Tuesday, 19 May 2015

Public Health Post-election: What is its future?

Posted by David J Hunter, Professor of Health Policy and Management, Durham University and Fuse Deputy Director

The Conservatives’ election victory has brought both old and new faces into the ministerial team at the Department of Health. Jane Ellison returns as a junior minister and will retain the public health brief thereby bringing a degree of continuity to the post. She was growing into the post in the run-up to the election and public health insiders speak well of her.

Public Health Minister Jane Ellison
The fact there has been extensive coverage of the other ministerial appointments in health excluding hers might say a great deal not only about the place of public health in the government’s health priorities but about the level of importance the media attaches to the subject.

Clearly the funding difficulties plaguing the NHS will be uppermost in Jeremy Hunt’s (back as Secretary of State for Health) in-tray with the integrated health and social care agenda not far behind. But the new government is also committed to implementing the Five Year Forward View (5YFV) produced by the NHS Chief Executive, Simon Stevens, last October. Herein lies the hope for public health and surely the near certainty that it will occupy a high place on the government’s list of priorities.

Public health did not feature prominently in the Conservative Party’s manifesto and no major new initiatives were promised. None of the parties had much to say about public health during the campaign. And yet the new government is going to come under significant pressure to up its game over the next five years with the call for ‘a radical upgrade in prevention and public health’ featuring prominently in the 5YFV.

Not only that, but Simon Stevens rarely misses an opportunity in public to stress the importance of public health, admonishing successive governments for their failure to implement the Wanless ‘fully engaged scenario’.  Since the NHS failed to heed the warning, it ‘is on the hook for the consequences’. Wanless wanted a transformed NHS that put health and not illness first.

The 5YFV urges the NHS to redeem itself over the wasted years by becoming an advocate for ‘hard hitting action’ on avoidable lifestyle-related illnesses. Because these put added pressure on health care services, tackling them at source has to be a high priority if a universal service free to all at the point of use is to be sustained.

The latest projections from WHO published a week ago show that Europe faces an obesity crisis by 2030 and that urgent action is needed by governments. In the UK, 33% of women are forecast to be obese by 2030 compared with 26% in 2010. For men, the figures are 36% and 26% respectively. The figures are worse in some other WHO member states with only The Netherlands doing better and remaining stable.

As we know, although there is no silver bullet for tackling obesity restricting unhealthy food marketing is regarded as a key policy lever available to governments. Where this leaves the government’s responsibility deal approach to addressing key public health challenges is uncertain. Even if its critics are persuaded that it is working, the key question in the light of the WHO projections is whether it is working fast enough given the urgency of the crisis looming in under 15 years’ time.

Another key development concerns devolution within England and the Northern Powerhouse initiative. Local MP for Stockton South, James Wharton, has been made the first minister for the project. It builds on the DevoManc announcement earlier this year which put local government in charge of the NHS budget for the Greater Manchester region. Chancellor George Osborne, the architect of this experiment, in his first speech since the election will announce today similar devolved arrangements for the City regions, including Newcastle.

The move to devolve power and responsibility could have major implications for public health as local government will be able to pool budgets and adopt place-shaping policies to improve health and wellbeing and tackle the social determinants of health.

But the catch must be that these developments are occurring at a time when local government is on its knees. With no let up to austerity in sight and with further public spending cuts to come which will fall heavily on local government, the question has to be asked: is local government being set up to fail? Whatever the outcome, there will be significant implications for public health which cannot be predicted. Watch this space.

Thursday, 14 May 2015

How active are pregnant women? Measuring the methods

Posted by Louise Hayes and Cath McParlin 

Louise and Cath are presenting on the subject of physical activity in pregnancy at the Fuse Phyical Activity Workshop tomorrow (15 May) at Sunderland University.

So we all know we should move a bit more to be more healthy and reduce our risk of getting diseases like diabetes. For a long time pregnancy was seen as a time when a woman could put her feet up, take it easy and ‘eat for two’. But not any longer! Guidance published over the last few years recommends no ‘pregnant pause’, but rather that pregnant women should aim to achieve at least 30 minutes of activity of at least moderate intensity activity on most days of the week - just like the rest of us.

Part of the justification for this is that physical activity might help to reduce the risk of gestational diabetes (GDM) – that’s a type of diabetes that is diagnosed in pregnancy and (usually) resolves after the pregnancy. However, to some extent, the jury’s still out on whether or not being active when you’re pregnant really does reduce GDM.

