The HDA Evidence Base Improving diet and nutrition

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The HDA Evidence Base Improving diet and
nutrition

• Rob Howard
• Health Development Agency

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• The HDA East Midlands regional team are based
  with and work as part of the regional Public
  Health Group at the Government Office in
  Nottingham and also have an office base with the
  East Midlands Public Health Observatory at
  Pleasley Vale Business Park

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Carl.Neal_at_dh.gsi.gov.uk

• Training Jan 11th on evidence and evaluation

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The HDA Evidence Base

• Evidence Briefings Third level reviews of
  reviews
• Very robust approach strong evidence of
  effectiveness
• Critical appraisal transparency, systematicity
  and relevance

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The HDA Evidence Base A Health Warning!

• Not the answer
• Review of reviews of RCTs - may be less effective
  in real situations
• Lack of evidence doesnt mean it doesnt exist!
• Need to also consider case studies, local data
  and interventions, other types research, expert
  and practitioner opinion (try PHeL)
• A starting point

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HDA Publications

• Evidence on managing obesity and overweight An
  analysis of reviews of diet, physical activity
  and behavioural approaches Evidence Briefing
• Prevention of low birth weight assessing the
  effectiveness of smoking cessation and
  nutritional interventions Evidence Briefing HDA
  2003
• The effectiveness of public health interventions
  to promote the initiation of breastfeeding
  Evidence Briefing HDA 2003
• Breastfeeding for longer what works? Evidence
  Briefing HDA 2004
• Workplace intervention alcohol and diet HDA
  Choosing Health Briefing 2004
• Interventions on obesity HDA Choosing Health
  Briefing 2004
• Care pathways for the prevention and management
  of obesity. HDA Choosing Health Briefing 2004
• Cancer Prevention A Resource to Support Local
  Action in Delivering the NHS Cancer Plan HDA 2002
  

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The Evidence of Effectiveness of Public Health
Interventions and the implications. HDA 2004
http//www.hda-online.org.uk/downloads/pdfs/choos
ing_health/CHB1-public-health.pdf Implications
for Public Health Interventions - based on

• Strong evidence likelihood success high
• Effective intervention at national, regional,
  local and school level
• Judgements based on evidence, guidance, getting
  evidence into practice

Plus - HDA response to DH consultation
Priorities for Food and Health Action Plan,
June 2004
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National

• Regulation/ban food promotion children (including
  school manufacturer link ups)
• Recommendations needed on max levels and targets
  for fat and sugar reduction as well as salt
• Encourage end marketing on portion size, promote
  lower energy density foods
• National catering awards
• Role of CAP e.g. inclusion of fruit and veg
  high price,
• LA statutory requirement to provide healthy
  environments through planning process incl.
  healthy food access
• FAHAP comprehensive long term nutrition
  strategy
• Holistic food based supplementation programme for
  pregnant women
• Increased paid maternity leave
• Tax incentives employers supporting breastfeeding

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Local NHS

• Routine brief intervention in primary care
• Training for health professionals
• Specialist obesity treatment services
  universally available
• Family based behaviour modification programmes
  universally available
• Extension Better Hospital Food programme
• Ban fast food companies promoting or opening
  branches in hospitals
• Clear practical information and support for
  pregnant women
• Integrated multi-faceted approach to increase
  breastfeeding media, health education,
  professional training. Ring fenced local funding
  and PCT performance management

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Schools

• Multi-faceted interventions should be introduced
  integrated curriculum, nutrition, cooking,
  school meals, tuck shops, teacher training. Role
  for OFSTED.
• Extension NHSS to all schools
• Prohibition of all snacks except water, fruit,
  milk juice
• Better evaluation needed of schools based
  interventions

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Local Community effective interventions

