a scrappage scheme for diesel. This would produce air-quality benefits in the short-term, instead of in the 2040s – or even the 2050s and 2060s, as some individuals and businesses keep their vehicles for a long time. A scrappage scheme needs to be available to all individuals and businesses, regardless of size, and needs to encompass vehicles of all ages. Although older vehicles are known to be very polluting, no-one really knows about new vehicles! This could be complemented by financial help for retrofitting, particularly for older buses and lorries, if replacement isn’t an option.

Drivers of diesel cars are understandably aggrieved. They were urged to buy diesel engines by previous governments and given financial incentives to do so, because of the lower CO2 emissions per km. The higher emissions of other pollutants were ignored. Those with newer vehicles have no idea what their car really emits, due to the scandalous behaviour of manufacturers. This is yet another parallel with the tobacco industry (1) which designed cigarettes to produce low tar and nicotine in the laboratory but not when used by actual smokers.

Chargeable clean-air zones (low or ultra-low emission zones) are, according to a technical report issued by the government earlier this year, the most effective mechanism, but we understand that the government’s strategy will restrict charging to the last, not the first, resort. This is one of the areas, along with improved infrastructure for transport options other than private car use, that local authorities can contribute to greatly, but they need adequate powers and adequate resources. As air pollution costs the country £20 billion annually (2), the proposed figure of £255million to local authorities is a drop in the ocean.

The government is apparently also going to urge local authorities to speed traffic flows, by amending traffic-light settings and removing speed humps. What is actually needed is more calming, not less, to support smoother driving. It is not speed humps but the marked acceleration and braking that many drivers do that increases pollution. Greater use and enforcement of, and adherence to, area-wide 20mph limits without traffic calming would be better still.

Lower speeds, which would also support more and more pleasant walking and cycling, bring me to the better approach. Instead of persuading (in the next two decades) or requiring (from 2040) people to replace their existing car with an electric car, the health gains would be far greater if people travelled by public transport, walked or cycled whenever possible. As well as reducing pollution and carbon emissions, this generally increases physical activity and can improve wellbeing and reduce obesity and its consequences.

Reductions in pollutant emissions can also be achieved by reducing the need to travel. If people who could do so worked at home once a week, that would reduce their commuting by 20%. Land-use planning that encourages mixed use can shorten journeys sufficiently to make non-car options more feasible, although this will take longer. But as the government proposal for banning sales of diesel and petrol cars is to start in 2040, they are talking longer term anyway.

The government also needs to acknowledge that, although mobile sources are the largest category of pollutants, they are not the only ones. Two major contributors are buildings, including both homes and businesses, and transboundary industrial pollution from mainland Europe. Ministerial engagement with European countries will be necessary to deal with the latter. Local authorities need to be given the powers to address the former.
Air pollution is a major contributor to health inequalities. Poorer people are more likely to be exposed to higher pollutant levels. They are also more susceptible to the harmful effects of pollutants as they are more likely to have circulatory diseases (particularly heart disease and strokes) and respiratory diseases, such as chronic bronchitis or emphysema (now called chronic obstructive pulmonary disease) or asthma. Improving air quality is an important factor in reducing health inequalities.

The other option that we trust the government won’t take is to move the goal posts when (or if?) the UK is no longer bound by EU legislation. That would really be a cynical approach to the population’s health.

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1. Mindell J. Lessons from tobacco control for advocates of healthy transport. J Public Health Med. 2001; 23:91-7.

2. Royal College of Physicians, Royal College of Paediatrics and Child Health. Every breath we take: the lifelong impact of air pollution. London: RCP, 2016.

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  • Amy Smullen
  • Policy Officer
  • British Heart Foundation

The nation’s oversized waistline is putting our hearts under increasing strain.

We know that obesity puts people at a greater risk of coronary heart disease and having their lives shortened by a heart attack or stroke. But this isn’t just a problem of the here and now. It’s one that’s already waiting in the wings to devastate future generations as well.

junkfood_image

Watershed? why we need to ban some food adverts before 9pm

Around 30% of children in the UK are now classed as either overweight or obese. (1) Dietary surveys show that children are also eating too much saturated fat, salt and sugar. (2) Together, these factors put too many children at risk of carrying their excess weight and poor eating habits into adulthood, putting their hearts at risk.

That is why the British Heart Foundation (BHF), alongside many other organisations, such as the Faculty of Public Health want to see advertisements for food and drink that is high in saturated fat, salt and sugar (HFSS) banned before the 9pm watershed.

The BHF are acutely aware that obesity is a complex problem that requires action on lots of fronts. We don’t pretend banning junk food adverts is a magic bullet. But the sad reality is that our children are being bombarded with clever marketing encouraging them to eat products that have little nutritional value whether it’s walking to school, surfing the internet or watching TV at home. Banning these adverts before 9pm and tightening online regulation has to be part of the solution.

