It is time to ban the sale of energy drinks to children in the UK

Guest post by Prof Amandine Garde, Dr Amelia Lake and Dr Shelina Visram

In 2016 in the UK alone we consumed 679 million litres of high sugar, high caffeine drinks known as “energy drinks”. Described as the fastest growing sector of the soft drink market, they have become a major public health concern and have been subject to both a House of Commons Science and Technology Committee Enquiry (April – December 2018) and a Department of Health and Social Care consultation (which closed on 21 November 2018).

In the report it published on Tuesday (4 December), the Committee found that “the current quantitative evidence alone is not sufficient to warrant a statutory ban”, though it noted that “societal concerns could justify a ban on the sale of energy drinks to children”. This conclusion is puzzling for several reasons.

Energy drinks and children

Firstly, a growing body of evidence has established that energy drinks consumption, particularly by children, is associated with a wide range of harmful effects.

• Whilst childhood and adolescence are periods of rapid growth requiring adequate sleep and good nutrition, energy drinks play a role in disrupting sleep (1 - see references below).
• It is established that energy drinks are highly erosive in terms of dental health: they have low pH and a high non-reducing sugar content (2).
• Consumption is also linked to increased energy intake and therefore obesity (3). Hence the proposal of the UK Government to ban the sale of energy drinks to children in the second iteration of its Childhood Obesity Action Plan, published in August 2018, and the public consultation that followed.
• However, energy drinks consumption is also linked to physical symptoms such as headaches, stomach aches and sleeping problems (with some evidence of a dose-response effect), as well increased risk-taking behaviours, including binge drinking, smoking, illicit drug use, screen time and poor dietary behaviours (4). Moreover, mixing energy drinks with alcohol increases the risk of injury and unsafe driving (5) and 6).

Secondly, the Committee has failed to engage with the fact that gathering “quantitative evidence” on the impact of energy drinks on child health would be unethical (other than the aforementioned studies, which tend to involve large-scale, school-based surveys).

To our knowledge, there have been no experimental studies involving children’s use of other age-restricted products such as alcohol, tobacco, aerosols, solvents, fireworks, knives, crossbows, petrol or even Christmas crackers (sales of which are restricted in England to those aged 12 and over). Why should energy drinks be subjected to a higher standard of evidence than any of these products?

Thirdly, the evidence base has not prevented other countries from regulating the sale of energy drinks to children. In Europe, Lithuania introduced a ban on the sale of these drinks to under 18s in 2016, followed by Latvia, whilst Norway and Sweden are reflecting on similar legislation.

It is therefore unclear why the Committee has concluded that existing evidence is insufficient to adopt a similar law in the UK. The rationale seems to lie in the absence of a “causal link” between energy drinks consumption and childhood obesity, tooth decay and other diet-related diseases. This arguably demonstrates a lack of understanding by the Committee of the strategies required to address complex and multifactorial nature of these diseases.

It is indeed difficult to establish a causal link between the various measures adopted and the burden of non-communicable diseases: no single policy option can realistically tackle broad phenomena, such as growing obesity rates or tooth decay, when taken in isolation.

Governments must ensure that public health is effectively protected, and they can invoke the precautionary principle in the event of any outstanding scientific uncertainty regarding the impact of energy drinks consumption on public health. Hence, probably, the acknowledgement from the Committee that “it would be legitimate for the Government to go beyond the evidence that is available at the moment and implement a statutory ban based on societal concerns and evidence, such as the experience of school teachers and pupils”.

The logic of their reasoning is nonetheless difficult to follow. There is no doubt that the Government should introduce legislation banning the sale of energy drinks to children, following the lead of Lithuania and Latvia. This would not amount to going beyond the evidence; it would be acting on the basis of existing evidence. It is this body of evidence that has prompted very real and major societal concerns of the effects of energy drinks on our children’s health.

Fourthly, the call of the Committee for more effective labelling measures should not be envisaged as providing an alternative to a ban on the sale of energy drinks to minors; it should only be viewed as complementing such a ban. This is all the more so as labelling could increase existing health inequalities. Children and young people from all backgrounds consume energy drinks. However, as the Committee has noted “energy drinks are consumed disproportionately by disadvantaged groups”.