Partly this is because we don’t really know how to measure physical activity accurately in pregnant women. The more precisely we can measure physical activity, the more accurately we can establish the relationship between it and GDM and other health outcomes.

Physical activity measurement is fraught with difficulty in any circumstances – it’s a challenge to measure such a complex and multi-faceted behaviour. Pregnancy brings additional challenges. With the development (and increasing affordability) of numerous objective methods for measuring physical activity – pedometers, heart rate monitors, accelerometers - objective measurement of physical activity in epidemiology is increasingly common. For pregnant women, however, the validity and acceptability of these methods remains unclear.

We have agonised over how best to measure physical activity in a pregnant population. What effect does the increasing size of the ‘bump’ have on the validity of waist-worn monitors? How good are monitors at recording low-level activity, common in pregnant women? What are appropriate cut-offs for different activity intensities in pregnant women?

The choice of measurement method has a huge influence on conclusions we draw about how active women are during pregnancy. We have compared questionnaire methods and accelerometry using different criteria to define activity intensity and found that, depending on the method used, we identify anything from 12% to 65% of pregnant women to be meeting the current guideline (30 minutes of at least moderate activity per day) in the first half of pregnancy.

We’re looking forward to discussing the whys and wherefores of different methods of assessing physical activity with the experts attending the Fuse PA Group Workshop at Sunderland University tomorrow (Friday 15 May).

Wednesday, 6 May 2015

Party manifestoes, part 2: A war on junk food?

Guest post by Avril Rhodes

The Fuse blog has seen pieces on the marketing of junk food near supermarket checkouts in recent weeks. Interestingly, whilst all the political Parties profess many policies related to children and young people, this is a specific topic where they are silent. Perhaps it’s too micro an issue or maybe involves dealing with too many big business interests. Who knows? However, I wouldn’t wish to be called cynical and neither would our potential political masters, who are working hard on the junk food agenda…to varying degrees.

Conservatives will:
  • Act to reduce childhood obesity (how?) 
  • Continue to promote clear food information (not all that clear an aim, on reflection) 
  • Introduce a national evidence based diabetes prevention programme (sounds interesting) 
  • Invest more in primary care to prevent health problems (needs more detail)
Labour will:
  • Set a new national ambition to improve the uptake of physical activity (and this means…?) 
  • Set maximum permitted levels of sugar, salt and fat in foods marketed substantially to children (assuming we know what these foods are, and can get over the qualifier “substantially” without disappearing in a legislative quagmire, this, could, in the end improve the offer at the proverbial check out)
Liberal Democrats will:
  • Restrict marketing of junk food to children, including restricting advertising before 9.00pm, and maintain the ‘5 A DAY’ policy (more specific, but perhaps would have the unintended consequence of driving the advertising onto the internet, and what about the argument that the 9.00pm watershed is an anachronism in light of current TV viewing technology?)
  • Encourage traffic light labelling of food and publication of information on calorie, fat, sugar and salt content in restaurants and takeaways (and would this be better than dealing with the check-out offer? Or are people going out already committed to a more unhealthy option in the interests of convenience?)
Greens will:
  • Extend VAT at the standard rate to less healthy foods, including sugar, and spend the money raised on subsidising a third of the cost of fresh fruit and vegetables. This, it is stated, could prevent 5,000 premature deaths a year. (A bold one this. Could the money raised be tracked to ensure this happened? What about ensuring the quality of the subsidised produce? Who provided the calculations on lives saved?)
Before you despair and think that there are more questions than answers, there is some good news here. All the parties (well except perhaps UKIP, who don’t discuss junk food, though are loud on backing British farming and fishing) have got the message that action needs to be taken about what our food contains. This should encourage the world of public health research. 

All views expressed are exclusively those of the author.

Tuesday, 5 May 2015

Party manifestoes, part 1: Four lessons to untangle the public health policies

Guest post by Avril Rhodes

Hung over by the election talk? Worn down by the TV debates? Well how about reading the manifestoes? Be honest with yourself, when did you last read a manifesto? The Liberal Democrats’ manifesto is 158 pages, but the remaining largest national parties (Conservative, Labour, Green and UKIP) make do with around 70 to 80ish pages. And the public health policies are all over the place, under welfare, housing, transport, the environment, education, the economy and, occasionally, under health – so need some real work to find. However, that’s good, even if the party seems untroubled by, or hasn’t heard of, the wider determinants of health, at least they’re there…or somewhere. So, first lesson, be prepared to find a public health policy just about anywhere. 

