What came first, food insecurity or severe mental illness?

Posted by Heidi Stevens, Research Associate, Teesside University, and Jo Smith, Consultant Dietitian and Clinical Academic, Tees, Esk and Wear Valleys NHS Foundation Trust 

Well before the current COVID-19 pandemic hit our shores, it was already apparent that food insecurity was an emerging issue in the UK. In 2014, the Children’s Society presented evidence to an All-Party Parliamentary Group (APPG) to raise awareness of the issue. Four years later after a visit to the UK, Special UN Rapporteur Sir Phillip Alston highlighted the increase of people depending on foodbanks across the UK. Despite these high-profile reviews of the evidence, it has taken a pandemic and the persistent efforts of a professional footballer to thrust the circumstances of food insecurity in children firmly into the spotlight. 

Marcus Rashford has led campaigns to end child food poverty over the course of the pandemic

While the issues around food insecurity and the longer-term detrimental implications of this for children are now well documented, the implications of food insecurity in other vulnerable groups have been seldom considered. Research has documented the effects of food insecurity on mental health, but less is known about the impact of food insecurity specifically on those with existing severe mental illnesses (SMI) (ie. bipolar disorder and schizoaffective disorders). For example, research has shown that people with a mental health diagnosis face an income gap as high as £8,400 per year compared to the general population. Additionally, almost 25% of food banks have reported an increase in the number of people with mental health conditions accessing them. However, this does not distinguish between mental health conditions and severe mental illness which can be complex to manage often impacting every aspect of a person’s daily life.

Public health guidelines encourage a balanced diet, for a healthy lifestyle. But when faced with financial constraints, food purchases are often restricted to poorer quality foods which are more accessible on lower budgets. Research by Jones et al. (2014) found an average price disparity of £2.50 per 1000kcal of less healthy food products versus £7.49 for more healthy food products. The study classified food products in their data set (basket of food) according to the Eatwell Guide to include carbohydrates (bread, pasta), fruit and vegetables, dairy, protein (meat, beans) and high fat/sugary foods.

Cheaper foods may often be high in salt, saturated fat and/or sugar, the effects of which on long-term health are well documented. However, for people with SMI there are also additional health risks because they may already be at risk of weight gain due to psychiatric medication. Additionally, for those taking prescribed lithium for bipolar disorder, too much salt in a diet can be very dangerous.

UN Sustainable Development Goal 2.1 ‘Zero Hunger’ challenges us to ensure access to nutritious and sufficient food for everyone but in particular poorer people and those in vulnerable positions. This certainly will not happen until we take a “Marcus Rashford approach” and use the current impetus from the COVID crisis to highlight the issue of food insecurity in other vulnerable groups of people, such as those with SMI. The syndemic nature of having severe mental illness in conjunction with food insecurity means these two factors may interact to further marginalise and disempower people with SMI and yet this remains an under-researched area worldwide. This potentially leads to food insecurity in those with severe mental illness being under-managed and under-supported in mental health practice. In order to achieve parity of esteem between physical and mental health it is essential that we understand the issues relating to food insecurity in this population group.

To this end, we are currently working on research aiming to assess the prevalence of food insecurity in adults with a diagnosis of SMI and explore their experiences for better understanding and increased exposure to the issues they face. Preliminary findings of our review of the available research on this topic (a systematic review) show a lack of targeted measurement for this group of people who are sometimes included as part of wider studies. The issue of cause and effect (or causality) is also often referred to; what came first, food insecurity or SMI? We hope our overall findings later this year will provide an overall picture of food insecurity in people with severe mental illness and potentially a basis for affirmative action.

Supporting authors: Lauren Bussey, Emma Giles and Amelia Lake from the School of Health and Life Science, Teesside University.

Image: 'Rashford Mural' by Rathfelder via Wikipedia, copyright © 2020: https://en.wikipedia.org/wiki/File:Rashford_Mural.jpg (CC0 1.0)

Is it ethical to promote quitting smoking to patients with mental health issues?

Posted by Susan Jones, Research Associate, Teesside University

Smoking rates and levels of dependency are high in people with psychiatric problems and, it has been argued, that smoking helps people with mental health disorders to cope with the struggles in their lives (Malone et al., 2018). On the other hand, the National Institute for Health and Care Excellence (NICE, 2013) argues that introducing a smokefree culture into NHS Trusts offers an opportunity for patients and staff to benefit in terms of physical and mental health and is achievable with appropriate support. Certainly this viewpoint was supported in our research:

"I think for some of our patients because it’s actually a learning disabilities hospital but obviously a lot of them have mental health issues as well, it increased their confidence and self-esteem. A lot of our patients had poor self-esteem and they actually achieved something by stopping smoking, they achieved something that was extremely difficult and I think it made them think, if we can do that we can do other things as well." 

