Tag Archives: Healthcare

The Whole Grain Truth

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Professor Chris Seal is a Professor of Food and Human Nutrition, and Kay Mann is a postgraduate student, within the Human Nutrition Research Centre at Newcastle University. They are calling for the next government to introduce clear guidelines on the amount of whole grain we should be consuming.

Whole grain truth

The evidence: Whole grains are good for us

Current literature suggests that those eating three or more servings of whole grain, compared with those that eat none or only small amounts, have a 20-30% reduction in their risk of developing cardio-vascular disease and type 2 diabetes. Higher whole grain intake has also been linked to lower body weight, BMI and cholesterol levels. Other research suggests that eating whole grains can make you feel fuller for longer and that you do not need to eat as much of a wholegrain food compared with a refined version to feel full.

The problem: The picture in the UK

Our new research on over 3000 UK adults and children who took part in the National Diet and Nutrition Survey (NDNS) between 2008 and 2012 shows that over 80% of us are not eating enough whole grains. Amazingly, almost one in five people don’t eat any whole grains at all!

One reason for this may be that in the UK there aren’t any specific recommendations on the amount of whole grain we should eat each day, other than the NHS Eatwell Plate advice to “choose wholegrain varieties whenever you can”. Countries such as the US, Canada, Australia and Denmark give much more specific daily recommendations. These range from a minimum of 3 servings (or 48g) per day in the US to between 60g and 90g per day for women and men in Denmark.

Three servings (around 48g) is equivalent to:

  • 3 slices of wholemeal bread
  • A bowl of porridge or wholegrain breakfast cereal and a slice of wholemeal toast
  • A portion of whole grain rice/pasta/quinoa or other whole grains

UK public advice about whole grains was first introduced back in 2007, when it was recommended to look out for ‘whole’ on food labels and to ‘choose brown varieties where possible’. We analysed whole grain intake from the NDNS back then and it seems little has changed in consumer habits since.

The amount of whole grain we eat in the UK is still very low – an average of around 20g a day for adults– compared with Denmark where the average daily intake is around 55g. In the UK, we tend to eat a lot of white bread, rice, pasta and cereals and lots of processed foods, all of which have no – or very little – whole grain in them and also tend to be higher in fat and sugar.

In Denmark, since the introduction of a whole grain campaign backed by the government and food producers, whole grain intake has risen by 72 per cent. We’d like to see a similar commitment here in the UK with a government-backed daily intake recommendation which can be used to develop successful public health campaigns.

So what are whole grains and what do they do?

Whole grains are defined as the ‘intact, ground, cracked or flaked kernel after the removal of the inedible parts such as the hull and husk’. This means that the three component parts of a grain – the outer bran, the germ and endosperm – remain in the final food product. Combined, these contain important nutrients such as fibre, vitamins and minerals and phytochemicals. When grains are refined to make white flour, many of these valuable nutrients are lost, and only a few are return with mandatory fortification.

Whole grains include; whole wheat (wholemeal), whole/rolled oats, brown rice, wholegrain rye, whole barley, whole corn/maize, whole millet and quinoa. The key is to look for the word ‘whole’ on an ingredients list and also for the ingredient to be high up on the list. These ingredients can be found in foods such as wholemeal bread, wholegrain breakfast cereals, porridge, wholegrain pasta and rice.

There are a small number of people that suffer from a gluten intolerance, which means that they have to avoid eating grains that contain high levels of gluten such as wheat, barley and rye. It is still possible for them to get their whole grains. Whole grain oats do not contain gluten but can sometimes be contaminated with wheat during harvesting and processing, others such as amaranth, buckwheat, brown rice and quinoa are also gluten free.

How whole grains have their effects is not clear. Certainly a key factor is better digestive health, but we also see lowered blood cholesterol, reduction in inflammation, lower body weight and lower weight gain in people who eat more whole grains.

The solution

We advocate:

  • the introduction of specific guidelines to promote whole grain intake in the UK
  • an emphasis on how easy it is to introduce more whole grains into diet – no major lifestyle change is needed
  • small tweaks to diet such as replacing white rice and pasta for brown, eating porridge or a wholegrain cereal for breakfast instead of a refined grain breakfast cereal, or swapping white bread for whole meal bread

Freeing public service to perform

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Dr Toby Lowe from the Centre for Knowledge, Innovation, Technology and Enterprise (Newcastle University Business School) presents his Idea for an Incoming Government: make public services more effective. He urges us to move away from a ‘Payment by Results’ approach, and suggests alternatives that would cope better with the messiness of the problems we face in our society.

What is the problem?

Governments have attempted to make public services more accountable for producing desirable social outcomes. From reducing reoffending to helping the long-term unemployed to find work  increasing numbers of programmes are commissioned using a ‘Payment by Results’ approach (PbR).

The rationale behind seems compelling – we should only pay for work undertaken that is effective in solving the problems that society has identified. Unfortunately, the evidence suggests that PbR creates a paradox – programmes commissioned on this basis produce worse results, particularly for those with the most complex needs.

