Supporting people with Severe Mental Illness who face food insecurity to access a nourishing meal

Sally Smith, Peer Lead for Research, Tees, Esk and Wear Valleys NHS Foundation Trust (TEWV)

I have met many wonderful and interesting people on the inside of a psychiatric ward. The immediacy and depth of connection between peers in there was an unexpected comfort in the most challenging of environments.

Illustration by Sally Smith

I remember lots of the stories shared in the smoking corners of gardens. We often reflected on how misunderstood we felt in the ward and in the world.

One young woman was desperate to stay on the ward as she knew that was the only way she was certain of ongoing access to food. Her cupboards empty, her benefits paused, she was terrified about discharge. I was unsure how much Dialectical Behavioural Therapy or anti-depressants would help: wouldn’t anyone feel miserable with no food or money?

I remember physical health checks on the ward being introduced. Being weighed and measured, compared to the graphs…. and yet being given medication that makes you want to eat sugar out of the bag, being locked on a ward with no way to exercise, offered beige food four times a day and feeling so damn lousy and desperate that motivation to even clean your teeth was a challenge.

It felt cruel and shaming. It certainly never helped me to change anything.

In my mind it is no surprise that the mortality gap for people with severe mental illness (SMI) continues to rise, the challenges and barriers around nutrition that people living with SMI face continue to go unseen. No amount of lessons on what makes a healthy plate will make avocado cost less than crisps, and no knowledge of a healthy Body Mass Index (BMI) will reduce the intense effects of psychiatric medication.

And perhaps this is more of an issue than ever with austerity and the cost-of-living crisis exacerbating people’s struggles.

Increasing accessibility of affordable healthy food to adults living with SMI in Middlesbrough

With this perspective in mind, I was delighted to join the team working on this National Institute for Health and Care Research (NIHR) Communities study as a peer researcher. With co-production and the voice of lived experience running throughout the project, we are seeking to develop practical solutions for people living with SMI who face food insecurity in Middlesbrough.

The project is a collaboration, bringing together lived experience with the best bits of Tees, Esk and Wear Valleys NHS Foundation Trust (TEWV), Teesside University and Middlesbrough Environmental City, a charity dedicated to promoting healthy and sustainable living.

Over a period of 16 weeks, we plan to co-design and co-develop a nutritious meal with surplus fresh ingredients from local Eco shops (social supermarkets) that would otherwise go to waste.

With the support of the food scientists at Teesside University, this will then be turned into a healthy ready meal and distributed back to Eco shops in Middlesbrough. Aiming to be an appetising, nourishing and accessible meal for local people battling severe mental illness, who for whatever reason may struggle to cook the fresh ingredients themselves.

Through the design and delivery group we are hopeful that there may be additional benefits for all participants and the collaborating organisations, for example:

• The opportunity to learn some cooking skills and explore recipes that are good to cook on a budget.
• The opportunity to develop peer relationships amongst the delivery group that support connection and foster hope for change.
• The opportunity for organisations to learn from one another’s strengths and take a fully bio-psycho-social lens on mental health difficulties.

We are currently in the recruitment phase for participants and a collaboration of this type has not been without substantial challenge. It is has not been easy to marry NHS language and expectations and academic protocols with how a community organisation runs. It has not always been easy to find middle ground between the clinical expertise and lived experience expertise. However, I look forward to sharing the progress we make as the delivery team becomes established.

 

Research published by the project team

This study published today explores food insecurity prevalence and the experiences of adults with Severe Mental Illness (SMI) living in Northern England.

This systematic review paper found that people with SMI are more likely to experience food insecurity.

Another recently published paper identified strategies to tackle food insecurity centred on making food banks more accessible and improving the quality of available food available.

Treats: a helpful reward, or to be approached with care?

Posted by Anita Attala, Lead Adult Weight Management Dietitian from Northumbria Healthcare NHS Foundation Trust, and research team from Teesside University

We all like to have a ‘treat’ and to give ‘treats’ to others. Indeed, the use of food, and in particular what we in public health call ‘high fat, sugar, and salt’ containing foods or ‘HFSS’, are often chosen as rewards. The notion of food cultures is certainly a social anthropological (study of humans) concept, with an example being the use of food in positive reinforcement; using ‘treat’/HFSS foods to reward children in particular. Taken at ‘face-value’ such treats may appear harmless, however repeated use of HFSS in this way has been shown to physiologically influence the human food reward system, and impact on our ability to regulate how much food we eat. This, together with other detrimental impacts, has led to advice not to regularly use food as a reward. Research has also shown that using food rewards in adults can hinder healthy weight management, especially from a psychological perspective.

