How can governments reduce health inequalities in high-income countries?

Guest post by Dr Katie Thomson, Institute of Health and Society, Newcastle University

In recent months, there have been high profile stories of how governments can influence public health. The Scottish minimum unit price for alcohol introduced on the 1 May 2018, and more recently the publication of Chapter 2 of the Government’s Childhood Obesity Plan. This update proposed measures to address children’s exposure to junk food advertising on television and online, and called for a ban of price promotions on products that are high in fat, salt or sugar.

20mph zones were shown to increase inequalities in cycle accidents and

 rates of death between more and less deprived neighbourhoods

Such policies have great potential to improve public health, by shifting the distribution of health risk and addressing the underlying social, economic and environmental conditions (Hawe and Potvin, 2009)1. However, it is imperative to understand the impact of these policies on health across the entire social gradient. Thereby ensuring the most marginalised, are not adversely effected by policies which aim to improve health overall.

I have been part of a group of academics which recently completed an umbrella systematic review (‘review of reviews’) which aimed to understand the effects of public health policies in high-income countries. You can read about the research in a handy two-page Fuse research brief. As part of the Health inequalities in European welfare states (HiNews) project, we found evidence of 29 reviews (comprising 150 unique primary studies) which detailed the evidence of how fiscal (government revenue), regulatory, education, preventative treatment and screening approaches can be used by governments to influence health inequalities across eight key domains.

Conceptual framework of population-level preventative public health policies to reduce health inequalities

Our review highlighted 13 key interventions which were demonstrated to reduce health inequalities. These include taxes on unhealthy food and drinks; food subsidy programmes for low-income families; incentive schemes linked to immunisation status; proof of immunisation for school admission; tobacco advertising control measures; traffic calming measures; oral health (water fluoridation and tooth brushing campaigns); some nutritional and cancer education programmes; universal and targeted vaccinations for indigenous populations; and targeted and population screening interventions.

Worryingly, we also found evidence of interventions that were shown to increase health inequalities – potentially leading to so-called 'intervention generated inequalities’ (Lorenc et al., 2013)2. For instance, lowering alcohol tax by 33% was shown to increase inequalities in rates of death amongst disadvantaged groups in Finland. Environmental interventions, including 20mph and low emission zones, were also shown to increase inequalities in cycle accidents and rates of death between more and less deprived neighbourhoods.

Our research also demonstrates that for some potentially important interventions, such as for policies to control alcohol, there is a lack of robust evaluations highlighting the effects on different groups of people.

Given the volume of literature we found on the effects of government-led policies on health overall, it was disappointing that we could only identify 29 reviews that reported data on health inequalities. Going forward, those tasked with evaluating such policies must report how health outcomes differ for specific interventions by subgroup as standard. Furthermore, reviews should incorporate sufficient information on how the intervention was implemented and enforced to be useful for policy makers thinking of adopting such approaches. We also found many of the reviews and their primary studies were US-based, which could potentially limit the transferability of interventions from one country to another.

Undertaking a systematic review is not without its challenges. When published, the article reads like a definitive narrative when in reality it comprises a multitude of subjectivities – which reviews to include? Which primary studies are relevant? Which outcomes are most appropriate? And how to summarise the state of evidence in a particular field given multiple studies/reviews? The methodology is designed to be systematic, but as it uses human interpretation there is always an element of judgement. Umbrella reviews assess the state of the evidence across a wide area of interest, and are therefore worth the blood, sweat and tears which goes into producing them.

Upstream public health interventions involving state or institutional control offer great hope to improve health for all. However, a comprehensive understanding on the effects of different interventions is a necessary first step to ensure policies have an equitable benefit for all members of society and therefore are worthy tools at the disposal of governments tasked with improving health.


The Health inequalities in European welfare states (HiNews) project is a collaboration between the universities of Newcastle, York, Trondheim, Siegen and Harvard and funded by the New Opportunities for Research Funding Agency Cooperation in Europe (NORFACE).

References:

1. Hawe, P., Potvin, L., 2009. What is population health intervention research? 100, I8-I14.
2. Lorenc, T., Petticrew, M., Welch, V., Tugwell, P., 2013. What types of interventions generate inequalities? Evidence from systematic reviews. Journal of Epidemiology and Community Health 67, 190-193.

Photo: © Albert Bridge (cc-by-sa/2.0)

The challenges (and joys) of evaluating babyClear©: a package of support to help pregnant women to stop smoking

Guest post by Sue Jones, Research Associate, Teesside University

A team of Fuse researchers from Newcastle and Teesside Universities published findings from the babyClear© study a few weeks ago and I thought that I’d put finger to keyboard to share with you the challenges and joys of evaluating the roll out of this innovative intervention.

In 2012, I became involved with evaluating babyClear©, a package of support for maternity and stop smoking services, designed to help them to deliver the stop smoking message more effectively to pregnant women. BabyClear© was due to be rolled out regionally across North East England and evaluated throughout, which presented a number of challenges:

• Challenge 1: different research questions – we wanted to know if this new approach worked and would it help women quit but we knew that this would not be enough; we wanted to understand what influenced those figures, and what healthcare staff need to do to be most effective.
• Challenge 2: ethical dilemma – ethically we could not deny pregnant women a test like carbon monoxide monitoring that was known to improve outcomes to some degree, so the regional rollout of babyClear© offered a prime opportunity to evaluate the intervention using a natural experiment1.
• Challenge 3: wide variety of stop smoking delivery models – the extent of austerity measures experienced by the public sector has been far greater than anticipated when the research was envisaged in 2011. At the same time responsibility for delivery of stop smoking services has been moved to local authorities who themselves are under extreme pressure to reduce spending. This has created a wide variety of stop smoking delivery models, all trying to provide a low cost service but with implications for the implementation. For example: babyClear© was designed to be a package that could easily slot into existing services, however it assumed a number of systems were standard when they were not, such as a midwife available at dating scan appointments and a local stop smoking specialist in pregnancy. All those Heinz 57 varieties of stop smoking service delivery models and systems within maternity services, each one different from every other, made it logistically challenging to implement the new pathway, leading to delays of varying lengths in each Trust area.
• Challenge 4: researching within a changing system – due to ongoing changes largely in the delivery of stop smoking services, but also in maternity, and their impact on the implementation of babyClear©, data collection plans had to be re-thought again ... and again ... and again to reflect what was happening out in the real world! 

