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    Watching and reading the arguments Tory MPs put forward for voting against an extension of free school meals over the school holidays, there seems to be a common thread. Nearly all of them use the argument of dependency, that is relying on the state to provide for us rather than supporting ourselves through personal responsibility.

    These arguments are not new, “Booth and Rowntree found the greatest cause of poverty was not, as often believed, feckless shirking by the irresponsible lower classes, but low pay for full-time work, or inability to get regular work despite best efforts”. In other words dependency is invalid as an argument for poverty. The causes of poverty are well known. This research was conducted before 1914.

    What the Tories call dependency, Labour calls decency. Whatever defence the Conservative MPs type, say, shout or even belief is at odds with fundamental human rights. The right to water and food is part of our existence. The Tories commodify them through privatisation, e.g. the English water companies. Now, they are re-defining them – again – as dependency.

    The language of dependency is interesting yet alarming. From 1997 onwards, society was not focussed on this language, but on how to design policy around alleviating poverty. These alleviation measures while not focussing on the eradicating poverty, sadly, but they helped reduce child and pensioner poverty.

    Without the state focussing on alleviation and the eradication of poverty, we will go backwards in time rather forwards. I know, as I grew-up in poverty in the 1980s and received free school meals. I am very proud that Lewisham through the leadership of Damien Egan and Cllr Chris Barnham acted quickly in Lewisham to extend the free school meals entitlement over half-term.

    Finally, I suspect the dependency argument will continue to be spoken by Tory minsters and MPs. If they can use that past descriptor for free school meals then it won’t be long before it is extended to universal, free at the point of need, NHS healthcare. I have no doubt that a significant number of Tory MPs want us to follow the US system of healthcare. Such a system is the number one cause for bankruptcy among the American population.

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    The crises in health and social care are rightly at the forefront of people’s anger about the government’s lack of preparation for an inevitable pandemic, as we now face with Covid-19. People are dying unnecessarily. An integral element, simmering under the surface, is the fragmentation of public health nutrition services that should provide food security within our communities so vulnerable people are kept in good nutritional status. Yet even before this crisis there was an estimated 3 million malnourished people, with an aging population this will increase, and 8 million people in food insecurity. As lockdowns began, research from the Food Foundation estimated 3 million households were already experiencing hunger. Inequalities underpin the right to life in this crisis: mortality rates for people living in deprived areas are double that for those in less deprived areas, and interlocks with ethnicity. Some highlight ‘obesity’ but is not the problem food and health inequalities? Poverty underpins people’s lack of access to foods of good nutritional quality. Rising poverty levels are driven by erosion of welfare state and neoliberal restructuring of our economy through deregulation, precarity and low pay. Child poverty has increased by 100, 000 over the past year with around 30% of all children living in poverty. Food poverty is increasing and requires structural change not short term solutions. To protect child health and meaningfully tackle poverty a host of fiscal steps are urgently required to enable families to buy food, such as basic living income and immediate action to increase welfare. This does not remove the need for a food security system that ensures a basic level of socially acceptable nutrition is available for all; that includes universal free school meals and hot meals for older people. Public health nutrition is more than just food. It’s about ‘social’ nutrition: the infrastructure of community resources that enable people to eat together and to collectively care.

    The networks of care within our communities have broken down as the infrastructure providing services and civil spaces have closed. There is little research that documents how the spending cuts and restructuring within public health has impacted public health nutrition. However, research is underway that aims to inform the inevitable public enquiry on Covid-19. As socialists, we need to go further and give a call to action to stop further privatisation and charitisation of PHN. Fundamentally, the interests of private industry and charity conflict with the welfare state. Despite the altruism of many involved, these organisations cannot meet current or future needs which will increase in the looming economic depression. They cannot enable the voices of those who are suffering in our communities.

    Privatisation of PHN began under New Labour as food companies were brought into public health policy. From the 2000s non-NHS providers entered PHN. Local government spending cuts and austerity hit prevention budgets including nutrition-based, child weight management and life style interventions. Cuts to nutrition-related services are broadly felt because nutritional health is cross-departmental involving education, community engagement, adult and children and young people’s services and a range of professions including health visiting. Nutrition was embedded in the Sure Start programme. Since 2010, 1000 children centres have closed as £1 billion has been cut from budgets. The number of community centres, lunch clubs and meals on wheels for the elderly has been decimated. In this crisis, the role of schools in feeding children has shown their centrality in community life. Yet there are barriers due to privatisation that limit a strategic approach. For example, in most neighbourhoods, schools have the only industrial kitchens capable of preparing and distributing foods to large numbers of people. Yet access to these is mostly controlled by private food companies, including multinationals, that hold the catering contracts. So, in many ways communities are isolated, disconnected from power and the resources to enable local solutions. Social theorists argue that ‘austerity localism’ brought cuts, disempowered local communities creating distrust and disconnect with local government. Community involvement is further limited by democratic deficits that are created by material constraints and lack of structural mechanisms. All this suggests that it will be harder for public health to connect with communities and understand the scale of their need. While not supporting the authoritarian Chinese State, community engagement was integral to the Chinese response.

    Responsibility for public health nutrition lies with local government who have enlisted third sector organisations (TSOs), social entrepreneurs, and food industry to construct the state’s food aid response in this emergency. From a dietetic standpoint, it is concerning that food banks can distribute foods that may unintentionally cause harm. For example, food banks only need warn of potential allergens, if they are set up as a business.  Food banks can distribute infant formula. This is risky  for example, for vulnerable families with complex needs and should not be the responsibility of food banks. It suggests a lack of a cross-departmental strategic approach that links with professionals such as nutritionists and health visiting teams.  Providing food at the general level of need is also problematic. The voluntary sector has strategic limitations in its ability to scale up according to need. In London, developing a strategic approach has been spearheaded by NGOs at City level, and boroughs through food action alliances. The food alliances are networks of non-state and non-industry providers, involving a range of activities such as food banks, food growers, community kitchens – supermarkets- fridges. They connect with local government through their public health departments. As crisis hit, they quickly turned their energies to organising emergency food aid. Phenomenal efforts are being made to scale up to meet increased demands. However, they face barriers. For example, many TSOs are involved in competitive processes to win and maintain local government contracts. Funding is often short term; a precarious situation for TSOs. In this crisis they need to collect evidence for ‘sustainability’, that is, to secure future funding.

    Despite the existence of resilience structures at regional and borough levels, strategies to meet increased food needs were not apparent. Indeed, there was little national food strategy (Lang, 2020). In London, as the crisis unfolded new charitable funding streams emerged. Four weeks into the crisis, the owner of London’s free newspaper, Evening Standard, and son of Russian oligarch intervened to feed ‘vulnerable’ Londoners through a new charitable alliance. This centralises food surplus supplies and distribution across boroughs. This role of charities is legitimised by London’s Mayor, albeit likely unintentionally. This upscaling of charities to deliver such large-scale logistical challenges raises concerns about the future direction for PHN.

    Altruism continues with the emergence of new food banks, food project social entrepreneurs and the Mutual Aids. With roots in 19th Century social welfare based on fraternalism not paternalism, these are today on the one hand wonderful, inspiring acts of solidarity but what will they become? There are many questions to consider: Do they adopt a public health perspective that considers inequalities including class and ethnicity or are these individual acts of charity and kindness? What is the class composition of the Mutual Aids? Will there be unintended consequences? Within communities, will they bridge or increase class divides and inequalities? Do they provide uniform and equitable support?  Do they contribute to food democracy within our communities? How are they accountable?

    These and other new solidarity networks enter into the terrain of unevenly shared and disjointed public health resources. Across London, a postcode lottery in public health nutrition pre-dates this Covid crisis. For example, eligibility for free school meals depends on the political priorities of local councils as well as government policy. Universal free school meals (UFSM) for all primary age children are provided in only 4 of the 33 boroughs. This includes children in families with no recourse to public funds (NRPF). Their temporary access to FSM during this crisis will be withdrawn as schools reopen. A cruel, intentional political act belonging to the ideology of hostile environment; socially divisive among young children teaching them that ‘others’ are undeserving and go hungry. What will Labour councils do when the onus for feeding children with NRPF returns to them?

    The differences between and within boroughs is seen at the level of schools. Schools take different approaches with some providing food for all children in-need and others based on FSM eligibility. Seven weeks since its introduction, the government’s voucher scheme that replaced FSM continues to be problematic, adding to the suffering of families; some schools are bypassing with their own voucher systems. Schools are filling the gaps but cannot do so as a cross-borough strategic approach due to privatisation. In contrast to London, New York took a pan-city approach with 400 public schools providing food for all adults and children in-need.

    Despite incredible efforts, TSOs, have made it clear they cannot fulfil the function to feed ALL in need:    ‘There is not enough free food or volunteer capacity to feed all economically vulnerable people through local authority and charitable means’. Instead they argue that central government should provide the financial means to enable everyone to buy food that meets their nutritional and cultural needs. From an ethical view it is irresponsible that central government assigns responsibility to local authorities and TSOs without giving the resources to carry out responsibility. It is well established that emergency food aid systems need to be nationally co-ordinated strategies. The UK government’s use of the armed forces for food distribution to the 1.5 million shielded clinically extremely vulnerable people, is recognition of the level of strategic organisation that is needed. It shows that only central government has the resources and therefore responsibility to feed ALL people in-need, across all vulnerabilities. It is not possible for this to be a function of TSOs. How do TSOs and local government decide ‘vulnerability’ without interlocking socially divisive ideas of ‘deserving’ and ‘undeserving’ poor? These are political decisions. Solving hunger takes political will (Caraher and Furey, 2018).


    The politics of privatisation and charitisation are felt most strongly on the frontline by the community food activists some engaged for decades in fighting to hold their communities together. One such leading activist and mother, Maya in South London, said

    I’m tired of fighting, fighting, fighting”. Yet she remains on the frontline running the local food bank/social supermarket. She says: diets will slump in areas like this … people use social supermarket but can’t get the foods children want … fresh fruits and vegetables have short shelf life ..we have to respond to new issues that come along …the hidden people that now come out who are in extreme poverty. While caring for her community she comments on new oppression by powerful borough groups and lack of accountability: people are going crazy with this food thing … there’s a lot of money around food …all they want to do is help the ‘poor’ people … they’re doing deliveries, taking selfies and putting it on twitter …  some people are stepping on our heads… others are cashing in on it.” On a part-time London living wage, she finds her own living standards are slipping backwards.