Second lesson, be ready to make comparisons and choose your topic. Take the broad sweep and you will find the whole thing indigestible, and it may turn you into a floating voter after you’ve agreed and disagreed in about equal measure with all you’ve read.

So, here’s one of the easier examples: booze and fags.
  • Conservatives will end open display of tobacco in shops, introduce plain packaging and support people “struggling with addictions”. The latter is swept up in a review in how best to treat long term yet treatable conditions, which include alcohol addictions. 
  • Labour come in with a levy on tobacco firms to pay for NHS staff and they will target high strength, low cost alcohol products, their argument being that this fuels problem drinking. 
  • The Liberal Democrats want to reduce smoking rates, complete the introduction of plain packaging and also make a tax levy on tobacco companies, in their case to contribute to the costs of health care and smoking cessation services. They will also monitor evidence on e-cigarettes and “ensure restrictions on marketing and use are proportionate and evidence based”. Finally they will introduce a minimum unit price (MUP) for alcohol. 
  • The Greens will increase alcohol and tobacco taxes to help fund NHS spending increases and set a MUP of 50p. In a big section on road safety they will reduce the alcohol limit for drivers “to as close to zero as possible”. 
  • UKIP under their “Save the Pub” campaign will provide tax breaks for micro-breweries, amend the smoking ban to give pubs the chance to open smoking rooms, “properly ventilated and separated”, oppose minimum unit pricing and reverse the plain packaging rules. All of this, which you will have guessed, is in a chapter on “Heritage and Tourism”.
Third lesson, consider what’s not been said. Reading between the lines I think it’s probable, for example that Labour and the Greens would favour plain packaging, the Liberal Democrats might consider 50p for their MUP, and Labour might be amenable to, say, reducing the blood alcohol limits. But we can’t be sure.

Fourth lesson, if you’re going to have a debate with your friends about what’s on offer, anticipate the arguments they might offer, like, for example, that good local pubs, will combat loneliness, provide employment, and maintain community cohesion. Does that end justify the means? Or is UKIP’s claim that 6,000 pubs closed due to the smoking ban and ending the alcohol duty escalator worth bringing in the smokers from the cold?

All views expressed are exclusively those of the author. 

Wednesday, 29 April 2015

A blether with Scotland’s fast food vendors

Guest post by Michelle Estrade, Scottish Collaboration for Public Health Research and Policy (SCPHRP)

In June 2014 the Scottish Government published a voluntary framework, entitled Supporting Healthy Choices, which encourages the food industry to take action towards offering healthier food choices to consumers. The recommendations include guidance on promotional activities, healthier cooking practices, and types and portion sizes of foods offered. Just after the recommendations were drafted, I sat down with owners of independent fast food shops in lower-income neighbourhoods across Scotland to discuss how they felt about offering healthier menu options. They shared many thoughts on tradition, customer demand, and the deprived neighbourhood context, suggesting that food vendors in disadvantaged areas would need additional incentives and assistance in order to implement healthy menu guidelines and ensure that their customers don’t miss out on the potential benefits.

The shop owners I talked to took pride in their menus, using words like “traditional” and “proper” to describe the foods they sold. Because they felt food was being prepared the proper way, there was a sense of reluctance to change cooking methods. One example was the use of traditional beef dripping for frying, rather than healthier oil alternatives. During our conversation, the food vendor I was interviewing looked at me quizzically and asked: “I mean, how can we say we’re traditional if we’re cooking in palm oil or rapeseed oil?”

Most places I visited had a well-developed sense of niche, which was a common reason for offering only certain types of foods and not others. When I asked about the possibility of adding other [healthier] options, a fish and chip shop manager gave me a cheeky smile and quipped: “…they’re not coming here because they want fruit.” Again and again, the food vendors I talked to explained that they needed to respond to customer demand in order to keep their clients; competition was described as “cut-throat”, and the fear of losing business was palpable.