There may indeed be a link between regular consumption of energy drinks and eligibility for free school meals (FSM), which is often used as an indicator of lower socio-economic status. The 2018 Health-Behaviour in School-Aged Children Survey found that, among those who reported that they drank at least one energy drink per day, 23% received FSM, whereas those who said that they never drank energy drinks or did less than once a week, 11% received FSM (compared to 13% of FSM recipients across the whole sample). A study conducted in schools in the South West England also found that being eligible for FSM was significantly associated with drinking energy drinks once a week or more (Richards and Smith, 2016).

Energy drinks have no place in a healthy diet

Finally, the Committee does not seem to be aware that the Government has a duty to protect the rights of all children to the enjoyment of the highest attainable standard of health and to adequate nutritious food. Energy drinks have no place in a healthy diet. Shifting the responsibility of protecting them onto business actors, such as food manufacturers or food retailers, is highly problematic, not only because a voluntary ban will fail to create the level playing field within which all these actors should operate, but also because it will fail to protect child health and their rights and cannot therefore contribute to an effective obesity prevention strategy.

The Responsibility Deal has failed; regulatory measures that apply to all and are duly enforced are required to address the growing burden of obesity, tooth decay and other diet-related diseases. The conclusion that a statutory ban would be too restrictive is ideological rather than grounded in evidence.

A statutory ban is the most likely measure to ensure that children and young people are effectively protected from the many harmful effects of energy drink consumption.


About the authors:

• Professor Amandine Garde, Professor of Law and Director of the Law & Non-Communicable Diseases Unit at the University of Liverpool. 
• Dr Amelia Lake, Associate Director of Fuse - the Centre for Translational Research in Public Health and Reader in Public Health Nutrition at Teesside University. Amelia is a Dietitian and registered Public Health Nutritionist. 
• Dr Shelina Visram, Programme Lead of the Complex Systems Research Programme for Fuse - the Centre for Translational Research in Public Health and Senior Lecturer in Public Health at Newcastle University.

The views expressed here are those of the authors and do not necessarily reflect those of the author's employer or organisation.

References:

1. Do sleeping habits mediate the association between time spent on digital devices and school problems in adolescence?
2. Short Communication: In vitro assessment of Erosive Potential of Energy Drinks
3. Systematic review of the literature on the effectiveness of product reformulation measures to reduce the sugar content of food and drink on the population's sugar consumption and health: a study protocol
4. Consumption of energy drinks by children and young people: a rapid review examining evidence of physical effects and consumer attitudes
5. Alcohol Mixed With Energy Drinks and Risk of Injury: A Systematic Review
6. Alcohol mixed with energy drink use among U.S. 12th-grade students: Prevalence, correlates, and associations with unsafe driving

Steering the Coca-Cola Christmas trucks off course in 2018

Guest post by Beth Bradshaw, Alex Holt and Robin Ireland, Food Active

You may remember our guest blog for Fuse from last year, which discussed the media frenzy that goes into overdrive when the Coca-Cola Christmas Truck Tour sets off on its journey across various locations in the UK. We also noted our own campaigns and the efforts of others such as SUGAR SMART to make the case against welcoming the truck into towns and cities already grappling with a childhood obesity and oral health crisis.

 

Every year, we are met with growing support from the public health community and the public including GPs, dentists, teachers and parents. Last year Public Health England issued guidance to local authorities about hosting the Coca-Cola truck. However, there was also some criticism of our position, especially where we were seen as ‘spoiling’ Christmas in some way.

However, this year, things seem to be different. We feel a change in the air this festive period with a scaling back of the Coca-Cola tour, both in terms of numbers of locations and less prominent venues.

There are a number of important changes that have happened both in the build-up and the start of the Coca-Cola Christmas Truck Tour for 2018. While these might appear small, together they demonstrate quite a significant shift by the soft drinks corporate giant.

This year, the Coke Truck allowed just three days between the announcement of the tour and its start, compared to 11 days last year. Within this time frame, SUGAR SMART coordinated an open letter to Coca-Cola bosses with over 40 signatories from local authorities, Clinical Commissioning Groups, and national campaign groups to oppose the truck visiting their areas [1]. This meant there was time to coordinate responses both nationally and locally, including a series of Tooth Fairy stunts, and for noise to be made to create negative publicity before the truck had even arrived.