We were greatly helped in approaching some of these challenges by the publication in 2014 of the Medical Research Council (MRC) Guidance on process evaluation of complex interventions. Using this guidance, we were able to start re-shaping our thinking in terms of how the qualitative data could be used synergistically with the numerical data. We set about strengthening the methodology with a retrospective logic model, weaving contextual data into the mix and with an eye on the mechanisms of impact.

After overcoming these challenges, along came the joys: the findings of our study proved that babyClear© was not only effective but also cost-effective, which was a great achievement in such a short timescale. This new approach, which supported midwives to offer universal carbon monoxide screening and refer pregnant smokers quickly to expert help, nearly doubled quit rates.

The findings highlighted that we could systematically help women to stop smoking in pregnancy which will result in already well-evidenced outcomes such as:

• Help mothers have babies who are heavier and healthier than if they continued smoking
• Help more mothers lead healthier lives
• Help mothers live longer and see their children grow up
• Help the children to live and run and grow up surrounded by smoke free air; and 
• Enable them to not be held back by smoking-related poor health

So have a read of our paper, this has the nitty-gritty of the statistical outcomes.

Importantly, soon we hope to be publishing the details about the how, what, when, where, why questions that were the focus of the qualitative process evaluation. Without this it is difficult to know how to implement it elsewhere to best effect and why it works well in one place and not another.

Celebrate our findings with us; if the maternity and stop smoking services are able to use the babyClear© approach to implement best practice/national guidance it can offer the support that is needed so that more women stop smoking during their pregnancy than did before. So keep your eyes peeled for my next blog – which will focus on the findings from the process evaluation.


Reference:

1. “A natural experiment is an empirical study in which individuals (or clusters of individuals) exposed to the experimental and control conditions are determined by nature or by other factors outside the control of the investigators, yet the process governing the exposures arguably resembles random assignment”. (Reference: en.wikipedia.org/wiki/natural_experiment)     More info: Craig P, Cooper C, Gunnell D, Haw S, Lawson K, Macintyre S, Ogilvie D, Petticrew M, Reeves B, Sutton M, Thompson S. Using natural experiments to evaluate population health interventions: new Medical Research Council guidance. J epidemiol commun h. 2012 May 10:jech-2011.

Related content:

• News story: Scheme’s success at stopping mums-to-be smoking
• Video courtesy of Fresh - Smoke Free North East, the region’s dedicated tobacco control office

It’s complicated: health inequalities and e-cigarettes

Guest post by Frances Thirlway, Fuse Associate member, Anthropology Department, Durham University

While the e-cigarette wars continue to rage, we still have very little information on the extent to which the most disadvantaged smokers are using e-cigarettes to quit. The smoking toolkit provides invaluable information regarding overall UK usage; however, most international research into the practices of e-cigarette users has been done via on-line user groups or forums. For anyone concerned with health inequalities and the social gradient in smoking, this is of limited use since the digital divide means that e-cigarette users active on internet forums are unlikely to come from the poorer communities where smoking is now concentrated.

Figure 1: The life cycle of a vaper - but note the gendered image

In contrast, slow research ‘takes the local as a starting point’ and does this through ‘extended interaction in particular sites’ (Adams 2014 p. 181). Anthropological work involving in-depth place-based research and examining local culture as a dynamic influence can be particularly helpful in researching e-cigarette use. This is not only because user practices vary according to age, gender, class and other factors, but also because e-cigarettes themselves are not a single product. Moreover, the typical ‘user life cycle’ involves a progression from basic to more sophisticated models of e-cigarettes over time. Complete smoking cessation can happen at any point in this process and is likely to be gradual and difficult to capture in simplistic smoker/former smoker divisions, which is why research which follows smokers and quitters over months or years is needed – one participant in my recent study took three years to move from dual use of tobacco and e-cigarettes to e-cigarette use only, and he was not untypical. As Figure 1 and the associated article illustrate, most successful users start with ‘first-generation’ models, but those who persevere generally find that second-generation models and beyond are more satisfying.

The key word here is ‘successful’ - because switching from tobacco to e-cigarettes is not an easy process. I found that users: ‘struggle with the time, effort and expense involved in finding the ‘right’ e-cigarette and the frequency of product failure i.e. cheaper tank models splitting, leaking, or bubbling if over-tightened or dropped, and problems with batteries running out or failing to charge.’ This meant that: ‘unless users were highly motivated to quit, smoking was significantly easier, and often cheaper taking into account the cost of e-cigarette replacement and the ready availability of illicit tobacco.’ (Thirlway 2016 pp. 109-110)

Whilst some public bodies and individual users have started to provide information and guidance about using e-cigarettes to quit smoking, many barriers to use remain, particularly for the poorest. There is little doubt that you are more likely to switch successfully if you can afford to try different models, and replace the ones you break. It also helps if you have time to spare, a fondness for electronic gadgets and the ability to feel at home in the – largely male - vaping subculture.