    What will emerge from this crisis? Local authorities will soon be planning their recovery processes. With depleted and finite funds will we see a redefining of ‘vulnerable’; a new means testing for referrals to emergency food aid? We are facing a long recession/depression with increased food poverty, malnutrition and hunger. This is potentially on an unprecedented scale. How will the increased charitisation together with ongoing cuts impact the public health infrastructure and jobs? Who will be providing food for public health? These are important questions for all of us in PHN whether Director of Public Health or unpaid community food bank worker. How we tackle feeding EVERYONE in-need is not just a practical question but a basic ethical one concerning food rights and health equity that requires reconnecting with our communities and schools for grassroots participation in decision-making. Enabling participation requires tackling the material conditions, of work and physical food environments, that underpin health inequalities.

    A weak public health nutrition infrastructure, including diminished community services, contributes to undernutrition, reduced immunity, more illness, more hospital visits. Pre-Covid estimates showed  £200 million could be saved in health and social care spend if greater attention is paid to caring for the nutritional status of vulnerable adults. This would contribute to the inequality seen in the distribution of Covid-19 death rates. Our right to nutritious food is essential to enable our rights to good health and longevity free from illness. To make this a reality, for all, will require fiscal measures that guarantee universal basic living income, that integrates food costs, as well as massive investment in communities and public health nutrition. One among many lessons for how we plan for food and health resilience in times of crisis, is to meaningfully, democratically involve our communities and workforces on the ground.

    Sharon Noonan-Gunning, Registered Dietitian, PhD in Food Policy.

    Caraher M., Furey, S. (2018) The Economics of Emergency Food Aid Provision: A Financial, Social and Cultural Perspective. Palgrave Macmillan. London.

    Lang, T (2020) Feeding Britain: Our Food Problems and How to Fix Them. Pelican Books.

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    The current crisis has brought to our attention the state of the food industry, from agriculture to supermarket. Tim Lang, Professor of Food Policy at London City University, published Feeding Britain last week[1]. He says that although Britain is not actually at war, we are nevertheless, in practice, facing a food challenge on a wartime scale.

    When there was no panic-buying, as we have at the moment, supermarket shelves were usually full. But that hid a highly fragile just-in-time supply chain, with British agriculture only producing about half of what we consume[2]. On top of that, methods of production are not only damaging the environment but human health as well. There is a massive gap in access to food between rich and poor, reflecting differences in wealth and income. Michael Gove, when Secretary of State for Environment, Food and Rural Affairs (DEFRA), said he was going to introduce a national food strategy, but the January 2020 Agriculture Bill contained hardly any mention of food.

    In the current coronavirus epidemic, the irresponsible scare-mongering of the media has clearly played a major part in emptying the shelves in supermarkets, and in addition to food shortages there has evidently been panic-buying of surface cleaners, soap and toilet rolls. There has been an upsurge in community support for the elderly, sick and disabled unable to leave their homes; but at the same time we must consider the threat of rising social tensions over shortages and availability of food and other necessities. Those with the most precarious incomes, dependent on benefits and zero-hours contracts, or with no entitlement to unemployment or sick pay, will be the worst affected. It will be other consumers who are blamed, rather than the Government which has been so slow to respond and done so much less that it could and should have done. During World War II shortages led not only to rationing but also looting and crime, despite the “Spirit of the Blitz”.

    Even without coronavirus (or brexit), the underlying problem is the small number of big firms that dominate the food retail sector: Lang points out that eight firms control 90% of food supply, of which Tesco has about 30% of the retail market. Price has been the dominant form of competition, so that farmers get only 5-6% of the value of the food we buy. A tiny 2.8% of cultivable land in Britain is used for fruit and vegetables. We import food we could grow, and most of what we do grow feeds animals or is used to make processed foods. It is a habit that dates from Britain’s past dependence on an Empire.

    Of particular interest to the NHS and to the SHA is Lang’s point that “food is the biggest driver of NHS spending as a result of obesity, diabetes and heart disease”. Even food which appears cheap has often created enormous and unsustainable costs elsewhere. A long-term solution is necessary, and not just a response to the current crisis.

    Tim Lang proposes that we need a “Food Resilience and Sustainability Act with legally-binding targets”; food procurement contracts based on “national nutritional guidelines”; an “audit of food production” in the UK; and a doubling of the budget for public health “from £2.5bn to 5bn” out of “the £130bn health budget”. He says that the coronavirus is reminding us “of the value of state institutions”. “We need to think about where our food comes from and move from a ‘me’ food culture to a ’we’ food culture”.

    Vivien Walsh


    [1] Tim Lang, Feeding Britain, Penguin books, 2020.

    [2] Jay Rayner, “Diet, Health, Inequality: why Britain’s food supply system doesn’t work” interview with Tim Lang, The Guardian, 22.03.2020.



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    Posted: 16 Aug 2018 11:27 PM PDT

    In 1976, we ate more than we do today. So why are we fatter?

    By George Monbiot, published in the Guardian 15thAugust 2018

    When I saw the photo, I could scarcely believe it was the same country. The picture of Brighton Beach in 1976  featured in the Guardian a few weeks ago appeared to show an alien race. Almost everyone was slim. I mentioned it on social media, then went on holiday.

    When I returned, I found that people were still debating it. The heated discussion prompted me to read more. How have we changed so far, so fast? To my astonishment, almost every explanation proposed in the thread turned out to be untrue.

    Unfortunately, there are no consistent obesity data in the United Kingdom before 1988, at which point the incidence was already rising sharply. But in the US, the figures go back further. They show that, by chance, the inflection point was more or less 1976. Suddenly, at around the time when the photograph was taken, people started becoming fatter, and the trend has continued ever since.

    The obvious explanation, many of those debating the photo insisted, is that we’re eating more. Several pointed out, not without justice, that food was generally disgusting in the 1970s. It was also more expensive. There were fewer fast food outlets and the shops shut earlier, ensuring that if you missed your tea, you went hungry. So here’s the first big surprise: we ate more in 1976.

    According to government figures, we currently consume an average of 2131 kcals per day, a figure that appears to include sweets and alcohol. But in 1976, we consumed 2280 kcal, excluding alcohol and sweets, or 2590 when they’re included. Can this really be true? I have found no reason to discredit the figures.

    Others insisted that the cause is a decline in manual labour. Again, this seems to make sense, but again the data don’t support it. A paper in the International Journal of Surgery  states that “adults working in unskilled manual professions are over 4 times more likely to be classified as morbidly obese compared with those in professional employment”.

    So how about voluntary exercise? Plenty of people argued that, as we drive rather than walk or cycle, are stuck to our screens and order our groceries online, we exercise far less than we did. It seems to make sense – so here comes the next surprise. According to a long-term study at Plymouth University, children’s physical activity is the same as it was 50 years ago. A paper in the International Journal of Epidemiologyfinds that, corrected for body size, there is no difference between the amount of calories burnt by people in rich countries and in poor ones, where subsistence agriculture remains the norm. It proposes that there is no relationship between physical activity and weight gain. Many other  studies suggest that exercise, while crucial to other aspects of good health, is far less important than diet in regulating our weight. Some suggest it plays no role at all, as the more we exercise, the hungrier we become.

    Other people pointed to more obscure factors: adenovirus-36 infection, antibiotic use in childhood and endocrine-disrupting chemicals. While there is evidence suggesting they might all play a role, and while they could explain some of the variation in the weight gained by different people on similar diets, none appear powerful enough to explain the general trend.

    So what has happened? The light begins to dawn when you look at the nutrition figures in more detail. Yes, we ate more in 1976, but differently. Today, we buy half as much fresh milk per person, but five times more yoghurt, three times more ice cream and – wait for it – 39 times as many dairy desserts. We buy half as many eggs as in 1976, but a third more breakfast cereals and twice the cereal snacks; half the total potatoes, but three times the crisps. While our direct purchases of sugar have sharply declined, the sugar we consume in drinks and confectionery is likely to have rocketed (there are purchase numbers only from 1992, at which point they were rising rapidly. Perhaps, as we consumed just 9kcal per day in the form of drinks in 1976, no one thought the numbers were worth collecting). In other words, the opportunities to load our food with sugar have boomed. As some experts have long proposed, this seems to be the issue.

    The shift has not happened by accident. As Jacques Peretti argued in his film The Men Who Made Us Fat, we have been deliberately and systematically outgunned. Food companies have invested heavily in designing products that use sugar to bypass our appetite control mechanisms, and packaging and promoting them to break down what remains of our defences, including through the use of subliminal scents. They employ an army of food scientists and psychologists to trick us into eating more junk (and therefore less wholesome food) than we need, while their advertisers  use the latest findings in neuroscience to overcome our resistance.

    They hire biddable scientists and thinktanks to confuse us about the causes of obesity. Above all, just as the tobacco companies did with smoking, they promote the idea that weight is a question of “personal responsibility”. After spending billions on overriding our willpower, they blame us for failing to exercise it.

    To judge by the debate the photo triggered, it works. “There are no excuses. Take responsibility for your own lives, people!”. “No one force feeds you junk food, it’s personal choice. We’re not lemmings.” “Sometimes I think having free healthcare is a mistake. It’s everyone’s right to be lazy and fat because there is a sense of entitlement about getting fixed.” The thrill of disapproval chimes disastrously with industry propaganda. We delight in blaming the victims.

    More alarmingly, according to a paper in the Lancet, over 90% of policymakers believe that “personal motivation” is “a strong or very strong influence on the rise of obesity.” Such people propose no mechanism by which the 61% of English people who are overweight or obese have lost their willpower. But this improbable explanation seems immune to evidence.

    Perhaps this is because obesophobia is often a fatly-disguised form of snobbery. In most rich nations, obesity rates are much higher at the bottom of the socio-economic scale. They correlate strongly with inequality, which helps to explain why the UK’s incidence is greater than in most European and OECD nations. The scientific literature shows how the lower spending power, stress, anxiety and depression associated with low social status makes people more vulnerable to bad diets.

    Just as jobless people are blamed for structural unemployment and indebted people are blamed for impossible housing costs, fat people are blamed for a societal problem. Yes, willpower needs to be exercised – by governments. Yes, we need personal responsibility – on the part of policymakers. Yes, control needs to be exerted – over those who have discovered our weaknesses and ruthlessly exploit them.
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    It is a pleasure to be speaking with you about something that I know all of us in the room are passionate about changing in this country – health inequality.

    It comes as no surprise that the Office for National Statistics found earlier this month that the least deprived men at birth in 2014 to 2016 could expect to live almost a decade longer than the most deprived. This decade has seen a slowdown in improvements in life expectancy, an appalling consequence of this Government’s failure to improve the chances of the worst-off, as years of underfunding in health and social care take their toll.

    Similarly, the north south divide remains as relevant as ever. For both males and females, the healthy life expectancy at birth is the highest in the South East, at 65.9 years for men and 66.6 for women. I am sure you can guess which region is the lowest!

    Here in the North East healthy life expectancy for men is 59.7 years and for women it is 59.8 years – significantly lower than the England average. That means that inequality gap in healthy life expectancy at birth for the South East and North East is 6.2 years for men and 6.8 years for women.

    There are lots of factors that play into these figures, and life expectancy here is increasing faster than anywhere else in the country, but it is simply not good enough that those from deprived areas are having their life expectancy shortened. That is why we all need to make a pledge to change this.

    Today I’m going to speak about three public health epidemics that affect, not just the North East but the whole country: smoking, obesity and malnutrition. If we are able to tackle these epidemics, then we will be a step closer to achieving the goal of the UK having some of the healthiest people in the world.


    Smoking continues to be the leading cause of preventable deaths – in 2015, 16% of all deaths in people aged 35 or over in England were estimated as being attributable to smoking. It is estimated that 474,000 hospital admissions a year in England are directly attributable to smoking, which represents 4% of all hospital admissions. Smoking causes around 80% of deaths from lung cancer, around 80% of deaths from bronchitis and emphysema, and about 14% of deaths from heart disease. Therefore, smoking and its related health problems leave a heavy burden on our already financially strapped NHS, costing more than £2.5 billion each year.  Addressing smoking in our society could therefore help reduce that high financial cost and money could be directed towards improving our NHS and ensuring that we have a healthy society.

    Smoking prevalence is decreasing across the country, and I’m pleased to say that smoking rates in the North East is declining faster than the national average. This is due to great support from programmes such as Fresh North East, which since 2005 has been tackling high smoking rates here. They have clearly been doing an excellent job, as since 2005, the North East has seen a fall of nearly a third with around 165,000 fewer smokers. However, the North East still has the highest lung cancer rates in the country and smoking rates still remain high, especially among those who are unemployed or members of lower socioeconomic groups and it is deeply concerning that those groups, for whom poverty is rife, are not being sufficiently helped to quit smoking.

    I welcome the Government’s Tobacco Control Plan – even though it was delayed by 18 months – but the Government must move away from warm words and empty promises and commit to the right funding for smoking cessation services so that smoking rates can decline across the country.

    Obesity and malnutrition

    I have also been calling on the Government to go further in their commitment to reduce obesity levels.  The UK has one of the worst obesity rates in Western Europe, with almost two in every three people being either overweight or obese. I am one of those two, but I am back on a strict diet now to try and become the one, I hope that there will soon be a lot less of me! It is hard though, if it was so easy no one would be overweight.

    However, I was a skinny kid and a slim teenager and proud to say a size 10 when I got married and I still ended up overweight as time went by. So therefore I worry greatly when I see all the stats for this country’s children when a pattern now emerges at a very early age. In 2016/17 almost a quarter of reception children, aged between 3 and 4, were overweight or obese. In the same year, for pupils in year 6, it was over a third. An obese child is also over five times more likely to grow up into an obese adult, so the Government should be doing all that it can to ensure that child obesity rates are reduced as a matter of urgency.

    The Government’s Child Obesity Strategy to tackle this was welcome, but left much to be desired. I am sure some of you will know that it was published in the middle of summer recess, during the Olympics and on A- Level results day. At first, I thought the strategy must have been missing some pages. But it turned out, this world-first strategy really was just thirteen pages long. For whatever reason, many of the commitments David Cameron had promised and desired as his legacy had been taken out by Theresa May and her staff. We now know that May’s former joint chief of staff, Fiona Hill, is said to have boasted about “Saving Tony the Tiger”, the Frosties Mascot. Now that Fiona is out of the picture, we are expecting a second Childhood Obesity Strategy this summer, so I hope that there will be more than thirteen pages!

    Of course, there is no silver bullet to tackling childhood obesity. As I said, if staying slim and losing weight was easy then we wouldn’t have the problem we have now.  However, there are two policy suggestions that I have been championing recently: restricting junk food advertising until the 9pm watershed on all channels not just on children’s channels and restricting the sale of energy drinks to young people.

    Advertising is so much more powerful than we all think. There is a reason they spend many millions on it!  According to a University of Liverpool report, 59% of food and drink adverts shown during family viewing time were for foods high in fat, salt and sugar and would have been banned from Children’s TV.  The same report also found that, in the worst case, children were bombarded with nine junk food adverts in just a 30- minute period, and that adverts for fruit and vegetables made up just over 1% of food and drink adverts shown during family viewing time. It is therefore no wonder that there are so many children in this country who are overweight or obese. That is why I’ve been calling for restrictions on junk food advertising on TV, but I know that other modes of advertising need to be investigated more widely too like advergames and food brands which are high in fat, salt and sugar sponsoring sporting events that are popular with children.

    This leads me to my next point of energy drinks, because to pin point just one brand, Red Bull who sponsor several extreme sports competitions which are not necessarily marketed to children, but are watched by children. When my son was a teenager, I would go so far as to say that he was addicted to energy drinks. And it was a huge problem for me, especially as he could legally buy them as he told me every day in his defence, in his eyes I was being ridiculous! He and his friends would buy and drink bottles and cans of them every day and it would completely change his personality. I’m pleased to say that ten years on he is older and much more sensible now, thanks to me warning him of the health dangers of energy drinks.

    Although that was a decade ago, the trend still remains that children, as young as ten, are buying energy drinks for as little as 25p. The UK has the second highest consumption of energy drinks per head in the world.  You might expect America to have the highest consumption, but it is actually Austria, home to Red Bull headquarters. A 500ml can of energy drink contains 12 teaspoons of sugar and the same amount of caffeine as a double espresso.  You wouldn’t give a child have 12 teaspoons of sugar or a double espresso, so why are we allowing them to drink it in an energy drink?

    If we want our children to be the healthiest in the world, we cannot sit idly on this any longer. Thankfully, many supermarkets and some retailers have now taken the step to restrict the sale of energy drinks to children. Supermarkets such as: Waitrose, Aldi, Asda, Sainsburys, Morrisons, Tesco, Lidl have restricted the sale. Boots lead the way in being the first non-food retailer to restrict the sale of energy drinks to children a few weeks ago, and just this week they were joined by Shell Petrol Stations and WH Smith. I am still calling on all supermarkets and retailers to take steps to do this.

    The Government have got to do better if our children are going to be encouraged to live a healthy lifestyle and eat a healthy diet.

    However, there are millions of people up and down the country who do not have access to healthy and affordable fresh food or the skills to cook up tasty meals or even the cooking equipment or the energy such as gas or electric especially when poor and on key meters, which leads us to another issue which certainly does not get the attention it deserves: malnutrition. Malnutrition affects over three million people in the UK, 1.3 million of which are over the age of 65.  Like obesity, malnutrition is a Public Health epidemic, but because it is literally less visible, it does not receive the attention or outcry that you would expect. On this Government’s watch, we have seen a 54% increase in children admitted to hospital with malnutrition and in the last decade, we have seen the number of deaths from malnutrition rise by 30%.  It should be at the forefront of this Government’s conscience that in one of the 6th richest economies in the world in 2018, malnutrition is increasing instead of being eradicated.  I’m proud to say that Labour will make it a priority to invest in our health services and ensure people don’t die from malnutrition in 21st century Britain.

    Both obesity and malnutrition are costly to our NHS, estimated at £5.1 billion a year for obesity and £13 billion a year for malnutrition. That is why prevention is so important and why I am a key campaigner for Universal Free School Meals, because it gives all children access to a hot and healthy meal, encourages a healthy relationship with food and is beneficial to their mental and physical development. Healthy food needs to be both affordable and accessible, and individuals need the skills to prepare and cook a fresh and healthy meal.

    NHS funding

    Finally, we all know that the NHS lacks the funding and the time it needs to do all of the things I have just mentioned. Since local authorities became responsible for public health budgets in 2015, it is estimated by the Kings Fund that, on a like-for-like basis, public health spending will actually fall by 5.2%. This follows a £200 million in-year cut to public health spending in 2015/16 and further real-term cuts to come, averaging 3.9% each year between 2016/17 and 2020/21. On the ground this means cuts to spending on sexual health services by £30 million compared to last year, tackling drug misuse in adults cut by more than £22 million and smoking cessation services cut by almost £16 million. Spending to tackle obesity has also fallen by 18.5% between 2015/16 and 2016/17, again with further cuts still in the pipeline in the years to come.

    The North East Commission for Health and Social Care Integration area spends £5.2bn on health and care each year. Over 60% of this is spent on tackling the consequences of ill health through hospital and specialist care, compared to the 3% devoted to public health. That is over twenty times more spent on consequences rather than prevention. So if the UK is going to be one of the healthiest countries in the world, then the Government really does need to recognise the importance of prevention and public health.  If we invest in our NHS and public health services, then we invest in the health of everyone in this country and that is why public health is so important.

    I look forward to working with you all now and in the future to ensure that one day we can proudly say that people in the UK are some of the healthiest in the world.

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    Non Communicable Diseases are the biggest cause of mortality, morbidity, disability, healthy life years lost and a major cause and consequence of health inequalities

    The priorities for action should have the biggest impact, the shortest timescale, be most sustainable, most equitable in reducing health inequalities and injustices for the vulnerable and across generations, achieve the maxim co-benefits for the environment and reducing demand on public services and realisation of human rights.

    Linked Avoidable Non Communicable Diseases and conditions:

    • CHD and Stroke -cardiovascular
    • Circulatory diseases
    • Cancers
    • Respiratory diseases
    • Liver disease
    • Type 2 Diabetes
    • Kidney disease
    • Obesity
    • Neurovascular and mixed Dementia
    • Musco-skeletal etc.
    Deaths by cause in UK men 2014

    Deaths by cause in UK men 2014

    Impact on healthy life expectancy and life expectancy

    Non Communicable Diseases are a cause and manifestation of health inequalities in current and future generations.  These are diseases that “break the bank “

    Impact on economic growth and sustainability of public services

    • Estimated at $47 trillion over the next two decades.Approximately 75% of the 2010 global gross domestic product (GDP). Source: World Economic Forum / Harvard School of Public Health. 2011
    • Alter demographics
    • Stunts country level development
    • Two –punch blow to development- national economies and individuals in poverty
    • Not a mark of failure of individual will power, but politics at the highest level

    What are the real determinants of this spread?

