Download Department of Health West Midlands

D:\565324357.doc
Department of Health West Midlands
Quality, Innovation, Productivity & Prevention
Food
1.
INTRODUCTION
The Government has reaffirmed the need to place quality of care at the heart of the
NHS. The White Paper, Equity and Excellence: Liberating the NHS 1 makes it clear
that quality cannot be delivered through top down targets but by focusing on
outcomes, giving real power to patients and devolving power and accountability to
the frontline.
Despite the recent good funding settlement for health, the NHS needs to make
savings because of growing demand. With factors such as an ageing population
putting the NHS under increasing pressure, it is not possible to go on as before.
Now, more than ever before, the NHS has to achieve value for money and the best
possible quality so that patients get the greatest benefit.
The Quality, Innovation, Productivity and Prevention (QIPP) programme is all about
ensuring that each pound spent is used to bring maximum benefit and quality of
care to patients.
The NHS needs to achieve up to £20 billion of efficiency savings by 2015 through a
focus on quality, innovation, productivity and prevention. Every saving made will be
reinvested in patient care by supporting frontline staff, funding innovative treatments
and giving patients more choice.
The Public Health White Paper also emphasises that public health evaluation and
research will be critical in enabling public health practice to develop into the future
and address key challenges and opportunities, such as how to handle the wider
determinants of health and how to use behaviour change science to support better
more cost effective practice. This is supported by the setting up of a new School for
Public Health Research and a Policy Research Unit on Behaviour and Health.
Public Health England, the new service that will be part of the Department of
Health, will be expected to properly resource research into interventions happening
outside the NHS. Public Health England and others will work together to identify
research priorities and use the best evidence and evaluation and will support
innovative and cost effective approaches to behaviour change.
2.
THE HEALTH RISKS OF POOR NUTRITION
Good nutrition is vital to good health. While many people in England eat well, a
large number, particularly among the more disadvantaged and vulnerable in
society, do not. In particular, a significant proportion of the population consumes
less than the recommended amount of fruit & vegetables and fibre but more than
the recommended amount of fat, saturated fat, salt and sugar. Such poor nutrition
is a major cause of ill health and premature death in England. Cancer and
cardiovascular disease, including heart disease and stroke, are the major causes of
1
D:\565324357.doc
death in England, accounting together for almost 60% of premature deaths. About
one third of cancers can be attributed to poor diet and nutrition.
Increasing the consumption of fruit & vegetables can significantly reduce the risk of
many chronic diseases. It is estimated that eating at least five varied portions of
fruit & vegetables a day can reduce the risk of deaths from chronic diseases such
as heart disease, stroke and cancer by up to 20%. Research has shown that each
increase of one portion of fruit or vegetables a day lowers the risk of coronary heart
disease by 4% and the risk of stroke by 6%. Evidence also suggests that an
increase in fruit & vegetable intake can help lower blood pressure.
Unhealthy diets, along with physical inactivity, have contributed to the growth of
obesity in England. Obesity brings ill health, including hypertension, heart disease
and type II diabetes. Obesity is responsible for an estimated 9,000 premature
deaths per year in England (6% of all deaths, compared to 10% for smoking). It is
estimated that the treatment of ill health from poor diet costs the National Health
Service at least £4 billion each year.
3.
WEST MIDLANDS’ OVERVIEW
In the West Midlands 25% of men and 26% of women are obese and 41% of men
and 32% of women are overweight2. Based on 2009 mid-year population
estimates3, this means there are approximately 1.4 million overweight or obese men
and 1.3 million women (of which approx 539,450 are obese men and 585,312 are
females). The latest Health Survey for England (HSE) data suggests that obesity
prevalence for 2-15 years olds in the West Midlands is 16% for boys (74,688) and
18% (80,352) for girls4.
The number of pupils having school meals in the West Midlands5 varies from 32.8%
in Worcestershire to 64.4% in Herefordshire (primary schools) and 24.5% in
Sandwell to 56.1% in Herefordshire (secondary schools). 79.6% of the 85.3% of
pupils in the West Midlands eligible for free school meals take them up6.
4.
OVERALL RECOMMENDATIONS
4.1
Maternal Nutrition
The evidence around nutrition and, in particular the nutrition of mothers is very
strong. This is primarily based on evidence from where nutrition is poor and the
consequences are readily seen. It would be unethical to undertake a trial to reduce
nutrition but evidence relating to supplementing the diet with vitamins and minerals
shows the benefits not only to the mother, but also to her children at home, as well
as the child that is being carried.
The recommendations on ‘maternal and child nutrition’ are unlikely to have a
significant impact on national resources. Costs are most likely to be incurred locally
for the provision of Healthy Start vitamins, training (for both health professionals
and support workers), breastfeeding peer support, link workers and family nutrition
programmes.
2
D:\565324357.doc
4.2
Breastfeeding (there is a separate QIPP document for this priority)
Implementing the breastfeeding guidance may bring the following benefits:


4.3
a reduction in childhood illnesses such as gastroenteritis, otitis media and upper
respiratory tract infections and reduced hospital admissions due to the protective
effects of breastfeeding on children
a reduction in forecasted obesity rates among adults and children, following
family nutrition programmes and an increase in breastfeeding rates.
a reduced risk of some cancers among mothers who breastfeed due to the
protective effects of breastfeeding on mothers.
Diet
4.3.1 Fruit & Vegetables
Fruit & vegetables are good sources of many vitamins and minerals. In addition,
they contain a range of other compounds called phytochemicals, including
flavonoids, glucosiniolates and phyto-oestrogens. These have a range of beneficial
effects on the body. They act as antioxidants which can help prevent damage to
tissue that is associated with the development of cardiovascular disease and some
cancers. Furthermore, it is thought that nutrients and phytochemicals act in concert
to influence the risk of certain chronic diseases.
Dietary supplements containing isolated vitamins or minerals do not appear to have
the same beneficial effects as fruit & vegetables themselves. Indeed, in some
studies, supplements caused more harm than good7.

5ADay
The 5ADay message – to eat at least 5 portions (400g) of a variety of fruit &
vegetables each day – was developed based on a recommendation from the World
Health Organisation (WHO) following evidence that populations consuming at least
400g of fruit & vegetables per day can reduce the risk of deaths from chronic
diseases such as heart disease, stroke and some cancers8.
Fruit & vegetable consumption in England is currently lower than recommended
although available trend data suggests there is an overall upward trend in
consumption. Most recent trends in data from the Health Survey for England show
that the average number of portions consumed in adults is 3.5 portions for men and
3.8 portions for women9.