The Coke Truck vs the Tooth Fairies

Another important shift is the size of the tour – downsizing by over a third (37% to be exact), from 38 stops last year to just 24 this year. The 2018 tour is also visiting some much smaller locations - the media has called it ‘snubbing’ cities such as Milton Keynes and Liverpool - and there are just four visits on council-owned land. We are pleased to see so few local authorities allowing the truck on council-owned land but would urge those that are welcoming the truck to seriously consider whether this is in the best interest of their local population.

There are also more stops hosted on supermarket car parks this year, with as many as ten of the stops to Asda and Tesco. The same Tesco that announced a five-year ‘strategic partnership’ with national health charities including the British Heart Foundation, Cancer Research UK and Diabetes UK to help ‘remove barriers to healthy habits’ earlier this year. A Coca-Cola truck pitching up in their car park is certainly a barrier to healthier habits, both literally and figuratively speaking. This move has also been met with criticism and Sustain and SUGAR SMART are calling on the public to write to Asda and Tesco to ask them to reconsider hosting the truck next year. On taking this action ourselves, we received a response from Asda customer relations which said:

“We have been in conversation with Coca-Cola prior to this tour and we are happy that they will be encouraging customers to sample their sugar-free brands. They will only provide Red Coke on request and they estimate that at least 90% of their drinks sampled will be sugar free.”

As of yet and unsurprisingly, we have had no response from Tesco.

Asda’s response is consistent with the quote provided by Coca-Cola’s press release, which also appears to have satisfied Public Health England’s concerns, as they have decided not to respond to the truck this year.

Finally, in the North West of England (where Food Active is based), the truck is visiting just one city in the region compared to six visits in 2016 and four in 2017. Over the past four years, Food Active has been lobbying against the arrival of the truck in the North West, including publishing an article in the British Medical Journal [2], writing an open letter to local and national press (with over 100 signatories) and supporting SUGAR SMART’s open letters to Coca-Cola bosses. We hope that this continued pressure, even in the face of significant criticism, has helped to steer the Coke truck away from the North West.

However, we know the battle is by no means over - 14 of the 19 stops in England have above average prevalence of excess weight amongst 10-11 years old, and in some locations including Manchester, over 30% of the children have experienced tooth decay.

Last year, our blog concluded that “our experience shows us that public health has to be persistent in ensuring our messages are heard in the current victim-blaming culture”. This statement is perhaps even more validated following this year’s experiences.

In the spirit of good will this Christmas, we thank Coca-Cola for helping more of our local authorities in the North West to help tackle issues of childhood obesity and dental decay in their areas - many of which are already disproportionately burdened with deprivation and health inequalities.

www.foodactive.org.uk

@food_active


References:

1. Ireland, R and Ashton, J.R. (2017) “Happy corporate holidays from Coca-Cola” i8633. Available at: https://www.bmj.com/content/356/bmj.i6833
2. SUGAR SMART (2017) Spending holidays in good health. Available at: http://www.foodactive.org.uk/wp-content/uploads/2017/11/Open-Letter-to-Coca-Cola.pdf

Images:

1. Courtesy of Beth Bradshaw
2. With thanks to Sustain and Sugar Smart UK: https://www.sustainweb.org/blogs/nov17_coke_truck 

Please mind the health gap: turning complex equations into a call for action

Guest post by Heather Brown, Senior Lecturer in Health Economics, and Michelle Addison, Research Associate, Newcastle University

As a quantitative researcher, I sometimes find it difficult to see how the output from complex equations can make a difference to people’s lives. The launch event for the Northern Health Science Alliance (NHSA) Health for Wealth report was a fantastic opportunity to see first-hand how statistical analysis can actually be used to influence policy and practice.

The productivity and health gap

There is a well-known productivity gap between the Northern Powerhouse and the rest of England of £4 per person per hour[1]. There is also a high health gap between the Northern Powerhouse and the rest of England, with life expectancy 2 years lower in the North. Given that both health and productivity are lower, the NHSA commissioned the Health for Wealth report to understand the impact of poor health on productivity and to explore the opportunities for improving UK productivity by unlocking regional growth through health improvement.

