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/

Walking football for people with chronic breathlessness – has it got legs?

Posted by Callum Bradford, Research Associate, Teesside University

Following on from the recent success of the England Women’s football team, and with the Men’s World Cup final just around the corner, now seems like a good opportunity to talk about our walking football project, designed exclusively for people with chronic breathlessness. What is walking football you ask? Well it's football, without running (you don’t say?!), and the physical contact is a bit more restricted. Thankfully, FIFA hasn't got its hands on walking football just yet, with the World Cup being an example of why we perhaps should avoid such a thing.

 

Chronic Breathlessness is predominantly caused by pulmonary conditions, such as chronic obstructive pulmonary disease (COPD), impacting 75 million people globally. With Covid-19 and an ageing population this number is expected to rise, increasing the burden on families, carers, and health and social care services. For individuals, breathlessness is associated with a lower quality of life, decreased capacity to do exercise, and higher levels of anxiety and depression

Pulmonary rehabilitation is recommended for everyone with breathlessness. Consisting of both exercise and education, its benefits on health are unequivocal, however, any benefits gained by patients are often reduced three months after completion. This is primarily because patients go back to doing less physical activity once the programme has finished and support from healthcare professionals is removed. With this in mind, we wanted to develop an intervention that could step-in when patients finish their rehabilitation, offering a form of exercise maintenance and continued social support. Given the nation's love of football (most of the time), we believed walking football might have potential.

To develop the intervention, we initially consulted pulmonary physiotherapists, and a local walking football team. The physios were initially very sceptical, raising concerns that the pace would be too fast, and highlighting the number of people with breathlessness who required oxygen or walking-aids. Walking-aids?! Oxygen?! I hadn't even considered that. I was starting to worry that this idea might be a complete non-starter.

So next stop was to see some walking football for myself at Middlesbrough’s Herlingshaw Centre. I left the session with mixed feelings. They played three-touch, meaning everyone got the opportunity to play, forcing that one player who thinks they're Allan Saint-Maximin to pass the ball. It was also proactively refereed to the benefit of everyone, with players encouraged to talk to the ref if they felt the pace of the game was too fast. However, after giving it a go myself, the pace was still surprisingly quick, despite what Father Ted might have you believe, bringing back concerns as to whether it would be too high an intensity. What I really needed to know was what patients themselves thought of walking football.

So we linked up with Breathe Easy Darlington, a local support group for people with lung conditions. Describing the input from Breathe Easy members as invaluable to our research over the last few years would be a massive understatement. So much so that, as a small thank you, we held a fundraiser for them last month on World COPD Day, raising £1120.76.

Their opinions would be vital to walking football’s success... however, they were also dubious of the idea. Again, concerns were raised about the speed, the walking-aids, and the balance required to play. So I asked, under what circumstances – if any – would they consider giving walking football a go? They stated that if the football was exclusive to people with breathlessness like themselves, they would give it a try, as they would be able to dictate the pace of the game and not feel too self-conscious of their footballing abilities. Our original plan involved asking patients to join onto sessions at the Herlingshaw. Luckily, by consulting with Breathe Easy members, I now understand how that plan – to mix people with and without breathlessness - would have likely ended in disaster, demonstrating the importance of including end-users when designing research studies.

Twelve Breathe Easy members agreed to play and the stage was set for our walking football taster sessions, and as you can see from our video, I don't think it could have gone much better.

The players embraced the competitive aspect of football, stating that “On the pitch you forget about breathlessness”; and the concern for walking-aids was turned on its head after we agreed that hitting the ball with a walking-stick is a perfectly fine way to score a goal. Our coach, Monty Towers, was key to its success, mixing up the session with fun games, while allowing everyone to play football at their own pace. In our follow-up conversations, members also suggested implementing a buddy system, where more experienced participants take responsibility for introducing new patients to the group so they feel more welcome – a brilliant idea that we intend to implement in the future.

Throughout 2023 we will be assessing the feasibility of walking football following pulmonary rehabilitation in collaboration with both North Tees & Hartlepool and South Tees NHS Foundation Trusts, plus the North Riding FA; and I’m confident if it’s anything like our sessions with Breathe Easy members, it will be a great success.