5ADay Multifaceted Intervention
5ADay evidence is very strong and is widely agreed to evidence the second most
important area for cancer prevention – ie diet related cancers. However, there are
many other benefits that cross over into CHD, diabetes, dyslipidemia, depression,
osteoporosis, hypertension, strokes, and other areas which in conjunction with
exercise interventions add much more to the effects of improved diet.
3
D:\565324357.doc
The effects of obesity are lifelong, incremental and such that it adds to the risk of
different co-morbidities that impact on various ages and aspects of health10,11,12.
Burden of Disease
Chronic diseases, particularly cardiovascular disease (CVD) and cancer are a major
cause of death in the UK (accounting for 1.9 and 1.1 million deaths each year) –
they are a huge public health challenge. Moreover, they are one of the main
causes of disability arising from ill health13.
In Europe, the burden of disease attributable to low fruit & vegetable intake has
been estimated to be between 19 and 35% for heart disease, 12 and 23% for
stroke, 13 and 24% for stomach and oesophageal cancers, 8 and 16% for lung
cancer and 1 and 3% for colorectal cancer14 .
Cardiovascular Disease
In 1994, the Committee of Medical Aspects of Food & Nutrition Policy (COMA)
Cardiovascular Review Group reviewed the evidence with regard to fruit &
vegetable consumption and recommended that the population’s mean intake of fruit
& vegetable should increase by at least 50%15.
More recently, a meta-analysis of 13 cohort studies found that intakes of more than
five portions of fruit & vegetables a day were associated with a 17% reduction in
coronary heart disease (CHD) risk and intakes of three to five portions per day were
associated with a more modest decrease in CHD risk (7% reduction)16.
According to another study in Europe, the burden of isachaemic heart disease and
stroke could be reduced by up to 17% and 10% respectively, with an increase in
fruit & vegetable consumption to 600g per day17.
Cancer
In 1998, COMA reviewed the evidence on the nutritional aspects of the
development of cancer and concluded that higher vegetable consumption would
reduce the risk of colorectal cancer and gastric cancer18.
More recently, the World Cancer Research Fund (WCRF), together with the
American Institute for Cancer Research (AICR) published a rigorous review and
evaluation of 7,000 studies on food, nutrition, physical activity and body composition
in relation to cancer19. Among other findings, the Expert Group concluded that the
evidence shows vegetables, fruits and other foods containing dietary fibre (such as
whole-grains and pulses) may protect against a range of cancers including mouth,
stomach and bowel cancer. WCRF subsequently recommended “Eat at least five
portions/servings (at least 400g) of a variety of non-starchy vegetables and of fruits
every day”.
More specifically, they concluded that non-starchy vegetables “probably” have a
protective role against cancers of the mouth, pharynx and larynx as well as those of
the oesophagus and stomach. In addition, there is evidence that certain fruits
protect against mouth, pharynx, larynx, oesophagus, lung and stomach cancer20.
4
D:\565324357.doc
Other Health Benefits
Eating more fruit & vegetables will also help to increase intake of dietary fibre. It
may also help to reduce total energy and fat intake, if eating more fruit & vegetables
replaces consumption of energy dense foods. It has been suggested that
increasing fruit & vegetable consumption may help to reduce the energy density of
meals21.
Long-term studies examining the effects of various dietary interventions suggest a
positive role for fruit & vegetables in weight management, where increased
consumption of fruit & vegetables may enhance satiety and help to avoid hunger22.
4.3.2 Reducing Saturated Fat Intake
Reducing general consumption of saturated fat is crucial to preventing CVD. Over
recent years, much has been done (by the Food Standards Agency, consumers and
industry) to reduce the population’s intake. Consumption levels are gradually
moving towards the goal set by the Food Standards Agency to reduce population
intake of saturated fat from 13.3% to below 11% of food energy.
However, a further substantial reduction would greatly reduce CVD and deaths from
CVD. Taking the example of Japan (where consumption of saturated fat is much
lower than in the UK), halving the average intake (from 14% to 6-7% of total energy)
might prevent approximately 30,000 CVD deaths annually. (Note that low-fat
products are not recommended for children under 2 years, but are fine thereafter).
4.3.3 Trans Fats
Industrially produced trans fatty acids (IPTFAs) constitute a significant health
hazard. In recent years many manufacturers and caterers, with the encouragement
of the Food Standards Agency and other organisations, have considerably reduced
the amount of IPTFAs in their products. However, certain sections of the population
may be consuming a substantially higher amount than average, eg those who
regularly eat fried fast food. It is important to protect all social groups from the
adverse effects of IPTFAs.
In some countries and regions (for instance Denmark, Austria and New York),
IPTFAs have been successfully banned. A study for the European Parliament
recently recommended that it too should consider an EU-wide ban. In the
meantime, some large UK caterers, retailers and producers have removed IPTFAs
from their products.
4.3.4 Reducing Salt Intake
High levels of salt in the diet are linked with high blood pressure which can, in turn,
lead to stroke and coronary heart disease. High levels of salt in processed food
have a major impact on the total amount consumed by the population.
Over recent years the food industry, working with the Food Standards Agency, has
made considerable progress in reducing salt in everyday foods. As a result,
products with no added salt are now increasingly available. However, it is taking