Indeed, price was viewed as a major barrier to offering healthier options to current clientele. The owner of a sandwich shop shared a personal example of the dilemma: “I don’t allow my kids to have fizzy juice, so I dinnae really like having it. I’d like to buy fresh juice, but it’s so expensive, you wouldn’t make any money. With the price you would have to charge, they wouldnae want to buy it.” Another told me: “We’re barely making a profit just now. If we were anywhere else we’d be able to charge more, but in [this neighbourhood], most of our customers are on a limited budget...”

I went into this project assuming that the major problem I would uncover would be a lack of awareness and knowledge about healthy eating. All we would need to do is help food vendors realise how important it is to get people to make healthier food choices, and they would be eager to jump on board with guidelines like Supporting Healthy Choices. What I found though was a much more complex set of circumstances at play – a constant struggle to cope with economic pressures, intertwined with the enduring characteristics of the neighbourhoods in which these people did business. Reflection on this has helped me realise that perhaps what needed uncovering was my own lack of awareness about the pivotal role of environment and context. Too often, I think, researchers are eager to jump into intervention mode and change what is happening without first thoroughly understanding why it’s happening.

Michelle is presenting at the Fuse Quarterly Research Meeting - More than enough on our plates: tackling the takeaway food diet at source tomorrow (Thursday 30 April).

Tuesday, 28 April 2015

Whipping town planners into shape

Guest post by Michael Chang, Town & Country Planning Association

Obesity is climbing up the national and local government agenda, and following two previous seminal publications – the Foresight Report on reducing obesity in 2007 and the Marmot Review of health inequalities in 2010 – one of the many spotlights has now firmly fixed on town planners and the planning system.

So all eyes will be on town planners at the Fuse event – More than enough on our plates: tackling the takeaway food diet at source – on Thursday (30 April).

This blog will attempt to shed some light on what planning can, must, should and could do. Coming from a non-academic background and admittedly a town planner, I take a pragmatic but liberal view of the planning system. This is not surprising as I work for a charitable organisation which essentially championed good planning for healthy outcomes for people in the Victorian times through the building of two garden cities in Letchworth and Welwyn.

Planning is a legal mechanism tasked with a land use function and exists to ensure the sustainable use of a scarce resource that is the land and the natural environment. What we do is grounded in what planning law, dating back to the 1990s, allows us to do and what national policy in the National Planning Policy Framework (NPPF) published in 2012 requires us to do. Why do I emphasise these dates? Simple. Laws change and policies evolve. Of all the planning laws and policies we have had, there has never been an explicit reference or requirement to consider access to fresh healthy food. That is, until 2014 with the online Planning Practice Guidance which the government hailed as a triumph in condensing thousands of guidance into an accessible and evolving online guidance, and which supports the NPPF. In addition to having a section on health and wellbeing, it states:
The range of issues that could be considered through the plan-making and decision-making processes, in respect of health and healthcare infrastructure, include how: opportunities for healthy lifestyles have been considered (e.g. planning for an environment that …promotes access to healthier food).
Healthier food is of course not defined but at least planners are now strongly encouraged to consider food in planning.

Laws and policy frameworks haven’t stopped some enlightened local planning authorities in doing what they think is right for their local areas to use current planning powers to improve access to healthy food or rather, to restrict the proliferation of unhealthy land uses. We know there are dozens of councils now pursuing planning policies to prevent burgeoning shops serving unhealthy foods, albeit meeting increasing resistance from the food industry and also from within different sections of the planning profession. Actions in planning also take time: five years between the publication of Foresight (2007) to the first Supplementary Planning Document (SPD) on takeaways in 2009 and the Greater London Authority’s takeaways toolkit in 2012. Also there are more than 350 local planning authorities across England, so we still have a long way to go.

The Town and Country Planning Association (TCPA) published the Planning Healthy Weight Environments resource in 2014 which highlighted the following considerations regarding food in planning:
  • Development avoids overconcentration of hot-food takeaways (A5 class use for the sale of hot food for consumption off the premises) in existing town centres or high streets, and restricts their proximity to schools or other facilities for children and young people and families.
  • Shops/markets that sell a diverse offer of food choices are easy to get to by walking, cycling or public transport.
  • Leisure centres, workplaces, schools and hospitals with catering facilities have a healthier food offer for staff, students, and/or customers.
  • Opportunities for supporting innovative approaches to healthy eating through temporary changes of use have been explored.
  • Development maintains or enhances existing opportunities for food-growing, and prevents the loss of food-growing spaces.
  • Opportunities are provided for households to own or have access to space to grow food – for example roof or communal gardens, or allotments.
So the key message of this blog is: there is actually no legal, or professional, basis that stops town planners from taking appropriate policy actions to promote healthier communities through the provision and access to fresh healthy food. Much of what is needed is a cultural change within the profession, more active support of colleagues in public health in the planning process, continuing advocacy by national organisations, and last but not least (especially where Fuse is concerned), translating valuable evidence from academia to a format planners can use.

