Friday 21 December 2018

The power of cookies

Posted by Peter van der Graaf, AskFuse Research Manager / Fuse Knowledge Exchange Broker, Teesside University

With the festive season upon us, many are looking forward to indulging in a mince pie or two and getting stuck in some extra helpings of turkey or brandy-soaked Christmas pudding. This often sparks some well-intentioned health warnings from public health folk about the risks of overindulging, binge drinking and the increasing obesity epidemic. Not wanting to dismiss these important messages, I would like to focus on a different message in this blog: food as a great tool for knowledge mobilisation (making information useable and accessible through working collaboratively).

If there is one thing that I have learned in my time as AskFuse Research Manager, it is that nothing is as useful as biscuits for bringing people together and contributing to a positive meeting between researchers and health professionals. 

This insight started from my own weakness: I have an incurable sweet tooth and my colleagues and students have quickly learned to exploit this asset for plying me with Dutch liquorice and other delicacies into supporting their requests and theses. So, I decided to turn their own weapons on them, with surprising results.

Stuck in a challenging debate about the usefulness of research evidence for commissioning local health services? Bring some cookies and fruit (to balance; I am a public health researcher after all!) and you will find that conversations all of sudden move in more fruitful directions.

Although my experience told me that cookies are a great conversation starter when brokering knowledge, I did not realise until recently that this was an area of serious academic study. In a recent paper published in Medical Education[1], Michael Hessler and colleagues from the University Hospital of Münster in Germany decided to put the power of cookies to the test and conducted their own Randomised Controlled Trial while delivering an emergency medicine course.

They were worried about the evaluations at the end of their course and suspected that these were not the measures of quality that the University was hoping for. Therefore, they were looking for a ‘content-unrelated’ intervention that would alter their evaluation results significantly and prove that their evaluations were seriously under-baked.

Third‐year medical students (n=118) were randomly allocated into 20 groups, 10 of which had free access to 500g of chocolate cookies during the course sessions (cookie group!) and 10 of which did not (control group). The groups had the same teachers and were taught the same content. After the course, all students were asked to complete a 38‐question evaluation form.

The results were very appetising: the cookie group evaluated teachers significantly better than the control group, they rated the course material as considerably better and overall satisfaction scores for the course were significantly higher. In summary: the provision of chocolate cookies had a significant effect on course evaluation.

One might conclude that course evaluations are seriously flawed but I prefer the ‘cookie-jar-is-always-half-full’ interpretation: providing cookies to participants is a great way to boost results! The German research adds baking powder to my own observations in UK knowledge brokering: cookies are a great way to boost exchange of knowledge and relationship building in conversations and meetings.

The ingredients of each meeting and conversation might be different but they all need a baking agent to rise to the occasion. So, whatever you do this Christmas, if you would like to avoid awkward questions during social and family gatherings about ‘what it is that you do as a researcher’ or ‘when are you finally going to finish your PhD?’, just bring a plate of cookies and subtly but swiftly change the conversation to a sweeter topic.

Happy Christmas!

  1. Hessler M, Pöpping DM, Hollstein H, Ohlenburg H, Arnemann PH, Massoth C, Seidel LM, Zarbock A, Wenk M. Availability of cookies during an academic course session affects evaluation of teaching. Medical education. 2018 Oct;52(10):1064-72,

Tuesday 11 December 2018

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.


Friday 7 December 2018

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.


  1. Ireland, R and Ashton, J.R. (2017) “Happy corporate holidays from Coca-Cola” i8633. Available at:
  2. SUGAR SMART (2017) Spending holidays in good health. Available at:
  1. Courtesy of Beth Bradshaw
  2. With thanks to Sustain and Sugar Smart UK: