Where you live can kill you

Posted by Clare Bambra, Associate Director of Fuse and Professor of Public Health Geography, Durham University

In 1842, the English social reformer Edwin Chadwick documented a 30-year discrepancy between the life expectancy of men in the poorest social classes and the gentry. He also found a North-South health divide with people from all social classes faring better in the rural South than in the industrial North.

Today, these inequalities persist. People in the most affluent areas of the United Kingdom, such as Kensington and Chelsea, can expect to live 14 years longer than those in the poorest areas, such as Glasgow or Blackpool. Men and women in the North of England will, on average die two years earlier than those in the South. Scottish people also suffer a health penalty with the highest mortality rates in Western Europe.

House for sale in New Orleans

Such geographical inequalities in health exist, to varying degrees, in all high-income countries. People living in more deprived areas fare particularly badly in the casino capitalism of the United States; where gaps in life expectancy between rich and poor areas of some cities, such as New Orleans, are as large as 25 years. Indeed, the US as a whole has a significant health disadvantage in comparison to other high-income countries with, for example, American men living on average three years less than their counterparts in France and five years less than Swiss men.

Understanding and reducing these health inequalities remains a major public-policy challenge worldwide and has garnered significant recent political attention. For example, in her opening speech on the steps of 10 Downing Street, the new British Prime Minister Theresa May highlighted the nine-year gap in life expectancy between the richest and the poorest boys in England. It is not only a moral issue though; health inequalities carry significant economic costs to individuals and society (e.g. NHS costs, lost productivity). But the causes of such inequalities are complex and the solutions contested.

Explaining health and place

Where you live affects how long you live and the health of different places is determined both by the population composition (who lives here) and the environmental context (where you live).

Who lives here? The demographic, health behaviours and socio-economic profile of the people within a place influences its health outcomes. Generally speaking, health deteriorates with age, women live longer than men, and health status also varies by ethnicity. Levels of smoking, alcohol, physical activity, diet, and drugs – all influence the health of populations significantly. The socio-economic status – or social class in “old money” – of people living in a country also matters as those with higher occupational status (e.g. professionals such as teachers or lawyers) have better health outcomes than non-professional workers (e.g. manual workers). So differences in the characteristics of people living in a country, city or neighbourhood will impact on the health of that place.

However, where you live matters. The economic environment of a country, such as poverty rates, unemployment rates, or wage levels can all influence public health. The social environment, including the services provided within a country to support people in their daily lives such as child care or health care and welfare, can also impact on population level health. The physical environment is also an important determinant with research suggesting that proximity to waste facilities and brownfield or contaminated land, as well as levels of air pollution can negatively affect health. So countries, cities or neighbourhoods with worse economic, social or physical environments will have worse health outcomes.

Reducing health inequalities

Even though both composition and context matter, and can be supported by scientific evidence, politics can matter more than science in determining which strategies policymakers pursue to reduce health divides – or if they even care about inequalities at all. After all, some potential solutions are politically easier to implement within existing systems than others.

For example, interventions aimed at changing individual health behaviours are far less challenging to prevailing power structures than those that demand extensive investment in improving the social economic environment. Indeed, by blaming people for their own health problems, such interventions let governments and businesses off the hook for the wider economic, social and environmental determinants of health inequalities.

Such “downstream” approaches only tackle one side of the coin and there is little evidence that lifestyle interventions are effective in reducing health inequalities: more comprehensive measures are needed. Most of the health gains over the nineteenth and twentieth centuries were brought about by far-reaching economic, political, and social reforms which improved the wider environment and also significantly improved the financial position of the poorest people.

It has been clearly demonstrated that more equal societies almost always do better in health terms and the poorest and most vulnerable groups, say in Sweden or Norway, are far healthier and live longer than the equivalent groups in the UK or the US. These countries have done so through the development of a stable, inclusive economy, a supportive welfare system and a high standard of living.

So, where you live matters for how long you live – and changing how we live could reduce health inequalties.


Professor Bambra’s book Health Divides: where you live can kill you is available now from Policy Press.

Clare Bambra
Professor of Public Health Geography, Department of Geography, Durham University, Associate Director of Fuse: the Centre for Translational Research in Public Health and lead of the Health Inequalities research programme
Twitter @ProfBambra

Photo attribution: “House for sale, New Orleans” by K.G. Schneider via Flickr.com, copyright © 2006: https://www.flickr.com/photos/kgs/177196564/in/

Au revoir et bonnes vacances

Posted by Emma Dorée, Fuse Communications Assistant, Teesside University

The blog has spent the last few weeks trying to stay motivated at work whilst watching everyone else share their holiday snaps on social media - enough of the hot-dog legs, already!  It feels as though everyone is enjoying a nice relaxing break except for the blog. However that is all about to change as it is holiday time!

It’s been another busy (academic) year for the blog but the crowning glory has to be winning the award for best blog in the Education category at this year's UK Blog Awards. A fantastic achievement for everyone involved, especially as this was the first time the Fuse blog had been nominated.

So where is the blog going on holiday this year I hear you ask? Well, instead of going abroad it is having an ever so trendy ‘staycation’ and going to the Lake District. This will be a good chance for the blog to get away from its desk, do some physical activity and take in the lovely views. Not to mention, improve its chances of catching some water-type Pokémon - gotta catch 'em all!

Saying goodbye to friends at Teesside University



As well as the blog taking a well-deserved break, this will be my last blog post as a Communications Assistant for Fuse. After having a holiday myself in the sunny south of France, I will be working at West Park Hospital in Darlington as a Communications Assistant.

I have really enjoyed my time working for Fuse and have gained much experience and many skills from being given the opportunity of working in this post. Working as part of a great team to help the blog to victory in the UK Blog Awards has definitely been one of my greatest achievements and something that I will treasure.

So that’s it! It’s farewell from me and happy holidays from the blog.

The blog will return in September with many more exciting posts about public health. Enjoy your summer everyone!


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We still need your 500-700 word blog posts so that we can start September in style.

Please email them to Mark Welford (m.welford@tees.ac.uk).

Here’s how to take part and why you should blog.

Making an impact with your research: may I have this dance?

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

Early career researchers from the five UK Public Health Research Centres of Excellence met recently (14-15 July) in Norwich to discuss their research and bust out a few moves on the dancefloor at the conference dinner. While some career-focused academics (the conference theme was about career transitions) might frown upon this behaviour, the policy and practice partners participating in the conference made it very clear that, for them, dancing is a key move in public health, particularly if you want to make an impact with your research. 

Before you don your dancing shoes, let me explain what keynote speaker Jim McManus, Director of Public Health at Hertfordshire County, was talking about. He argued that knowledge exchange is not really a science or even an art but very much a dance: a dance between researchers and policy makers about the use of research evidence. To complete this dance successfully and get evidence used in commissioning, both partners need to follow certain steps. However, learning the steps (science) or performing them perfectly (art) is not sufficient: it requires instinct and feel for where you are in the dance and why you are doing it.

You need to understand who you are engaging with and why they are the best partner to talk to. How would you like them to use your evidence and why would it be of interest/ value to them? In other words, as a researcher it is not enough to present your partner with the latest evidence. You need to know when and how to use your evidence and this cannot be gleaned from an internet profile page or academic paper, but is based on an ongoing relationship with policy makers. As the context and process in which evidence is useful changes constantly it is an important skill for researchers to be able “to go with the music”.

 

https://twitter.com/okaneniamh/status/753700134605754368 

For instance, if a public health commissioner is challenged in a council meeting by an elected member about the lack of progress in bringing down local childhood obesity, it is of limited use to the commissioner to cite a research paper on the complexity of obesity and the need for a long-term, multi-pronged approach, particularly in times of austerity. A better move could be to signpost the commissioner to an existing two-page evidence brief about the most effective way to reduce inequalities in childhood obesity. A more elaborate dance routine could involve suggesting an action research project to identify how to make better use of existing services in a more integrated way, based on in-depth conversations with elected members and other service providers and users.

To get a better feel for the music, Jim McManus emphasised the need for emotional engagement between researchers and policy makers. A heart-to-heart helps you feel the steps and allows you to adapt your steps based on where you are going. This might sound difficult and un-academic but, given what I witnessed at the evening do, the participants at the UKCRC16 conference in Norwich proved that they were more than happy to move around the dancefloor with our public health partners, given the right music.

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

Interdisciplinarity – facilitated serendipity?

Guest post by Jane Johnson, PhD student at Teesside University

With Professor Brian Caulfield booked to speak at the European Congress of the World Confederation of Physiotherapy Therapy in November on the topic of ‘the impact of interdisciplinary engagement’, and physiotherapists being encouraged to get out of discipline thinking (1), this is a topic I am coming to think about more and more, not least because my PhD involves supervisors from various fields. There is myself and the Director of Studies, both physiotherapists and from the School of Health and Social Care, a senior lecturer from the School of Computing, a professor of psychology from the School of Social Sciences, Business and Law, plus a Director of Research from the Anglo European College of Chiropractic; input has been necessary from a patenting specialist.

 Interdisciplinarity ‘…involves teams or individuals that integrate information, data, techniques, tools, perspectives, concepts, and/or theories from two or more disciplines or bodies of specialized knowledge to advance a fundamental understanding or to solve problems whose solutions are beyond the scope of a single discipline’ (3). Perhaps because it is …. ‘a term that everyone invokes and none understands’ (2) that I jumped at the chance of attending a free workshop* on this topic, welcoming the opportunity to explore how best to maximise the potential of this collaborative approach.

Asked to consider how we defined our disciplines, it was interesting to discover that whilst myself (physiotherapy), Profession Jane McNaughton (medicine), Andrew Rathbone (pharmacy) and Samuel Azubuike (public health) defined our disciplines in terms of codes of conduct and a sense of rigidity, workshop attendees from the fields of anthropology, theology, sociology, history and english defined themselves according to the methodologies they employed. This in itself was telling and got me thinking about how different disciplines understand and use common words. For example, in my own research, how physiotherapists, psychologists and those from the computing world use the word ‘functionality’ needs clarification in order for us to work together efficiently.

During the workshop we considered how disciplines linked to one another and I reflected that with respect to my own work, linkages came about in both a structured and an unstructured way: some team members were involved from the onset, others have been brought on board as the PhD has evolved. During the first nine months of this project I have come to understand that whilst one must have structure, fluidity is important too, and I am put in mind of the presentation given by Sir Ken Robinson in which he describes how life is not linear but serendipitous (4). I am a planner by nature and came home pondering how one follows a structure whilst leaving space for chance meetings. Some of the most useful contacts I have made in the first nine months of this PhD have been through attending workshops outside of my discipline. There is a need for balancing how many conferences, workshops and seminars one attends, where opportunities exist to meet people from other disciplines who may turn out to be helpful but where this is not guaranteed, against the necessity of following the designated research path. My conclusion is that there needs to be a kind of facilitated serendipity, a contradiction in terms I know.
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References

*Supported by the Welcome Trust, the workshop The Practice, Benefits and Challenges of Interdisciplinarity hosted by the Medical Humanities Department at Durham University.