The perfect setting

The launch of the report took place in Newcastle at the Boiler Shop in the morning and at Lancaster House in London in the evening. The Boiler Shop is an impressive, urban industrial building set back from the Central Station. It was built in 1820 and was where Robert Stephenson and Company developed the world’s first locomotives. This has to be the perfect setting for the launch of the report. What better way to discuss how to build a healthier Northern Powerhouse for UK productivity than in this historically important space regarded as the ‘crucible of the Industrial Revolution’? The space is filled by a 100 plus audience of local policy makers, employers, health care practitioners, representatives from third sector organisations, academics, and the general public.

The morning event in Newcastle was kick started with a welcome address by Dame Jackie Daniel, Chief Executive of Newcastle Hospital and NHS Foundation Trust. She outlined how the Trust was very good at meeting targets and is one of the best performing Trusts in the country. But, the North East is still faced with reduced life expectancy and worse health outcomes than the rest of England. To solve this problem she said, we need a joint approach working with employers, local government, the voluntary sector, and the NHS. The report makes the case why it is in everyone’s interest to work together and that improving health, will improve economic prospects.

Fuse Deputy Director Professor Clare Bambra presents the report findings 

This was followed by a summary of the report findings by Fuse Deputy Director Professor Clare Bambra highlighting how 30% or £1.20 of the productivity gap between the Northern Powerhouse region and the rest of England can be explained by health. Reducing this health gap would generate an additional £3.2 billion in Gross Value Added (a measure of economic productivity). 

Next up was the leader of Newcastle City’s Council Nick Forbes. He discussed how in his role he can take the results from the report to try and make a positive change to the economic and health prospects for Newcastle. He also outlined the challenges faced from the current political climate in terms of squeezed budgets for local authorities and public health in particular.

Then there was a Q&A session where interesting questions were raised by a member of the voluntary sector on implementation and the need to involve the local community.

Finally, there was a closing address by Dr Hakim Yadi OBE, CEO of the NHSA, stressing how there was a need to make an economic case for improving health to get the central government to listen and take actual steps to make a difference.

I left the event thinking about how I present my research questions and findings and that when presented in a way that can be understood by key stakeholders, quantitative analysis can be meaningful and useful. The focus does not need to be on the complex equations but how the output from these equations can be used to change opinions or make a case for action.

I hope that the findings from this report lead to real change in improving health and economic prospects for all of us living in the Northern Powerhouse. I also hope that it changes the way I think about how I present my findings and research questions to generate evidence that can easily be used to make a real difference to public health and reducing health inequalities.

Report: Health for Wealth: Building a Healthier Northern Powerhouse for UK Productivity 
News: Major new report connects North’s poor health with poor productivity

The universities involved in the Northern Health Science Alliance (NHSA) commissioned ‘Health for Wealth’ report are: Newcastle University, University of Manchester, University of Lancaster, University of York, University of Liverpool and Sheffield University.

Reference:

1. Office for National Statistics (2015), Regional and sub-regional productivity in the UK, https://www.ons.gov.uk/employmentandlabourmarket/peopleinwork/labourproductivity/articles/regionalandsubregionalproductivityintheuk/jan2017

The Age of Bubble-gum Gin?

In a post for Alcohol Awareness Week, John Mooney, Fuse Associate and University of Sunderland Senior Public Health Lecturer, ponders how the alcohol industry will respond to declines in youth drinking. 

1990s alcopops on display at the Museum of Brands

There is no doubt about the current trend: youths and young adults are clearly drinking less alcohol. In what seems to run counter to the traditional image of “irresponsible teenagers” drinking to excess and partying the night away, a number of recently published studies and reports have confirmed an increasing indifference to the “charms of the demon drink” on the part of young people that extends across all age groups. In their recent report for example, University of Sheffield alcohol research group (SARG) in a Wellcome Trust funded study [1], highlighted that:

“Among 16-17 year-olds, the proportion who reported drinking nowadays fell from 88% in 2001 to 65% in 2016 and the decline over the same time period for 16-24 year-olds was from 90% to 78%...”