So why have we focused in on junk food adverts?

Firstly; because children aren’t like us adults. They cannot distinguish between what is harmless entertainment and what is persuasive advertising (3) and are they are therefore classed as a vulnerable group when it comes to advertising. Industry regulator Ofcom (4) states that ‘media literacy develops with age and … it isn’t until after 11 or 12 years of age that children can articulate a critical understanding of advertising.’

Second, research shows that food promotion, such as TV ads, can influence children’s food preferences and consumption. (5) Adverts also encourage general consumption, meaning that an advert for a specific chocolate bar won’t make you more likely to buy just that specific brand but any chocolate bar in general. (6)

And thirdly, on average our children are spending 27 hours either online or watching TV every week. That averages out at just under 4 hours per day. And it’s not just a few children skewing the average. Over 80% of children aged 5-15 watch the TV almost every day (7).

In 2007, the Government acknowledged that HFSS advertising was a problem, and banned any HFSS adverts during children’s programming. (8) But, while reducing the number they saw, this hasn’t stopped children seeing them.

That’s because adverts which are banned during children’s shows can be shown during family programming. Shows such as The Simpsons, X-Factor, and Britain’s Got Talent are technically classed as ‘family programmes’ despite high child audience levels. (The last two programmes made it into the top 20 programmes most watched by children in 2013.) (9) As such, marketeers are allowed to advertise any product they want. An audit by the University of Liverpool in 2013 showed that  almost one in four TV adverts shown between 8-9pm, when children’s viewing peaks, were for food products. (10)

Online, it’s even worse. It’s no secret that our children are online more than ever. Worryingly many of the techniques used to promote food and drinks online blur the lines between persuasion and entertainment, making it difficult for children to identify online marketing. (11)

Take, for example, advergames. These are online games that have a brand or marketing message integrated into them. Where a TV advert may only last for 30 seconds, research has shown that children spend longer engaging with the product message and engage with the brand at a deeper subconscious level. (12)

Adding to this the Committee of Advertising Practice Code, which governs marketing on advertisers own websites and their social media channels, doesn’t distinguish between healthy and unhealthy food.

The code states that “marketing communications should not condone or encourage poor nutritional habits or an unhealthy lifestyle in children’ – but what constitutes ‘condoning and encouraging’ or ‘poor habits’ is not defined.

But isn’t it all down to the parents? Shouldn’t they be policing their children more?

While we agree that parents are responsible for helping children eat a healthy balanced diet, these adverts undermine their efforts to do that. When we asked parents for their views, 70% of them told us that they had been pestered to buy HFSS products that their children had seen advertised on TV and 39% of parents said that these adverts were making it difficult for them to help their children eat a healthy diet. (13)

Over 30,000 people have already signed our petition, which calls on the Government to ban HFSS adverts before the 9pm watershed. Alongside the BHF and Faculty of Public Health the Academy of Medical Royal Colleges, the Royal College of Paediatrics and Child Health, Children’s Food Campaign, UK Health Forum, The Heart of Mersey, the British Dental Association, Family and Childcare Trust, the Association for the study of Obesity and the University of Liverpool also call for a 9pm watershed ban.

The demand for action is getting stronger and louder.

Help us stop these adverts by signing our petition to send a clear message to the Government that they must stop our children from being bombarded with HFSS adverts to protect their health.

1) British Heart Foundation (2013) ‘Children and Young People Statistics’ http://www.bhf.org.uk/publications/view-publication.aspx?ps=1002326
2) Department of Health (2014) ‘National Diet and Nutrition Survey: Headline Results from Years 1, 2 and 3 (combined) of the Rolling Programme 2008/09 – 2011/12.
3)  E.g. Young B (2003) ‘Does food advertising influence children’s food choices?’ International journal of Advertising 22: 441-459. Hastings et al (2003) ‘Review of the research on the effects of food promotion to children.’ Food Standards Agency
4)  Livingstone S (2004) Childhood Obesity – Food Advertising in Context.
5)  Ofcom (March 2006) ‘Television Advertising of Food and Drink products to Children: Options for new restrictions: A consultation’ (para 1.8).
6) Hastings et al (2003) ‘Review of the research on the effects of food promotion to children.’ Food Standards Agency.
7)  Ofcom (2014)
8) Ofcom (2007) ‘Television advertising of food and drink products to children – final statement.’
9) Ofcom (2014)
10) Boyland, E and Whalen E (2014) ‘Analysis of food adverts shown during a sample of primetime television.’
11)  A.Nairn (2009) ‘Changing the rules of the game: implicit persuasion and interactive children’s marketing.’ Berkley Media Studies Group
12) Nairn, A. (2012) ‘Advergames: It’s not child’s play.
13)  British Heart Foundation (2015) survey.