(1) Hitchcock, G. (2016) ‘Physios must get out of discipline thinking’, Frontline 22, 15 June, p.8.
(2) Cited in Mansilla, V., Lamont, M. and Sato, K., 2015. Shared Cognitive–Emotional–Interactional Platforms: Markers and Conditions for Successful Interdisciplinary Collaborations. Science, Technology, & Human Values, 1-42
(3) Callard, F. and Fitzgerald, D., 2015. Rethinking interdisciplinarity across the social sciences and neurosciences. Palgrave Macmillan. P.4
(4) School of Life & Passion - Ken Robinson - POWERFUL!!
https://www.youtube.com/watch?v=nj0NXky1rh8

Keeping up with the pace of physical activity research

Posted by Liane Azevedo, Fuse staff member and Senior Lecturer in Physical Activity and Public Health, Teesside University

The American College of Sports Medicine (ACSM) Annual Meeting takes place at an intense pace with around 20 sessions running in parallel from 8am to 5pm for four days. I have been attending the conference since the year 2000 and at first really struggled to understand the language and content, often returning to my room completely drained and with a thumping headache.

Things are a little bit better now and I was brave enough this year to stand up in quite a few sessions to ask questions. Of course my heart rate was racing but in my early years at the conference just the thought of standing up in front of so many renowned researchers would cause me palpitations.

There were quite a few presentation highlights for me this year, so much so that I’m going to need two blog posts to cover them. Here I’ll talk about the prestigious Joseph B. Wolffe Memorial Lecture, physical activity interventions in children, and an interesting presentation which gave an evolutionary perspective on whether changes in energy expenditure contribute to the problems of obesity.

Liane with her poster at the ACSM Annual Meeting

So let’s start… The Joseph B Wolffe Memorial Lecture (named in memory of the first ACSM President) was delivered by Prof Russell R. Pate from University of South Carolina. Prof Pate is well known by all who do research in physical activity in children. With more than 300 publications in the field, his works mainly concentrate on children, from pre-school to school intervention and policy implementation (he is a member of the US Physical Activity Guidelines Advisory Committee). From all the papers that Prof Pate has written, the articles on pre-school children are those that I am most interested. He showed some data that children spend only 3 per cent of their time in moderate to vigorous physical activity and were sedentary for more than 80 per cent of the time when attending childcare. He then used policy recommendations in US childcare to show that few regulations in childcare are consistent with this recommendation. Surprisingly, no state in the USA has regulations in place for staff joining children in physical activity, and about providing education to carers to increase physical activity. Professor Pate then showed some initiatives that are taking place, for example ABC Grow. This is something that I would be really keen to see in the UK too, having a child that has just recently left the childcare setting and knowing about the limited opportunities and training currently provided here.

In another symposium, I heard about current approaches (and difficulties) to do with helping kids move. There is a great initiative from UNICEF called Kid Power in which by making children active (tracked by an arm band pedometer) it unlocks food packages for malnourished children across the world. The symposium also talked about another initiative running in the United States that is supported by Michelle Obama called The Aspen Institute Project Play. Take a look at this video in which the First Lady talks about the numerous physical activity opportunities for affluent kids and the absence of opportunities for those who are deprived, very thought-provoking….

Finally, I went to a very intriguing presentation, which gave an evolutionary perspective on whether changes in energy expenditure contribute to the problems of obesity. The presenters showed studies from hunter-gatherers and other African rural societies that revealed a lack of association between total energy expenditure and obesity, and that activity energy expenditure is the same between Nigerian and American women but American women are more obese. They also showed that hunter-gatherer populations had surprisingly similar total energy expenditure to adults from developed countries. The presenters suggested that ‘traditional’ lifestyles (without an exercise intervention) may not protect against obesity, and change in diet might be important to reduce the trends of obesity seen in our society (this is a good reading if interested).

In my next blog I will talk about the most recent updates on sedentary behaviour research, interventions to promote physical activity and academic performance, how my own presentation went, and about an interesting debate entitled ‘Who Wins: The Tortoise or the Hare in the Race for Health Benefits?’ which talked about the health benefits of sedentary behaviour, moderate physical activity and high-intensity physical activity. See you then…

Acknowledgment: Liane Azevedo would like to thank Fuse and Teesside University for the support to attend this Conference.

The 63rd American College of Sports Medicine Annual Meeting was held in Boston with around 5,500 people attending from all disciplines related to exercise science and sports medicine.

Learning to be a researcher

Guest post by Jane Johnson, PhD student at Teesside University

Have you ever had the experience of thrusting your hand into the air, “Oo! Oo! Pick me! Pick me!” and afterwards think, “Uh oh, why did I offer to do that?” Despite being invited to give a poster presentation at CAMSTRAND, the Complementary and Alternative Medicine Strategic Direction and Development Conference hosted by University of Warwick’s Medical School, I felt apprehensive. The topic of the conference was ‘The Application of Qualitative Methods in CAM Research’ and not only is my research mostly quantitative, I have only been doing the PhD for eight months so thought, “how on earth will I hold my own in a room of forty experienced researchers?” My intention to seek out and explore opportunities to learn and to contribute during the limited PhD time frame of 36 months had yet again left me with my hand up, and not in an air-punching Bruce Springsteen Born in the U.S.A. kind of way.