too long to reduce average salt intake among the population. Furthermore, average
5
D:\565324357.doc
intake among children is above the recommended level and some children
consume as much salt as adults. Progress towards a low-salt diet needs to be
accelerated as a matter or urgency.
5.
RECOMMENDATIONS FOR SPECIFIC INTERVENTIONS
5.1
Early Years
Food and Nutrition Guidance for Early Years Settings23 in England has been
published by the School Food Trust. The Advisory Panel on Food and Nutrition in
Early Years included nutritionists, policy advisors and national organisations
representing children’s centres, childminders and maintained, private, voluntary and
independent nurseries. The report contains a series of other recommendations
including a commitment that providing healthy, balanced and nutritious food and
drink must continue to be a statutory component of the Early Years Foundation
Stage for children’s welfare and should be seen as integral to children’s learning
and development.
5.2
School Based Multi-Facetted Programmes
Good evidence from some studies this, especially from the US and limited evidence
from the UK. Recent Cochrane review indicated that the results are inconsistent
and there is no consensus for overall change in BMI.
Childhood obesity continues in adulthood. Non-obese children also have a gradual
propensity to increase in weight. Evidence on effectiveness is present for the
improvement of physical activity and dietary behaviour.
The National Healthy Schools Programme interim report found the programme
affected schools by influencing the development of healthy eating policies, including
lunchbox guidelines and promoting healthy eating in school and practical changes
such as increased staff training and selling healthy snacks.
As with smoking, there is evidence that the more interventions undertaken the
greater the likelihood of showing an effect. Little and often works best and requires
all health professionals to give out consistent and repeated messages relating to
this area.
5.3
Folic Acid Intake
Advise all women to take 400mg of folic acid daily before pregnancy and through
the first 12 weeks of pregnancy. Advise them about suitable supplements like the
Healthy Start vitamin supplement for women. Advise them to eat foods rich in folic
acid and folate.
NICE Public Health Guidance 11, Maternal & Child Nutrition24 states that Healthy
Start vitamin supplements should be offered to all children aged from 6 months to 4
years whose families receive Healthy Start benefit.
Ensure both types of Healthy Start vitamin supplement (for women and for children
aged from 6 months to 4 years) are available for distribution by health
professionals. Consider distributing the maternal Healthy Start vitamin supplement
6
D:\565324357.doc
to all women in receipt of Healthy Start benefit for children aged 1–4 years,
particularly those who may become pregnant. Women and children of South Asian,
African, Caribbean and Middle Eastern descent and those who remain covered
when outside, are at the greatest risk.
5.4
Reducing Saturated Fat Intake
High intakes of saturated fats linked to high rates of CHD. In communities with a
high incidence of CHD, the intake of saturated fatty acids typically ranges between
15-25% of the energy intake.
NICE Guidance: Lipid Modification25. People at high risk of or with CVD should be
advised to eat a diet in which total fat intake is 30% or less of total energy intake,
saturated fats are 10% or less of total energy intake, intake of dietary cholesterol is
less than 300 mg/day and, where possible, saturated fats are replaced by
monounsaturated and polyunsaturated fats.
People at high risk of or with CVD should be advised to eat at least five portions of
fruit & vegetables per day, in line with national guidance for the general population.
People at high risk of or with CVD should be advised to consume at least two
portions of fish per week, including a portion of oily fish.
Pregnant women should be advised to limit their oily fish to no more than two
portions per week.
People should not routinely be recommended to take omega-3 fatty acid
supplements for the primary prevention of CVD.
5.5
Caroline Walker Trust (CWT)
The CWT provides evidence based expert reports and training materials to
encourage eating well for children under the age of 5, school aged children, looked
after children, children and adults with learning disabilities, older adults and older
adults with dementia. The work of the CWT is particularly targeted towards
vulnerable groups and people who need special help and they produce nutritional
and practical guidelines for both young and old.
6.
COSTS AND COST EFFECTIVENESS
Estimating the Economic Impact of Healthy Eating
There is very limited data on diet and cost effectiveness. However, in one particular
initiative relating to the provision of breakfast clubs in London, they modelled the
economic impact associated with the change in attainment over time between
treatment and control schools at Key Stage 2. They estimated that the 0.45 point
difference in the change in attainment (average point score) at Key Stage 2
between treatment and control schools was equivalent to £1,330 in today’s money
terms over the lifecourse. This compares to an upper bound estimate of the total
annual cost associated with the provision of these services of £205,000. This
implies that the total ratio of benefits to costs stands at approximately 4.38. In
reality the ratio benefits to costs may be significantly higher. The London School of
7
D:\565324357.doc
Economics states “this is the first time that a model combining educational
attainment during the compulsory element of schooling and predicted lifetime
earnings has been combined in one model. Despite the caveats that are always
present with an exercise of this nature, we believe it is an extremely powerful tool
for policy makers to appraise and evaluate the relative economic benefits
associated with different policy initiatives”.
7.
FURTHER READING