    Multi-national capitalists

    • Transnational corporations are major drivers of NCD epidemics and profit from unhealthy commodities
    • Public regulation and market intervention can prevent harm caused by unhealthy commodity industries

    Public health measures

    Some key potential priorities for consideration:

    • Something like the  Office for Budget Responsibility for the Public’s Health
    • A comprehensive review of the marketing of unhealthy commodities and services to children, young people and the vulnerable
    • Levys on the unhealthy commodity industries to provide additional public health funding to cover the societal costs as well as reduce their consumption
    • Ensuring new trade agreements protect and promote the publics health
    • A new public health bill – the state has powers to monitor in real time the commercial risks to the publics health, to ensure the state has (reserve)powers to tackle unhealthy commodity industries and services, set out duties for public bodies to consider the health of future generations and the planet and address health inequalities and the right to health

    An OBR for health?

    • Health should be properly considered in all fiscal, economic and market policies (human and planetary ill health and poor wellbeing are anthropogenic)
    • Sustainability of Public Services especially the NHS and social care (“the miscalculation of sublime proportions”). NHS is set to cost 1.6 times GDP by 2065
    • Health as an asset to prosperity and productivity- Health Creating (not damaging) Economy
    • Focus on health life expectancy and health inequalities
    • House of Lords review – Sustainability of NHS and Social Care (2017) proposed an  Office for Health and Care Sustainability
    • Mechanism for health in all policies
    • Minimum Unit Price alcohol/Air Pollution etc.
    • Lead technical Agency – Public Health England

    Processed food marketing and promotions:

    healthy food


    The recommended diet vs the advertised diet

    Around three-quarters of food advertising to children is for sugary, fatty and salty foods. For every £1 spent by the WHO promoting healthy diets, £500 is spent by the food industry promoting unhealthy foods

    We need a comprehensive review of the marketing regulators and codes

    • Regulators and codes not fit for purpose
    • Regulators essentially accountable to industry – self regulation
    • Statutory instruments focus on protecting market and plurality and the protection publics health is a low order objective
    • Action is after the event and codes are produced by the industry so are not effective as their production is conflicted
    • Self regulation is a failure for children, young people and the vulnerable

    Unhealthy commodity Industry Levys

    • Could be applies to tobacco, alcohol and ultra processed food products and services (gambling etc.)
    • Reduce consumption
    • Some of these industries pay little tax- needs reviewing
    • Pay for the externalities and provide additional funding for public health
    • Sugar Drink Industry levy – way forward – Minimum Unit Pricing of alcohol in England
    • Tobacco – estimated £500 million- support for tobacco licensing scheme, smoking cessation support, Social marketing, Tso’s regulatory support etc.

    We need a new Public Health Act. The last one was in 1936. The legislation addresses the epidemics of yesterday

    • Non Communicable Diseases  require new forms of health protection
    • Duties for Public Bodies – consider health of future generations and the planet and address the causes of health inequalities
    • Realisation of human rights (Social rights and the progressive realisation)
    • Statutory monitoring and surveillance of unhealthy industries and services


    Trade agreements have an effect on health. They could be used to protect our health.  We could learn from the experience of other countries.

    Some key potential priorities for consideration:

    • An OBR for the Public’s Health
    • A comprehensive review of the marketing of unhealthy commodities and services to children, young people and the vulnerable
    • Levy’s on the unhealthy commodity industries to provide additional public health funding to cover the societal costs as well as reduce their consumption
    • Ensuring new trade agreements protect and promote the publics health
    • A new public health bill – the state has powers to monitor in real time the commercial risks to the publics health, to ensure the state has (reserve) powers to tackle unhealthy commodity industries and services, set out duties for public bodies to consider the health of future generations and the planet and address health inequalities and the right to health

    More details in the proposals for a health-creating economy. 2017. UK Health Forum

    This was presented at our conference Public Health Priorities for Labour

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    Labour’s policy is to extend Free School Meals to all pupils in primary schools. We now know that Theresa May wants to take them away from millions of children in infant schools.

    This affects children over the whole country, however, a survey commissioned by the London Food Board and carried out by IPSOS Mori found that 74,000 children in London alone regularly go to bed hungry. For many children, the food they get in school at lunchtime is their only nutritious meal of the day. As a long-time campaigner on school food, and co-founder of the Labour Campaign for Free School Meals for All, I genuinely like the idea that every child would be entitled to a free breakfast. However, this must not be at the expense of a healthy lunch. When the previous government introduced Universal Infant Free School Meals – on the basis of evidence provided by pilots commissioned by the Labour government – they recognised that universal free school meals can save families an average of £487 per child per year. They also acknowledged that universal free school meals improve attainment of all children, not just those who would previously have been eligible for free school meals. By committing to scrap universal free school meals for infants, Theresa May is breaking a cross-party consensus on this issue. With experts also saying this will damage attempts to tackle childhood obesity, she is also being short-sighted and mean-spirited.

    If you agree that Theresa May is wrong, please sign my petition on Universal Infant Free School Meals and share it with your friends, colleagues and family –

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    Exact figures may be disputed but there is little doubt that social inequality and poverty are growing in the UK. Around four million people suffer from food insecurity, which means being hungry at least some of the time. There are even reports of people being hospitalised for malnutrition and claims of several deaths from starvation.

    As an anthropologist who has worked for several decades on issues of food and food security in both Tanzania and India, I was shocked to discover in 2014 that a significant proportion of the UK population was currently experiencing similar problems to those encountered in much less developed economies. How could this be possible in one of the richest countries in the planet?

    I started to investigate by studying food poverty and forms of food aid at the micro-level in two areas of the UK, one in the north London borough of Barnet and the other in a more rural part of west Wales. Much of my research has taken place in food banks and included interviews with both clients and volunteers, and serving occasionally as a volunteer myself.

    Food poverty needs to be understood in its social context in order for long-term solutions to be found. It is this kind of fine-grained ethnography which enables connections to be made between the state and its policies, the market, and the voluntary sector.

    While wages have risen very little if at all in most sectors and benefit entitlements have often been cut, some people turn to food banks as a coping mechanism. In the UK today, the main food bank charity, the Trussell Trust, has more than 400 such centres and there are likely to be at least as many independent food banks. They rely on long-life food donated by the public in supermarket and school collections.

    Food poverty

    The usual reasons for coming to a food bank include problems with benefits (including sanctions which means no benefits at all for a period of weeks), low-income and debt. Some clients have chronic problems, like this man:

    I used to live in a middle class area of London and cared for my father. But when he died I lost both the flat, which was rented, and my job both at the same time. So I lived in my car for 3 years. Then I got another job, but it didn’t last because I had back problems… I am on pension credit which is paid every two weeks and I don’t have to pay council tax but it’s not enough to live on and pay energy bills, loan from bank, TV licence etc. I come here every Monday and it’s ‘thank goodness for the food bank’.

    Others encounter a sudden emergency with which they cannot cope financially:

    I used to work in administration, specialising in human resources. My problems developed after my husband deserted me and our 3 kids, as a result of which I had a mental breakdown and couldn’t work. So I went on to benefits but these were stopped because I had ticked the wrong box on the form. I have been to the food bank a couple of times and found the people there very friendly. I also had food given to me at Christmas by the food bank.

    Food bank client in north London

    Most food banks are run by volunteers, often out of churches, like this woman:

    I heard about the food bank from my church, which had an item in the newsletter… People (clients) are here because of benefit cuts, sickness leading to loss of work, unemployment, disabilities, domestic violence, bills piling up. There are extremes of people who are so angry and bitter that it is difficult to talk to them, while others are so grateful they burst into tears and hug and kiss you. Often these people live alone, so they also come for company, they have a tea or coffee and feel slightly loved and cared for…

    Volunteer at a north London food bank

    Each food bank has a manager (volunteer or paid) one of whose responsibilities is to keep track of food, clients and volunteers:

    Last year we gave out 1300 food parcels, of which roughly 300 might be to returnees (that is the national average). That means we fed 1000 people in a town with a population of 5,000. The main problems are benefits cuts and changes which account for maybe 60% of the people we see. When their circumstances change, benefits are cut until the new status comes into force. That might take several weeks and meanwhile people have nothing. Another is housing. I am expecting a client just now. She and her partner, plus their children, have just moved out of half-way accommodation. They are lucky – they only spent 8 weeks there before getting re-housed. But others spend many months in such places.

    Welsh food bank manager

    Alongside the problem of food poverty is one of food waste and surplus, which is generated by the food and restaurant industries, and by domestic consumers. While making use of the waste coming from restaurants is difficult, but not impossible, that generated by food retailers can be redistributed provided it is not past its ‘sell-by’ date.

    A number of organisations, including well-established ones like FareShare and Foodcycle and more recent local additions, such as the Felix Project in London, collect food surplus from both wholesalers and retailers such as supermarkets. They use this to supply charities like homeless hostels, women’s refuges, and breakfast clubs which turn it into meals for their clients. Recently, FareShare has made use of an app to develop the FareShare FoodCloud, partnering initially with Tesco (and, more recently, Waitrose) to allow surplus food to be collected daily by different charities in a managed and monitored way.

    It may thus appear that using the considerable surplus generated by the food industry and ensuring that is it channelled to organisations dealing with food poverty constitutes a win-win situation, effectively a problem solved.

    In my forthcoming lecture in memory of the distinguished anthropologist Professor Mary Douglas, I shall be using some of her work and my own to argue against such a view. The late Professor Dame Mary Douglas was a prolific writer on many topics, one of which was food. Like other anthropologists, she was interested in the social and symbolic aspects of food and her work encompasses economics and social policy. Douglas maintained that giving out food was rarely the solution to more fundamental problems of poverty, a lesson which has been re-learned a number of times in contexts ranging from famine in Africa to food insecurity in the USA.

    She argued rather that obtaining food should come from reciprocity either in the form of payment for labour or some other kind of reciprocal exchange. Where food is given out without any commensurate return, it is a form of charity which only alleviates an immediate problem, but not the reasons for its existence. Her argument draws upon classic anthropological work on gift-giving which demonstrates that gifts should not only be received (never look a gift horse…) but also returned.

    It is for this reason that receiving something for nothing creates a highly asymmetrical status between giver and receiver, which is why many people feel that it is stigmatising to go to a food bank. While many clients feel gratitude for the help they receive, most also feel shame, because in accepting such help, they deem themselves to be failures. Such a view is reinforced by much of the media which views clients of food banks and other food aid organisations as ‘scroungers’.