And if you’re still upset about the World Cup, don’t worry, I’m sure our walking football team will bring it home next year.

The views and opinions expressed by the author are those of the author and do not necessarily reflect those of Teesside University or Fuse, the Centre for Translational Research in Public Health.

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

Posted by Susan Jones, Research Associate, Teesside University

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

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

Frontline Staff, Trust B

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

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

Normalisation of smokefree policies

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

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

Promoting normalisation through collective action

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

Role of context

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

Sustainability

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

What we found 

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

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

Policy relevance and implications

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

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

References:

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

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

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

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

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

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

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

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

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

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

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

Images:

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

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

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

Does antibiotic prescribing penalise communities in most need?

Posted by Adam Todd, Reader in Pharmaceutical Public Health in the School of Pharmacy, Newcastle University

Since the discovery of penicillin by Alexander Fleming in the 1920s, there have been over 150 antibacterial drugs developed and marketed for human or veterinary use. The effect these drugs have had on infectious diseases and population health is remarkable. A once considered serious bacterial infection can now be successfully managed using antibiotics prescribed from the doctor. This was not always the case, as our grandparents may testify: bacterial infections were often fatal and the choices available to manage such infections were limited. Bloodletting for pneumonia, mercury for syphilis, and honey for wound infections were all commonly used approaches before the discovery of antibiotics.

This "golden age" of discovery may, however, soon come to an end, as more and more bacteria are becoming resistant to the antibiotics available to us. It is for this reason that healthcare organisations across the world have been focusing on developing 'stewardship policies' to promote the appropriate use of antibiotics. In England, the situation is no different, and the Department of Health and Social Care has developed an antimicrobial resistance strategy. As part of the plan, doctors have been urged to reduce the amount of antibiotics they prescribe when it is safe and appropriate to do so. As the majority of antibiotic prescribing occurs in primary care settings, such as GP surgeries, healthcare providers working in this setting are set specific prescribing targets.

It is important to establish if the polices are working from an antibiotic stewardship perspective, but also that these polices are fair, and do not penalise communities in the most need of care. Our work aimed to address these questions. To do this, we used antibiotic prescribing data from the NHS, as well as working out the characteristics of the local areas in England using nationally available data sources.

Overall, we found that, in England, the plan to reduce antibiotic prescribing appears to be working: since 2014, antibiotic prescribing has reduced by around 14 per cent. We also found that the prescribing of 'broad spectrum' antibiotics, used to treat a wide range of infections, have also reduced.

When we considered local factors in our analysis, we showed that the most deprived areas of England had the highest levels of antibiotic prescribing. And even when we factored in two long-term conditions – diabetes and Chronic Obstructive Pulmonary Disease – both of which are associated with increased antibiotic use, we still found higher levels of prescribing in the most deprived areas of the country. We also showed that geography was an important factor too: compared to London, all other areas of England had higher levels of antibiotic prescribing – with the East of England, and the North East of England having the highest levels.

You might ask why this is important? Well, that's a good question. Our work shows that in addition to a national strategy to reduce antibiotic prescribing, it is important to consider local needs too. People living in more deprived areas might, for example, have greater health need for antibiotics compared to people living in more affluent areas. National one-sized-fits all targets might not necessarily account for this. If there is greater antibiotic need in deprived areas, doctors working in these areas might be unfairly penalised for prescribing them. This is not fair on the doctors working in primary care, but may also impact on patients too.

The antibiotic stewardship polices appear to be reducing overall antibiotic prescribing, which is a positive thing, although there is still significant variation in prescribing across England. It would be appropriate for future prescribing targets to account for local factors to ensure the most deprived communities are not inappropriately penalised.

The bottom line is if someone is in medical need of an antibiotic, they should be prescribed it, regardless of the characteristics of their local area or where they live.

Adam leads a programme of research that explores how pharmaceutical interventions, including medication, immunisation and screening approaches, can be used safely, appropriately and equitably at a population level.