These and other issues are explored further in: Thirlway, F. (2016) Everyday tactics in local moral worlds: e-cigarette practices in a working-class area of the UK. Social Science & Medicine 170 pp. 106-113

Giving Grandmothers a Voice

Guest post by Roz Rigby, a Health Improvement Practitioner at Newcastle City Council and Doctoral student in Public Health at Northumbria University

Today is Grandparents’ Day, a day which celebrates the contributions of grandparents to families and
society overall. Grandparents can have important roles in the health related decisions of families and my research is looking at the influence of grandmothers on introducing solid food. Much of the literature describes grandmothers in a negative light, suggesting they may advise their daughters to start solids before the recommended six months. I found that there was very little research that addressed this from the perspectives of grandmothers’ themselves, and therefore I set out on my research journey with the intention of finding out ‘how do grandmothers make sense of the role they play in introducing solid foods to their grandchildren?’

 I am using constructivist grounded theory methods based on the works of Charmaz (2014)1, and am still finding new meaning in my data, as I try to write up my findings. I am finding this an exciting time in the research, after the arduous task of trying to understand the terminology in qualitative methodology! I must admit that I expected to find grandmothers defending the older methods of introducing solids, which was generally started at around four months, but I actually found that they were open to change and generally accepted the new guidelines. I have also uncovered a complicated web of dynamic family interactions in which grandmothers can struggle to come to terms with competing values of the wider family that they find themselves in. Some grandmothers expressed how marginalised they feel, as they do not have access to the latest information, except through their daughters or daughters in law, and yet, they are often providing extensive childcare.

One of the issues that this research has highlighted for me, is the contested levels of responsibility that grandmothers face. On the one hand they are ‘proxy’ parents, making autonomous decisions about the food that they offer their grandchildren, whilst on the other hand, this can compete with the parents’ decisions and parenting styles (which may in turn be influenced by the other grandparents). Being able to switch this responsibility on and off can cause tension and conflict, particularly if there is a feeding issue. The problems of having a fussy eater can cause parents and grandparents immense distress, with issues of power and control coming to the fore. Grandmothers often worry about conflict within the family and are wary about raising their concerns, for fear of fracturing relationships and possibly losing contact with their children and grandchildren.

Of course it’s not all doom and gloom, as they all report feeling immense love for their grandchildren and a similar nurturing feeling that they had for their own children. They get tremendous satisfaction from these relationships, and I hope that my research will help practitioners to have a better understanding of the issues grandmothers face. I am looking forward to using the findings to develop an intervention that will help families navigate potential intergenerational conflicts and find ways of developing collaboration within families, as they all have the best interests of the children at the heart of what they do.

Reference:

1. Charmaz, K. (2014) Constructing Grounded Theory (2nd Edition). Sage

What should we do about children and young people’s consumption of energy drinks?

Guest post by Shelina Visram, Fuse Associate and Lecturer in the Centre for Public Policy & Health, Durham University

Did you know that cigarettes are the only product on the market that, when used exactly as intended by their manufacturers, will kill around half of their users? And yet you can buy them legally in every country of the world, with the exception of Bhutan? But you probably knew that already (except maybe the bit about Bhutan). It’s just one example of the type of paradoxical situation that occurs when public health evidence suggests we should do something and this is then contradicted by the actions of government and industry.

Here’s another example: did you know that energy drink consumption by school-age children is linked to hyperactivity, risky behaviours and health complaints such as headaches and stomach aches? And yet children of any age can buy these drinks in a variety of shops? You may have heard that the supermarket chain Morrisons banned sales of energy drinks to under 16s, but this was a trial that ended in early 2015. Some retailers choose not to sell energy drinks to younger children – often in response to pleas from teachers at nearby schools – but they do this on a voluntary basis and have to accept that they will probably lose revenue as a result.

Regular readers of this blog may be aware that Fuse members have been involved in conducting research on youth energy drink consumption over the past couple of years (you can read previous blog entries here and here). You may have read our Fuse brief, seen us present our findings at a seminar or conference, or downloaded our report from the HYPER! study website. So why the renewed call for action? At a time when the Government’s delayed childhood obesity strategy has been described as "pathetic", we need to take every opportunity to push for clear messages around food and health. We have worked with the Food Research Collaboration (FRC) to produce a briefing paper – published today – that clearly sets out the main ingredients of energy drinks, the current market situation, the scientific evidence base, and existing interventions, ranging from school-based educational activities to country-wide bans. The paper concludes with a series of recommendations on what could (and should) be done by policy-makers and others to address this issue.

To go back to the example of cigarettes, we know that sales and marketing restrictions are key factors in preventing uptake of smoking by children and young people, even if they do not eradicate the problem completely. Obviously energy drinks are nowhere near as harmful as cigarettes. They do not kill one in two consumers. But, like all sugar-sweetened beverages, they do contribute to increasing levels of childhood obesity and type 2 diabetes, as well as poor dental health. By law, energy drink labels must include the following warning: “High caffeine content. Not recommended for children or pregnant or breastfeeding women”. So isn’t it time we stopped sending out conflicting messages and made it clear that these drinks are not suitable for children and young people?

Download the briefing paper Energy Drinks: What’s the evidence? written by Shelina Visram (Durham University) and Kawther Hashem (Action on Sugar).


Illustration: Cathy Wilcox via http://www.essentialkids.com.au/food/nutrition/caffeine-concern-over-teens-and-energy-drinks-20130905-2t6hb

Alcohol Awareness Week: just who are those risky drinkers?

Posted by Dorothy Newbury -Birch, Professor of Alcohol and Public Health Research at Teesside University.

It's national alcohol awareness week and I've been asked to write a blog about it and as I sit and wonder what I would like people to be ‘aware’ of, one thing comes to mind. It’s the thing that I say in every lecture I give and hope that it’s the one thing that people take away with them: “Its not a them and us issue when it comes to alcohol-related harm”. What do I mean by this? Well we know that around 30% of people (any people) who go to the GP will screen positive for risky drinking (an alcohol use disorder). That’s 30% of folk you see walking down the street and in shops – that’s us – not those people over there. If we realise this then we become more aware of how risky drinking is affecting all of us. If I were to screen everybody who is reading this blog then around 30% of you would screen positive for risky drinking and about half of you would have no idea that you had an alcohol use disorder. You don’t believe me do you? Well here is an alcohol screening questionnaire – have a go...