Similarly in a nearly 10,000 strong sample of participants aged 16 to 24 years using a ten year analysis of Health Survey for England datasets, rates of non-drinking increased from 18% in 2005 to 29% in 2015 (largely attributable to increases in lifetime abstention) [2]. In the same study for the same period, “not drinking in the past week” increased from 35% to 50%. The SARG Wellcome Trust report noted that younger drinkers were also consuming alcohol less often and in smaller quantities: Between 2003 and 2016, for example, the proportion of 11-15 year-old drinkers who “had consumed alcohol in the last week” fell from 41% to 19%. Among 16-17 year-old drinkers, the decline was from 58% to 39%, while for 16-24 year-olds it was from 75% to 60%.

As the Sheffield report also notes, these declines in alcohol consumption are by no means confined to the UK with similar reductions in youth drinking being seen across many European nations, North America and Australasia.

Declines in drinking would be expected of course to be accompanied by public health benefits and therefore alcohol-related hospital admission rates in England have been falling in line with consumption, as have the numbers of under 18s referred to specialist alcohol services. This has a particular resonance for North East England, where the rates of alcohol-related hospital admissions for under 18s have been among the highest in the country [3] and which in recent years have been falling more sharply than for England as a whole (though of course, the starting point was higher).

While the reasons behind these regional, national and international declines in youth drinking are as yet not particularly well understood, it is probably worth noting that we have been here before, with the early 1990s seeing international declines in youth drinking. Many experts on alcohol consumption trends at that time also noted that this decline was accompanied by a robust ‘product diversification’ response by the alcohol industry, most notably the rise of ‘alcoholic soft drinks’ or ‘alcopops’. In an article published in the Independent in 2003 [4], the then chair of Alcohol Concern, Eric Appleby commented:

"The whole alcopops thing came about because at that stage the industry had realised that they weren't getting the normal flow of drinkers coming through. Young people were more independent and drugs had taken over for a lot of young people as a recreational high instead of drink. The industry knew it had to do something. They will always deny it but it is pretty clear that the whole alcopops thing was about recruiting young drinkers and getting them at an early stage. Young people don't have a natural affinity for the taste of alcohol – this was a crash course, cutting out the middle man."

Consumption data confirmed these suspicions, with figures released by the UK Department of Health in 2002 revealing the average alcohol consumption of children aged 11 to 15 who were drinkers had rocketed from 5.3 units a week in 1990 to 9.8: ‘Alcopops’ or ready to drink mixes (RTD’s) of spirits and soft drinks were blamed.

This previous experience and the industry response does of course beg the question if there will be a similar response this time around and the format that this might take. As the Sheffield report also notes, drinking habits formed when young, have a major influence on lifetime alcohol consumption patterns, so these trends will not have escaped industry analysts and those who might be concerned about maintaining “medium to long-term consumption and sales forecasts”.

For a number of commentators, the industry responses are already clearly in evidence, most notably perhaps being a proliferation in novelty gin varieties, perhaps the most blatant ‘cross-over’ with confectionary style marketing being ‘bubble-gum gin’ or ‘marshmallow flavoured vodka’.

Of course, there is also a ready-made consumer base among young adults for energy drinks, which have been the focus of much publicised research by Fuse colleagues and there is a long established practice of these drinks as alcoholic mixers, to say nothing of the fortified caffeine and sugar enriched wine of choice, most popular in my native Scotland and the product of serene ‘Buckfast Abbey’ surroundings in South West England.

Current downward trends in alcohol consumption therefore might already be seeing a familiar  marketing response… but the extent to which that will succeed is still guesswork, given the as yet lack of clear understanding around what might be behind current trends.

From a North East public health perspective of course, long may these trends continue, since the medium to long-term population health benefits in this part of the world in particular are likely to be considerable!


#AlcoholAwarenessWeek

#AlcoholChange 

References: 

1. Oldham M, Holmes J, Whitaker V, Fairbrother H, Curtis P: Youth Drinking in Decline. University of Sheffield Alcohol Research Group & Wellcome Trust; 2018. 
2. Ng Fat L, Shelton N, Cable N: Investigating the growing trend of non-drinking among young people; analysis of repeated cross-sectional surveys in England 2005–2015. BMC Public Health 2018, 18(1):1090. 
3. Public Health England: Local Alcohol Profiles for England In.: https://www.gov.uk/government/collections/local-alcohol-profiles-for-england-lape; 2017.
4. Harding N: The Demonised Drink: How Has Youth Drinking Evolved 20 years Since The Launch of Alcopops? Independent. London; 2013.