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Gelada baboons
Move along there: Gelada baboons

By Dr Jackie Spiby

We are still here in Addis Ababa. We have survived the rainy season and the sky is blue again.

Many of you will have seen the news about the famine in the south east of Ethiopia where it borders Sudan and Kenya. Sitting in Addis, it is as difficult to understand the whole story here as it is at home. We pick up the news and some of the debate from the BBC when the internet is working. When we travelled to the south recently, everywhere looked really fertile and verdant as it was just after the rains. But at work I do hear about problems with food-aid delivery and families that can’t feed their children.

As recipients of Global Fund money, my organisation has to have pristine financial arrangements. The management audit letter we received recently could have been one found in any PCT. By the way do PCTs still exist? The only difference was that they were querying why a goat had been bought. I recently found myself on an appointments committee for an internal auditor – something I have managed to avoid in the UK. Amazingly my interviewing instincts rose to the fore. I was delighted that my first choice was the same as the finance director’s. It did help that the interviews were in English. So, another country another culture but actually much is the same.

We took a few days off to travel north to trek in the Simien mountains. Ethiopia lies in the East African Rift Valley so much of the north and central areas are hilly in stark contrast to the desert areas bordering Sudan and Somalia. We were walking at three to four thousand metres and were surprised that it was still scattered with villages, and, wherever we went, small children were keeping an eye on the cattle and sheep. They said they went to school but I wasn’t really convinced.

Walking into a BBC crew filming the gelada baboons was quite surreal. We had just stopped to put on our macks as it was raining when we heard a very posh voice asking if we could move please as they were trying to film the baboons running down that particular hill. If you ever see a documentary on these baboons in the Simiens we were there, and we saw the locals on the other side of the hill ‘encouraging’ the baboons to move.

One of my areas of work is developing a volunteers’ strategy. Not international volunteers but local volunteers. PLHIV associations are similar to charitable organisations in the UK so their boards are all volunteers and most of the programmes workers are also volunteers. However they do get expenses. The latter get 206 birr a month for travel. That is £7.60. In the focus groups they tell me they do it for humanitarian reasons. However when I asked if they also had paid work, they said it was hard to get work as they were HIV+. So what is a volunteer? I really enjoy the focus groups: however formal I try to make them, we have to have a coffee ceremony, and they usually end with music and dancing. The highlight last week was meeting a 22-year-old woman who finished school at grade 6 but was carrying a beautiful, chubby smiling baby who everyone proudly told me was HIV negative.

Am I making any difference? Not an unusual question for anyone in public health. I’ve been asking it my entire career. I’d better get back to work and make sure that I am.

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Eleven time Paralympian gold medallist Baroness Tanni Grey-Thompson spoke to the UK FPH conference today (7 July) about the importance of the 2012 Olympics in encouraging physical activity, particularly amongst women and children.

She called for the 2012 budget to be protected from cuts, underlining the potential cost savings to the NHS if it can be used to promote and support people to exercise more often. Inactivity costs the economy an estimated £8.2 billion a year in England, and Grey-Thompson challenged the public health community to find more innovative ways of encouraging participation in sports and exercise.

Physical activity contributes to the prevention and management of conditions including coronary heart disease, diabetes, cancer, mental ill health and obesity. Grey-Thompson said that “Promoting physical activity is integral to the preventative agenda. In a time when budgets are being cut across all public services, the NHS and wider economy cannot continue to bear the increasing financial burden of preventable conditions.”

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19 June 2010

In sultry heat, I join a continuous stream of people making their laborious way up the 392 steps to the mausoleum of Dr Sun Yat-sen. It’s beautifully situated on the slope of a wooded mountainside in a huge park in Nanjing, Eastern China.

Everyone is in holiday mood, stopping frequently to rest, drink and take snaps of each other against the backdrop of the splendid double-eaved sacrificial hall built a few years after Dr Sun’s death in 1925.

But as soon as they reach the sarcophagus, absolute silence descends in an atmosphere of deep awe and respect. Dr Sun is a much revered figure, considered to be the ‘Father of the Republic of China,’ honoured by Chinese people on both sides of the Taiwan Strait.

He qualified in medicine at the turn of the century, but soon gave up medicine for politics, plotting the overthrow of the Qing Emperor and helping to establish the fledgling republic. As its inaugural President he extolled three fundamental ‘Principles of the People’ inspired by Abraham Lincoln: One nation of the people – governed by the power of the people – for the welfare of the people.

Back at the conference I’m attending on public health in Asia and the Pacific Rim by the APRU World Institute, I think about the parallels between Dr Sun’s three principles and Michael Marmot’s basic tenets of a healthy society – one that upholds fairness, social justice and the pursuit of wellbeing.

