Thinking Upstream?

I’ve had several reminders this month of the importance of the upstream focus health promotion. We have been working in prisons, considering the usefulness of peer approaches to improve health and other outcomes. Two prisoners’ stories have stayed with me. One was a teacher, clearly in prison for a long time and so had presumably committed a serious crime. At that time, he was suffering from a serious mental illness that had not been diagnosed. He stated, quite simply, that if he had received the health care he needed, he would not be in prison. The other was a young woman who was relishing the educational opportunities she now had in prison; she was loving learning. She clearly had not had these as a youngster in school, which had been a part of her problem – that familiar drift into unemployment, boredom, and the taking up of a drug-filled lifestyle. Both, in my view, had been let down by the services they should have received upstream, and both were now paying for that.

Another example is how, in the mid-1990s, a group of us was doing work in primary schools in Leeds trying to tackle the impending ‘obesity crisis’ by developing healthier eating and exercise for all children. What we noted was the large number of children who were not only already overweight, but who were obese. The purpose of the project, ‘Apples’ was not to tackle obesity management, but due to our observations, we had no choice but to attempt to provide a service for those families already struggling, so ‘Watch it!’ was set up, initiated by Prof. Mary Rudolf. It did a lot of good for many years as an independent organization, but after being taken over by the Primary Care Trust, it folded. Although we published our findings widely and had the ear of policy makers, the warnings of the obesity problem were not heeded. Now, 15 years later obesity has truly become a ‘crisis’.

In the last week, the Academy of Medical Royal Colleges has made a statement to the effect that the obesity crisis in the UK is becoming ’unresolvable’. They called on the government to take urgent action as ‘generation after generation [is] falling victim to obesity-related illnesses and death’. Moreover they say that the government’s anti-obesity efforts, along with those of previous governments, are ‘disappointingly ineffective’. One in four adults in the UK are now obese and in certain ‘hotspots’, it is as much as 30%. Tamworth in Staffordshire and Gateshead in the Northeast for example, according to the National Obesity Observatory are such towns.  The Academy, comprising 220,000 doctors, sets out an ambitious plan, which not surprisingly focuses on such activities such as NHS staff taking opportunities to talk to patients, an expansion of bariatric surgery, and for the NHS to spend £300m over the next three years to remedy the shortage of weight management programmes. It does also call on the government to tax sugary drinks and to restrict fast food outlets located near schools and leisure centres, but it’s not surprising that doctors think of solutions that they can see from where they stand, in medical settings – which is relatively downstream on the proverbial riverbank.

We know that once doctors are involved, a problem has reached crisis status. On the whole, doctors rescue people once they are struggling in the river. The status of doctors might mean that now government will listen – but what a major disaster it is that government did not listen to the warnings given more than a decade ago by health promotion specialists. We know that individuals behave like this too – people often do not take action on their health until they face a scare, by which time damage has occurred. For governments to behave like this though, is negligent.

The latest outburst about the scale of the obesity epidemic comes at a time of other major concerns about the food we eat. The ‘horsemeat scandal’ shows an extraordinarily widespread fraud, exposing how the free market contaminates food. It does appear that the food industry has been hoodwinked itself, but that same food industry has also deliberately set about not being clear about the calories in the food it sells.  Given that calories are given per 100gms, and that people might not have a clue about what 100gms looks like, food labels contain a ‘portion size’. However, that portion size is chosen by the manufacturer and might not bear any relation to what people might eat. As an example, Kellogg’s new breakfast cereal. ‘Krave’ contains 440 calories per 100gm but the portion size is given as 30gm (four tablespoons). People might think therefore that they are eating about 130 calories – yet will their portion really be only four tablespoons? For more on this kind of trickery, read James Erlichman’s latest book.

Meanwhile, a meeting of the American Association for the Advancement of Science this week has declared that the way we count calories is mistaken, and has been for decades. This has led Prof. Richard Wrangham of Harvard University to declare that the public receives ‘erroneous information about the energy value of many foods’. Basically, the system used for so long (the Atwater system) overestimates the content of some protein-rich foods by up to 20% and underestimates the calories of other foods, especially high fibre foods, (such as muesli) by up to 25%. It seems that labeling does not take into account the calories in fibre.  So the science is not easy, which plays into the hands of the food industry.

Also this week, the government appears to have woken up to some of the effects of its austerity measures, including the dramatic rise in the UK of food banks. The media talks of an explosion in food banks, soup kitchens and school breakfast clubs. Again, in the 1990s, some of us working in school health promotion wrote of the need for breakfast clubs and were involved in setting them up. They are clearly needed more than ever now. The recent investigation into food banks comes from research commissioned by a government department,  (Dept. for Environment, Food and rural Affairs). Those using such food aid are likely to be a tip of an iceberg; the Trussell Trust, a provider of 309 foodbanks reckons that more people use them because they face financial crisis caused by benefit stoppages or delays. Given this food insecurity and more people facing lower incomes and therefore seeking out cheap food, it is not surprising that they fill up on calories, that obesity is worse in deprived areas – and that people want cheap food that tantalizes the criminal elements to provide it in the form of horsemeat. Once again, this government has failed to have any sense of upstream thinking and seems oblivious to the effects of its policies on health and wellbeing.

On a more optimistic note, I was also reminded of the value of health promotion and of early warnings by one of our student groups (on the MSc Public Health – Health Promotion) which has had work from a course assignment adopted by Leeds Community Health Care NHS Trust. The Communicating Health module involves students producing a piece of health information, and this group designed a card to be used in ante-natal booklets held by parents-to-be, on the dangers of cords around the house – the sort of cords found commonly on blinds and curtains. The group (Sharon Underwood, Emma Moore, Emmanual Darko, Janet Berry and Lisa Buchanan) produced a very eye catching but simple postcard sized warning, ‘don’t be blind to dangers’. It’s great to see how the course impacts on practice in this way, and the group, all experienced health workers, have shown how by coming together, they have achieved the creativity needed not only to pass the module, but also to make a difference on the ground.

22 deaths have been caused by cords in the UK since 1999, and tragically, one that hit the headlines last November was that of the three-year-old daughter of wealthy tycoon in London. The Royal Society for the Prevention of Accidents has campaigned for manufacturers to stop making looped cords. Sadly again, it often takes an accident to make people perceive hazards– hence ‘don’t be blind to dangers’ could be a useful, upstream, preventive tool.

Erlichman, J. (2013) Addicted to Food: Understanding the Obesity Epidemic.

Sahota, P. Rudolf, M.C.J. Dixey, R. Hill, A.J. Barth, J.H. Bartrop, J. Chaudary, N. APPLES: A School-based intervention to reduce obesity risk factors:- results of focus groups with children. International Journal of Obesity and Related Metabolic Disorders 1998, 22 Supplement 4, p102.

Sahota, P., Rudolf, M.C.J., Dixey, R., Hill, A.J. Barth, J.H.
APPLES: A School-based intervention to reduce obesity risk factors.
International Journal of Obesity and Related Metabolic Disorders  1998, 22 Supplement 3, p.230.

Sahota, P., Rudolf, MCJ.,  Dixey, R.,  Hill,A.,. Barth, J.,  Cade J., 2001  Evaluation of implementation and effect of a primary school-based obesity prevention programme to reduce risk factors for obesity. BMJ 3 November 1027-1029

Sahota, P.,  Rudolf, M.,  Dixey, R.,  Hill,A.,. Barth, J.,  Cade J.,. 2001 Randomised controlled trial of primary school-based intervention to reduce risk factors for obesity BMJ 3 November 1029-1032