Image: "1990s alcopops on display at the Museum of Brands, west London" by Ben Sutherland via Flickr.com, copyright © 2017: https://www.flickr.com/photos/bensutherland/37299742285

Why I left a full-time teaching role to pursue a passion for school food research

Kelly Rose, Graduate Tutor/PhD researcher at Teesside University, writes about her journey to help young people make healthy food choices in a guest post for National School Meals Week.

‘Why?’ was the question I was asked numerous times when I first announced that I would be leaving my role as ‘Head of health education, and food and nutrition’ teacher in a well-respected secondary school. A job everyone around me knew I had loved; it had provided me with job satisfaction and I was able to make a difference everyday (because that’s what teachers do). To add to the incredulity of those around me, not only was I leaving this hard earned role, I was taking a 50% pay cut to embark on a short-term research contract to complete my PhD with no assurance of job security afterwards!

Here is a little background about why I came to - what was for me - a very easy decision.

As an adolescent I found myself in an extremely confused state about healthy food choices, being the ‘right’ weight and having a positive mental health. Then, when I became a mum, the painful realisation that my girls may be feeling that confusion made me want to make a societal change in whatever way I could. Not really knowing where to start, at 32 years old I threw myself into a degree in Food, Nutrition and Health Science. At this stage my only qualifications were four GCSEs and a BTEC diploma in Travel and Tourism. I still don’t know how I believed I could do it!

Three years later I had become so passionate about the power of food that I wanted to teach it to as many young people as possible. With renewed confidence, my First-class honours, and an award winning third-year ‘school lunch’ poster project, off I went to complete a PGCE in design and technology. In that year I spent more time making a wooden stool than learning about nutrition (approximately three hours) because that’s how we still train food teachers – but that’s a story for another time.

I discovered that I loved to teach and, in addition to my teaching, did all I could to help young people make healthy choices. I researched interventions, registered on courses, spoke at various events including ‘Food Matters Live’ in London and was invited to speak at a dietetic student conference at The Hague, Holland. I was thriving and learning so much about the education system: the teaching leads were happy, the GCSE results were superb, and we were improving the healthy choices and the health education in the school. It was a fantastic opportunity to be in a place where the leadership supported the health agenda. Even so, after a while, it became clear that there were barriers that were much larger than the school environment: policy change had become confusing and the support in implementing food standards had disappeared. The external environment of advertising close to schools, proliferation of fast food outlets and shops offering cheap energy drinks. The social norms around eating behaviour in our teenagers had become a turbulent misunderstood tangle of factors, and this with all of the curriculum changes and budget cuts! It was in my last two years (of seven teaching) that I spent time writing PhD proposals, knowing that to make a change I needed to be able to add research to this field, to inform the decision making processes.

That is why I feel extremely lucky to have been given the opportunity to do research at Teesside University and to have access to inspirational researchers and existing work through the Fuse network, and of course to fulfil the dream of having a positive impact on the school food environment.

I am now 8 weeks into my graduate tutor/PhD researcher post and I am sure that I have made the right decision. I used the library every day in my first week, pinching myself, not quite believing I was here with time to research and learn. Every day I am learning and have so far developed a timeline of policy past-to-present, an ecological framework of everything that impacts school food choice from the macro level (government structure and policy, sustainability focus, food supply, food industry and manufacturing, behaviours etc.) to the external and internal physical settings and the individual students. I know from my time in education that consistency and communication are key components of making sustainable healthy change in schools. I hope that I will be able to provide a clear direction on where that focus should be to contribute to the reduction of the ‘obesogenic’ environment for our young people. I have far to go in understanding the myriad of methodologies required to do this work, but I will delve into past research and attend workshops to learn all I can. As I develop questions and embark on a systematic review I have the feeling that I am at the bottom of a huge mountain, ready to make the climb. It is just the beginning and I am aware that significant patience and discipline are going to be needed to get to the top of that mountain.