There are two reasons why this is the case:

Firstly, real life is complex and messy. But PbR programmes need life to be simple and measurable. They require that desired ‘outcomes’ can be easily measured – because payments are triggered by these measures. Unfortunately, the complex social issues which social interventions most often deal with are frequently those that are most difficult to measure. Take, for example, tackling obesity. Body Mass Index (BMI) is the measure that is most frequently used to measure obesity.  It is used a measure of obesity because it is easy to measure: it is a simple measure of weight in proportion to height. Anyone with a BMI of more than 25 is overweight. Anyone with a BMI of more than 30 is obese.

Unfortunately, real obesity is much more complicated than that. BMI doesn’t effectively measure obesity for children, individuals with different body shapes, with different exercise regimes, and with certain medical conditions.  According to BMI measures, this woman, Anita Albrecht, who is a personal trainer, is very overweight, and is only one BMI point short of being clinically obese.

Anita Albrecht

So what happens if you use what is measurable as mechanisms to pay by results? You end up wasting time and money targeting obesity programmes on people like Anita – because that’s what simple targets, which are abstracted from the intrinsic messiness and complexity of life make people do.

The second reason that PbR makes it more difficult to create good outcomes is that they work on very simple cause and effect logic: if you are going to pay a person or organisation for producing a result, then you need to know that it was that person or that organisation which did it. How else do you know who to pay?

Unfortunately, the messiness of real life gets in the way once more. Real outcomes are emergent properties of complex systems. Look at the complex system which lies behind obesity as an issue:

Causes of obesity

This is the reality of what causes obesity. If you pay an organisation to undertake obesity activity, they can only influence a small part of this system.  Whether people actually end up obese or not is the result of the interaction of a hundred other factors.

If you pay people or organisations on the basis of whether they achieve particular results, you are asking them to be accountable for things they don’t control. As a result, they learn to manage what they can control – which is the production of data. This is the evidence about what people do:  They reclassify what counts as success (for example, counting trolleys as beds in hospitals in order to meet waiting time targets). They only work on clients who they know will provide the desired results, and they ignore the more difficult clients. They ‘teach to the test’ – only doing things which relate to what is measured, ignoring people’s needs that don’t fit into the simple measurement framework. And if all else fails, they simply make up data.

They do this because Payment by Results is nothing of the sort. Payment by Results should really be called ‘Payment for Data Production’. It changes the purpose of people’s job from helping those in need to producing the data which gets them paid.

All this is an enormous waste of resources. We end up paying huge fees to organisations who can play the data production game well, rather than those who are good at helping people. We waste resources paying organisations not to help those most in need.

The solution

The evidence is clear. If you want to achieve good outcomes, don’t pay by results. Evidence shows that these alternative approaches are successful:

1) Use systems thinking and invest in relationships. Design systems around people’s needs. Invest in organisations that build relationships with clients, and so who understand their needs authentically. Commission locally, so that the organisations have a connection with the people they serve.

2) Promote horizontal accountability. Make practitioners accountable to one another for the quality of their work. Create mechanisms for peer-based critical reflection, such as Learning Communities.

3) Create positive error cultures. Create cultures in which people talk honestly about uncertainty and mistakes – because this is how people learn and improve.

 

Restricting the Marketing of Alcohol Directed Towards Young People

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What impact does alcohol marketing have on young people? Our newest Idea for an Incoming Government is from Professor Eileen Kaner and Dr Stephanie Scott (Institute of Health and Society), who call for restrictions to be put in place, protecting our national health, and improving young lives.

Alcoholic beverages in bottles

What is the problem?

Alcohol use is the leading risk to health and well-being in young people, accounting for seven percent of disability adjusted life years in 10-24 year olds globally, with UK adolescents amongst the heaviest drinkers in Europe. Frequent, often high-intensity drinking in early to mid-adolescence has been linked to a myriad of adverse effects. Short-term implications, which pose the greater immediate risk, include accidents; early and unprotected sex; exacerbation of mental health problems; and poor school attendance and reduced educational attainment. Acute problems may have life-time consequences, such as early disfigurement or unintended pregnancies. Moreover, the longer and heavier an individual drinks, the greater the risk of developing chronic health problems such as liver disease or cancers later in life.

As a caring society, we should do more to limit youth exposure to alcohol marketing. But how can we be sure that there is a connection between this and alcohol misuse?

A growing body of literature, including two recent systematic reviews (Anderson et al, 2009; Smith and Foxcroft, 2009), demonstrates an association between exposure to alcohol marketing and initiation or progression of alcohol use, as well as development of pro-drinking attitudes and social norms (Gordon et al, 2010; Lin et al, 2013). UK research suggests that alcohol brand recognition is common amongst young people as young as 10-11 years old (Alcohol Concern, 2012) with US studies demonstrating identification with desirable images in alcohol advertising in 8-9 year olds and brand-specific consumption in 13-20 year olds (Austin et al, 2006; Siegel et al, 2013).