If you score 5 or more than you would be classified as a risky drinker. So, I hear you ask, what is a unit? Well this is a massive problem as a lot of us don’t know what a unit (or standard drink) is. Did you realise that a bottle of wine has around 9 units? Did you realise that a man drinking more than 4 units and a women more than 3 units in one go is classified as a ‘binge drinker’? Did you know that the recommended drinking units are 3-4 per day for men and 2-3 per day for women, with two days free per week? All sounds rather complicated doesn't it?

So what can we do about it if we are drinking too much? Well you've done something already by realising it – remember I said a lot of us don’t realise. Small things make a massive difference. We can keep an eye on what we are drinking; we can think about having a soft drink in between a glass of something; don’t drink in rounds (it’s much easier to drink more when in a round) and remember you can leave some wine in that bottle for another night. 

Alcohol-related harm costs the UK around £21 billion a year. Alcohol is a causal factor in more than 60 medical conditions including cancers, high blood pressure, cirrhosis of the liver and depression. Alcohol-related hospital admissions have increased by 35% in the nine years to 2011/12 when there were 1.2 million admissions related to alcohol. Alcohol is implicated in, or responsible for around 30% of visits to primary health care and around 70% of A&E attendances from midnight to 5am at weekends. These are well known statistics but who do they relate to? The Alcohol and Public Health Team at Teesside University is carrying out research to reduce the harm caused by risky drinking. This includes research with young people in the school setting (SIPS JR-HIGH) and the Accident and Emergency Setting (SIPS JR) and work in the criminal justice system.

If you want more information then have a look at the following websites: 

• www.nhs.uk/change4life/Pages/cutting-down-alcohol.aspx
• www.dryjanuary.org.uk
• www.balancenortheast.co.uk

If you want to find out more about the research, myself and the team that are involved, you can follow TeamAlpha’s research on www.facebook.com/TeamAlpha and @TeamAlphaTees

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Sublime and ridiculous: the glamorous life of a public health researcher

Guest post by Rebekah McNaughton, Research Associate in Public Health and Lecturer in Research Methods at Teesside University 

They say that variety is the spice of life and that is certainly true in my line of work. When I started my career as a public health researcher I understood that a great deal of my time would be spent reading other people’s research, doing fieldwork and writing numerous reports. That has certainly been true of the last 10 years of my career. What I didn't expect was the huge variety that I would come to love.

Doing fieldwork is by far my favourite aspect of the job. I'm naturally quite inquisitive and I'm really lucky to get paid to do something I enjoy- being nosey! So far, I have worked on projects with children and young people, parents, teachers, public health professionals and patients. You name it: I've probably worked with them. And, to be honest, it has ranged from the sublime to the ridiculous…

Crowd control: Some research participants refused to be quiet for the focus group

Yes, I've done focus groups in schools and community venues. I've sat on people’s sofas having a cup of tea and a biscuit. I've been challenged by young people determined to embarrass me whilst talking about sex and relationships education. All of this I expected as part of the ‘routine’.

What I didn't expect, however, was trying my hardest to concentrate on asking ‘the right questions’ whilst the washing machine was screaming in the background on the extended spin cycle. Or being mauled by a rather ‘licky’ dog and trying to make sense of the tape afterwards. I didn't expect to need crowd control skills when trying to carry out work with 24 new mums and their 28 babies and toddlers, all wriggling on the floor and not one of them being courteously quiet for the tape. However, today took the biscuit. I went to talk to two health visitors, at their place of work. Nothing out of the ordinary, or so I thought. In need of some privacy, I was led into a tiny windowless room (a cupboard), a cupboard lined with patient notes and not enough room to swing a cat. The three of us huddled around a mop and bucket, like women dancing around their handbags in a club circa 1989, whilst I held out the voice recorder. At the same time I was trying desperately not to drop it in the murky water swimming at the bottom of the bucket. Oh, the glamorous life I lead…

Would I change it? Absolutely not! No two projects are the same. Meeting participants is by far the best aspect of my job; it brings obstacles and challenges but most of all it makes my job a lot of fun!

Photo attribution: www.flickr.com, Anthony J, 'Six pack', The results of the 'final project' in our childbirth class, (Left to right: Sienna, Maguire, Sophia, Ethan, Claire and Noah)

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End of life care: looking through a different lens

Guest post by Joanne Atkinson, Director of Programmes, Northumbria University to coincide with World Palliative Care Day 2015.

When reflecting on my professional journey I often ask myself how did I get where I am today? The thing is your personal story has great resonance for you as a professional; this is an insight into my doctoral journey.

I have worked in palliative care for many years, firstly as a Macmillan Nurse in the acute sector, and then at Northumbria University teaching palliative care. Commencing a professional doctorate I had a stuttering start, but eventually arrived at where I am now with my research which is a study using Foucauldian discourse analysis. My research explores the influence and impact of emerging, competing and overlapping discourses on practice in end of life care, and provides insight into the discursive tendencies impacting on end of life care practice in the hospital setting.

Recent years have seen unprecedented media interest in end of life care, and the emergence of powerful discourses that influence health care professionals delivering care. My research focusses on the tensions, challenges and possibilities that emerge from this intersection.

You may recall some time ago the tragedy that occurred in Greater Manchester when Harold Shipman, a GP, killed his patients. The media coverage that occurred as a result of this has had a significant impact on the way in which doctors and nurses caring for people at the end of life. The public and other professionals questioned the prescribing of opiates for pain and symptom relief. This cultured the germ of a research idea. So my research journey started.

As I commenced my professional doctorate the media frenzy related to end of life care and the Liverpool Care Pathway developed, and I found myself at the cutting edge of end of life care. It is fair to say that I was taken aback by some the media outputs. 