Image: 

"England Map silhouette" by Natasha Sinegina through Creazilla: https://creazilla.com/nodes/2538-england-map-silhouette. You may obtain a copy of the License at https://creativecommons.org/licenses/by/4.0/ (CC BY 4.0).

Can cancer ever be a good thing?

Post by Fiona Menger, Research Associate, Institute of Health and Society, Newcastle University

Dr Menger blogs about how she was inspired early in her career by Times Journalist John Diamond and has recently returned to his writing while working on a study on the positive consequences of having cancer.

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John Diamond, author of “C, Because cowards get cancer too”

As a newly qualified speech and language therapist in the late 90s, I was an avid reader of Times journalist John Diamond’s weekly columns on his experiences of being treated for head and neck cancer. Diamond was one of the UK’s first ‘cancer columnists’, writing about his reaction to his diagnosis and treatment, and the correspondence he received from his thousands of concerned readers. His columns became two books, a documentary, a play, a TV drama, and were followed by many other cancer survivors writing about their experiences in the media or on personal blogging platforms.

John Diamond conveyed to his readers not only that it was ok to write about personal experiences of cancer, but that it was positive to share his story. He was adamant that he was neither brave nor strong, but that he was, in his own words, ‘a coward’, a passenger on a journey where he had very limited control. For me, John’s strength lay in his writing and his reflection. He was simultaneously eloquent and rude. Each day when the radiologist would ask, “How are you today?” he would grumpily reply, “Well, since you ask, I’ve got cancer.” I loved that about him. He was honest and funny and had a natural ability to convey the serious level of crap he was living through. He also taught me a great deal about viewing care from a patient’s perspective, something I have tried to carry with me throughout my career.

I recently returned to John Diamond’s writing because, twenty plus years later, I find myself working on a head and neck cancer-related project with a focus on a phenomenon called post-traumatic growth. Around 20 years ago, psychologists began to investigate post-traumatic growth in survivors of traumatic experiences such as natural disasters or accidents, but more recently the concept has begun to receive attention within the cancer research community. The principle of post-traumatic growth is that a person can, over a period of months and sometimes years, come to perceive positive benefits as a result of their trauma (in this instance, cancer). It might mean, for example, that a person feels emotionally stronger, that they appreciate their life and relationships more, or that they feel they have renewed focus and direction. The researchers who coined the term report that to experience post-traumatic growth, a person must go through a process of rumination and reflection. They write that it is necessary to work through a period of recurrent thinking about the event with the aim of trying to make sense of what has happened, to problem solve and to reminisce. These were skills that John Diamond demonstrated in spades. In the final chapter of his book, ‘C – Because cowards get cancer too’, Diamond recounted a conversation with his wife, the chef and author Nigella Lawson:

‘It’s such a strange time, isn’t it?’ I said.

‘How so strange?’

‘Oh you know. Strange in that I’ve never felt more love for you than I have in the past year, that I’ve never appreciated you as much, nor the children. In a way I feel guilty that it should have taken this to do it, I suppose. But it is strange, isn’t it?’

For the first time, I found myself talking like this without resenting that it had taken cancer to teach me the basics, without resenting that there was part of me capable of talking like a 1950s women’s magazine article without blushing.

I still don’t believe that there is any sense in which the cancer has been a good thing but, well, it is strange, isn’t it?

Quote from: Diamond, J. C. Because cowards get cancer too. Vermillion. 1999

So, is there ever any sense in which cancer can be a good thing? Research across different types of cancer survivors suggests that post-traumatic growth is a common occurrence but that it doesn’t happen for everyone. There is also some limited evidence to suggest that people with cancer who experience higher degrees of post-traumatic growth may have better health-related quality of life. What we don’t understand is what helps or hinders people to experience these positive changes. This is what our project – “Life after Head and Neck Cancer” aims to determine. We plan to interview people who have finished treatment for head and neck cancer and have had time to reflect on their experiences. We will explore coping mechanisms, support systems and beliefs about the impact head and neck cancer has had on people’s lives. Why is it important to better understand post-traumatic growth? Well, if researchers can somehow identify and understand how people develop post-traumatic growth, this could inform the development of services to support people to have more positive outcomes after cancer.