But I was glad to have been brave enough to attend because the experience was invaluable for many reasons. I heard 18 presentations and in addition to learning about the variety and content of on-going qualitative research into complementary therapies, discovered the following:

• Standing up in front of experienced researchers gave me heartburn but not heart failure.
• Even experienced researchers don’t always get their point across to the audience in the way they intend.
• Researchers are curious. They ask questions and reflect on what people say.
• For the most part, researchers want to share their experiences to help prevent other researchers making the same mistakes.
• Researchers are solution-focused. They can’t help but start questions with, “have you thought of trying…”
• Researchers like to network.
• Everyone presents their posters differently. I made a mental note to make the font size of the title of future posters even larger than PowerPoint’s recommended 24 and to use more yellow.
• Even as a novice researcher I can contribute. I helped out two attendees who were struggling to understand the concept of ‘coding’, proving that sitting in on Dr Maura Banim’s qualitative methods lessons at Teesside Uni has not been wasted on me.
• The abstract that got me accepted to CAMSTRAND will be published in The European Journal of Integrative Medicine and the discipline of having to put this together was useful.

Even when you think you are alone at a conference, there are opportunities for surprise and comradery. “Oh you’re that Jane Johnson,” said a woman noting my name badge, “I was looking at one of your books the other day in the library.” I braced myself ready to explain that I didn’t write novels featuring romance in the Moroccan desert. “Posture …something,” she said. I relaxed. “Yes,” I confirmed, “I was that Jane Johnson”, suddenly feeling an affinity for a woman I’d never met and slightly more at ease.

CAMSTRAND is an annual conference organised by the Research Council for Complementary Medicine and I look forward to attending other conferences that provide equally good opportunities for me to learn how to be a researcher.

‘First, do no harm’: How to think about austerity and public health

Posted by Ted Schrecker, Fuse Associate and Professor of Global Health Policy, Durham University

The current ‘neoliberal epidemic’ of (selective) austerity directs our attention to public health impacts of choices about public finance in several ways. Most fundamentally, anticipated post-2015 public expenditure cuts in the UK will reduce public expenditure as a proportion of Gross Domestic Product (GDP) to the levels of the 1930s, ‘taking the size of the state to its smallest in many generations’, in the words of a 2014 Institute for Fiscal Studies briefing. In fact, on recent projections by 2020 public spending in the UK as a proportion of GDP will be below the figure for the US, despite the latter country’s bloated defence budget. It is implausible that a National Health Service that is free at the point of use can be maintained with pre-World War II levels of public spending. Even a brief conversation with anyone familiar with US health care reminds us just how much that matters.

Meanwhile, the health consequences of social spending cuts that fall disproportionately on the poorest people and regions are beginning to be manifest in rising food insecurity and increased use of food banks – the latter trend probably related to the rising rates at which benefit recipients are sanctioned. Further health impacts, more difficult to isolate epidemiologically but probably at least as significant, are associated with the stresses of chronic insecurity, powerlessness, and lack of ‘control over destiny’.

There is a basic ethical and political point here about the politics of evidence. Sir Michael Marmot and colleagues wrote in 2010 that ‘It is hard to see how even ideologically driven commentators could think that having insufficient money to live on is irrelevant to health inequalities’. Good point.

In a previous blog with Clare Bambra, we demonstrated that politics can make us sick; Clare recently wrote a similar blog highlighting large health divides across Europe, showing that where you live (and the health policies implemented there) strongly affects how long you live. Against the background of austerity and the rising costs of healthy diets, it is indefensible to ask public health professionals and advocates to demonstrate, over and over again, that (for example) inadequate incomes lead to unhealthy diets and poor health. Rather, the burden of proof should be shifted: we must insist on clear and convincing evidence that national governments’ choices about the level and composition of public expenditure first, do no harm to health, except in extraordinary and clearly justified circumstances. This is an important part of the case for (independent, third party, adequately resourced) health impact assessments, especially of policies and programmes outside the health sector. Such a shift in the burden of proof is also congruent with the strong presumption in international law against retrogression (backsliding) with respect to human rights such as the right to health – a presumption that assumes special importance in an era of austerity.

Is corporate tax avoidance a public health issue?

Public finance, then, is a public health issue. This point applies to the revenue side, as well. The publication of the ‘Panama papers’ reminds us of the extent to which cross-border tax avoidance, whether legal or questionably legal, represents one of the ‘fiscal termites’ that can undermine states’ ability to provide everyone with the prerequisites for a healthy life. (Interestingly, the phrase ‘fiscal termites’ was coined by the former director of the International Monetary Fund’s Fiscal Affairs Department.) The question of how maintaining health services free at the point of use and investing effectively in prevention could be financed should be asked as a routine element of public health practice and advocacy – part of a broader strategy of interrogating scarcity. One answer could be using revenues from clamping down on UK corporate taxes avoided by major transnational corporations. In the real world, resources can almost always be found for the purposes of the powerful: think HS2, Trident renewal, and so on.

Choices about public finance are political choices with consequences for health and health inequalities; academics and practitioners must not be shy about pointing out those consequences.


A more extensive list of references is available from the author.  All views expressed are exclusively those of the author.

Photo: Servizi Mediali.  Reproduced under a Creative commons 2.0 licence. 

Being critical of how bodies are ‘sinking’ the NHS: Lessons from the University of Wollongong (Part 2 of 3)

Guest post by Stephanie Morris, PhD Candidate at Durham University

My time at The University of Wollongong has been one of the biggest learning experiences so far on my Overseas Institutional Visit to Australia. My conversations with scholars there have led me to think more critically and question the status quo regarding physical activity, health and obesity. I had many conversations with Professor Jan Wright that made me realise the way in which physical activity is often promoted may have some unintended consequences for the health and wellbeing of those whose behaviours public health initiatives constantly seek to change.