Despite the heavy attention paid to price and traditional advertising, alcohol marketing is much more extensive and comprises price, product (image/branding), promotion (including advertising) and placement (point of sale and outlet density or distribution), defined as the ‘4 Ps’ or ‘marketing mix’. This means that availability as well as how a product looks or tastes can be of as much importance as how much it costs. The extensive nature of alcohol advertising, including through new media (e.g. sponsorship of social networking sites) means that young people are regularly exposed to alcohol promotion including many who are below the legal age to purchase alcohol.

A recent qualitative study in North East England among 14-17 year olds found that marketing seemed to play a key role in building recognisable imagery linked to alcohol products, as well as associations and expectancies related to drinking (e.g. having fun, drinking games, brand slogans or logos, drinks associated with certain TV shows, such as cocktails).

The solution

  • Restrict alcohol advertising in newspapers and other adult press, with content limited to factual information about brand, product strength and provenance, mirroring The Loi Evin model in France.
  • Establish an independent body to regulate alcohol promotion in the interests of public health/safety.
  • Review the use of new media to market alcohol with a view to limiting the exposure of ‘under age’ young people who frequently access key sites (e.g. Twitter, Facebook etc.).

The evidence

In terms of price restrictions only, recent research conducted in Canada over the course of eight years (where a minimum unit price has been implemented) suggests that a 10% increase in the price of most drinks led to a 32% fall in alcohol-related deaths (Stockwell et al, 2013). This international evidence is supported by UK modelling work which demonstrates the effects that setting a minimum unit price of 40p would result in (see below).

Alcohol graphic

It is increasingly accepted that a fully joined-up public health response to tackle alcohol problems needs to include policy-focused interventions as well as individual-level input from health and social care practitioners (NICE, 2010). Individual and policy-level interventions are needed which can limit youth exposure to alcohol marketing whilst not curtailing producers’ legitimate right to market their products to adults.

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Joining the dots: making healthcare work better for the local economy

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On Thursday 26th February Professors Rose Gilroy and Mark Tewdwr-Jones (Newcastle School of Architecture, Planning and Landscape) launched a collection of papers that they co-edited in association with the Smith Institute and the Regional Studies Association. Below is the latest in our Ideas for an Incoming Government series from Professor Gilroy, taking a look at the connection between health and the economy, and suggesting a way forward for public health delivery.

Jigsaw puzzle, success in business concept

Who should take responsibility for improving the health of the nation? Is it the role of the NHS, or are we simply shifting responsibility by asking our health system to pick up the pieces (and the cost) caused by policy failures elsewhere? What is the real cost of poor health?

The Marmot Review of 2010 estimated that health inequalities cost the taxpayer over £30 billion a year in terms of lost productivity and associated welfare and health costs. Can we really afford to ignore this? A new joint report from Newcastle University academics, the Smith Institute and Regional Studies Association aims to address the issue of health inequality. Launched at Portcullis House, Westminster last Thursday, 26th February in front of an audience of local government officials, researchers, representatives of the TUC, RTPI, NHS, The Design Council and lobby groups, the report – Joining the Dots: Making healthcare work better for the local economy – discusses the far-reaching consequences of poor health and the responsibility of employers, local planners, and new governance structures in taking a pro-health position that will help to tackle health inequalities.

From considering the social and economic determinants of health; the limitations placed on people’s lives from shrinking local investment in the supply and quality of public services; the need to consider the whole city as an arena for older people’s wellbeing and the struggle to overcome institutional and cultural barriers to make new legislation work, this collection of research challenges all sectors of British society to put health at the heart of its thinking.

The debate was chaired by Andy Love, Labour MP for Edmonton, with the report launched by myself and my School of Architecture, Planning and Landscape colleague Professor Mark Tewdwr-Jones, as co-editors of the report. David Buck, Senior Fellow in Public Health and Inequalities at the Kings Fund joined us to talk about the links between poor health, poverty and worklessness, while Professor Sarah Curtis of Durham University presented compelling evidence linking employment status to health outcomes. Professor Curtis emphasised the long shadow that regional unemployment casts across the course of people’s lives. Elsewhere, Deputy Lords leader Lord Philip Hunt considered the role of the NHS as an employer and reflected on the recent news that Greater Manchester will have devolved power over its local NHS spending, with huge potential implications for local accountability and a new, more holistic understanding of people’s health and social needs.

However, as several contributors argued, it is the ability of individuals and organisations to overcome the often complex local governance map and develop a joint vision and shared objectives that will lead to success in addressing the UK’s deep health inequalities.

The conclusion of this report is clear: too often we intervene too late and forget that health starts where we live, learn, work and play. The key to good health is to build preventative services in communities, helping us to take care of our families, our schools, our workplaces and our playground and parks. When considering national and local spending priorities, we must understand the need to make pro-health choices to tackle the scandal of health inequality in modern Britain.

View the full report via The Smith Institute. (PDF)

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