This Sunday (2 June) marks National Cancer Survivors Day. We are hopeful that, if post-traumatic growth can in some way be encouraged and supported, more and more cancer survivors can live well following their experiences. This work is in its very early stages, but I am extremely proud to be part of it.

John Diamond died in 2001, following a recurrence of his throat cancer.



Figure image: reproduced with permission from: Diamond, J. Close encounters of an alternative kind. BMJ 2000; 321:1163

All articles posted on this blog give the views of the author(s), and not the position of Fuse, the Centre for Translational Research in Public Health; the five North East Universites in the Fuse collaboration, or funders.

Making the rural a bit more idyllic

Guest post by Christina Dobson, Research Associate, Institute of Health and Society, Newcastle University

Ah, the countryside. The home of all that is natural and healthy, the epitome of the ‘good life’. Where you can stroll down the lane to collect fresh eggs or veggies from your neighbour, simply dropping your money in the honesty box left at the end of their drive. I grew up in a rural area, and still live in one now. I love that I only have to walk (more like dawdle - I have a very curious and distractible three year old!) for 10 minutes (five minutes without said three year old) from my front door and I am in the North Yorkshire Moors National Park.

And it seems that living in a rural area could actually be good for you in a number of ways. You are likely to be more satisfied with your life, experience better health overall, and live an average of two years longer than people in urban areas. Maybe it’s the un-polluted air, the connection between land and food, the sense of belonging and community? Or maybe that is just a myth, sold to us all through Postman Pat?

Because, actually, living amidst the beautiful rolling hills may not be so good for you if you develop cancer. In fact, it may even put you at greater risk of developing certain cancers and make you less likely to survive your cancer. With roughly 20% of the population of England living in a rural area, this poses a serious public health problem.

However, we don’t really know why rural patients are facing poorer survival rates than urban patients. One of the strongest factors is that cancer is often diagnosed at a more advanced stage in rural patients, limiting the treatment options available to them. We know that delays in diagnosis are strongly linked to advanced stage cancers, and, as such, encouraging early diagnosis has been central to UK cancer policy for over a decade.

When we begin to think about where diagnostic delays may be occurring for rural patients, it seems that they are investigated and diagnosed just as quickly as urban patients, after referral to hospital for specialist assessment. It follows then that there may be problems prior to referral to hospital that are slowing down rural cancer patients’ diagnoses, either in the way patients respond to symptoms, or the way they are managed in primary care.

Thanks to funding from Yorkshire Cancer Research, and alongside colleagues from Aberdeen and Glasgow, we are starting to look for answers to some of these questions. This study will involve interviewing people in rural Yorkshire to understand their experiences of bowel cancer symptoms and decisions around if, how, and when to seek help about them. The findings from these interviews will be used to work with local communities to think about what interventions we may be able to design to encourage people in rural areas to present to their GP and, hopefully, increase the likelihood that their cancer is diagnosed at an earlier stage and that they will survive.

It is an exciting study, as there is so little known about symptom experiences in rural populations, with lots of issues to explore. For instance, availability and regularity of public transport, provision of health care services in rural areas, hidden poverty, cultural beliefs and experiences of ill health and employment, to name but a few. And then there’s the messy complexity of defining the ‘rural’, or maybe we should be looking to instead describe the multitudes of ‘rurals’? Plenty to keep me busy!

With the arrival of National Bowel Cancer Awareness Month it’s been valuable to reflect on the importance of this study and the opportunities and challenges that lie ahead. Understanding some of the barriers to timely presentation that exist for rural populations, and devising ways to overcome them is our challenge for the next two years, and beyond. Maybe, longer term, we can help to make the ‘rural’ a bit more idyllic.

Sustainable diets must be a public health priority

Guest post by Tom Embury, Public Affairs Officer at the British Dietetic Association

The publication this week of the EAT-Lancet Commission report on healthy diets from sustainable food systems makes it clear that our health and the planets are inextricably linked. As such, improving the sustainability of our diets must be a public health priority. This is something that the British Dietetic Association (BDA) has recognised for some time, and we have recently launched our One Blue Dot toolkit to help dietitians, as key public health actors, deliver on that priority.