But what exactly is a ‘treat’? Why do we feel the need to ‘treat’ someone? Are ‘treats’ always a positive experience or can they be used in a detrimental or harmful way?

While working in a forensic service I saw patients gain weight, and often gain this weight very rapidly. I also noted that some staff seemed frustrated and concerned about the weight gain some patients experienced. However, I also noticed that HFSS food was frequently used as part of patient care. This sparked my interest in wanting to understand this apparent conflict.

Forensic services provide care for people with a severe mental illness or learning disability, who have committed a crime but are too vulnerable to be in prison. For example, they are high risk either to themselves or the public, and therefore are unable to live in the community. People in these environments are often here for a long time and are reported to die 15-20 years prematurely, often from avoidable diseases. There are often restrictions imposed on the person and their environment. These restrictions will depend on the level of security required and the risk posed by the patient, and can be directed by the Ministry of Justice. An example of a restriction might be the person is not able to leave the ward.

Limited research seems to have been undertaken around the use of HFSS food ‘treats’ for adults, let alone adults who are in hospital. Yet, it is something many of us seem primed to do – bring (HFSS) food to someone when they’re ill.

The word ‘treat’ conjures up a particular thought of food – which is often high in calories, high fat and high in sugar. What you view as a ‘treat’ and how to ‘treat’ can often have been learnt in childhood and can differ from person to person. But, while it is entirely possible to have a non-food ‘treat’, it’s often harder to think of one and can be more difficult to provide while in hospital (particularly one with restrictions such as forensic wards).

You could argue that ‘treats’, by definition, can only be a ‘treat’ if you don’t consume them on a regular basis. As research shows, regular behaviours of any kind, can soon develop into habits.

Wanting to learn more about the use of ‘treats’ to show care and kindness, particularly in a hospital setting, I applied for research funding from my Trust (Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust). Also, in 2020, I was successful in obtaining a clinical academic internship with Health Education England (HEE) and the National Institute for Health and Care Research (NIHR). Both awards enabled me to research the use of treats in forensic inpatient care settings.

Using this funding, I decided to focus on whether ‘treats’ were being used to prompt a particular behaviour from a person, while in inpatient care settings; whether these ‘treats’ impacted on a person’s weight and physical health; and why treats were chosen and if it was related to ideas of care and kindness. Certainly, from my observations this is what seemed to be happening - often perhaps unconsciously – but this research allowed us to evidence what may be happening.

What we found

Our research into treats in the health care sector has now been published. It found that treats were used for a number of reasons including:

• Being an affordable way to reward someone
• An incentive to encourage patients to participate in activities, and
• A way to express love/care for someone.

Of course, food as a bonding mechanism is not a new phenomenon, and the idea of certain foods providing comfort is well-established.

It’s entirely possible to have ‘treats’ as part of a healthy balanced diet, and that the origin of using HFSS as treats may be from a place of nurture, but the advice is that food treats should be infrequent and limited in quantity. While it would appear ‘easy’ to say that those working in institutions, like in NHS care services, need to be mindful of how food is being used, our research findings suggest that it may take a much bigger system/cultural change to reduce the use of HFSS as treats in services. I think the idea of a ‘positive food culture’ is useful here. One where the focus is on preserving and nurturing good health and wellbeing through the use of healthy, positive, food behaviours, attitudes and values.

Authors:

Anita Attala, Lead Adult Weight Management Dietitian from Cumbria, Northumberland, Tyne & Wear NHS Foundation Trust, and postgraduate student from Teesside University.

Jo Smith, Consultant Dietitian (Clinical Academic) from Tees, Esk and Wear Valleys NHS Foundation Trust, and PhD student from Teesside University

Amelia Lake, Fuse Associate Director and Professor of Public Health Nutrition from Teesside University

Dr Emma Giles, co deputy-lead of the Fuse Behaviour Change Theme and Associate Professor Public Health from Teessside University

References:

