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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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By Dr Frank Atherton, Chief Medical Officer, Wales

(This article is based on a presentation to the Faculty of Public Health Conference in Telford on 20 June 2017 – view slides from the presentation)

Public health should be proud of the fact that we are an evidence-based profession. We have brought both the ethos and the tools of evidence-based clinical practice to the NHS and the wider public sector. However, we should not lose sight of the fact that public health is both a science and an art; this requires us to bring judgment to bear alongside evidence.

There are plenty of reasons that can be deployed in order not to use evidence. Sometimes issues can be seen as “blindingly obvious”; I recently saw a video of Brian Cox using the fact that we can actually see cosmic background radiation to energetically (and using colourful language) rebut a claim that the Big Bang is just a theory and may not have happened: “YOU CAN JUST ****** SEE IT.” As a newly qualified doctor on my first surgical firm, I worked with the team that had led the development of highly selective vagotomy as a curative treatment for peptic ulcer. In addition to the small operative mortality, many of the patients were left with long-term side effects such as malabsorption or diarrhoea. If I had dared to suggest that peptic ulcer might be a consequence of infection and amenable to curative treatment with antibiotics I would have been ridiculed, or worse. And yet this was subsequently found to be true and most patients are now successfully treated by H.pylori eradication rather than surgical intervention. The lessons I draw for my public health practice is that we should beware of our hidden prejudices and the influence of received wisdom; we should always be willing to challenge our assumptions. Other, less noble reasons for ignoring evidence include laziness, incompetence, pressure of work, and vested interests in outcomes; all issues that we should recognise and guard against as part of the ethical management of our own work.

Sometimes the evidence is rock solid but it is still not used to drive population health. The classic example must be smoking; we have known about the link between smoking and lung cancer since the work of Doll and Hill in the 1950s. But it took until 2007 for smoke-free public places to be enshrined in legislation across the UK. The 10-year anniversary of this achievement is an opportunity to recognise and celebrate its impact but also to raise the important question about where accountability lies for the thousands of avoidable deaths that have resulted from the decades-long delay in effective action. The answer seems to be “nowhere”. It seems to me that there is a failure in public sector governance if there is no accountability for inaction in the face of convincing evidence. The horrific events at Grenfell Tower perhaps serve as a more recent example.

And, of course, the evidence base is never complete, and we are often faced with contradictory evidence that steers us towards different courses of action. The recent debate about regulation of electronic cigarettes is a useful example. Evidence of the benefits as a smoking cessation aid have to be balanced by currently unquantifiable risks including the direct and indirect effects of vaping, and the potential for a new generation of young people to become addicted to nicotine. When faced with these sorts of uncertainty we have several options. We can commission further research, but that takes time. We can use a trial and error approach, but that brings risk (think of the death and illness last year of fit young volunteers in pharmaceutical trials in France). We can use a risk management and mitigation approach – something we all do unthinkingly in our daily lives when we buckle our seatbelts. And we can use a precautionary approach but, if used inappropriately, this might stifle innovation and change that could have a positive impact on population health.

Our approach in Wales has been to follow the thread of evidence-based public health action, from our research and development commitments (£43m per year), through the programme of action for our government, the legislative framework of the Wellbeing of Future Generations Act which requires public bodies to plan and report on population health outcomes, then through to our recently passed Public Health Act which has incorporated health impact assessment into our policy and planning. In Wales, we believe that evidence matters, but judgment and compassion also need to factor into our decision-making.

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