At Least Five A Day
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/docume
nts/digitalasset/dh_4080981.pdf

FSA Salt Reduction Programme
http://collections.europarchive.org/tna/20100927130941/http://food.gov.uk/healthier
eating/salt/

The Eatwell Place
http://collections.europarchive.org/tna/20100927130941/http://food.gov.uk/healthier
eating/eatwellplate/

Saturated Fat Campaign
http://www.food.gov.uk/news/pressreleases/2009/feb/launchsatfatcampaign and
http://collections.europarchive.org/tna/20100927130941/http://food.gov.uk/healthier
eating/satfatenergy/

NICE Public Health Guidance 11: Maternal & Child Nutrition
http://guidance.nice.org.uk/PH11
8
D:\565324357.doc
REFERENCES
1
http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/Publichealth/Healthimprovement/FiveADay/Fi
veADaygeneralinformation/DH_4002343
2
http://www.ic.nhs.uk/webfiles/publications/HSE/HSE08/Volume_1_Physical_activity_and_fitness_revised.pdf
3 http://www.statistics.gov.uk/statbase/Product.asp?vlnk=15106
4
http://www.ic.nhs.uk/webfiles/publications/HSE/HSE08/Volume_1_Physical_activity_and_fitness_revised.pdf
5 School Food Trust/Local Authorities Catering Association, Annual Survey, July 2010
6 Department for Education, School Census, January 2010.
7
http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/Publichealth/Healthimprovement/FiveADay/Fi
veADaygeneralinformation/DH_4002343
8 Op Cit (2)
9 Op Cit (2)
10 http://www.5aday.nhs.uk/original/professionals/HealthBenefits.aspx
11 http://www.dietandcancerreport.org.uk/downloads/summary/english.pdf
12 www.food.gov.uk
13 Peterson S, Rayner M, Leal J, Luengo-Fernandez R, Gray A (2005) European Cardiovascualr Disease
Statistics. 2005 ed Oxford: British Heart Foundation, 2005
14 Pomerleau J, Lock K, McKee M (2005) The burden of cardiovascular disease and cancer attributable to
low fruit and vegetable intake in the European Union: differences between old and new Member States
Public Health Nutrition 9 (5): 575-583.
15 Department of Health (1994) Nutritional Aspects of Cardiovascular Disease. London: HMSO
16 He FJ, Nowson CA, Lucas M, MacGregor GA (2007) Increased consumption of fruit and vegetables is
related to reduced risk of coronary heart disease: meta-analysis of cohort studies Journal of Human
Hypertension 21: 717-728
17 Pomerleau J, Lock K, McKee M (2005) The burden of cardiovascular disease and cancer attributable to
low fruit and vegetable intake in the European Union: differences between old and new Member States
Public Health Nutrition 9 (5): 575-583
18 Department of Health (1998) Nutritional Aspects of the Development of Cancer. London: The Stationery
Office.
19 World Cancer Research Fund/American Institute for Cancer Research (2007) Food, Nutrition, Physical
Activity and the Prevention of Cancer: A Global Prospective. Washington DC: AICR
20 World Cancer Research Fund/American Institute for Cancer Research (2007) Food, Nutrition, Physical
Activity and the Prevention of Cancer: A Global Prospective. Washington DC: AICR
21 Dauchet L, Amouyel P, Dallongeville J (2009) Fruits, vegetables and coronary heart disease Nat Rev
Cardiol 6(9):599-608
22 Rolls BJ, Ello-Martin JA, Tohill BC (2004) What can intervention studies tell us about the relationship
between fruit and vegetable consumption and weight management? Nutr Rev 62(1):1-17
23 http://www.schoolfoodtrust.org.uk/research/advisory-panel-on-food-and-nutrition-in-early-years
24 NICE Public Health Guidance 11: Maternal & Child Nutrition (March 2008)
http://guidance.nice.org.uk/PH11
25
NICE Clinical Guidance 67: Lipid Modification (Re-issued March 2010)
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_40809
81.pdf
9