1. Alonso-Alonso M, Woods SC, Pelchat M, Grigson PS, Stice E, Farooqi S, Khoo CS, Mattes RD, Beauchamp GK. Food reward system: current perspectives and future research needs. . Nutr Rev 2015;73(5):296-307. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4477694/
2. Roberts L, Marx JM, Musher-Eizenman DR. Using food as a reward: An examination of parental reward practices. Appetite 2018;120:318-326. https://doi.org/10.1016/j.appet.2017.09.024
3. Hsu A BA. Designing for Psychological Change: Individuals’ Reward and Cost Valuations in Weight Management. J Med Internet Res 2014;16(6). https://www.jmir.org/2014/6/e138
4. Attala A, Smith J, Lake AA, Giles E. Investigating ‘treat culture’ in a secure care service: a study of inpatient NHS staff on their views and opinions on weight gain and treat giving for patients in a forensic secure care service. J Hum Nutr Diet 2023; 1-13. http://doi.org/10.1111/jhn.13129
5. Human Relations Area File. Craving comfort: bonding with food across cultures. 2023; Available at: https://hraf.yale.edu/craving-comfort-bonding-with-food-across-cultures/
6. Mingay E, Hart M, Yoong S, Hure A. Why We Eat the Way We Do: A Call to Consider Food Culture in Public Health Initiatives. International journal of environmental research and public health 2021; 18(22) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8623951/

My passion for research comes from always asking "why?"

Posted by Pascal Landindome Navelle, FRSPH, Public Health Research Operations Officer and Doctor of Public Health Student at Teesside University.

In today's Fuse blog, Pascal gives his top tips for anyone starting out in research, and shares his own experience which began working with Fuse and Teesside University.

His advice? A passion for the "why?" question and accessing the right mentorship.

As part of the NIHR ‘Your Path In Research’ campaign.

 

After working as a clinician for several years, I felt that my impact on service users was limited. So, upon a thorough reflection, I was inspired to progress into public health research, where I felt I would have a broader impact on society.

Research work is fascinating as it provides a clear pathway to contributing to advancing the knowledge of the disciplinary sector to which I am dedicated. The importance of research should go beyond conceiving theoretical works that would only find a physical location in a library. Research should be "living", circulating, interacting, multidisciplinary, and impacting the environment.

What I enjoy about research is that it allows me to pursue my interests, learn something new, hone my problem-solving skills and challenge myself in several unique ways. Working on a faculty-initiated research project enables me to work closely with a mentor–a faculty member, and other experienced researchers. With a self-initiated public health research project, I can leave the community with a service that represents the distillation of my interests and studies and, possibly, a real contribution to knowledge.

There are many training and support systems that I have found valuable during my career. Researchers usually embark on increasingly diverse careers, where collaboration, networking and interdisciplinarity have become more important. Critical reading, academic writing and critical analysis are valuable training and support required of a researcher. Transferable skills, such as effective communication and problem-solving abilities, have helped me operate more effectively in different work environments.

Starting a research career can be daunting but exciting! The challenge of getting the support needed to achieve my dream came true when I enrolled at Teesside University for a research degree. This began by getting involved with AskFuse (Fuse’s responsive research and evaluation service) and with Associate Professor Dr Peter van der Graaf, working on an enquiry to evaluate Northumbria NHS Foundation Trust’s staff health and wellbeing resources during the pandemic, as part of my PhD research. This then led to working on the South Tees Arts Project (STAR) with Peter, a pilot study to co-produce wellbeing measures with primary school children, their parents, teachers, and artists for a school-based dance intervention. I supported the data collection, analysis and report writing for the STAR project as a Research Assistant and even wrote a song for the engagement activities with children in the research!

I had the opportunity of getting mentorship and some academic resources to enhance my knowledge. I connected and contacted very experienced researchers in the field of public health who supported my interest in growing as a research professional. Through the people I’ve met, I have had the opportunity to work on exciting but substantial research projects that have had a massive impact on the public health community.

My top three tips for somebody starting out in research are:

1. First and foremost, you should be motivated, passionate, and curious about your research topic – do it for science, not tenure! No one ever became a successful scientist with the sole premise of being awarded the Nobel Prize. And remember that plans rarely work out the way you thought they would.
2. Be prepared for a challenging career. Research is ever-changing. Be prepared for the change that research comes with strengthening your problem-solving skills to enhance the fun aspect of research. Problem-solving skills refer to handling difficult situations and overcoming complex challenges. They involve breaking a problem down into its parts, thinking critically about each element, analysing the information you find and using that information to form an effective solution. Having strong problem-solving skills will help make you an asset in your research practice and help you advance your research career.
3. Finally, be proactive, network and connect more with like-minded professionals. Sometimes, the key to getting to places is not what you know but who you know. We can learn a lot from talking to peers and senior colleagues. Attending symposiums, seminars and conferences is a great way to meet people who share common interests with you but have different experiences.