The University of Wollongong

Many academics and practitioners stress the importance of understanding the political economy of health and health inequalities yet it appears that the media and other discourses in our neoliberal society remain focused on stigmatising individual bodies and their behaviours. I came across an article in The Spectator (a conservative magazine) recently entitled, Our NHS will sink under the weight of Britain’s fatties. The title alone got my blood curdling but one paragraph written by Dr Dawn Harper stood out in particular. It went as follows:

If you are a woman with a waist greater than 32in (80cm) or a man with a waist greater than 37in (94cm) you are at risk of type 2 diabetes. If you are a woman with a waist circumference greater than 35in (88cm) or a man with a waist greater than 40in (102cm) then your risk is very high… For your sake and for the sake of our beloved NHS, take this as a warning shot across your bow and get yourself on a healthy living plan.

Now, the first thing I thought about this extract was how fear mongering and morally loaded its tone was. The emphasis is put on the individual for being a bad citizen, immorally and self-indulgently sinking the NHS. Yet, causations and prevalence of obesity and diabetes is much more complex than a waist circumference category. The key question that I wish to raise here stems from the work of two critical scholars, Gard and Wright (2005), whose work is part of the literature critiquing the ‘obesity epidemic’, the link between body size and diseases like diabetes, and health education curriculums. They ask whether the prevalence of such obesity discourses are actually more connected with the morality included in cultural attitudes concerning fatness than about the clear communication of objective and conclusive scientific knowledge. I am not suggesting that there is no reason for some focus on body weight and size, nor am I attempting to condemn all quantitative research in this area. However, I am questioning what implications such a focus on the body might have for people, and future research and policy. First, many have argued that focusing on the individual body distracts us as researchers and citizens from looking at wider structural issues and health inequalities that need to be researched and addressed. Second, others show obesity discourses and 'Healthism' (a term coined by Crawford (1980) to describe a discourse where individuals are held morally responsible for their own health. Individuals then self-monitor and manage their health by objectifying the body.) fuel body dissatisfaction, feelings of guilt and eating disorders, thus negatively impacting on the wellbeing of children and young people.

Positive vibes from a hostel in Sydney

Due to these negative consequences on people's wellbeing I ask what we as scholars, practitioners and third sector workers in the field of public health really consider ‘health’ to be? Do we consider 'health' to be “a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity” (The WHO definition)? Or do we view ‘healthy’ as appearing as an active and slim body? There are movements away from focusing on weight and body size, including Health at Every Size (HAES) – which Peter van der Graaf also writes about in this blog post – that focuses on promoting happiness in eating and an enjoyment of movement in life. Although HAES has been critiqued by many I wonder if some of its elements can be valuable. I do not think continually worrying about one’s body or fat composition is a ‘healthy’ way to grow up or live, as I don’t think it helps achieve “physical, mental and social wellbeing”. Moreover, perhaps if we stop fixating on the body and move away from changing individual behaviours we might consider societal inequalities more and help reduce inequalities that constrain people’s daily lives. What do you think?

Aspiring to new lows in North West waistlines

Guest post by Naoimh McMahon, Postgraduate student, NIHR CLAHRC NWC

In theory weight management is a ‘simple’ balance between consuming enough energy to adequately fuel ourselves and moving enough to ensure that extra energy is used up. However, in reality there is a complex web of influences that determine our eating and activity habits. We are becoming increasingly more sedentary and are prone to consuming more energy-dense foods. This combination is making the energy balance harder to achieve. When it comes to weight management interventions, what works for one individual is rarely guaranteed to work for the next and so there are real challenges to understand what the right mix of actions are to enable people to achieve and maintain a healthy weight.

Last summer, when preparing a doctoral fellowship application I met with providers and service users from a range of local health improvement initiatives in the North West of England. I was really intrigued by one initiative in particular called Aspire. Aspire is a weight loss programme delivered by a local charity. The design of the programme was unlike any other weight loss programme I had encountered and there was a real sense of personal investment in the programme from both the providers and participants. The thinking behind Aspire is that for individuals who have a lot of weight to lose, intensive and ongoing support is needed to make a positive and sustainable change. The programme runs for 26 weeks and each group has 12 participants. Aspire includes all the traditional elements that you would expect to find in a weight loss programme such as advice and education on food and healthy eating. It also supports participants, many of whom have a body mass index (BMI) of over 35, to engage in graded physical activity.

I think what I found most intriguing about this programme was the emphasis it placed on the person, trying to build confidence and esteem to really convince people that they could achieve their weight loss goals. For example one of the activities that participants spoke about with most feeling was a step climb in a local park at the beginning of the programme. The Aspire providers discussed how this activity served two purposes: (i) to act as a ‘shock to the system’ by allowing the participants to really reflect on their current fitness levels and (ii) to provide a goal to work towards and make a commitment that it will never be that hard again. The group returned to this step climb at the end of the 26 weeks with smart phones in tow and there is some really fantastic footage that captures the excitement and pride at the progress they had made along with the disbelief at how it had once taken hours to complete.

There is never a ‘one size fits all’ and any programme will work for some but not for others. It certainly seems like now it is less about finding a single ‘effective’ or ‘perfect’ programme and more about trying to understand what it is about programmes that enable different people to make positive and sustainable changes. I think we will all know people personally who have taken control over their weight by stumbling upon park runs and ‘getting the bug’ or by using commercial weight loss programmes such as Weight Watchers or Slimming World - finding a system that really works for them. Like other weight loss programmes, there were Aspire participants who did not achieve their goal weight and there were participants who regained the weight that they had worked so hard to lose. What is important is not to write-off such efforts as ‘ineffective’ but to get a better understanding of how and why these outcomes came about. Aspire is only one example of a novel approach to enable people to lose weight but there are certainly elements that have been particularly effective for some participants.