I undertook an analysis of artefacts from journalistic press not tabloids (although this did include the Daily Mail!) and terrestrial television (factual outputs). Initially this was to be over a period of six months, but this was extended due to the profile of end of life care at the time. In addition tape-recorded narratives were taken from four consultants and six clinical nurse specialists working in palliative care, and a cancer centre. Participants recorded the narratives over a two-week period.

The media artefacts and narratives have reaffirmed the metaphorical language utilised when discussing end of life care, and highlighted the impact that the sensationalisation of end of life care has on practice, instilling a moral panic that both disables and fuels the need for change. Prominent discursive formations have emerged related to the power of representation and the impact on practice when caring for people at the end of life.

Back to my personal story which is inextricably linked with the research journey, having life happen throughout this research has no doubt enriched my understanding, but holding a very old man’s hand when he thinks he is going to be killed because he is so ill makes the impact discussed above so real especially when that very old man is your father.

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Photograph (5138623107_b05613223b_o) by More Good Foundation via Flickr.com © 2009: https://www.flickr.com/photos/moregoodfoundation/5138623107

Energy drinks: Don't believe the hype

Guest post by Shelina Visram, Lecturer in the Centre for Public Policy and Health, Durham University

When asked where the idea for our study on energy drinks came from, I usually say it was through discussions with colleagues as part of another project I’m leading on in County Durham. But that's not strictly true. The original spark came from my experience a few years ago of lecturing at Northumbria University in the dreaded Tuesday 9am slot (student night in Newcastle is on a Monday), where I noticed some students regularly downing a couple of energy drinks throughout the lecture. This was my first encounter with these drinks being consumed during daylight hours and I was fascinated by the idea that some people might have them for breakfast. So this got me wondering - why would young, seemingly healthy students feel the need to use an artificial source of energy to get them through the day? Or was it just my lectures sending them back to sleep? (That is if they had even been to sleep).

Over the years I noticed more and more of these drinks appearing in shops, on TV shows, in adverts and as litter on the streets, and assumed that they were used primarily by adults to stay awake. Most cans and bottles state that these products are not recommended for children, given that they contain high levels of caffeine which children are advised to consume in ‘moderation’ [1]. But then I overheard a couple of external partners discussing energy drinks in the context of them being seen as a growing 'problem' in primary and secondary schools in County Durham. They were looking for support in scoping the evidence base and exploring what types of interventions or educational materials could be developed locally. Around the same time, a call was circulated via Fuse for research proposals to The Children’s Foundation [2]. Colleagues from Fuse and the Wolfson Research Institute for Health and Wellbeing at Durham University [3] were keen to collaborate on an application. We developed our proposal, were awarded funding, and the HYPER! (Hearing Young People’s views on Energy drinks: Research) study was born [4]. 

Since June 2014, the HYPER! study team has been busy: reviewing the published literature on children and young people’s use of energy drinks; conducting a series of focus groups and interviews with students, parents and staff from four local schools; and involving young people in a mapping exercise, drawing on their knowledge of the area around their school to identify local energy drink vendors. Here are some of the things we’ve learned:

• If you come across a paper that says ‘energy drinks are good for you’, check to see if the work has been funded by Red Bull or conducted by someone with shares in PepsiCo.
• Most papers that say ‘energy drinks are bad for you’ are based on expert opinion, rather than robust research.
• Young people in the UK drink more energy drinks than those in other European countries, yet there are no published studies from the UK.
• Sales restrictions might seem like a sensible option; they would help to send a clear message but our study participants had concerns that they would be difficult to enforce.
• The strong influence of the marketing activities of energy drink companies should not be underestimated.
• Any interventions should ideally involve children and young people, as well as parents, schools, retailers and the industry.
• There is a lot of confusion around whether energy drinks are safe for children, and parents, teachers and young people need help to make more informed choices.  At least one young person in all but one of our focus groups thought that energy drinks contained bull or horse sperm [5]. They don’t.

There are still lots of unanswered questions. For example, if the government requires energy drinks to carry warnings stating that they are not recommended for children, why are manufacturers allowed to market them so obviously towards young people? What are the long-term health and other effects? Is there a link to health inequalities? And why would anyone knowingly drink something that they thought contained bull sperm? We’re hoping to answer some of these questions by conducting further research so please get in touch if you’d like to collaborate with us or if you’re already involved in work on energy drinks. We would love to hear from you.

You can find out more about this study by reading the new Fuse Brief here.

Shelina spoke about the HYPER! study at the CPPH/Wolfson Seminar - Sweetness, social norms and schools: factors influencing children and young people’s food and drink practices (9 September)

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Getting our hands greasy: The joys of researching food and drink sold near secondary schools

Guest post by Wendy Wills, Sociologist of Food and Public Health, University of Hertfordshire

Next Wednesday (9 September) I will be at Durham University to present and discuss the findings from a study which colleagues and I conducted that focused on exploring the reasons that young teenagers at secondary school buy food and drink outside school.

It was a busy project, with just two weeks at each of our seven selected case study schools to run an online survey in classes of 13-15 year olds, as well as asking them to take part in a written exercise and focus groups. We also conducted interviews with the young people, as well as the head teachers, school kitchen supervisors and local retailers. Over 600 young people took part. I had two brilliant early career researchers working full time collecting data in Scotland (the work was funded by the Food Standards Agency north of the border) plus some part time help from colleagues.

I love conducting fieldwork – there is nothing quite like getting your hands dirty (or greasy in this case but more on that later) during data collection and no better way to fully get to the heart of your research questions than being ‘in the field’ with your team. I particularly enjoy research with young people as they are often very happy to tell you exactly what they think and indeed, they are often pleased to be asked about matters that they are often not consulted about – such as the food and drink they have access to.

So, being in Scotland and racing from classroom to chip shop to follow young people (with their consent of course!) as they decide where to go on a particular day to buy their lunch was something of an adventure.