Frontline Staff, Trust B

Nevertheless, by taking this position, NICE have highlighted a contentious issue. In our research we found that the patients and healthcare community were still divided about introducing smokefree policies and supporting patients and staff to quit smoking (Jones et al., 2020). There was a lot of passion on both sides! In some wards (mostly those with non-acute patients, such as those with learning difficulties or associated with forensics) staff and patients took on the challenge to change their environment and behaviours and embrace a smokefree way of life. They were creative in how they prepared for quitting and even made it fun, with games and decorations.

In other areas e.g. acute services, the challenges were different and there was much more scepticism about the ethics and value of offering support to quit smoking. Although awareness raising and training in smoking cessation was available, the role of choice and a pro-smoking narrative was widespread. 

Normalisation of smokefree policies

In mental health, smoking is an established cultural norm both in the community and in healthcare settings. We found that it is seen as an acceptable, even beneficial, coping mechanism for people who suffer from mental health disorders.

Research evidence would argue the converse; that the physical and mental benefits are far greater than continuing to smoke (Harker & Cheeseman, 2016). People with psychiatric problems tend to be highly addicted and there is a definite need to push through the initial stages of withdrawal from nicotine, which can be harder due to greater dependency, and more complicated due to interactions with psychiatric medication. Nevertheless, the evidence shows that people still want to be physically healthier, free from the downsides of addiction and supported to achieve these goals (Harker & Cheeseman, 2016).

Promoting normalisation through collective action

Perseverance is required to change any norm; old habits and perspectives die hard and continual reinforcement of new patterns are needed for success (Jones et al., 2020). This applies at an individual level but also at the organisational level.

Role of context

Our environment is so important in enabling or blocking behaviour; or even ‘nudging’ it in a certain direction (Ratschen et al, 2011). If a hospital is smokefree, then patients who don’t smoke will be able to maintain their status as non-smokers more easily. Alternatively, a smoking environment legitimises and encourages continued smoking. 

Sustainability

Maintaining changed behaviours, like smoking, is known to be challenging; however there is an inherent contradiction in implementing smokefree policies on-site only. Patients and staff move between hospital and community and it is all too easy for this to be seen as abstaining while in hospital, rather than quitting for good.

What we found 

Two mental health trusts in North East England - Northumberland Tyne and Wear NHS Foundation Trust and Tees, Esk and Wear Valleys NHS Foundation Trust - went smokefree in March 2016. In our research to evaluate the implementation of smokefree policies within the trusts, we found that:

• Inroads had been made in changing an entrenched, smoking culture into one that was smokefree on Trust sites. However, there remained variations across specialities and challenges to full implementation.
• Once there was sufficient ‘buy-in’ to a non-smoking culture it was anticipated that the issues relating to enforcement and perceived risk would diminish.
• Long-term perseverance is required to establish smokefree sites in participating mental health trusts, supported by robust, routine, data collection.
• Normalisation Process Theory and logic modelling are helpful in increasing understanding of the dynamic implementation process. 

Policy relevance and implications

• Careful use of language is needed to encourage smokefree policies to be seen positively.
• When interpretation of the term ‘patient leave’ was left open for leave to be used for smoking, it led to inconsistent practice.
• Consistency of enforcement is key to success.
• There were many details that needed to be worked out following the introduction of the policies; suggesting a requirement for ongoing review and response in a timely manner.

Read more about Sue's research in this Fuse research brief: Introducing smokefree policies into hospital mental health services.

References:

Harker K, Cheeseman H. The mental health and smoking action report: the

stolen years. 2016 [Available from: https://ash.org.uk/information-and-resources/reports-submissions/reports/the-stolen-years] 

Jones, Susan E; Billett, A; Mulrine, S; Clements, H; Hamilton S. (2020) Supporting mental health service users to stop smoking: findings from a mixed method evaluation of the implementation of nicotine management policies into two mental health trusts. BMC Public Health, 20:1619

https://doi.org/10.1186/s12889-020-09673-7

Malone V, Harrison R, Daker-White G. Mental health service user and staff

perspectives on tobacco addiction and smoking cessation: a meta-synthesis

of published qualitative studies. J Psychiatr Ment Hlt. 2018;25(4):270–82. https://doi.org/10.1111/jpm.12458

National Institute for Health and Care Excellence. Public health guidance 48:

smoking: acute, maternity and mental health services. London: NICE; 2013. https://www.nice.org.uk/guidance/ph48

Ratschen E, Britton J, McNeill A. The smoking culture in psychiatry: time for

change. Brit J Psychiat. 2011;198(1):6–7. https://doi.org/10.1192/bjp.bp.110.081372

Images:

1. “Smoke-Free Bench” by Michael Coghlan via Flickr.com, copyright © 2011: https://www.flickr.com/photos/mikecogh/5645977385/in/photostream/ (CC BY-SA 2.0)

2. Copyright © South Tees Hospitals NHS Foundation Trust: https://www.southtees.nhs.uk/news/services/trust-to-go-completely-smokefree/ (2019)

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

Children’s exposure to junk food advertising: can the UK hold firm in the face of industry resistance?