Pale Blue Dot - photograph of Earth taken by the Voyager 1 space probe

One Blue dot – the only home we have

The BDA chose to name our Environmentally Sustainable Diets Toolkit 'One Blue Dot' for the famous image taken by Voyager 1. It is of the Earth from a distance over 3.5 billion miles, and in it our planet appears as a pale blue speck, less than one pixel wide, in the vast darkness of space. The astronomer Carl Sagan said of the image:

"To my mind, there is perhaps no better demonstration of the folly of human conceits than this distant image of our tiny world. To me, it underscores our responsibility to deal more kindly and compassionately with one another and to preserve and cherish that pale blue dot, the only home we've ever known"

Our eating habits are having an adverse impact on the environment and we are endangering the future of the planet – up to 30% of greenhouse gas emissions (GHGe) come from the production of food – and it’s the only one we’ve got. We also know that our current food system is not providing for human health either. Over 800 million people worldwide still do not have enough to eat, while nearly two billion are now overweight or obese.

We believe that eating more sustainably can be a win-win – good for us and good for the planet. It’s also the responsible thing to do. As Ursula Arens, one of the dietetic experts who helped us write the toolkit put it: "Eat healthily for you, eat sustainably for your grandchildren".

Practical help

The BDA’s 2017 policy statement on sustainable diets emphasised the central role we believe dietitians need to play, translating the complex science of environmental sustainability as it relates to food into practical dietary advice for patients and the public at large. The statement was well received by our members but they also made it clear that we needed to do more to support them to make this policy a reality. This is a big topic and can be daunting, not just for the public but for healthcare professionals as well. That is why the idea for a toolkit was born, designed to provide a summary of the key evidence, some practical tools and links for more advice.

So far, we’ve developed a comprehensive reference guide which looks in detail at the key elements of a sustainable diet, outlines the evidence on the impact of certain foods on areas like GHGe, land use and water use. We’ve included practical meal swaps, which highlight the relatively easy ways in which common meals can be made both more nutritious and have less impact on the environment. We then include detailed information on specific nutritional considerations, in particular those nutrients that may be lacking if red meat is reduced and dairy intake moderated, such as calcium, iron and iodine.

Key recommendations

The main two recommendations within the toolkit are to reduce red and processed meat (RPM), and to moderate dairy intake. These two actions will lead to the biggest reduction in GHGe in particular, and we know that there are positive health benefits from reducing RPM and shifting away from certain dairy sources such as cheese which have high environmental impact and are also typically high in saturated fat and salt.

Other considerations, like sourcing sustainable fish, eating more fruit and veg, consuming locally produced food and reducing food waste will also make an important contribution to public health. No one action will be enough on its own. It becomes clear once you delve into the science and evidence on sustainable diets just how complex this issue is, and that even seemingly innocuous differences in the way (or indeed where) food is produced makes a big difference to its environmental impact.

What next

This toolkit is not finished; it remains a live document which we hope to add to and update over the coming months and years. While the first part is focused on dietitians themselves, we know that the next phase will be to make this a public health message. We’ve already got some more materials planned, and been delighted with all the questions and suggestions from dietitians and others about what we could look to include in future iterations. If you have any further suggestions, including on how this message can be translated for public health audiences, they’re very welcome!

We know that changing our diets alone will not save the planet - we also need to make big changes in transport, energy, waste and many more besides. However, as the experts in diet and health, it’s the area in which we have the expertise to make the biggest difference.

You can find out more about the One Blue Dot toolkit on the BDA website: www.bda.uk.com/onebluedot

Image: 'Carl-Sagan-Pale-Blue-Dot' by Owen Iverson via Flickr.com, copyright © 2006: https://www.flickr.com/photos/oweniverson/4671868416

Star Trekkin' across the (research and quality improvement) universe

Posted by Peter van der Graaf, AskFuse Research Manager, Teesside University

Does improving the quality of care from health organisations need research? This was the question asked at the Annual Network Event of the Clinical Research Network for the North East and Cumbria. The network has been successful over the last four years in bringing together a wide range of clinical staff across the region and promoting and supporting high quality health research, which was celebrated at the event, but the organisers didn’t shy away from asking some tough questions.