Tuesday, 14 April 2015

Have we been had?

Guest post by Jean Adams, Centre for Diet and Activity Research (CEDAR)

Parents don’t like sweets at supermarket checkouts. The ‘guilt lane’, as it’s been called, seems designed to attract children in a place where they are a captive audience – you can’t just move away from the checkout when you have a trolley full of shopping that you need to pay for.

This consumer concern is what seems to have prompted many supermarkets to impose total, or partial, bans on checkout confectionary.

It was certainly a healthy dose of parental curiosity that prompted our recent study on food at checkouts in non-food stores. The lead author was in Primark with her pre-schoolers, noticed a LOT of sweets by the till, and started to wonder how pervasive a phenomenon this was.

We felt food at checkouts in non-food stores was a worthwhile thing to study for two reasons. Firstly, these are places where we assumed most people aren’t naturally thinking about food. Buying confectionary at a supermarket is, perhaps, appropriate. But at a clothes shop? Presumably most people don’t go into Primark to buy some energy-dense, nutrient-poor snacks. So any purchases they do make are unplanned and prompted entirely by the display, rather than, say, hunger. Secondly, a lot of campaigning attention has been devoted to #junkfreecheckouts in supermarkets. To some good effect. But if the problem has just shifted to other types of shops, then any war is not yet won.

So we enlisted the help of two medical students, who were keen to get some hands-on experience of public health research, and did a survey of all the non-food stores in the MetroCentre - which has the dubious accolade of being the second largest shopping centre in the UK (I’m sure it was the largest in Europe at some point).

Of 205 non-food stores in the MetroCentre, 32 of them, or 16%, had food within arm’s reach of the checkout queuing area. All these stores stocked less healthy checkout food, although about half of them also had foods that were not specifically identified as less healthy. This was mostly bottled water or chewing gum – so not exactly healthful! Overall more than four-fifths of checkout food was less healthy and would not be allowed to be advertised on children’s TV in the UK.

As well as making life easier for the parents of young children, there may well be health benefits of #junkfreecheckouts. Around the world, most checkout food really is ‘junk’ – soft drinks, and foods high in energy and salt, and low in vitamins and minerals. Checkout food may prompt impulse purchases and purchasing requests from children, which parents find hard to resist.

But, importantly, I’m not aware of any research that shows that people who see more checkout junk food eat more junk food, or that removing checkout junk food leads to changes in what people buy or eat. This is one of those absence of evidence, rather than evidence of absence situations – we just don’t know what effect checkout confectionary has on what kids eat.

There was an interesting discussion on the Food Programme recently suggesting that sales of confectionary from UK supermarkets were steady, or rising, despite many stores removing it from checkouts. Checkouts aren’t the only way to prompt impulse purchases in supermarkets. Prominent, end-aisle displays, and price promotions seem to be keeping sweets sales buoyant. At least for now.

This wasn’t what we meant: a prominent confectionary display opposite a #junkfreecheckout at my local supermarket (that pizza wasn’t mine!)
Which makes me wonder…have we been had? Have supermarkets taken confectionary off tills because it makes them look responsible and ‘part of the solution’, knowing full well it will have no effect on sales? And what might the consequences of that be for public health? Well, no change on the diet front. But what if supermarkets voluntarily choosing to remove checkout junk food, means that it also closes down a conversation on unhealthy food environments? Could the supermarkets keep referring to this non-change as a way of trumpeting how importantly they take health, and silencing any requests for further, serious, meaningful change?

I find this a bit scary. Some well-intentioned public health campaigning might have made things worse? I don’t know that it has. Maybe it hasn’t. Probably it hasn’t? Hopefully it hasn’t. Probably it’s just made no difference. At the very least, it makes life a bit easier for stressed out parents trying to get the shopping done and their kids to eat a healthy diet?