Find out more about the programme and how participants felt about what worked for them.

Boring to Baywatch

Guest post by Jane Johnson, PhD Researcher at Teesside University

The title of this post is perhaps not what you’d expect to hear at an academic conference but then again not all conferences broach the tricky subject of ‘sexy communication’.

The Hoff

This month I was invited - and funded thanks to help from Teesside University and the Royal College of Chiropractors (RCC) - to present an outline of my PhD at the Researchers’ Day of the European Chiropractors’ Union (ECU) Convention in Oslo. The theme for researchers was Down from the Ivory Towers: Breaking Down the Barriers Between Research and Clinical Practice.

As a clinician-turned-researcher and someone who has sat through countless presentations by researchers, this was a theme close to my heart. It felt like a win-win because not only was the RCC getting to see where its money was being spent but - as a fledgling researcher - I gained a valuable insight into the world of research and particularly into the opportunities and challenges presented to us in disseminating what we are doing and what we discover.

President of the ECU Executive Council, Øystein Ogre opened the conference by saying that research has always been a priority for the ECU, not least because chiropractors need a sound evidence base; a concept which, as a physiotherapist, drew me to apply for the PhD on which I am now engaged.

Two speakers from whom I took home important messages were Alice Kongsted and Jørgen’s Jevne. Firstly, Alice suggested that, when presenting our message to clinicians, we should “decide on a clear message” and “drop the details”. She gave examples of PowerPoint slides where the message was unclear and the details many, contrasted to the same information presented in a pared down format. The second take home message was from Jørgen, whose claim to fame could be that he managed to get the word ‘sexy’ into a British Medical Journal publication when they published his article The Sexy Scalpel: unnecessary shoulder surgery on the rise. He said that in getting our message across to clinicians we need to be ‘message brokers’, maximising the use of social media and including images, videos, catchy quotes in our delivery.

Having previously felt anxious about presenting my own work in a highly visual and often interactive way for fear of being criticised as lacking gravitas, I suddenly felt an immense sense of relief. These were experienced researchers and skilled presenters advocating not that we dumb down the content of what we say, but that we change the way we say it. For the first time I felt like I was being given permission to present in a manner that I was drawn to even if it didn’t match the majority of presentations I have sat through. Jørgen’s said that we need make the way we communicate sexy: we need to go “from boring to Baywatch”. I may not have the skill to incorporate images of David Hasselhoff or Pamela Anderson into my slides, but I’m inspired to think more creatively about communication to clinicians.

Photo attribution: flickr.com, Geoffrey Chandler, "David Hasselhoff": https://www.flickr.com/photos/hotrodhomepage/53065807

Why England could get knocked out in the quarter finals

Posted by Clare Bambra, Fuse Associate Director & Professor of Public Health Geography, Durham University

If Euro 2016 was based on how healthy each nation is, there would be some surprising results. England would get knocked out in the quarter finals of Euro 2016 if the tournament was based on how healthy each nation is. Based on health statistics, Switzerland would walk away as European Champions for the first time in the competition’s history, narrowly beating Iceland on penalties in the final. 

Click here to see more Country Health Fact Files‌

Our analysis of differences in life expectancy for men in the 24 countries taking part in the forthcoming football tournament shows huge health divides across Europe and highlights the links between where you live and how long you live.

The European Health Championship is an accessible way to shed light on these stark differences. It scores each nation’s football team based on the country’s male life expectancy at birth for 2013. From these scores, the winners and losers of each group are decided as well as the results of the games in the knock out stages.

England, with a male life expectancy of 79 years, would be winners of their group by beating Russia (63 years), Slovakia (72 years) and Wales (78 years). England would then beat Czech Republic (75 years) in the round of 16 knockout stage but would lose to Iceland (81 years) in the quarter-finals. Likewise, Wales and Northern Ireland, with a male life expectancy of 78 years each, would be beaten by Austria and France (79 years each) in the round of 16 knockout stages. Switzerland and Iceland both with male life expectancy of 81 years meet in the final, with Switzerland winning on penalties because female life expectancy there is 85 years compared to 84 years in Iceland.

The European Health Championship also reveals a clear east-west gap with worse health in the countries of Eastern Europe compared to those in the West. For example, in the host country France (the runners-up in group A), baby boys are expected to live up to 79 years old whilst in Ukraine, who finish bottom of group C, it is just 66 and in Russia (bottom of group B) it is a mere 63 years. Spain and Italy also fare well with men expected to live up to 80 in those countries.

But what explains these differences in health across European countries? Why do some countries perform so much better in health terms than others? Geographical research suggests that the answer is twofold: the health of places is determined by the population composition (who lives here) and the environmental context (where you live).

Who lives here? The demographic, health behaviours and socio-economic profile of the people within a place influences its health outcomes. Generally speaking, health deteriorates with age, women live longer than men, and health status also varies by ethnicity. Levels of smoking, alcohol, physical activity, diet, and drugs – all influence the health of populations significantly. Indeed, research has strongly linked Russia’s comparatively low life expectancy amongst men with the high levels of alcohol consumption in the country particularly since the collapse of communism. The socio-economic status – or social class in “old money” – of people living in a country also matters as those with higher occupational status (e.g. professionals such as teachers or lawyers) have better health outcomes than non-professional workers (e.g. manual workers). So differences in the characteristics of people in the countries of Europe will contribute to these country level differences in life expectancy.