Q (John de Lancie) pictured behind Captain Jean-Luc Picard (Patrick Stewart)

While the network has put a strong focus on numbers, particularly related to regional recruitment targets for patients in trials, its clinical Director, Professor Stephen Robson, acknowledged that this was only part of the story and that it also ignored what happened later in the research process. For instance, how do we ensure that the research findings get adopted by practice organisations? Brilliant studies are useless if they don’t result in changing clinical practice. But how to change this practice?

The event therefore put a renewed focus on quality improvement. How can we help health professionals to improve their practice? One of the network’s partners, the Academic Health Science Network for the North East and Cumbria (AHSN NENC), joined forces last year with NHS Improvement and the Health Foundation to play a leading role in the national roll out of the Q community.

Unfortunately for us ‘Trekkies’, this is not a new Star Trek episode about the famous Q tormenting various Starfleet Captains; instead, the Q community is a force for good that connects health professionals across the UK to improve health and care quality. The community supports members in their existing improvement work and tries to enhance their skills, helps members to share ideas and enable them to make changes in their organisations that benefit patients.

For this episode, Q came out of the 2013 Berwick report, which followed the publication of the Francis Report into the breakdown of care at the infamous Mid Staffordshire Hospital. The report urged health organisations to make better use of members of staff with improvement expertise and made a case for a system devoted to continual learning and improvement. In response, NHS Improvement (with support from the Health Foundation) developed the Q community in 2015, which now has 236 members in the North East (5000+ nationally) and is expected to grow considerably over the next few years.

I unashamedly applied to become a member of this network last year and they were crazy enough to accept me, so I was looking forward to the Q workshop at the annual event, led by Suzy Cook. The workshop looked at the link between research and quality improvement but, to my surprise, focused on the differences and argued that they should be viewed as separate activities with distinct aims, following different processes and timescales. Research was described as a linear and long-term process that is mostly concerned with the effectiveness of existing and new services, while quality improvement was pictured as a more cyclic and shorter term process with linked PDSA cycles (Plan-Do-Study-Act) that focus on the sustainability of services.

This distinction does not do justice to both activities and feels like a rather odd separation: why can’t research inform what practice needs to improve and how? And what about evaluating quality improvement; isn’t research a key component of the PDSA cycle? Luckily, participants in the workshop raised the same objections and an alternative view was provided in the next workshop by Seamus O’Neill, Chief Executive of AHSN NENC.

He argued instead that there was a clear link between research and quality improvement by looking at the adoption of research in the NHS. Quality improvement needs evidence to select the right intervention in the right context. Just sinking money into an innovation because we think it is going to make a difference will not impress funding and commissioning bodies. At the same time, he warned that many quality improving and cost-saving interventions are not used by health care organisations. They are either not aware of them (clinicians do not read journal articles) or they do not know how to adopt them (how can we make it work here?). According to Seamus, this is where quality improvement can come in: using dedicated health professionals, such as the Q community, and their skills to study, plan, do and act on the research evidence.

Researchers and quality improvement professionals need each other, not to put more clear blue water between them, but to make both activities more useful and effective. Even Q in Star Trek perhaps saw the wisdom of this when he remarked: “I look at the universe in an entirely different way now. I mean, I can't go around causing temporal anomalies or subspace inversions without considering the impact it'll have”. (Star Trek: Voyager: The Q and the Grey #3.11, 1996).

North East and North Cumbria - Annual Network Event: Research Matters was held on 26 April at the Stadium of Light in Sunderland.

Photo attribution: “John de Lancie, Denise Crosby (at back), Patrick Stewart, Star Trek TNG, "Encounter at Farpoint," 1987” by Classic Film © 2015: https://www.flickr.com/photos/29069717@N02/20607700773