Certainly, health inequalities is a recurring theme at the conference. There are huge disparities between the rich and the poor across the region – and between the cities and rural areas – and this is reflected in the disease patterns observed.

The conference theme is the epidemic of chronic, non-communicable diseases (NCDs) in the tiger economies of east Asia. This part of the world is now going through the escalation of cardiovascular disease we saw in the West about 40 years ago.

But it’s happening so fast here. Urbanisation is rampant – by 2020 China will have over 200 cities each boasting more than a million population. And this is coupled with globalisation, code for westernisation. Nearly every major city has its MacDonalds, KFC and Pizza Hut. Smoking is on a roll – mostly western brands – and in many Asia-Pacific countries, notably China, it’s still allowed in public places.

As to physical activity, whilst it’s true that cycling is still a common means of transport – here in Nanjing for example there are dozens of pushbikes bunched together at the front of the traffic at every stoplight – nevertheless people are increasingly switching to scooters or cars. Air pollution is a big problem in China – not good for the lungs, especially if you’re on a bike. All in all, there can be little surprise that obesity, diabetes, stroke, coronary heart disease, lung cancer and chronic obstructive pulmonary disease rates are rocketing right across the region.

What’s more, although these health problems were first seen most among the better-off – the early adopters of western lifestyles – in recent years the problems have begun to extend down the social gradient, particularly among the urban poor.

Effective prevention and early diagnosis are clearly crucial – yet many Asia-Pacific countries have health systems skewed to favour hospital and specialist services, with little or no investment in health promotion or primary care. Although China for example has well developed communicable disease prevention and control systems, its approach to non-communicable disease is much less robust and its primary care is largely based on private specialists and a vast unregulated army of traditional medicine practitioners.

This pattern is typical of the whole region, and poorer people thus face the double whammy of unhealthy lifestyles plus inadequate access to preventive, diagnostic or curative care. So, despite the best efforts of policymakers to reduce health inequalities in many of the emerging tiger economies of the Asia Pacific, the headlong rush to the cities has meant that the cards are truly stacked against the less well-off.

As in the West, it will take a multisectoral mix of interventions to halt the rising tide of NCDs in these countries – health education, social marketing, regulation of the food and tobacco industries and, above all, health systems change. Marmot argues that efforts should be applied across the social gradient. But from the workers’ high-rises of China’s cities to the slums of Mumbai and the favelas of Rio, there’s also a clear need to focus on the world’s urban poor.

As the conference closes I think again of Dr Sun Yat-sen. I’m sure that, as a medical man, democrat and visionary, he would wish to see public health of the people, by the people, for the people, applied fairly to all the people, not just those who can afford to pay.

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Friday, 4 December 2009.

I’m somewhere over the steppes of Central Asia – on my way back from an international conference in Hong Kong on the theme of emerging issues in public health. Time to sit back and reflect.

It was a good conference – attracting delegates from all over East Asia and beyond. Inevitably, much of the focus was on the ever-increasing burden of chronic disease in this rapidly developing and urbanising region – not just China and India, but Vietnam, Cambodia, Thailand, Malaysia and even Burma.

The same pattern is repeated again and again.  People flock to the cities to find work, the buildings zoom up, the traffic multiplies, the diet westernises and the waistbands expand. Obesity linked to diabetes linked to heart disease and stroke. Not helped by the efforts of the tobacco industry. As a result, the health systems, mostly private sector, creak and buckle. There’s widespread recognition that public health improvement and primary care are vital – but also widespread concern that they are chronically underfunded, patchily organised and poorly linked together.

One key to this is education – linking public health and clinical training -, a recurring theme of the conference and the main thrust of my keynote presentation.

But the real value in my travelling to Hong Kong was undoubtedly in the face-to-face meetings with people who have the power and influence to build up public health and primary care and link them together. There is no substitute for the personal touch in this part of the world – perhaps in any part of the world. Tele-meetings, invaluable though they are for many purposes, simply don’t cut it for forming close working relationships and building camaraderie and trust. Business people know this – to clinch a deal you need to get to know each other.

But, as I fly back across Mongolia and Siberia towards Moscow, St Petersburg and the Baltic, Copenhagen edges into my moving map and gnaws at my conscience. I know that this kind of meeting will have to become a rarity – at least for me. I do not want to be a climate criminal. I do not want to let the planet down. Of course I only fly long-haul to meetings where I feel my being there might make a real difference. But even so, I am determined to be much more selective in future. And I’m sure many others will be making the same resolution.

Yes, it poses awful dilemmas – can I really accept this next invitation to another faraway place? But it’s a nettle the academic world, and the business world, will increasingly have to grasp.

Otherwise Heathrow will need a third runway – and we’ll all need another Earth.

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