The young people had us salivating over their lunchtime purchases, though not for any health-related reason! For the most part it was the complete opposite. Part of our plan was to purchase the same edibles as the young people we accompanied so that we could weigh and record each item (to later conduct a nutritional analysis of the unpackaged food and drink they bought). We often had bags full of (extremely cheap) deep fried ‘chicken balls’ with luminous orange sweet and sour sauce from takeaway shops; warm sausage rolls with the grease oozing through their paper bags from bakeries and bottles of bright green, blue or orange ‘energy drinks’ from corner shops that sometimes had questionable hygiene and/or felt a little intimidating.

'Chicken balls'

As all this action happened over lunchtime you can imagine the team were often hungry by the time we left each school and so we sometimes resorted to trying some of the rapidly cooling food and drink that filled the boot of our car. The worst thing I tried was the battered and deep fried pizza slice – words cannot really describe it – the hard and tasteless pizza base, the smear of tomato paste, the greasy battered coating.

The fieldwork did not only provide us with greasy hands but also an appetite for supporting effective policies and interventions that promote healthy eating to secondary school pupils.

Wendy will be presenting this research at the CPPH seminar 'Sweetness, social norms and schools: factors influencing children and young people's food and drink practices' on Wednesday 9 September at Durham University. 

Would you accept money to be healthier?

Guest post by Emma Giles, Senior Research Lecturer in Public Health, Teesside University

As newspaper headlines have shown, the issue of encouraging individuals to adopt healthier lifestyle behaviours by paying them is controversial. Whilst many of us know that we should do a bit more physical activity, eat our five-a-day fruit and vegetables and even attend our vaccination and screening appointments, we don’t always do this. Many barriers prevent us from fully engaging with these healthy behaviours, and these barriers are often complex, individual, and are not always easily surmountable. These barriers range from living away from green spaces which would allow outdoor exercising, to deep-seated social norms that stop individuals from engaging in healthy behaviours because they are not well accepted by family, friends or the wider community.

In recent years there has been a growing body of research looking at paying people to be healthier. This essentially means providing individuals or groups with cash, shopping vouchers or gifts in return for the adoption of healthier behaviours. Such schemes include the Pound for Pound weight loss incentive scheme, the Give it Up for Baby scheme, and offering incentives for breastfeeding.

In order to hear recent research evidence, and to provide a forum for friendly debate, I organised the recent Fuse Quarterly Research Meeting, which focused on payment for health behaviours. Last Wednesday (22 July), policymakers, practitioners, and academics came together to hear presentations from four academics and practitioners working in the broad field of incentives. As Claire Sullivan, a Consultant in Public Health from Public Health England mentioned in her opening address as Chair of the meeting, often incentives can take various forms – including paper pants for Chlamydia screening!

In terms of specific incentives, Professor Pat Hoddinott, Chair in Primary Care, Nursing Midwifery and Allied Health Professions Research Unit at the University of Stirling, presented research which focused on incentives for breastfeeding and to quit smoking in pregnancy – the BIBS study. Key findings suggest that tailoring of incentives is important to meet local needs, but that they show promise to encourage these behaviours.

Professor David Tappin, Professor for Clinical Trials in Children within the School of Medicine at the University of Glasgow, followed Pat by showcasing data from the CPIT trial – a smoking cessation in pregnancy trial in its second phase. Results showed that there was a 14% increase in quit rate and further analysis showed that there was a 150g increase in birth weight of babies born to mothers who quit smoking. Findings suggest that financial incentives were found to be acceptable by the women involved, and may double the quit rate when used with existing smoking cessation services.

A practitioner perspective was provided by Mr Andrew Radley, Consultant in Public Health Pharmacy, NHS Tayside, who talked about operationalising the use of financial incentives in a stop smoking programme within a community pharmacy setting. In particular, 393 women in Tayside engaged with the smoking cessation services, and incentives were found to be effective. Of note was the finding that mothers preferred receiving their incentives on a weekly basis.

I spoke last and presented qualitative data exploring the acceptability of incentives. The findings suggest that incentives are more likely to be accepted if they are provided to certain population groups including pregnant women and those on a low income, but not for those who may have alcohol or drug problems. The ‘perfect’ incentive has yet to be identified, but it will need to be shown to be cost-effective for it to be accepted on a wider scale.

The presenters were then joined by Peter Kelly, Director of Public Health Stockton Borough Council, Jim Beall, Health and Wellbeing Board Chairman, and Dr Jean Adams NIHR Research Fellow at CEDAR for a panel discussion. The audience raised many questions and comments around the use of incentives, with particular concerns around incentives increasing health inequalities, aggressively placing the blame of poor health on individuals, and that incentives may result in moral implications when individuals are rewarded for their behaviour. The debate suggested that more research evidence is needed to discover what type of incentive works for whom, and in what setting, and to better explore group (rather than individual) incentives.

What is obvious is that paying people to be healthier is an emotive topic, a highly contested intervention approach, but at the same time, it also shows promise to encourage individuals to adopt healthier lifestyle behaviours. It certainly provides food for thought…how many of us would accept money to be healthier?

Follow this link to find out more about the Fuse Quarterly Research Meeting ‘Payment for health behaviours: the case of health promoting financial incentives’ on the Fuse website.

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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).

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?

No time to run: is role overload contributing to physical inactivity in parents?

Posted by Caroline Dodd-Reynolds

Last night during a Twitter exchange, it somehow came about that I would write a #fuseblog on barriers to physical activity and a healthy diet in working mums. Interestingly, my one-year-old daughter had just gone nicely to bed at this point and so my husband and I treated ourselves to a healthy(ish) home-cooked dinner, albeit at 9pm. Normal service was resumed however at 12.30am when we were woken by the sound of the one-year-old vigorously banging on her cot and shouting, ‘Is DARK!’ (yes, it’s the middle of the night). So here I am typing this blog with two hours of sleep under my belt. Primarily this is why I no longer do very much exercise-based physical activity, or indeed eat as healthily as I used to. I am sure there are many who can relate to this sleep-deprived existence. Certainly the transition to parenthood can be an experience of life-changing proportion. For me, the transition back to work after months of no sleep and complete displacement from my previous identity was interesting.