However, research also shows that where you live matters. The economic environment of a country, such as poverty rates, unemployment rates, or wage levels can influence health. Countries with lower poverty rates, for example Switzerland or Iceland, do better than countries with higher poverty rates such as England. The social environment, including the services provided within a country to support people in their daily lives such as child care or health care and welfare, can also impact on population level health. The physical environment is also important determinant with research suggesting that proximity to waste facilities and brownfield or contaminated land, as well as levels of air pollution can negatively affect health. So countries with worse economic, social or physical environments will have worse health outcomes.

Infographics

• ‌European Health Championship – final round of 16 to final‌
• Group results A-F‌
• Country health fact files‌

The underlying research to the European Health Championship and these links between health and place are explored further in Professor Bambra’s forthcoming book Health Divides: where you live can kill you. Reducing health inequalities between and within the countries of Europe is also the focus of HiNEWS, an international project led by the Department of Geography at Durham University. It is funded by the New Opportunities for Research Funding Agency Co-operation in Europe (NORFACE) which is a partnership of European research councils including the Economic and Social Research Council (ESRC).

Dementia: not drowning but waving

Posted by Mark Parkinson, Post Graduate Student at Northumbria University

It's Dementia Awareness Week in England as part of Alzheimer’s Society’s ongoing campaign to raise public awareness of this disease. It also affords us the opportunity to take stock of just how far we have progressed since the dark days of the 1980s. Back then a mood of extreme pessimism surrounded dementia amid stark warnings that this ‘rising tide’ represented an unstoppable tsunami-like force that would engulf the UK. Attempts to avert the coming disaster were seen as futile and hopeless, akin to King Canute holding back the sea. The prevailing mood of despondency was ‘justified’ by nine fallacies of dementia emanating from a general lack of knowledge and understanding about dementia.


The Great Wave off Kanagawa

• Fallacy No.1: Dementia was commonly perceived to be part of ‘normal ageing’. Dementia is now widely acknowledged as a clinical condition characterised by neurobiological abnormalities that distinguish it from so-called ‘normal’ ageing. The public perception of dementia as a disease that is separate from ‘normal’ ageing is increasing in the UK but campaigns such as Dementia Awareness Week are still necessary.
• Fallacy No.2: Dementia is unavoidable. Protective factors that help guard against vascular dementia in particular include our lifestyle choices, including smoking cessation, regular exercise, adherence to a healthy diet and avoiding becoming obese. The identification of potential triggers for dementia paves the way for future interventions that might mitigate the onset of dementia entirely, including monitoring for catalysts for dementia such as cardio-vascular disease, obesity, diabetes and depression. Intervention programs targeting at-risk groups have demonstrated success in preventing dementia, e.g. FINGER (a two-year programme that focuses on diet, exercise, cognitive retraining and monitoring and treating vascular risk). Latest research also highlights further candidate triggers for dementia such as interleukin 33 (IL-33) protein deficiency which may be remedied via injections to prevent dementia.
• Fallacy No.3: Dementia is irreversible. Although this remains the case for now, the development of treatments such as Galantamine have been shown to at least moderate the effects of dementia.
• Fallacy No.4: Dementia is untreatable. The search for a cure for dementia remains ongoing and we have moved into an era where the potential discovery of better treatments and an eventual cure has never been so high. For now though prevention via identification of key triggers remains the main option in the absence of a cure.
• Fallacy No.5: Dementia is a diagnosis to mortality within seven years. Dementia related diseases such as Alzheimer’s now have a typical duration of 10 or more years and evidence suggests that, in general, people with dementia are living longer. The challenge continues to be ensuring they live as well as possible.
• Fallacy No.6: Dementia is too varied and unpredictable to treat. Greater understanding of the different sub-types of dementia, their different causes and symptoms, combined with improved ability to detect them makes treatment for dementia a more viable possibility.
• Fallacy No.7: Dementia is only detected when it is already too late to act. This remains a key issue; however, improved diagnostic tests and screening have improved early detection of the disease.
• Fallacy No.8: Dementia is too expensive to treat. Recent interventions such as Cognitive Stimulation Therapy (CST) can be delivered to people living with dementia via just 14 hourly sessions. CST has demonstrated equivalent but more sustained effects compared to relatively expensive drug treatments.
• Fallacy No.9: The number of those with dementia will increase exponentially in the future. Recent comparisons between CFAS1 (Cognitive Function and Ageing Studies) (1991) and CFAS2 (2015) conducted by Cambridge University reveal that dementia prevalence in the UK has actually declined by 22 per cent over this 24 year period. Those born in the latter part of the 20th century exhibit a lower risk factor for dementia than those born earlier. The tsunami warnings of the 1980s have been proven wrong.

Importantly, all this does not signal a time to relax. The need to raise awareness of dementia and the challenges associated with it remains as urgent as ever. In the 1980s a sense of urgency towards tackling dementia provided a much needed catalyst for change. Today a key difference is that this urgency is no longer fuelled by impotent fear but by renewed hope and optimism that galvanises fresh impetus to all our endeavours to beat the disease.

With acknowledgement to the inspired presentation on 25 April, 2016 at the first Gateshead Dementia Conference by Dr.Daniel Collerton (Clinical Psychologist associated with dementia care at The Queen Elizabeth Hospital, Gateshead).

The 'Wow' moments

Posted by Rosemary Rushmer, Professor of Knowledge Exchange in Public Health, and Dr Peter van der Graaf, AskFuse Research Manager, Fuse and Teesside University

From the 26-28 April, Fuse hosted the Third International Conference on Knowledge Exchange in Public Health in Newcastle-Gateshead. The conference explored “Evidence to Impact in Public Health" in partnership with Tranzo (Dutch Scientific Center for Care and Welfare) and the World Health Organization (WHO), Regional Office for Europe. More than 160 participants from five continents descended upon the Quayside to discuss the latest research and evidence on knowledge exchange practices through papers, posters, interactive workshops and soapbox sessions – and continued these deliberations during the conference reception and dinner, organised walks and yoga sessions.