Posted by Chris Baker, primary school teacher and distance learning tutor at the London School of Hygiene and Tropical Medicine

Growing up in a sweet shop was, as you can imagine, an absolute dream. Who wouldn’t want an entire store of confectionery under their own roof? It was the 1990s and I didn’t realise how lucky I was - living above a newsagent run by my parents. I’d get home from school, give a cursory wave to my mum behind the counter and immediately grab a chocolate bar, or an ice cream. It was the best.

Clearly, it wasn’t a recipe for good health. I was continuously surrounded by the bold and colourful logos, the marketing strategies and the special offers - all designed to hook me into habitual consumption. I paid little attention to the nutritional contents of the things I was snaffling (this was long before front-of-package labelling came along). My physical health (particularly my teeth) paid the price.

Cut to 2020 and I find myself thinking back to that era - before the internet, before screen-time, before social media. I am now a primary school teacher (with experience in public health) committed to promoting children’s health and well-being. I see that the relationship between children and junk food today has not changed all that much. There are still products high in fat, sugar and/or salt that kids crave. And what’s helping them to connect with these products? Digital marketing.

I teach ten and eleven-year-olds in an international school, so the demographic group I am most familiar with is not representative of the UK. However, I believe there are important similarities. Many children of this age now have smartphones and use apps intended for older audiences. Through these apps, they are exposed to new and sophisticated marketing strategies, unheard of by older generations.

Fortunately, there are plans to address this. Last year the UK government proposed a total ban of online marketing for foods high in fat, salt and sugar. Not a restriction, or a tightening of rules: a total ban. The preamble to this consultation suggests that completely reducing exposure to ‘endless prompts’ to eat offers the best way forward. The government’s response to the consultation, with an accompanying plan of action, is due to be published this Spring.

The scope and scale of this proposal are noteworthy. To date, no countries have successfully implemented a complete ban (there are strong restrictions in Chile and French-speaking Canada). Implementation of the government’s proposal would place the UK firmly at the front of the pack, delivering strong policy action with the potential for significant public health benefit.

Unsurprisingly, industries affected by such a ban have been critical of the proposals. In an open letter, a consortium of food companies and advertising agencies called for a rethink. Their arguments are predictable and are representative of a cross-industry playbook, seen repeatedly in recent years across several other industries interested in unhealthy commodities. They claim the proposal is disproportionate. They claim the evidence is lacking in detail. They distance themselves from the issue and play down their role. They demand a meeting with the government to discuss ‘alternative’ (but unspecified) approaches.

A total ban would be an entirely appropriate response in the face of an industry that has altered considerably in recent years. An earlier attempt to merely limit adverts for unhealthy foods in and around children’s tv programming (as well as other non-broadcast media) was found to expose children to no less advertising. Artificial separation of children’s media and adult media is a fallacy, and doesn’t reflect the reality of tv consumption nowadays.

More importantly, this proposal addresses the issue of children’s developing ability to distinguish an advert (and its provenance). Research suggests that over a third of 12-15 year olds are not aware of the financial arrangements behind promotional posts. Astroturfing - the artificially-created “buzz” around a product, designed to look authentic and spontaneous - can be difficult to identify, especially when delivered by a relatable vlogger or influencer, who may not have disclosed endorsement arrangements.

Most schools nowadays (mine included) encourage “digital citizenship”. As a teacher, I am responsible for helping my students navigate the risks and benefits of the internet. Often, I hear children referring to spurious news stories, and am reminded of the sophisticated ways even adults can be tricked into believing something.

Age restrictions for social media platforms, often put forward as a robust mechanism to shield children from inappropriate content, are weak and inconsistently controlled. Parental control settings on popular sites are not widely understood or implemented and the rapid changes in children’s media habits is named as a key driver in the government’s desire to strengthen legislation.

I believe that young people should have the freedom to use television and the internet for enjoyment and education. Exposure to insidious marketing that promotes and profits from the development of unhealthy eating habits should not be a price to pay for this. The UK government has proposed a bold course of action. In the face of strong opposition from industry, they should stay firm with their intentions; the health of future generations stands to benefit.