    Most food banks and other food aid organisations recognise that their solutions are imperfect and hope that the need for them will be temporary, but argue that people cannot be left to suffer hunger when it can be alleviated, so ‘in the meantime’, their efforts remain necessary.

    In the 2017 Mary Douglas Memorial lecture, I consider where responsibility for food poverty lies and how more fundamental solutions to it may be found.

    First published on the  British Politics and Policy blog

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    NHS prescribing of gluten-free foods
    Many thanks Alex (Scott-Samuel) for sending me this.  I have a severe form of coeliac disease, and  my husband also has to follow a gluten free diet. He does so due to the risk of cross contamination, as if I have a coeliac attack it triggers an Addison’s crisis which is a certain visit to A&E and can be fatal.  I have to be very careful indeed, and am an A&E frequent flyer.  Our food bills have tripled and all meals have to be prepared from scratch.  Wheat is added to almost everything, and when it isn’t the item is expensive.  Even “good” meat or chicken is not  suitable if prepared in a factory where they are also making nuggets, or sausages, and porridge isn’t gluten free unless stated.  The extra expense is for dedicated factories. A tiny third of a loaf is around £3 to £4.00. Put that with a tin of beans (only Heinz is currently gluten free that I know of) and even a lunch of beans on toast becomes expensive.   I have been told that the poorer and elderly with coeliac disease are suffering already in my area, though the CCG have said that doctors can use discretion rather than issuing a blanket ban.  I have not followed up on  that to see if it is working as it should. Now imagine someone with coeliac who has been sanctioned, or is on a zero hours contract.  Food banks, at least locally, do not take such medical needs into consideration. This will certainly widen health inequalities and shorten the lives of  poorer, and even not so poor coeliacs. There are not that many of us (see below) and there is plenty of room for negotiating on price. The arguments against  are very much along the lines of Marie Antoinette’s response to the poor having no bread and starving “let them eat cake”.


    About Coeliac UK

    Coeliac UK is the national charity for people with coeliac disease and dermatitis herpetiformis (DH), for nearly 50 years we’ve been improving the lives of people living without gluten through providing independent and expert information, and campaigning on their behalf for better diagnosis for coeliac disease, better care and better access to gluten free food in and out of the home.

    As the only charity in the UK offering comprehensive support for coeliac disease and the gluten free diet, we are a trusted voice, advocate and partner for our community.

    Summary of main points

    1. Coeliac disease is a serious medical condition where the body’s immune system attacks its own tissues when gluten is eaten. Currently, the only medical treatment for coeliac disease is strict adherence to a gluten-free diet for life.
    2. Since the late 1960s staple gluten free food has been prescribed to support dietary adherence for the prevention of long term health complications and comorbidities. This rationale is now being challenged by some Clinical Commissioning Group (CCGs) in NHS England. The reason cited is, almost universally, the need for CCGs to make savings to their prescribing budgets.
    3. A significant proportion of CCGs in England are now choosing to restrict or to remove this support for patients with coeliac disease. This is leading to significant and unwarranted variation in access to gluten free food across the country and is exacerbating health inequalities, as changes disproportionately impact the most vulnerable. NHS patients across England are now subject to a postcode lottery for NHS support once diagnosed with coeliac disease. NHS patients in Scotland, Wales and Northern Ireland continue to receive full support in the treatment of their condition.
    4. CCGs report that the price paid for products by the NHS is higher than that paid in supermarkets, yet there has been no effort to improve procurement processes, including product price negotiations.
    5. The annual Net Ingredient Cost (NIC) of gluten-free foods to NHS England was around £25.7m in 2015, or around 0.3% of the total prescribing budget for NHS England of £9.3bn.
    6. Failure to treat coeliac disease or to follow a strict gluten free diet can lead to health complications and comorbidities. This means that restricting treatment is likely to be a false economy for the NHS, as it could lead to higher treatment costs and poorer health outcomes in the long term.
    7. Recent organisational and structural changes to the NHS in England has meant that innovation or the adoption of alternative forms of support, such as pharmacy-led gluten free prescribing or voucher schemes, has been hindered. Significant efficiency savings could also be made through improved procurement, but these innovations are unlikely to be cost effective at individual CCG level.

    Coeliac disease and associated long-term health complications

    Coeliac disease is a serious medical condition where the body’s immune system attacks its own tissues when gluten is eaten. This causes damage to the lining of the gut and means the body cannot properly absorb nutrients from food. It is not an allergy or simple food intolerance.

    Coeliac disease is an autoimmune disease that occurs in people who have the genes that predispose them to the condition. It is more common among people with other autoimmune diseases, such as Type 1 diabetes and autoimmune thyroid disease.

    The long term health complications associated with untreated coeliac disease are osteoporosis, ulcerative jejunitis, intestinal malignancy, functional hyposplenism, vitamin D deficiency and iron deficiency. Currently, the only medical treatment for coeliac disease is strict adherence to a gluten free diet for life.

    Background to the prescribing of gluten free staple foods

    Since the late 1960s gluten free food has been prescribed to support the treatment for patients with coeliac disease. Gluten-free food is prescribed to promote dietary adherence, and thus to prevent long term health complications and comorbidities. NHS support is available to those with coeliac disease in recognition of the highly restrictive nature of the diet, the high price of gluten-free substitute foods, and the very limited choice and availability of many gluten free staple foods.

    To assist clinicians and commissioners to support patients with coeliac disease, National Prescribing Guidelines for the Prescribing of Gluten-free Food have been produced by Coeliac UK, in consultation with the NHS and other professional healthcare bodies. These Guidelines are endorsed by the Primary Care Society for Gastroenterology (PCSG) and the British Dietetic Association (BDA); they are followed in Scotland, Wales, Northern Ireland and around half of the CCGs in England.1

    Only gluten free products that are approved by the Advisory Committee on Borderline Substances (ACBS) and appear on Part XV of the Drug Tariff can be prescribed by GP. Products are listed on Part XV of the Drug Tariff following ACBS approval of an application by producers. The ACBS list current includes hundreds of gluten free substitute products, prices are provided by producers at the time of application and subject to annual inflation increases.

    In the past, NHS policy has rightly recognised that the costs associated with the treatment of long term health complications are likely to dwarf the costs associated with prescribing gluten free staple foods, dietetic advice and monitoring. However, in some areas in England, local policies are changing to either remove, reduce or restrict this support.

    The challenge on price and availability

    The rationale for supporting patients with coeliac disease with prescriptions for gluten free food is now being challenged by some Clinical Commissioning Groups (CCGs). Several CCGs have highlighted improvements in access and affordability of staple gluten free foods, but have not properly researched the situation within their area of responsibility, nor presented evidence in support of these claims.

    Coeliac UK has asked through Freedom of Information (FOI) requests for details of the evidence used to drive policy change in affected areas. An example of the kind of research being conducted can be found in the FOI response from North East Essex CCG, where sweeping assumptions seem to have been made devoid of any systematic research, they state:

    “We appreciate that there is a large cost-differential between supermarket value brands and GF [gluten-free], but many people within the CCG buy their bread from bakers or do not buy the supermarket value brands and the cost differential is therefore much reduced.” 

    This type of anecdotal evidence, which is being used by CCGs to justify decisions about patient care, is in conflict with peer reviewed research published as recently as September 2015. A study in the Cost and availability of gluten-free food in the UK: in store and online by Burden, M., et al., concluded:

    “There is good availability of GF [gluten free] food in regular and quality supermarkets as well as online, but it remains significantly more expensive. Budget supermarkets which tend to be frequented by patients from lower socioeconomic classes stocked no GF foods. This poor availably and added cost is likely to impact on adherence in deprived groups.” ii

    NICE recommendations and duties to reduce health inequalities

    The National Health Service Act 2006 as amended by the Health and Social Care Act 2012 includes duties on the Secretary of State, the NHS England Board and CCGs to have regard for NICE quality standards. There are also legislative duties requiring CCGs to reduce inequalities with respect to access to patient services and health outcomes.

    The first NICE quality standard for coeliac disease was published on 19 October (QS134) and includes a statement on the need to discuss the gluten free diet with a healthcare professional, with specialist knowledge, once diagnosed. This statement from NICE includes guidance on the equality and diversity considerations for healthcare professionals, which recognises the higher cost and limited availability of gluten free food. NICE highlights the difficulties faced by patients on low incomes or with limited mobility, and because there is a genetic component to coeliac disease, NICE also highlights the strain on household budgets where there is more than one person in the family diagnosed. NICE asks healthcare professionals to advise patients on the availability of gluten free food on prescription.

    However, the lack of explicit recommendations on the need to provide access to gluten free staple food on prescription has led to CCGs in England to implement local policy change in this area, and a significant proportion are now choosing to restrict or remove all prescribing support for patients with coeliac disease.iii This removal of support is leading to significant and unwarranted variation in care across the country, and as noted above, is likely to further exacerbate health inequalities.

    NICE Guidance (NG20) was reviewed in 2015, and recommends that all patients with diagnosed coeliac disease are offered an “annual review”, which should include measurement of height and weight and a review of symptoms, as well as consideration of the need for specialist dietetic or nutritional advice, or clinical referral. Implementing and establishing the NICE recommendation on annual review within local services will be imperative to enable the monitoring of patient outcomes and assess the impact resulting from local policy change.

    The lack of a national prescribing policy from NHS England means considerable uncertainty for those who rely on access to gluten free staples on prescription to manage coeliac disease, and the most vulnerable are most acutely affected. In particular, those on fixed incomes or benefits who receive prescriptions free of charge, and those who are housebound and rely on deliveries from community pharmacies. The result is that NHS patients across England are now subject to a postcode lottery for NHS care and support, once diagnosed with coeliac disease.

    NHS costs and procurement

    The annual cost of gluten free food on prescription to NHS England was £25.7m in 2015, this was 0.3% of the total prescribing budget of £9.3bn for 2015. iv,v The main argument used for restrictions or service cancellation is the need for efficiency savings. NHS support for patients with coeliac disease is quickly becoming a “Cinderella” service.

    CCGs that are restricting or preventing access to gluten-free food on prescription often argue that gluten free food is now available to purchase in large supermarkets, and that patients can do this at a lower cost than the cost to the NHS to buy gluten free staples. For example, in a letter to patients dated 16 June 2015, the North Norfolk CCG stated:

    “Today these products are widely available from all supermarkets and are sold to the public at prices that are considerably lower than the NHS is charged when bought for use on prescription.”

    What is surprising about this statement is that prescription services seem to be now be risk because NHS procurement teams have been unable to secure competitive prices. As stated above, the price the NHS is charged for gluten free food products are advised by producers when applying to the ACBS for product listing on Part XV of the Drug Tariff.