I look forward to meeting you on my journey.


#schoolmealsshoutout #NSMW18

Find out more about National School Meals Week here: http://thegreatschoollunch.co.uk

Why dramatic enquiry as a form of public engagement gave me my most enjoyable week as an academic

Guest post by Santosh Vijaykumar, Vice Chancellor’s Senior Research Fellow, Northumbria University

“It’s important to eat healthy but we also need sugars, although in moderation.” These are not the words of an expert on BBC’s Food Programme, but a Year 5 student at Chillingham Road Primary School in Newcastle, fidgety and impatient for the next activity to resume. And the caution came about not through a series of in-depth interviews by public health researchers such as myself, but through ‘dramatic enquiry’. Brad McCormick and Katy Vanden from Cap-a-Pie, the theatre company that developed this approach, describe it as one that “places participants in a fictional scenario where they are in-role from start to finish. They are placed in a situation where there is no clear ‘right’ or ‘wrong’ answer and where they have to express their own beliefs and values.”

Brad directing the drama

Over the course of a week, we conducted four such dramatic enquiry workshops with three schools in Newcastle, each session comprising approximately 30 Year 5 pupils (10-11 year olds). Although these workshops were part of the public engagement strategy of my ongoing ESRC funded project* that seeks to understand psychological drivers of confidence in probiotics products, we decided to explore broader themes beyond just probiotics. The aim – suggested by Brad and Katy and gladly welcomed by us – was to avoid a top-down health education approach, and instead utilise this engagement format to get children to think and talk about fundamental issues: why do they eat what they eat? Can food be healthy and unhealthy at the same time? Should the government control what foods we consume? What is the relationship between responsibility and choice in the context of food? We used these themes as a funnel to eventually involve the children in a discussion on probiotics.

Each workshop starts with the children seated in a semi-circle. As soon as they are settled, Brad catches them off guard. He starts shaking hands with one of them and says “I ate at your restaurant last week, superb!”, and then goes to another: “I read your article on raw food diets, so interesting!”, and so on and so forth, setting off a series of giggles or muffled peals of laughter among the children as they make sense of the goings on. Soon after they are informed that they are all members of the Food and Drink Committee of Arcadia (a fictional country) and are asked to take a pledge of allegiance to Arcadia. A series of dramatic games such as DilemmaRama, Shake Hands/High Fives and Stop/Go has now completely warmed them up to Brad and to each other. This lays the foundation for their enthusiastic participation in the ensuing small group activities, each of which is followed by a philosophical discussion or reflection.

The small-group activities include identifying and enacting their favourite dish in a freeze frame, contemplating what it means to be healthy, and explaining the rationale for why they agree or disagree with a certain food policy from different viewpoints (as a journalist, scientist, manufacturer, etc.). In the second half of the session, they are introduced to a fictional probiotics product, to develop a commercial for it, and then asked to make a decision about whether it should be sold after exposing them to news articles reporting conflicting evidence related to the health effects of probiotics products.

As a researcher, observing these sessions live can be tough – it’s so much fun, you want to participate with the kids and leave taking notes for later. And taking notes is not easy either, even after you have committed to it. For, you realise quickly that every activity and philosophical discussion reveals a new strand of thought among children, a sharp, counter-intuitive insight, or a larger ethical perspective. As someone who is newly baptised to this form of public engagement, I realise how uninhibited and enthusiastic kids are in terms of participating in what would seem tricky terrain for adults, and how even seemingly quieter kids volunteer to voice their opinions. I am beginning to understand how this approach lends itself to unearthing perspectives of greater complexity and nuance than a traditional research method, such as a survey or experiment would. Essentially, if one were to invest in dramatic enquiry as a means of formative research for investigating a public health problem, they would reap a rich, and dare I say endless harvest of research questions worth investigating in a format that’s fun, engaging, and revelatory.

If you are waiting to know what we learned from these workshops, I will share links to a podcast series (on this blog) sometime over the next few weeks. These podcasts will give you a more detailed idea about dramatic enquiry, how the participating children benefited from it, and some perspectives that emerged about how kids perceive scientists, media, and the industry that really surprised us.