The NIHR has supported my career development through the provision of training, access to leadership development opportunities, networking events, mentoring and guidance on research funding.

The NIHR launched the Your Path In Research campaign this week. Better research leads to better services for the public. That’s why the NIHR want to encourage organisations and social care and public health professionals to play an active role in research, as a way to deliver even better services.

The Your Path in Research campaign highlights how people can make research part of their careers. Some amazing researchers have shared their experiences, how they started in research and what advice they can give to researchers that are considering adding research to their careers.

Take your first step in research today.

How I overcame my scholionophobia... a clinical pharmacist in an academic world

By Rachel Berry, Specialist Antibiotic Pharmacist, County Durham and Darlington NHS Foundation Trust, and Health Education England (HEE) and National Institute for Health Research (NIHR) Intern 2016/17

“Scholionophobia* – A fear of school, college or university”

So, I want you to picture the day ….. It was a sunny September morning and there I was, a clinical pharmacist currently working in hospital, standing by the River Tees at Queen’s Campus Stockton about to enter Durham University. And I was terrified. Honestly, the last time I was this scared walking into a university building was in 2004 and I was about to sit my Registration Assessment to become a qualified pharmacist. I was obviously suffering from scholionophobia.

Courtesy of mothmediatech & the creators of The adventures of Worrisome Wilf books

“But why were you so scared?” I hear you ask. Well, the answer is that I was just about to start my Health Education England (HEE) and National Institute for Health Research (NIHR) Integrated Clinical Academic Internship programme.

The HEE/NIHR funded internship is a programme to enable Healthcare Professionals working in clinical practice to gain research experience and skills by working alongside a university academic. I had ahead of me, 30 days away from my clinical commitments that I could use to gain an introduction into clinical academic research.

My fear was based on the fact that I didn't know anything about research or universities. Not one bit. And I definitely wouldn't be able to do it myself. In my mind, research was only done by brilliantly clever people who know everything. I was only a lowly hospital pharmacist. I was pretty sure that I would be the most stupid person there!

Fortunately for me, I was about to meet my amazing academic mentor, and go on an adventure into the unknown world of research. I have gained experience and skills in literature searches and critical appraisal, project design and data collection, statistics, statistical analysis software (SPSS) and writing for publication. I have met so many talented, lovely people who have been interested and willing to help me, even when I probably was the most stupid one there (try explaining Poisson regression and statistics to a person who doesn’t have A-level maths!). It really has opened my eyes to the world of research, and the possibilities for clinical practitioners. My mentor has helped me realise that the skills and experience I have from clinical practice are just as important in clinical research as the skills of doing the research.

I am now coming to the end of my time. I have completed my project, which will be disseminated to local Clinical Commissioning Groups (CCGs) to enable them to focus on key target areas to improve patient safety within antibiotic prescribing. I am also planning on publishing it, and hopefully this will allow the work to have wider impact. I have been able to take what I have learnt about research and its impact on patients back to my clinical work too. This has meant that I am more reflective and research-aware when doing my job. I have also shared this with the colleagues in my department, and hopefully encouraged them to be more research aware and active, to enable us to provide better care to our patients.

In the future I would love to do more research in conjunction with the School of Pharmacy as I have realised that blending our skills and experiences, whether they are clinical or research based, can lead to more relevant patient-focussed clinical research being undertaken. I am also trying to get other members of my department to apply for the Internship next year.

The 30 days spent at Durham University were some of the most challenging, interesting, frustrating and rewarding I have ever spent at work. My scholionophobia has been cured, with no medicines required. If you are a sufferer in clinical practice, I would recommend talking to academics in your clinical speciality and applying for the Internship; there is no need to be scared. And if you are an academic in health research there is a wealth of experience that you could utilise within the clinical teams; they would probably love to be involved, they just might be too scared to ask.


My thanks go to the team at North West Research and Development who ran the 2016/17 Internship Programme on behalf of HEE/NIHR. Also thanks to my managers at County Durham and Darlington Foundation Trust, and especially to Professor Cate Whittlesea and the School of Medicine, Pharmacy and Health at Durham University.

*Also known as Didaskaleinophobian or Scolionophobia.

Image credit: Thank you to mothmediatech and Séan Baldwin & Martin Gordon the creators of The adventures of Worrisome Wilf books.