    The total UK market value of gluten-free foods in 2015 in England was £247m, making the NHS England annual spend of circa £25.7m on gluten-free food around 10% of the total gluten-free food market. vi It would be reasonable to expect that such a significant market share provides sufficient purchasing power to negotiate prices equal to those paid by commercial retailers. Patients should not be suffering the consequences of inefficiencies within procurement systems. Pressing this point, Kevan Jones MP said during the Westminster Hall debate (November 2016):

    “I do not know why the NHS cannot negotiate contracts with some commercial companies. Failure in procurement will clearly have an impact.” (Hansard Online, Volume 616)

    The “patients can buy products at a lower price” position also ignores the additional benefits of appropriate support and monitoring by healthcare professionals, and the fact that this is true of a range of treatment and medicines available on the NHS. The annual cost of gluten free food staples to the NHS is significantly lower than the annual cost of other items prescribed, but available for purchase over the counter at a lower cost than that to the NHS, such as Senna (for occasional constipation) with a total cost of £32.3m and paracetamol at an annual cost of £85.1m and rising.

    More importantly, this argument contradicts the principles that guide the NHS, in particular that the NHS: provides a comprehensive service, available to all; that access to NHS services is based on clinical need, not an individual’s ability to pay; and that the NHS aspires to put patients at the heart of everything it does.

    Gluten free food producers

    While some CCGs are not always comparing like for like products when making price assessments, there are circumstances when the NHS does pay a higher price than the retail product equivalent. Coeliac UK has approached the trade association representing gluten free food producers in the UK, the British Specialist Nutrition Association Ltd. (BSNA) to challenge them on this issue.

    BSNA has reported several issues relating to increase costs, including the need to provide a universal service to all pharmacies across the country, ensuring “availability and access to a reasonable supply of staple gluten-free foods”. The use of community pharmacies ensures that all patients, regardless of where they live can access staple food when needed, including those who rely on home deliveries.

    Is cutting gluten free prescribing a false economy?

    The NHS is also guided by the principle of commitment to providing the best value for taxpayers’ money and the most effective, fair and sustainable use of finite resources. This raises the issue of false economy, where small savings in prescription costs could lead to higher treatment costs associated with poor health outcomes and increased health complications. For example, the cost of gluten free staple food over a 40-year period is approximately £7,770 (£194.24 per year) and the cost of treatment for a hip fracture £12,170 (increasing by £70,000 per patient if cases become more complex).vii,viii,ix

    Reducing dietary adherence, risks not only long term health complications, but is also likely to increase absences from work due to continuing ill health amongst patients who aren’t able to source or afford gluten-free foods.

    This issue was raised by Liz McInnis MP, commenting during the Westminster Hall debate on 1 November, she said:

    “Is the Minister aware that the annual cost per diagnosed patient of prescribing gluten-free food is £180 per year? Weight that up against the cost of avoiding infertility, bowel cancer and osteoporosis. What is the obvious conclusion for any NHS professional?” (Hansard Online, Volume 616)

    The case for continued gluten free prescribing

    Coeliac UK believes that it is important that gluten-free prescribing continues for the following reasons:

    1. Treatment and prevention of serious long-term health complications

    Adherence to the gluten free diet is greatly improved through prescriptions for gluten free staples and regular follow-up and support. x Once treated with the gluten free diet for three to five years, the risk of developing the cancers associated with coeliac disease reduces to no greater than that of the general population.xi The risks associated with osteoporosis are largely dependent on any damage already sustained, or lack of dietary adherence, due to the inability to absorb calcium.

    1. Price

    Gluten-free foods can cost around three to four times as much as their gluten containing equivalent. For example, gram for gram gluten-free bread costs up to six times that of standard bread. xii Therefore, the withdrawal of treatment impacts most significantly on those with the low or fixed incomes or those who currently receive prescriptions free of charge.

    1. Access

    Gluten-free or “Free From” products tend to only be available in larger supermarkets or health food stores. The former are often out of town, and increasingly supermarkets are opting for convenience sized stores in large cities and urban centres; these stores often cannot justify the shelf space for these low turnover items. Those who rely on community pharmacy deliveries or without access to a car or the internet often have difficulties in sourcing staple foods. It has also been suggested that online ordering is a solution. However, the delivery costs and minimum order restrictions can be prohibitive for some, and because these products lack structure (due to the absence of gluten) they do not always “travel well” through parcel services.

    1. Availability

    While many of us are used to the convenience of prepared or take away foods, availability of gluten-free products in these categories are extremely limited. This means that those with coeliac disease often need to make meals at home to take to work or on journeys, and therefore, need to have a range of gluten free staple foods, like bread, available at home.

    The financial pressures faced by the NHS are well reported. However, service provision should be driven by clinical need and not adjusted purely on budgetary constraint. The need for NHS England to provide value for money when deciding on appropriate clinical treatment and services is recognised. However, some CCGs are now taking a short term view on health spending. This flies in the face of preventative strategies favoured by NHS England and Public Health England, and has the potential to derail this long-term sustainable spending strategy.

    Innovating for efficiencies

    Cutting and reducing service provision is not the only way to find efficiencies in the NHS. Service innovation, improved procurement and national collaboration also have the potential to deliver efficiencies, as well as improvements in patient experience.

    Some CCGs have attempted to improve or innovate support services for patients with coeliac disease, while also looking for savings. The NHS Five Year Plan outlines use of pharmacy services to extend existing primary care resource, but there are significant hurdles in developing sustainable pharmacy-led service models using NHS England organisational and contractual arrangements.

    These hurdles appear to have been cleared by NHS Scotland, through the introduction of a national pharmacy-led scheme, which allows for a patient-centred approach which improves the quality of the service while providing for greater control of costs. One of the main benefits delivered by the Gluten Free Food Service (GFFS) in Scotland is the increased capacity in GP surgeries, as community pharmacy is the site of service delivery.

    The GFFS evaluation, at the conclusion of the 18-month pilot, reported from the survey of GPs “there was overwhelming support (98% n=442) for the trial GFFS to continue as an ongoing service” and similarly from the survey of community pharmacists “in the opinion of respondents, 92% (n=300), GFFS should continue as an ongoing service”. Patients also saw benefits, the evaluation reporting that “the vast majority of respondents liked the service (90% n=1,284) and want it to continue (93% n=1,318)”.xiii

    Some CCGs in England are innovating with the aim of reducing costs in all prescribing. NICE published a Quality and Productivity Case Study in 2014 from Walsall CCG, which provides a practical example of how savings can be made, the CCG implemented a pharmacist-led repeat prescription management service:

    “The service was aimed at reducing medicines wastage, minimising possible harm from medicines and improving the quality of repeat prescribing. Cash was saved by ensuring the least expensive, clinically appropriate medicines were prescribed by switching from branded to generic drugs. Practice-based pharmacists worked as an integral part of primary care general practice teams to manage repeat prescriptions.

    For the financial year 2013/14 the service delivered net savings of £610,270 and demonstrated that for every £1 invested in pharmacist time there was a saving of £3.05”.xiv

    Capacity in GP surgeries can also be gained through repeat dispensing. Around two thirds of all NHS prescribing in primary care is for patients that require repeat supplies of medicines, food or equipment. Repeat dispensing is available to increase patient choice and convenience, to minimise wastage by reducing the number of products dispense which are not required by the patient and to improve GP capacity by lowering the burden of repeat prescriptions.

    For these reasons, since 2005 repeat dispensing has been an Essential Services within the Community Pharmacy Contractual Framework (CPCF). However, according the Pharmaceutical Services Negotiating Committee (PSNC) take up as been very low. The PSNC reports that:

    Despite the benefits that the service can bring to patients and the NHS, uptake of it has been very low, in part due to lack of engagement by GP practices. In order to increase the benefits being gained by patients and the NHS from this service, it was agreed in September 2014 that from 1 March 2015 there will be a new requirement in the CPCF for pharmacies to give advice to appropriate patients about the benefits of the repeat dispensing service.”

    As well as using existing models to drive efficiencies, new schemes are being considered. The Vale of York CCG is trialling a new voucher scheme, or pre-loaded payment card, as a way of helping patients to access gluten free staples from local supermarkets. Coeliac UK supports these innovations, if supported by a positive evaluation of patient outcomes and ongoing monitoring. This scheme is delivering some local benefits, but is likely to need national support from supermarkets and scale to ensure it delivers the savings that warrant set up and administrative costs. This idea was supported by Kevin Foster MP in November 2016, he asked the Parliamentary Under-Secretary of State for Health:

    “Will he suggest to CCGS such as Torbay in south Devon that there is a halfway house and that instead of scrapping the prescription of gluten-free products they could provide vouchers that could be taken to a local supermarket?”(Hansard Online, Volume 616)

    Other possibilities, not yet being piloted, include web based e-commerce ordering systems, where all products approved for purchase can be loaded on to the site and paid for using a secure wallet (electronic allocation). The patient can then select the retailer, pharmacy or store to arrange a collection.

    Such a system could deliver significant savings to the NHS in clinician time and administration for NHS England. However, to be cost effective, such a scheme would need to be developed as a national service, not separate services in 209 CCG areas. All schemes need to be teamed with appropriate local dietary and health support and monitoring or “annual review”.




    Tagged | Comments Off on Let Them Eat Cake

    In 1850, the French economist Frederic Bastiat wrote the parable of a shopkeeper whose window is smashed. Aghast at the damage, the shopkeeper is consoled with the idea that at least his broken windows are good for the economy, since “Everybody must live, and what would become of the glaziers if panes of glass were never broken?”

    The alcohol industry is, in some ways, like the glazier of Bastiat’s story. Global alcohol producers profit from harmful behaviour. And they, too, try to defend themselves with the promise of employment and income. Such appeals to the economic benefits of a thriving alcohol industry have become deafening in recent weeks, as lobbying continues for cuts to alcohol duty in March’s Budget.

    Bastiat would have seen right through them, and urged us to pay attention to “that which is not seen” – the counterfactual. If the shopkeeper did not have to pay for a new window, he could have spent the money on repairing his shoes, and in so doing, supported the cobbler’s business. Similarly, if people do not spend money on drink, they will buy other products, and support other industries. We do not need to wreck windows or drinkers’ lives for the good of the economy.

    alcohol consumption? No thanks

    The Institute of Alcohol Studies’ new report, Splitting the Bill: Alcohol’s Impact on the Economy lays out this argument in more detail. It walks through the economic consequences of a fall in alcohol consumption to show that they are not to be feared. To begin with, just because people drink less does not necessarily mean they will spend less on alcohol: they may simply choose to buy more expensive drinks. Indeed, we find that the negative effects on the alcohol industry of a 13 per cent fall in per capita alcohol consumption between 2004 and 2014 were more than compensated for by premiumisation, price increases, and population growth. The fact that real-terms industry revenue did fall is due to the simultaneous shift in people’s drinking from pubs (where drinks are more expensive) to supermarkets (where they are cheaper).