How do you sum up a conference like this? We are used to filling in ‘happy sheets’ when we attend conferences, giving our scores on the speakers, the accommodation, and if the food was hot…but what about the ‘Wow!’ moments that participants share with each other in the informal spaces?

Below are a few of those hidden moments:

(Day 1: Keynote speaker Professor Bev Holmes, Vice-President, Research
& Impact at the Michael Smith Foundation for Health Research, Vancouver)

‘Wow, she has a lovely way of asking really difficult questions in such a nice, unthreatening way…’

(Day 2: Keynote speaker Professor Hans Van Oers,
Professor in Public Health, Tranzo, Tilburg University)

‘Wow, how did they manage to carry out that research against all that opposition and yet laugh about it now… you can have a good time, be funny, and serious as well…’

(Day 1: Keynote speaker Professor Kieran Walshe, Professor of
 Health Policy & Management, Manchester Business School)

‘Hmm, we can learn about innovation in public health from the car industry and Amazon…’

‘(Sigh) Is that how much we spend on pharmaceutical research and how little we spend on working together to get evidence used. That needs to change…’

(Day 2: Keynote speaker Claudia Stein, Director of the Division of Information,
 Evidence, Research & Innovation, World Health Organisation (WHO))

‘Wow’ it’s that last presentation of the conference and the room is still full.’

(Day 2: Professor Peter Kelly, Director of Public Health
& Adult Social Services, Stockton Borough Council)

‘Goodness! Your Directors of Public Health (DsPH) have taken time out to chair sessions and present…’ (When I fed this back to one DsPH, to show the planning committee’s appreciation of their participation, he was surprised at the delegates surprise… ‘What on earth happens elsewhere…?’ he said.






Maybe we, in Fuse, do have a ‘special relationship’ with our policy and practice partner that makes Knowledge Exchange in public health easier in the North East of England. We, the organising committee, were wowed by the enthusiasm and engagement of all participants during the conference. Discussions were lively with active and positive contributions from not only researchers but in particular public health practitioners and policy makers. Their engagement in the conference is the real evidence of how far we have come with knowledge exchange in the North East and the impact we are having together on public health and local wellbeing, and this is being noticed internationally.

Here's to the next conference!

Visit the Fuse website to find out more about the conference: www.fuse.ac.uk

You are now reading the award winning Fuse blog

Posted by Mark Welford and Emma Dorée, Fuse Communications team, Teesside University

You may recall that in January we used this platform to make a shameless plea inviting readers to vote for the Fuse blog in the UK Blog Awards and a month later you may have heard the news that we had been shortlisted in the categories of Education, and Health and Social Care.

Well… (drum roll) …. We only went and won!  That’s right, you are now reading an award winning blog – fancy contributing?!

Last Friday (29 April), we took the Fuse blog monster on a road trip to the big smoke, that there London, where the streets are paved with, well… paving stones to attend the awards ceremony, in eager anticipation.

The awards ceremony was held at the swanky Park Plaza Hotel in Westminster, London and it is safe to say that it more than exceeded our expectations.  The invitation advised that we ‘dress to impress’ but some of the attire on show would have made Lady Gaga and James Bond feel underdressed.

We were welcomed to the event, themed on Roald Dahl’s The BFG with free drinks and canapes (not to mention all the frogsquinkers, buzzwangles, and bugwhiffles we could handle), while we networked with other bloggers and even the Big Friendly Giant himself. The most exciting part however was still to come: the awards ceremony itself.

Tech Reporter Kate Russell (you might know her from BBC show Click) hosted the evening and provided a great commentary, making every blogger there feel very welcome.  Her quirky comments worked to relax the atmosphere and ease frayed nerves.

Each category had two blogs that were highly commended by the judges, followed by an overall winner.  As the Education category came up on screen, we watched in anticipation - the Fuse Blog wasn't announced as Highly Commended - oh well there was still the other category - but then to our surprise as the overall winner of the category!

Having let out a little scream of excitement (and possibly the odd expletive), we went up onto the stage to collect our trophy – a rather lethal looking glass affair - and have our photograph taken with Kate and the judges. It was a surreal moment and very much unexpected with a dash of relief as there were no speeches.

Obligatory award selfie

Once the presentations were over, we were invited to have our photograph taken with the other winners. After which it was time to celebrate properly with more free prosecco (consumed in moderation), posh food and of course a little bit of disco dancing.

This was a great event to be a part of and the venue made it feel even more special and exciting. As the night drew to a close and we collected our certificate and goody bags (with complementary BFG themed dream jars), the fact that we had actually come away as winners had not yet sunk in - it still hasn't now to be honest!

Dream jars - also good for storing ginger biscuits

  
 This is a fantastic achievement for Fuse, as more than two thousands blogs were submitted. There were more than seventy eight thousand votes in total and it is great to think that the Fuse Blog has such a loyal following and a lot of support.

A special thank you must go to Jean Adams who founded the blog in 2011 and to everyone who has contributed over the years.  The posts have sparked great discussion and helped our readers learn what it is really like to work in public health.  Our many writers make the Fuse blog what it is.

We really hope that you will continue to enjoy reading our posts and don’t forget, if you would like to contribute to the Fuse Blog then please do not hesitate to get in touch.

If you would like to discuss a potential blog post or have something already written then please get in touch with Emma Dorée (E.Doree@tees.ac.uk).