Overweight and obesity is on the increase in both adults and children. TheForesight: Tackling Obesities: Future Choices – Project Report(Government Office for Science, 2007) suggests that by 2050, 50% of the UK’s population will be obese. This is a major cause for concern as obesity can lead to coronary heart disease, type 2 diabetes, certain types of cancer and complications in pregnancy as well as many other well documented health complications (Ewles, 2005).
Not only is obesity and poor nutrition likely to increase the cost to the NHS from ? 2billion per year to ? 5billion per year in 2025 but the social implications are huge. By reducing premature deaths people, on average would enjoy and extra 1. 3 – 2. 5 million years of life and 2. 8 million years of illness and disability-free life (DoH, 2010). However, in contrast, the Health Survey for England (National Heart Forum, 2009) would suggest that although obesity is still a problem, the prevalence of obese children aged 2-11 years is, in fact, declining: By simply incorporating the recent Health Survey for England (HSE) data into the Heart Forum model, it is shown that for children of both sexes, aged 2 to 11, the predicted prevalence of overweight and obese in 2020 drop from their Foresight predicted values of 28% overweight and 16% obese to 22% overweight and 12% obese. Since the review of obesity predictions in 2005ii, the 2006 data showed a small reduction in obesity levels and the 2007 data have tended to confirm this decrease. ” This would indicate, that some, if not all of the health promotion strategies are beginning to take effect.
This essay will be critically examining the current early interventions, health promotion practices and Government policies aimed at reducing health inequalities with regards to improving nutrition and reducing obesity. All of the interventions discussed in this essay utilise the Public Health ‘Upstream Approach’ whereby the problems caused by disease and disability are addressed through prevention rather than treatment (Bournhonesque and Mosbaek, 2002). I have, therefore, not discussed weight-management clinics which aim to treat overweight and obesity – a ‘Downstream Approach’ which cannot be considered an early intervention.
The Black Report (DHSS, 1980), the Acheson Report (DoH, 1998) and the more recent Marmot Review (DoH, 2010) all identify that there are great differences between health behaviours and outcomes across a socio-economic gradient – widely known as health inequalities. In simple terms, the more money you have, the better educated you are and the better your housing and social environment are (including ethnicity) the better decisions regarding your health you will make andthe healthier you and your lifestyle will be.
The Determinants of Health and Wellbeing in Human Habitation model (Barton and Grant, 2006) demonstrates clearly the relationship between people and other external factors that contribute to health and wellbeing and, as stated by WHO, 2011: “The social determinants of health are mostly responsible for health inequities. ” For example, with regards to nutrition and obesity, the National Childhood Measurement Programme (2009) shows that in England approx. 23% of people in the most deprived quintile are obese but only approx. 13% of people in the least deprived quintile are obese.
It is also shown that whilst different areas of England are more obese than others (London having the highest figures and the South West having the lowest) the general trend remains the same. Despite Government initiatives like ‘Change4Life’ (DoH, 2011) which discusses portion sizes, healthy snack options and makes recommendations such as eating five portions of fruit and vegetables a day statistics suggest that there has been limited success. The House of Commons report, Health Inequalities (2009) showed that 35% of people of professional and managerial occupations will consume five pieces of fruit and vegetables per day but hat only 21% of people who are unemployed or in part-time employment will consume the recommended amount of fruit and vegetables. The Low Income Diet and NutritionSurvey (Nelson et al/Food Standards Agency, 2007) showed that 66% of boys will eat less than two portions of fruit and vegetables per day and in comparison 56% of girls will eat less fruit and vegetables per day. It also showed that the consumption of saturated fat differs between age and gender – men consuming 30. 4g per day, women 59. 4g, boys 27. 5g and girls 24. 7g.
There is also evidence of inequalities between race, gender and age and these are not always mutually exclusive. The Government White Paper Healthy Lives, Healthy People: A Call to Action on Obesity in England (DoH, 2011) highlights inequalities within ethnic minorities with women showing a higher prevalence of obesity than men. Healthy Lives, Healthy People (DoH, 2010) describes a partnership between the DoH and Association of Convenience Stores with the aim of making fresh fruit and vegetables more available in deprived areas and also providing chiller cabinets for fresh fruit and vegetables in work areas.
Healthy Start (DoH) is an initiative that allows low-income families to purchase free fruit, vegetables, milk and infant formula and vitamins in exchange for vouchers thereby encouraging the uptake of healthy foods. The Healthy Start Quality Impact Assessment (DoH, 2010) has been careful to identify and eliminate potential inequalities that could be connected with the vouchers e. g. Kosher alternatives can be purchased with the vouchers.
The same document indicates that the Healthy Start scheme has been largely successful but improvements to healthy nutrition education for families and awareness amongst eligible families of the scheme need to be made. Young children are, of course, reliant on their parents to provide their sources of nutrition. The Scottish Health Survey (2003) showed that children from families of lower socio-economic status consumed more fat, sugar and processed foods and less fibre, less ‘good’ carbohydrates like pasta and rice and less poultry and white fish.
A child’s weight can be influenced by many different factors including parental attitudes to food, family eating behaviours (young children model their eating on parental eating habits), food choices and reduced physical activity/increased sedentary lifestyles (DoH, 2009). It is therefore important to address parental nutrition as well as that of the children within the family. This can be a challenge if the family in question do not perceive there to be a problem with their current diet or lifestyle.
Sometimes recommending healthy nutrition to parents, handing out leaflets of signposting to websites or support organisations is simply not sufficient. It is important, as professionals, to recognise that some families will need a greater input than others and that the level of engagement with each family is likely to vary. The Educational Approach (Green and Tones, 2010) to Health Promotion aims to provide evidence-based information coupled with developing individual skills that will enable a person to make informed decisions about their health behaviour.
This can, however, result in the client making voluntary choices which may not concur with the health promoter’s. Training is available for professionals e. g. HENRY (Health, Exercise and Nutrition for the Really Young) funded by the DoH and Department for Children, Schools and Families. This scheme trains professionals working with families and young children to empower parents to provide an optimally healthy environment for their children.
It is soundly based upon the Family Partnership Model and uses solution-focused approaches and reflective practices and, having undergone evaluation, has shown to be a widely successful programme (Rudolf et al, 2009; Davis et al, 2002). For older children and their parents, cookery and nutrition lessons are now being made compulsory within schools (House of Commons, 2009) and ‘Cook It’ classes are available as part of the Healthy Lifestyles Service commissioned in some Primary Care Trusts.
There is a drive to improve school meals, children’s awareness and knowledge of healthy food and the general food experience through initiatives such as the Food for Life Partnership which through evaluation has shown to be a success (Orme, 2011). Christensen (2004) describes a Health-Promoting Family Model, whereby internal factors (such as genetics, family health history and values and goals) and external factors at societal level (income and wealth, housing, ethnicity etc. ) and community level (health services, mass media, peer-groups etc. can all shape a child’s health and well-being. It also discusses the idea of a child being an actor for health promotion and that their behaviour, opinions and self-awareness can be influential upon the family within which they are a member. The suggestion, therefore, that parental behaviour change is solely responsible for the health outcomes of family members is, perhaps, inaccurate. This model provides a substantial argument for Healthy Eating education within nurseries and pre-schools and also the promotion and implementation of the Food for Life Partnership.
It has been widely documented that the gap in health inequalities is widening despite best efforts to close it. The UKPHA (2004) responded to the White Paper Choosing Health – Making Healthy Choices Easier (DoH, 2004) by stating that choices in Public Health at a population level are spurious. The rich are becoming richer, the poor are becoming more likely to be victims and perpetrators of crime, progress in reducing the gender pay gap is slow and deprived communities suffer the worst effects of environmental degradation.
The response states that if you have lower socio-economic status, behaviour change and making healthy choices is simply not always an option; whilst Government initiatives and information given to families by health professionals is designed to empower people to make healthy choices, the locus of control is not always endogenous (Rotter, 1966). It should be recognised that the act of empowerment and giving advice to those who cannot act upon it, is, perhaps, an act of disempowerment serving only to feed the concept of a ‘Nanny State’ and creating a disconnection between behaviour and desirable outcomes (Freire, 1985).
WHO (1999) states that whilst national health policy should prioritise those most in need, all social groups are affected by unequal distribution of benefits related to socioeconomic growth and societal goods (e. g. access to education) and this needs to be addressed if the gap in health equality is to be closed. The Government has pledged to use evidence-based services to address the problem of inequalities in nutrition aimed at different population groups at National, Community and Local levels (DoH, 2011).
Beattie’s Four Paradigms for Health Promotion (1991) clearly shows how health promotion can be a ‘Top Down or Bottom Up’ exercise with the professional being either a leader or a facilitator for change. The Social Change model (Naidoo and Wills, 2009) whereby changes are sought within organisations at Government level to bring about improvements of the physical, social and economic environments thus promoting health can be demonstrated through the use of mass media, advertising and policy-change.
The Healthy Food Code of Good Practice (DoH, 2008) sets out seven targets including restrictions on the advertising of unhealthy food to children, information on nutritional content of food in a variety of settings and a single, simple and effective approach to food labelling. The Food Standards Agency has adopted the ‘Traffic Light System’ to visually indicate the nutritional value of foods with ease – this, the DoH (2008) states, has helped to drive behaviour change.
The Behaviour Change model (Naidoo and Wills, 2009) is concerned with making improvements to a client’s individual health by encouraging them to change their lifestyle. However, the client has to be ready to make the change – without this component, the act of behaviour change is likely to be ineffective (NICE, 2007). Subsequently, this can lead to ‘victim blaming’ (Ewles, 2005) if the individual is seen to be ‘ignoring’ advice whichis counterproductive when those choices are not really choices and the locus of control is exogenous.
However, with the gap in health inequalities no nearer to being closed, can the Government truly conclude that these measures are working towards behaviour change and healthier lifestyle choices? I would suggest that until the cost of healthy food is reduced, thereby making it more accessible to families with lower socio-economic status, surely the visual aids and advertising are futile? Both the Foresight Report (2007) and the Government White Paper Healthy Weight, Healthy Lives (DoH, 2008) recommend that early intervention could be a way oftackling the problem of overweight and obesity.
The Health Visitor Implementation Plan: A Call to Action (DoH, 2011) states that early intervention is ‘the most effective way of dealing with health, development and other problems within the family’ and the CPHVA/Unite (2008) recognise that Health Visitors play a key role in reducing childhood obesity through contact with families antenatally, postnatally and throughout the early years of a child’s life. This is discussed further within the schedule of the Child Health Promotion Programme (DoH, 2008) which states that healthy weight and nutrition should be discussed from the days of early pregnancy.
The Marmot Review (DoH, 2010) discusses a Life Course Approach which suggests that, even from the antenatal period, there will be certain life events that affect health (for example, in childhood, variation in nutrition affects growth which can then be associated with adult health risks [Wadsworth, 1997]) and wellbeing and that early intervention and prevention is key. A logical early intervention to prevent obesity would be to promote healthy nutrition in families. Singhal et al (2004) state that: “Early nutrition has a major impact on long-term health including cognitive function, bone health and risk factors for cardiovascular disease. ‘Start4Life’ (DoH, 2011) covers topics such as breastfeeding (which is widely recognised as a protective factor for obesity), weaning (again, widely recognised as a protective factor for obesity if started no earlier than 6 months) and physical activity for babies. EMPOWER (Empowering Mothers to Prevent Obesity at Weaning) is a specialist health visiting programme involving home visits to babies who are at high risk because their mothers were extremely obese prior to pregnancy. The programme has been developed and piloted and is currently undergoing phase 2 of a randomised controlled trial (Barlow et al, 2009).
Sure Start Children’s Centres offer support with healthy eating and breastfeeding, in conjunction with Health Visitor clinics, breastfeeding support groups and postnatal groups. However,the NESS (National Evaluation of Sure Start, Birbeck University of London, 2005) review of Sure Start Children’s Centres indicated that whilst the centres had benefit to less deprived families, there was little benefit to those families of greatest need. This could be explained by Tudor Hart’s (1971) Inverse Care Law; those who are most in need of an intervention either do not or cannot access ervices that are available.
The setting for health promotion is integral to effective health education and taking into account accessibility, the target group and the premises (or location) is a fundamental role of the health professional (Green and Tones, 2010). Getting this right can help to avoid the risk of increasing the health gap in society by addressing the needs of excluded groups and including unconventional settings (Linnan and Owens Ferguson, 2007). The Ottawa Charter (WHO, 1986) states that: Health promotion works through concrete and effective community action in setting priorities, making decisions, planning strategies and implementing them to achieve better health. At the heart of this process is the empowerment of communities – their ownership and control of their own endeavours and destinies. ” TheEuropean Health for All Policy Framework (WHO, 1999) demonstrates that by allowing individuals, groups and communities to influence the context in which they experience health and giving control over the environment in which they live and work, people are encouraged to take responsibility for their own health.
Witness accounts of a community successfully working together to prevent the closure of a budget supermarket in an affluent town centre rejuvenation project demonstrate how effective community empowerment can be (Ayre, 2011). As discussed throughout this essay there are a huge number of evidence-based documents that highlight the necessity for healthy nutrition and many more besides. Evidence-based practice and evidence-based health promotion are both becoming increasingly recognised within the public health domain (Nutbeam, 1999). Whilst, as identified by Perkins et al. 1999), evidence-based health promotion is a good thing, the UK Treasury Report (HM Treasury/DoH, 2002) would suggest that there is a high volume of research describing the problem of health inequalities but relatively little intervention research that helps to identify practical responses. Nutbeam (2004) describes the notion of ‘analysis paralysis’ for academics and policy-makers as a result of the complexities surrounding the differences in opportunity, access and resources and their impact on health status. This leads to continuous examination and debate about the nature of the problem but little effective action to tackle it.
Nutbeam carries on to say that a deficit in research surrounding wider social, economic and environmental determinants of health can discourage Government responses until more convincing evidence is obtained or can restrict attention to only good evidence of effect thereby narrowing responses significantly. Public health policies are inevitably guided by political considerations alongside available scientific evidence (Black, 2001) which can lead to restrictions in evidence-based assessments thus resulting in the ‘wrong answer to the right question’ (Davey-Smith et al. 2001). Having discussed healthy nutrition as an early intervention to prevent obesity, I would like to conclude that whilst there are many documents and initiatives concerned with reducing health inequalities across socioeconomic gradients, slow progress is being made. I feel it should be a priority to engage individuals, families and communities in health promoting activities and consultations that will encourage ownership in improving their diet and nutritional intake whilst taking into account their social, economic and environmental circumstances.
Until the cost of healthy food is driven down and the availability of cheap, unhealthy food is reduced little will change. As stated by the Royal College of Paediatrics and Child Health (2011): “Suggesting that children in particular can be “nudged” into making healthy choices especially when faced with a food landscape which is persuading them to do the precise opposite suggests this would be best described as a call to inaction. ” I perceive that, when combined, the Behaviour Change model and Educational Approach could be successful – when given the opportunity to make informed decisions, healthy choices may become more likely.
I also believe that, if used in isolation, neither model would have the desired outcome. Timely dialogue should occur to encourage the receptivity to behaviour change and evidence-based health promotion should be delivered in a way that is amenable and accessible to all socioeconomic groups. A ‘Bottom Up’ approach, whilst difficult to truly achieve, could be an effective way to tackle to problem of poor nutrition and the resulting overweight and obesity with clients identifying their own needs and gaining skills and confidence to act upon them (Naidoo and Wills, 2009).
I would suggest that the majority of interventions regarding healthy nutrition and reducing obesity (and perhaps all health promotion activities) are all top down as they all have a common goal – changing behaviour and improving health by providing evidence-based information with the professional acting as an ‘expert in the field’ (Naidoo and Wills, 2009). The delivery of the intervention, therefore, denotes not only the perceived role of the professional but also the level of success.