    Even if spending on alcohol does fall, this is unlikely to cause significant economic harm. Lower spending on alcohol would have an ambiguous effect on demand for goods and services in the economy: depending on the proportion that was saved, the types of product that were bought instead and the response of government fiscal policy, aggregate demand could rise or fall. By contrast, the impact on the supply side of the economy – the country’s maximum productive capacity – would almost certainly be positive.

    Alcohol consumption is associated with higher rates of sickness absence, ‘presenteeism’ (when people make it into work but perform below their optimal level), unemployment, and premature death. Government estimates suggest that these cost the economy in the order of £8-11 billion, between 0.4-0.6 per cent of GDP, each year. Reducing alcohol consumption would increase labour supply and productivity, and so increase the economy’s capacity to produce goods and services.

    So, to sum up, lower alcohol consumption and spending would increase the amount of goods and services that the economy can produce, but have an ambiguous effect on consumers’ willingness and ability to buy those goods. Whether this is good overall for the economy depends on whether economic growth is constrained more by producers’ capacity to make and sell or consumers’ demand. As it happens, the Office for Budget Responsibility estimates that the UK economy is very close to running into capacity constraints: it is just 0.2 per cent below its full productive potential. This implies that the UK economy’s priority should be boosting the supply side of the economy, as lower alcohol consumption would do.

    These are fairly abstract theoretical arguments, but they are supported by real-world evidence. A 2014 econometric study comparing the growth rates of US states between 1971 and 2014 found that a 10 per cent increase in per capita beer consumption is associated with a 0.41 percentage point drop in annual income growth. In other words, it suggests reducing alcohol consumption is good for the economy.

    Economic considerations are likely to be at the front of the Chancellor’s mind as he deliberates over whether to raise or cut alcohol duty. But the economy is only part of the story – alcohol, particularly cheap alcohol – causes immense harm to individuals and families up and down the country, and taxes should rise to account for this damage. Yet even on narrowly economic grounds, cuts to duty represent a false economy.

    First published on the British Politics and Policy blog

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    Official figures issued this summer highlighted the increasing rates of Type 2 diabetes in the UK, and the growing share of the NHS budget which it consumes. And since the poorest people are twice as likely to suffer Type 2 diabetes and its complications, this is also an issue which should concern all of us.

    The figures, I’d like to suggest, are just the latest warning sign of a continuing public health disaster which began in 1984.

    This was the year in which the Department of Health issued the first-ever governmental dietary guidelines for the population at large (not counting the advice issued during World War 2 on how to make the best of rationing).

    Those 1984 guidelines (still promulgated in various forms today) were based on very shaky evidence – although I am not sure it even justifies the label of evidence; a better description might be ‘unproven hypothesis’ – which has fuelled both an obesity and diabetes epidemic. This hypothesis – that saturated fat causes heart disease – led to the advice that we should all fill up instead on carbohydrates such as pasta, bread and potatoes.


    Just look at what happened to rates of Type 2 diabetes since then.

    Figure 1: Trend over time (1984 – 2007) in incidence of T2 Diabetes by age group.

    Key: = age 45-49 years; ● = age 50-54 years; = age 55-59 years; = aged 60-64 years;

    = aged 65-69 years; = aged 70-74 years. (Hardoon et al, 2010)

    Ok, correlation is not causation – but is it just a co-incidence?

    Most observers agree that the development of Type 2 diabetes is linked to an unhealthy lifestyle, including poor diet. And the NHS seems to be flailing about helplessly in the face of this problem; partly, of course, because it has to concentrate on fixing people when things go wrong, rather than helping us to stay well; but also, I suggest, because it still seems wedded to questionable theories about what constitutes a healthy diet – and individuals within the system are understandably afraid of taking up a career-limiting stand against current orthodoxy.

    Perhaps they know what happened to Professor John Yudkin, the British scientist who rashly proposed in the 1970s that it was sugar, not fat, that was the dietary culprit in obesity and heart disease.

    Start with food

    Because it’s so much easier for us to live unhealthy lives, I’m not arguing that there is one simple fix. But since what we eat every day can have such profound impact on our health, surely food is one of the best places to start?

    And one of the worst places to start is the NHS Eatwell Guide.

    When I began studying for an MSc in Public Health Nutrition and Weight Management almost 10 years ago, whilst also working in the NHS, it became clear to me that I could not reconcile the dietary advice I could see being handed out to NHS patients with the evidence I was coming across in the science journals I had access to in the University library.

    Research into low-carbohydrate diets, sparked by the popularity of the Atkins Diet, was consistently showing they were effective not only for weight loss, but for improved glycemic control in people with Type 2 diabetes, and a reduction in unhealthy blood fats and inflammation markers (or, in plain English, lower triglycerides and C-reactive protein).

    The Eatwell Plate – designed by the food industry for wealth, not health

    With my MSc under my belt, I could not in all conscience work in a nutrition-related role in the NHS where I would have to ‘toe the party line’ as far as the Eatwell Plate was concerned. This was a pictorial representation of government dietary advice, first issued in 2006, but the contents were simply a reinforcement of the 1980s advice to stuff ourselves with starchy foods).

    Over 60% of the foods on the Eatwell Plate contained forms of sugar (glucose-fructose, fructose-glucose, lactose and long-chain starches which break down into glucose): bread, rice, potatoes, pasta, cornflakes, milk products, tinned baked beans, cakes, biscuits, chocolate, sweetened yoghurt, fruit juice, cola and fruit. Eat well? Really?

    The Plate and guidelines were revised this summer with a call for a reduction of free sugars in the diet, but it still contains pictures of crisps, chocolate, cakes and ice-cream.

    An editorial in the British Journal Of Sports Medicine said it was ‘designed by the food industry for wealth, not health’.

    To compound the problem, the NHS still advises that we should ”Base meals on potatoes, bread, rice, pasta or other starchy carbohydrates. Choose wholegrain where possible Yet recent research indicates that wholegrain wheat is in fact no ‘healthier’ than white flour, since most modern wheat is a new hybrid which contains high levels of a highly-digestible form of starch – 70% carbohydrate by weight – called amylopectin A.

    In healthy, slender volunteers, two medium-sized slices of wholewheat bread increased blood sugar by 30 mg/dl (from 93 to 123 mg/dl), no different from white bread. In people with diabetes, both white and wholegrain bread increased blood sugar 70 to 120 mg/dl over starting levels (Davis, 2011).

    Far from helping us to ‘feel fuller longer’, wholegrain bread triggers a rise in blood sugar and higher levels of circulating insulin, followed by a sharp drop in blood sugar levels and increased hunger.

    The NHS response to the growing body (you might almost call it obese) of evidence on the effectiveness of low carbohydrate patterns of eating is to stick its fingers in its ears and shout ‘La La La – can’t hear you.’ (see end of this article, a roundup of the robust evidence available to the NHS before it revised the Eatwell Plate this year).

    Instead, the NHS advises: “Low-carbohydrate (low-carb) diets … tend to be high in fat, and eating a high-fat diet (especially saturated fat from foods such as meat, cheese, butter and cakes) could increase your risk of heart disease.” (

    Let’s deconstruct this a little…..

    The advice does not specify what ‘high’ is, or what proportion of the diet should be made up of fat.

    It suggests in a vague sort of way that a diet ‘rich’ in saturated fats could increase your risk of heart disease.

    Saturated fat and heart disease

    Six years ago, the Journal of the American Medical Association, having reviewed the evidence, stated that ‘saturated fat bears little relation to heart disease within most prevailing dietary patterns’ (JAMA, 2010). I sent a copy of this paper to NICE and asked if it would consider reviewing its advice in the light of the this information; and also if it could point me to the research on which its current advice (that saturated fat is dangerous) is based. It could not.

    It’s not just the USA which is tiptoe-ing away from the diet-heart hypothesis about saturated fat and cholesterol. Several other studies, including major epidemiological reviews, meta-analyses of intervention studies and an Expert Report by the World Health Organisation, have failed to find any link between intake of saturated fat and heart disease (Mente et al, 2009, Siri-Tarino et al, 2010, Skeaff et al, 2009).

    Low fat diets and heart disease

    A Cochrane meta-analysis of 48 studies found that low-fat diets do not lower the risk of cardiovascular events or overall mortality (Cooper et al, 2011). In the two decades after World War 2, USA consumption of vegetable fat doubled while that of animal fat dropped by over 12%, yet heart disease rates soared (Taubes, 2007).

    Equating meat and cakes

    In warning people to avoid ‘low carbohydrate diets’, the NHS advice groups together meat, cheese, butter and cakes, which are very different types of food and contain very different macronutrients but which are all identified as ‘culprits’ because they contain saturated fat. Yet each food has a unique metabolic fate in the body and can affect health in very different ways.

    For example, unless home-made, cakes are generally made with processed vegetable oil, and very often, this will be hydrogenated vegetable oil (trans fatty acids). This type of fat, although not a saturated fat, is now known to raise the risk of heart disease and stroke and increase levels of circulating LDL (Sun et al., 2007). Trans fats are also linked to an increased risk of Type 2 diabetes in women (Salmeron et al., 2001).

    Industrially-produced cakes usually contain processed grains such as white flour (which will cause spikes in blood sugar). If the sugar in cakes is cane sugar (increasingly rare nowadays), it will also cause a rapid rise in blood sugar, reinforcing the impact of the processed white flour. More commonly in processed foods, the sweetener is high-fructose corn syrup, which, while it does not impact on blood sugar in the way that simple sugars do, is now being linked with non-alcoholic fatty liver disease. Also, since it does not provoke an insulin response in the way that cane sugar does, it does not stimulate the satiety signals which might limit the appetite (Johnson & Gower, 2009).

    However, the ‘culprit’ in cakes – according to this advice – would be ‘saturated fat’.