There is guilt at leaving my little one at nursery and then there is the race through the day so that I can leave early enough for us to have an hour of (potentially active) play before bedtime. There is guilt at not being able to attend the evening functions at work, the interesting lectures that I know would be pure luxury to immerse myself in. There is pressure to succeed at work, not so much to prove that I can be both a parent and an academic, but more that if I don’t, then there is little point in having endured the guilt. And what of physical activity? Well, please see my previous points as to why this takes a seat so far back that I can barely see it.

The Chief Medical officers recommend 2hr 30min moderate-vigorous physical activity (MVPA) per week for adults; an individual is classed as inactive if achieving less than 30min moderate physical activity per week. Time spent engaged in MVPA declines with age and in 2012, 67% of men and 55% of women aged 16 years and over were meeting recommendations. These data were self-reported and objective monitoring methods suggest these figures are inflated. Guidelines for reducing sedentary behaviour are less clear but should involve avoiding prolonged periods of sitting. I am a full-time Lecturer in Physical Activity and Nutrition and so the irony of spending hours (sitting) writing lectures on the perils of sedentary behaviour and energy-dense snacks, is not lost on me. I did a quick PubMed search including physical activity and working mums as key terms and found a lonely but slightly reassuring 10 articles.

One article describes succinctly and astutely the fact that much is known about motherhood as a transitional influence on the physical activity habits of new parents, but actually very little about those new parents (or indeed any parents) who work. Emily Mailey and her colleagues, from the Dept of Kinesiology at Kansas State University, talk about ‘role overload’ and how this is associated with negative health outcomes such as elevated stress, depression and anxiety. I am starting to feel better here. The 25 mothers and fathers who participated in focus groups for this study reported barriers such as ‘scheduling constraints’ which I think many working parents may identify with – for me it is the Outlook calendar that keeps me on track and I know that if I schedule 30min into it on a Tuesday, I do have time to nip out for a run and I am more productive for it. But then what if someone requests a meeting or tutorial? Interestingly, ‘prioritising’ is noted as a facilitator. One mother comments that she had to get up at 5am to fit her physical activity into her day. Indeed this is a thought that often crosses my mind. Another, is that working parents may well comprise a special population in terms of physical (in)activity habits and sedentary behaviour; when I was on maternity leave I was certainly more active than I am now.

Anyway, I’m writing this on a Friday (thank goodness for the weekend). I really must clean the bathroom tomorrow, and the car needs a good wash, these will get my activity counts up, great. Oh but then there is that paper I need to write, and next week’s lecture I have yet to prepare. I know realistically what I will be doing this weekend – and it may not comprise any minutes of MVPA, nor help my preparation for next week at work, but I know it is the finest choice and that my little girl will laugh out loud with delight when she sees the animals on the farm.

Feeling slightly more awake after some strong coffee, I have just read this blog back and am sad that it sounds rather negative. It isn’t meant to, but it has made me think a little more about how I spend my days (and the potential to ask for a standing desk at work). And in case you were wondering, I would not swap my little girl for any amount of physical activity. Mailey and co. talk about being a role model and being active with your children. In a good week with no illness, sleepless nights or marking, we probably do manage to achieve this to an extent. And my little girl is happy, active and eats a healthy but balanced diet (vegetables and chocolate included) so perhaps we are doing things right after all?

Could your partner be bad for your health?

Posted by Amelia Lake

With Valentine’s day approaching, what better time than this to discuss the potential effect that moving in with your loved one could have on your health, and in particular on your eating habits. In 2006 I wrote an article for the nutrition publication Complete Nutrition summarising the evidence around the co-habitation effect. In 2006 I was not co-habiting nor was I a mother - how times have changed! Following on from last week’s Fuse blog and my mini rant about supermarket tills, I can feel a whole body of research emerging about the ‘children effect’ on eating, but for now, back to co-habitation.

My 2006 publication was based on research findings from the UK, North America and Australia which looked at the eating and lifestyle habits of co-habiting heterosexual couples, including married couples. Women eat more unhealthy foods and tend to put on weight when they move in with a male partner. On the other hand, a man’s diet tends to become healthier when he starts co-habiting with a female partner - and her influence has a long-term positive impact.

The reason for the change in dietary habits is that both partners try to please each other during the ‘honeymoon period’ at the start of a co-habiting relationship, by adjusting their routine to suit their partner and eating food that he or she likes.

However, women have the strongest long-term influence over the couple’s diet and lifestyle, mainly because the majority of female partners still assume the traditional role of food shopper and cook. Many of you will now be thinking about your own domestic (bliss) situation and who has made more changes and where. I can reflect on the issues we have, especially around portion size! In those early days of co-habitation, it was hard not to have a second helping as I sat at the table waiting for my much more active and taller husband to finish his first helping.

But this co-habitation thing isn't all bad news, or is it? A recent study of around 4,000 older married and co-habiting couples participating in the English Longitudinal Study of Ageing, reported a more positive spin. The participants - aged 50 and above - were more likely to make a positive health behaviour change if their partner did the same. There is an important message from this research, that involving partners in behaviour change interventions may help improve outcomes. However, this study didn't explore the negative effects.

So negative effects aside, it’s that time of year for love and romance. Hold that partner tight and let them know what an amazing team you can be for making positive lifestyle changes. When you are working up public policies, or if you are practitioners seeing your patients/clients or designing interventions, don’t forget about the co-habitation effect and the importance of partners.

Happy romancing everyone!