When I first arrived into the UK academic environment in February 2017, public engagement seemed a policy or media interfacing, translational exercise for researchers. Being involved in dramatic enquiry has now broadened my personal understanding of public engagement and triggered a cascade of ideas about creative ways to get a conversation going with communities whose lives we seek to positively influence through public health research. And, without a doubt, it has given me my most enjoyable week in eight years as an academic. Brad and Katy deserve some chocolate cake, but in moderation.

*Acknowledgment: This project was funded by the Consumer Data Research Centre, an ESRC Data Investment, under project ID CDRC 085, ES/L011840/1; ES/L011891/1.

What’s a night out without a takeaway?

Ingrained & intertwined risky drinking & eating habits

Posted by Stephanie Scott, Senior Lecturer in Criminology & Sociology, Teesside University

A recent Fuse blog post reflected on the ways in which alcohol and food come together in the lives of young adults (Cassey Muir and Alice Graye ‘the booze, the binge and the bulge’). For example, some young adults may eat a takeaway after a night of drinking and a fry-up the next day, some may choose not to eat prior to drinking and some may drink alcohol alongside a meal. Such reflections are based on findings from the recently completed FOrwaRD project, a study that I have had heavy involvement in as a project applicant and lead researcher.

Yet, whilst the reflections of those on the cusp of adulthood are extremely important, one of the key messages from this project and an abundance of public health research evidence is that behaviours such as risky drinking and associated eating patterns become ingrained and intertwined in our lives long before we turn 18. In other words, health behaviours cluster in adolescence and track to adulthood. Think back. How long have you associated a beer with a curry or white wine with fish or, more bluntly, that going for a takeaway at the end of a night of heavy drinking is the norm? And, are these messages instilled in us during adolescence or perhaps even earlier in childhood? We also know that an unhealthy approach towards food and alcohol is more likely for some young people than others, particularly for alcohol, where we have seen a steady decline in the overall percentages of those who drink alcohol juxtaposed against those who do drink doing so at extremely high levels.

My point here is that, not only do eating and drinking behaviours interact, but the influences on these behaviours, such as parents, peers, marketing, urban space, also overlap, and overlap from an early age. Frankly, we eat and drink certain products for pleasure, for popularity or to socialise. One way in which to tackle a growth in obesogenic and alcohol-related harm is to explore overlapping and distinct influences on these behaviours at the point in which they accelerate i.e. late childhood / early adolescence and use this knowledge in the design of interventions which link rather than separate out such behaviours.

With this in mind, we set out (using Fuse pump prime funding) to identify and synthesise qualitative research evidence into common underlying factors which influence alcohol use and unhealthy eating behaviours amongst young people aged 10–17. This involved bringing together two separate bodies of literature to enable analysis and comparison across two associated fields of study. Thus, our synthesis involves the interpretation of individual studies by identification of second-order constructs (interpretations offered by the original researchers) and third-order constructs (development of new interpretations beyond those offered in individual studies) by way of the development of a ‘model structure’ of shared influences upon both unhealthy eating behaviours and alcohol use amongst young people aged 10–17.

Of the 63 studies included in the review, 27 studies focused on alcohol whereas 36 focused on eating behaviours. Initial analysis of the data identified 16 themes, 14 of which demonstrate shared or overlapping influences on young people’s alcohol use and eating behaviours. For example, we found that both alcohol and food were used by adolescents to overcome personal problems such as to relieve stress, to push away negative feelings or emotions and in some cases to replace human interaction: “…it’s a way like any other to forget or to let off steam, it depends on the person.” (Petrilli et al., 2014).

Whilst these findings are at an exceptionally early stage, one thing is clear – there remains very little research linking young people’s eating behaviours and alcohol use together. Hopefully, emerging publications from this review and the FOrwaRD project will help to lead this change.

With thanks to the core project team Louisa Ells, Emma Giles, Frances Hillier-Brown and Wafa Elamin.


Reference:

1. Enrico Petrilli, Franca Beccaria, Franco Prina & Sara Rolando (2014) Images of alcohol among Italian adolescents. Understanding their point of view, Drugs: Education, Prevention and Policy, 21:3, 211-220, DOI: 10.3109/09687637.2013.875128