    As far as meat is concerned, if it is from grass-fed animals or non-factory-farmed poultry fed a natural diet which includes insects, worms and wild plants, then most of the fat in the meat will be monounsaturated fat, and rich in Omega-3 fatty acids, an essential dietary fat and a known anti-inflammatory (Maroon, 2006). If the meat is from grain-fed animals, then the meat is likely to be higher in Omega 6 fats, which can be deleterious to health if in a high ratio to Omega 3 intakes. (Simopoulous, 2002). A healthy ratio between Omega 3 and Omega 6 is no more than 2:1.

    Margarine, promoted as a healthy alternative to butter, is, however, associated with heart disease (Gillman et al, 1997). For each teaspoon of margarine consumed a day, risk of heart disease was raised by 10% (Willett et al, 1993).

    Food industry compliance

    Of course, most ordinary people have probably never seen the Eatwell Plate – but the food industry loved it and sprang into action. We now see the consequences of it every day in the so-called foods which line our supermarket shelves, emblazoned with healthy-sounding labels like ‘wholegrain’ and ‘low fat’ (but stuffed with sugar, processed vegetable oils and salt to make them taste of something other than wet cardboard).

    The 2010 position statement in the Journal of the American Medical Association (A Time For Food) criticises the nutrient-based official healthy eating advice of the last 40 years. (Of course, the USA started down this path a decade earlier than the UK and its ‘diabesity’ epidemic is, by a spooky co-incidence, about 10 years ahead of us.)

    The JAMA paper goes on to say that this approach has fostered dietary practices that defy common sense, and allows highly-processed foods to be marketed as ‘healthy’ because they have replaced saturated fat with refined carbohydrates. It notes that the proportion of total energy from dietary fat appears largely unrelated to risk of cardiovascular disease, cancer, diabetes, or obesity. It also states that carbohydrate is a nutrient for which humans have no absolute requirement.

    The paper concludes with calling for a major shift ‘to novel, evidence-based strategies (my emphasis) in which ‘foods’ [rather than individual nutrients] comprise the principal dietary targets.’

    So how about it NHS?

    Since in my view the roots of this dietary disaster lie in 1984, it seems appropriate to sign off with George Orwell, who presciently noted:

    We may find in the long run that tinned food is a deadlier weapon than the machine-gun.


    A sample of the evidence that was available before the NHS revised the Eatwell Plate this year

    Systematic reviews

    A number of metanalyses have found that the low-Glycaemic Index diet is effective for glycaemic control.

    Thomas & Elliott’s (2010) looked at Randomised Control Trials from 1950 to 2009. Criteria for inclusion included randomised controlled trials (RCTs) lasting four weeks or longer; and comparisons between a low Glycaemic Index diet and a higher Glycaemic Index diet for people with diabetes. The standard measure for blood sugar (glycaemic) control is the level of glycated haemoglobin (HbAIc) over the previous three months. In these studies, HbA1c measures were used as the primary outcome of interest, with adverse effects, insulin action and quality of life as secondary outcomes of interest. Twelve papers met the inclusion criteria (612 participants).

    Compared with people on the higher GI diets, there was a significant decrease in % HbA1c levels in people on low-Glycaemic Index diets, indicating improved glycaemic control in the low-Glycaemic Index group (WMD 20·4% HbA1c, 95% CI 20·7, 20·2, P1⁄40·001).There were also fewer episodes of hypoglycaemia, significantly higher insulin sensitivity, improved quality of life and compliance with the type of diet. In a study where medication needed adjusting, ‘significantly less medication was required in people with Type 2 diabetes on the low-Glycaemic Index diet than in those on the American Diabetes Association-recommended diet to achieve equivalent control of HbA1cs levels.’

    The paper concluded that lowering the Glycaemic Index of the diet ‘appears to be an effective method to improve glycaemic control in diabetes and should be considered as part of the overall strategy of diabetes management.’

    One trial (conducted in children) reported on quality of life, and found that it was significantly influenced by the type of diet: twice as many parents of those in the low-Glycaemic Index group than of those in the high-Glycaemic Index group stated that their children had no difficulties in selecting their own meals at the 12-month time point (51 v. 24%, P1⁄40·01). Also, almost twice as many parents of those in the low-Glycaemic Index group than of those in the high-GI group reported that diabetes never limited the type of family activities pursued (53 v. 27 %, P1⁄4 0·02).

    In a meta-analysis, Kodama et al (2009) reviewed randomized trials that investigated two kinds of prescribed diets (a low-fat, high-carbohydrate [LFHC] diet and a high-fat, low-carbohydrate [HFLC] diet); the diets were isocaloric with similar protein intake. Nineteen studies (with 306 patients) met the inclusion criteria.

    The LFHC diet significantly increased fasting insulin and triglycerides by 8% (p 0.02) and 13% (p 0.001), respectively, and lowered HDL cholesterol by 6% (p 0.001) compared with the HFLC diet.

    The findings suggest that ‘replacing fat with carbohydrate could deteriorate insulin resistance while the adverse effect on triglycerides from the LFHC diet could be avoided by restricting energy intake to a degree sufficient for the attainment of weight reduction.’

    A Cochrane Review (Moore et al, 2007) reviewed 36 articles reporting a total of 17 Randomised Control trials, of at least six months, involving 1,467 participants where dietary advice was the main intervention. Approaches included low-fat, high carbohydrate (LFHC), low-carbohydrate, high fat (LCHF), low-calorie (LC), (1,000 cal/d) and very-low calorie (VLC) (500 cal/d), and a modified fat diet. The study concluded that there are no high-quality data on the efficacy of dietary treatment of T2 diabetes, and there is an urgent need for well-designed studies examining a range of interventions.

    Randomised controlled trials

    A two-year study (Guldbrand & Nystrom, 2012) randomised 61 T2 diabetic patients into two groups, where they followed either a low-carbohydrate (high fat) diet (LCD) or a low-fat (LFD) diet. Both groups lost weight (approximately 4 kg on average), but after six months, the low-carb group had a clear improvement in glycaemic control, higher levels of HDL cholesterol and were able to lower Insulin doses by 30%. No such improvements were seen in the LFD group.

    A Randomised control trial involving 215 newly-diagnosed and overweight Type 2 diabetic patients (Esposito et al, 2009) aged 30 to 75, over a period of 48 months, randomised subjects either to a low-carbohydrate Mediterranean (LCMD) diet, of <50gms of CHO/day; or to a low-fat diet (LFD). Participants and investigators were aware of the treatment assignment but assessors of the primary outcome (length of time to introduction of hyperglycaemic drug therapy) were blinded. Secondary outcomes were changes in weight, glycemic control and coronary risk factors.After four years, only 44% of patients in the Mediterranean-style diet group required treatment, compared with 70% in the low-fat diet group (absolute difference, 26.0 percentage points [95% CI, 31.1 to 20.1 percentage points]). Those on the Mediterranean-style diet lost more weight and experienced greater improvements in some glycemic control and coronary risk measures than those on the low-fat diet.

    Similar results were observed in earlier RCTS (Dyson et al, 2007 and Samaha et al 2003) but the numbers were much smaller and the trials of shorter duration.


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    Loren Grant is an independent nutritional therapist and researcher based in Chorlton, Manchester.

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    Obesity has been in the news quite a lot during the past few months. In August, the government released its long-awaited obesity strategy, which was heavily criticised by health experts, MPs, and the CEO of Sainsbury’s; and which also left healthy eating campaigner Jamie Oliver ‘in shock’. The main critique has been that, with its focus on reducing sugar consumption and increasing physical activity, the strategy is far from Health Secretary Jeremy Hunt’s February promise of ‘robust action’ on the ‘national emergency’ of obesity. What is more, the focus within this new plan remains on voluntary action, with the exception of a sugar tax announced back in March.

    Indeed, a quick search in UK national and regional newspapers (available on Nexis) shows that, in the month of their respective announcement, the childhood obesity strategy was mentioned in 107 news articles and the sugar tax in 542. Yet a move that did not receive any coverage is an April 2016 Written Declaration launched by Members of the European Parliament calling for the European Commission and Council to work towards a Europe-wide recognition of obesity as a chronic disease.


    This is not, in fact, the first such call. A proposal for holding a European Obesity Day to raise awareness about the health consequences of obesity first came out in 2009. A European Obesity Day was then organised in 2010 and 2011 saw its President, Jean-Paul Allonsius, call on the EU and member states to recognise obesity as a chronic disease.

    Considering obesity a chronic disease is a change from the current definition of it as a contributor to chronic diseases, such as diabetes – a change that has already happened in the US in 2013 and in Canada in 2015. While it is uncertain how such EU-wide calls may impact a post-Brexit Britain, this would still be a development with potential ramifications for global health care.

    But what would be the implications if Europe follows in these footsteps? Arguments in favour of recognising obesity as a chronic disease typically include an improved rate of reimbursement for drugs, surgery, and counselling – all of which help obesity sufferers financially. The strongest argument in favour has been that calling obesity a chronic disease will reduce the stigma that stems from widespread misconceptions that obesity is down to moral failing and lack of self-control, manifested in over-consumption and lack of exercise. The latter point in particular does not always stand up to scrutiny; recent research has found that medically themed newspaper articles on obesity in Britain and Germany identified ‘lack of perseverance’ as the primary reason for the failure of drugs and therapy to reduce weight.

    Arguments against classifying obesity as a chronic disease include the point that people would have to be treated only because their Body Mass Index is above a certain threshold, even though they may be perfectly healthy. This weakness of basing decisions about one’s health on BMI has, in fact, received much popular attention and was among the main arguments against declaring obesity a chronic disease presented by the American Medical Association’s own Council on Science and Public Health. Evidence has also emerged that individuals can be ‘fat but fit’. Finally, in more severe cases, once obesity is seen as a chronic disease, individuals may be denied employment or insurance.

    In broader terms, what appears to be happening in this area fits wider trends where new definitions or lowered thresholds are turning millions of people into diseased overnight. This  trend is perhaps most pronounced in the mental health domain, where the latest edition of the Diagnostic and Statistical Manual of Mental Disorders defined persistently collecting items and being distressed upon discarding them as the treatable illness ‘hoarding disorder’. The path that obesity seems to be following is one where the condition is being broadened to include a larger patient population and de-stigmatised by being given a less embarrassing name – people would rather have ‘overactive bladders’ than be called ‘incontinent’ or, in this case, ‘obese’ instead of ‘fat’.

    Classifying obesity as a chronic disease appears to be based on a flawed BMI tool that is ill-equipped to measure fat tissue versus muscle mass; the argument also seems to rest on the unsupported premise that calling it a disease will automatically reduce, if not remove, the stigma. Against this background, it might be wiser to stick with the status quo.

    This article first appeared on the British Politics and Policy blog.

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