52 weeks in public health research, part 47

Posted by Bronia Arnott, Dominika Kwasnicka, and Lynne Forrest

From Bronia Arnott: The only way (is Essex)? Recently I was in Essex and the queue of traffic with all of the “slow” warnings on the road resonated with me as I had just had a systematic review of interventions to reduce car use and increase more active and sustainable modes of travel accepted for publication.

From Dominika Kwasnicka: National Institute for Health and Care Excellence (NICE) strongly recommends that adults engage in any suitable form of physical activity. So you just need to pick and choose the one that’s best for you. Here is an adult version of a bouncy castle at a great event co-organised by one of Fuse's practice and policy partners Scott Lloyd. It’s always good to try new things. And if a bouncy castle isn’t your thing, how about some ice skating this winter?

From Lynne Forrest: A number of Fuse representatives, including myself, Shelina Visram and David Hunter, were among the 1500 delegates who attended the European Public Health (EUPHA) conference on Health Inequalities in Glasgow. This is my poster on a systematic review and meta-analysis that found no evidence of socioeconomic inequalities in stage at diagnosis for lung cancer.

From Bronia Arnott: An early morning trip to Newcastle Central Station which has recently been refurbished and is now looking much better. They even have some bike racks in decent places rather than stuck out of the way at the wrong end of the station. Coincidently, I was off to talk to people about active travel!


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A reminder from the Fuse blog group:

Each Thursday of 2014 we’ll try and post around four pictures on the Fuse blog that capture our weeks in public health research, from the awe-inspiring to the everyday and mundane. Given that more of the latter than the former exists in most of our lives, we foresee problems compiling 208 images worth posting on our own. So this is going to have to be a group project. Send an image (or images) with a sentence or two describing what aspect of your week in public health research they sum up and we’ll post them as soon as we can. You don’t have to send four together – we can mix and match images from different people in the same week.

Normal rules apply: images you made yourself are best; if you use someone else’s image please check you’re allowed to first; if anyone’s identifiable in an image, make sure they’re happy for it to be posted; nothing rude; nothing that breaks research confidentiality etc.

Email your posts to m.welford@tees.ac.uk or contact any member of the Fuse blog group.

The day the media circus came to town

Posted by Jean Adams

Is it more scary when Monty Don slags off your research on Twitter, or when a professor who you respect a lot asks you nicely to be a bit more careful with your not-quite-what-it-was-designed-for use of his carefully developed tool (also on Twitter)? How about both on one day?

What seems like a long time ago now, an MSc student emailed to ask if I’d be interested in chatting about an idea he had for a dissertation project.

His idea was simple: compare the nutritional quality of ready meals to celebrity chef meals. I don’t think the student (now graduate) in question would mind me saying that he’s not unfamiliar with a ready meal, or currently maintaining his weight within the recommended BMI range. Slightly fed up with being told his ready meal habit was bad for him, he was interested in finding out just how bad and whether it was any worse than the alternative that seemed to be in his face whenever he was eating his ready meals – something served up by Nigella, Jamie or Hugh.

In contrast, I and my co-supervisor were backing the celeb chefs. I don’t think I’ve ever eaten a ready meal, and it is possible that I have an affinity for glossy recipe books that has resulted in a collection that outgrew the kitchen bookcase some time ago. Scientists are neutral (not). We might be able to collect and analyse the data objectively, but it was clear what results each member of the research team was hoping to find.

The project was perfect for an MSc dissertation: clear research question, data collection primarily via the web, fairly straightforward analysis, no ethics permission required. We joked in supervision that the BMJ would love it.

And so it came to pass that the student collected and analysed his data, perhaps stretched the use of front of pack labelling for a good gimmicky visual a bit too far, got a good mark, and toddled off back to his real job promising to send us a draft of a paper sometime. Often those manuscripts never materialise. But lo! This one did. I wasn’t absolutely convinced that the BMJ really would love it, but we’d said they would and it seemed a shame not to try. They say ‘no’ pretty quickly.

I was mildly offended when the BMJ’s response to our rather serious and important piece of work was that it was “quirky” enough for their Christmas edition. Sure it was fun and sure I wasn’t quite convinced that it was good enough piece of work to be considered normal BMJ material. But there is a serious point here: lots of public health advice suggests that people should cook from scratch and implies this is better for you than eating ready meals. If you don’t know how to cook from scratch, then it isn’t a wild assumption to suggest that you might learn from the most prominent cooks around – celebrity TV chefs. A nutritional comparison of the two doesn’t seem outrageous.

Presumably you know what our findings were? We found that, on a number of nutritional metrics, ready meals did better than celebrity chef meals, but neither of them did very well. The ready meals were less unhealthy than the celeb chef meals, but it would probably not be right to say the ready meals were healthier than the celeb chef meals.

I knew what was going to happen. I didn’t have any idea how to stop it happening. Perhaps there was none.

The BMJ went to town promoting our paper. The media loved it. We got on the Today programme headlines, the paper was covered by loads of newspapers and not just in the UK, all three of us spent most of publication day doing interviews with just about everyone and their dog. But however much we tried, it was very difficult to get the message across that neither group of meals were particularly good for you – we were definitely not saying that ready meals are the way to go. But that’s the message that everyone seemed to hear.

Ho hum. What can you do? The media circus would move on. No-one would remember. And presumably any colleagues who would, might take the time to read the paper (or at least the abstract), and not just go on what was in the newspapers?

I can understand why people went for the “ready meals healthier than celeb chefs” headline and why that then prompted all the various responses it did. But I was most bothered by Monty Don’s response. And not just because I’ve always thought he seemed like a nice, and thoughtful, guy.

Do lots of people think scientists should only do, and publish, studies that come up with the ‘right’ results? That we should make sure the measures we use are designed to come up with those ‘right’ results? What about Ben Goldacre and the All Trials campaign for open data and publication of all trial results – not just positive ones? How does that match with this attitude? Or maybe I’m assuming that Monty is more representative of ‘the public’ than he really is.