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Archive for the ‘Diet’ Category

By Jennifer Mindell, FPH Fellow and Chair of the Health Improvement Committee

Public Health England (PHE) and Department of Health and Social Care yesterday unveiled plans to limit excessive calorie consumption as part of the Government’s strategy to cut childhood and adult obesity. The plans target both consumers and industry, challenging the latter to reduce calories in products consumed by families by 20% by 2024. If the 20% target is met within five years more than 35,000 premature deaths could be avoided. Yesterday also saw the launch of the latest One You campaign, which will encourage adults to use the 400-600-600 calorie guidance for breakfast, lunch and dinner.

This is a very welcome step forward. We know that there are many drivers of obesity, including our environment, our genes, our behaviour and our surrounding culture. This very complexity means that if we are to tackle and prevent obesity, we must mobilise all sectors of society to take action and bring workable solutions to the table, and we are hopeful that PHE’s package of targeted reforms and initiatives will do just that.

We particularly welcome the Government’s focus on solutions that will impact families rather than just individuals. More than a quarter of children aged two to 15 in England are currently overweight or obese and younger children are becoming obese at earlier ages and staying obese for longer. This burden falls disproportionately on children and adults from low-income backgrounds. There are few effective interventions in place at the moment to help children identified as overweight or obese, making the prevention of obesity in children all the more urgent.

At the Faculty of Public Health (FPH) we believe that actions to protect children from obesity must be prioritised. This is why the FPH Health Improvement Committee has been developing policy to protect children from exposure to the advertising of foods high in fat, sugar, and salt (HFSS). We know that marketing greatly influences the food and drink children consume. The promotion of unhealthy food and drink is a significant risk for childhood obesity and the development of diet-related diseases. This is widely recognised by the World Health Organization (WHO) and many other countries. Industry spends 500 times as much on promoting HFSS products as the WHO spends on promoting healthy diets.

We recognise that regulations on HFSS food and drinks in the UK are among the toughest in the world. We are proud that the UK was the first country in the world to introduce scheduling restrictions on food advertisements, when in 2007, the Government banned HFSS product advertisements during or adjacent to ‘children’s TV’ programming or those that are likely to be ‘of particular appeal’ to children aged 16 and under.

However, we think that now is the time for additional progress to reflect modern family life. Children do not just watch children’s TV programmes and their viewing time actually peaks from 6-9pm, during what is called ‘family viewing time’. ‘Children’s TV’ programming generally is not broadcast during family viewing time, meaning that current regulations banning HFSS products make no impact then.

We started developing our thinking on this issue at the FPH conference in June of last year, where delegates discussed and debated how we could implement policy to limit children’s exposure to junk food marketing and encourage healthier behaviours. Around 15 different policy solutions were debated, covering a wide range of interventions. We’ve since refined our thinking; we believe that to protect children and support parents, the Government should take forward the following three interventions as priorities:

1. Strengthen existing broadcast regulations to restrict children’s exposure to junk food marketing by introducing a pre-9pm watershed on all HFSS food and drink advertising
2. Take action to ensure online restrictions apply to all content watched by children
3. Extend regulations to cover sponsorship of sports and family attractions and marketing communications in schools.

We believe that voluntary calorie reduction initiatives and behaviour change campaigns – like the ones launched by PHE and DHSC yesterday — will have the best chance of success if they are complemented by other regulatory measures like the ones we have proposed above.

We continue to be heartened by the progress that the Childhood Obesity Action Plan has made and are hopeful that PHE’s calorie and sugar reduction initiatives will prove to be world-leaders in tackling obesity and its health-related consequences. We believe that action against junk food marketing to children will support those aims and be critical to their success. We look forward to continuing to engage FPH’s membership and other partners in the development of this policy.

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By Alexandra Swaka, WHO Collaborating Centre, Imperial College London

In support of Eating Disorders Awareness Week, an international event that raises awareness on the challenges and stigma associated with various types of eating disorders, I invited clinical nutritionists, Rhiannon Lambert and Sophie Bertrand, to deliver a seminar to resident GPs and fellow academics of the Imperial College Faculty of Medicine to enhance current knowledge on eating disorders in the context of public health.

As the GP is most often the first point of call for the patient, with very little time to address the holistic needs of patients, Rhiannon and Sophie established some of the complex nutritional and psychological factors that are involved in catalysing both the onset and the continuance of disordered eating. The conditions, which include anorexia (the extreme limitation of calorie intake), bulimia (compensating binge eating through subsequent purging), emotional overeating, and orthorexia (a clinical obsession with eating only ‘pure’ food) are fuelled by severely unhealthy relationships with food and are usually exacerbated with prolonged suffering. With social media having more impact on everyone’s daily lives, sufferers of eating disorders are a particularly vulnerable group, facing greater susceptibility to impossible and unrealistic body ‘standards’ which they are bombarded with through mediums such as Instagram. In a study which Sophie was involved in conducting, she found that 21% of young people are referring to social media influencers for nutrition advice, and 44% of young people believe that eliminating an entire food group equals ‘health’. This may include complete elimination of fats, carbohydrates, or animal products. The two pointed out the dangers of turning to social media images for dietary advice.

It is now more than ever crucial for GPs to listen for clues that their patients might be internally suffering from an eating disorder, as body mass index may not always be an indicative factor of the psychological trauma associated with such conditions. While consultation time is limited, it is important to open up the conversation and have a list of resources, helplines, and referrals of nutritionists or charity organisations specialised in the field as an effective option to offer patients while (and if) they are on a waiting list for further clinical help. Like any illness, early intervention is key for successful long-term outcomes, and they recommend that patients are referred to qualified clinical nutritionists with professional experience in working with this vulnerable and impressionable population.

Rhiannon’s book, Re-nourish: A Simple Way to Eat Well, offers readers expert guidance to “eat like a Nutritionist” as well as evidence-based understanding of how nutrition affects the body, and sounds like a great starting point for everyone interesting in learning more about how to love food and feel great.

Links of interest:

www.nationaleatingdisorders.org

www.beateatingdisorders.org.uk

http://rhitrition.com

 

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By 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 Sarah Payne

I have the privilege to be a Health Education England (HEE) academic fellow this year, taking up my fellowship just as summer was throwing us an extra few weeks of warm weather to take forward into the Autumn. My first weeks were a blur of getting my feet under the table in my new home, the Nuffield Department of Primary Care Health Sciences at Oxford University, meeting new colleagues and setting out my plan for the year ahead. I was then straight off to a week-long intensive course to learn the art of changing people’s behaviours – courtesy of Susan Michie and colleagues at the University College London Centre for Behaviour Change. And what a week it was! Not only was it a great course but it was a great way to kick off my fellowship year, providing lots of inspiration and a ‘to-do list’ as long as my arm to get stuck into when I returned to the office.

Developing a suitable research project and securing research funding for it was one of the aims of my HEE academic fellowship, so I was thrilled when I found out I had been successful in securing an award, from the British Heart Foundation, to fund my proposed research project – investigating ways to help people with high blood pressure reduce their salt intake. Cue a short but wild celebration – short because the funding was contingent on having ethics approval for all elements of the research in place before the award would be given. So, duly inspired from my behaviour change course and brimming with enthusiasm to delve into the literature to understand more about the target behaviour I hoped to change and effective behaviour-change techniques to do so, and to spend some quality time developing a behaviourally informed intervention… I was faced with ETHICS FORMS! Hmmm….not so inspiring, though of course a critical part of the process.

Thankfully, the HEE fellowship provides a perfect bridge to support the development phase of my work, allowing me to prepare detailed research protocols and all the associated documents that support an ethics application for my proposed research and to begin some of the training in research skills needed to carry out the research. As well as fulfilling the immediate requirement to secure my longer term PhD funding, the process of preparing ethics applications has forced me to consider the finer details of my research and really think through how I will deliver it. I’ve had great support from my supervisors and my department – including the opportunity to gather valuable statistics feedback from the regular department Stats Coven!

So, a slightly different focus for my first six months than I had planned, but it has so far been a fulfilling and interesting time, as well as suitably productive. I’ve attended a couple of other short courses, both of which have helped to keep my ‘inspiration and enthusiasm’ barometer high. I’ve attended various department seminars and workshops and had an opportunity to meet and network with other PhD students. Naturally, I’ve also learnt the ins and outs of the various ethics processes and undertaken some training in research integrity and good clinical practice!

So onward and upwards. I have submitted my ethics applications and I’m in the midst of the lengthy process of amendments and waiting… and waiting… Perhaps I will use some of this time to explore that behaviour change literature-base I’ve been waiting to get to. Maybe there are even the beginnings of a systematic review in sight…

Sarah Payne is a Health Education England Academic Fellow

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