• Focus on diet alone, or diet plus physical
  activity, rather than on a range of health topics
• Are based on proven theories or models of
  changing peoples behaviour or improving their
  access to a healthy diet
• Use a range of different interventions or
  projects which work at different levels, i.e.
  with individuals, small groups, and the wider
  community
• Make changes to the environment so that healthier
  choices are affordable and available
• Are developed through participatory approaches,
  i.e. with the support and involvement of the
  local community

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Assessing the barriers to healthy eating

• Difficulties in accessing a healthy diet by
  those living on low income are not caused by one
  factor alone, but by a range of factors that are
  both diverse and interlinked. These include,
  social and psychological, and economic and
  environmental (physical) factors Those working to
  improve access to a healthy diet therefore need
  to take account of this diversity.
• Working in partnership is key to this
  approach.
• The price of food is the most important factor
  in determining what to buy. The food budget is
  often squeezed to meet other demands.
• Increasing access to an affordable healthy diet
  in low income areas HDA 2003

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Local Community key to success

• flexibility by agencies in responding to the
  needs of particular communities.
• access to secure, and ongoing, funds
• professionals working in partnership with a
  community
• projects that involve local people, and ensure
  equal respect
• evaluation which is not confined to narrow
  clinical and behavioural measures, but include
  for example, changes in food purchasing patterns,
  structural changes and social outcomes
• striking a balance between partnerships and local
  ownership
• training for professionals and members of the
  community to enable them to acquire skills for a
  new way of working
• planning an exit strategy for health
  professionals from the outset. The aim of a
  successful community based project should be to
  foster self-reliance and to set in place long
  term and sustainable changes to peoples behaviour
  and the environment
• networking and drawing on the skills and
  experience of existing food related projects, to
  enhance and extended the reach of the work
• setting up a food and health task force or
  strategy group can result in richer and more
  co-ordinated activity

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Cancer Prevention A Resource to Support Local
Action in Delivering the NHS Cancer Plan HDA 2002

• Chapter 2 Improving diet and nutrition
• Dietary recommendations, reducing inequalities,
  BME groups, older people, developing local
  strategies, professional knowledge and expertise,
  general feature for effective interventions -
  community, schools, and work place settings
• Large suggested range activities to support local
  action

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Evidence on managing obesity and overweight An
analysis of reviews of diet, physical activity
and behavioural approaches Evidence
Briefinghttp//www.hda-online.org.uk/Documents/ob
esity_evidence_briefing.pdf

• e.g. Diet v Physical activity debate
• diet alone was more effective than physical
  activity alone and Despite the commonly held
  view that physical activity combined with diet
  is more effective than either ...alone, the
  systematic review evidence is conflicting

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Interventions on obesity HDA Choosing Health
Briefing 2004.www.hda.nhs.uk/downloads/pdfs/choo
sing_health/CHB3-obesity-14-7.pdf

• summarises the evidence for interventions to
  prevent and treat obesity and overweight in
  children
• e.g. School based cooking skills clubs can
  stimulate confidence in developing cooking skills
  outside the school setting and may produce social
  and educational benefits

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Prevention of low birth weight assessing the
effectiveness of smoking cessation and
nutritional interventions Evidence Briefing HDA
2003http//www.hda-online.org.uk/Documents/low_bi
rth_weight_evidence_briefing.pdf

• Deceptively complex but ...evidence that poor
  maternal nutritional status...can result in low
  birth weight
• e.g. interventions evidence of effectiveness
  for calcium supplementation to reduce preterm
  birth and LBW only positive finding
• Interventions on magnesium, iron, folate, zinc,
  Vit D, fish oil and advice either lack of
  evidence or conflicting evidence
• High protein or isocaloric balanced protein may
  be harmful

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The effectiveness of public health interventions
to promote the initiation of breastfeeding
Evidence Briefing HDA 2003http//www.hda-online.o
rg.uk/documents/breastfeeding_evidencebriefing.pdf
Breastfeeding for longer what works? HDA 2004
ISBN 1-84279-418-3http//www.hda.nhs.uk/Documents
/breastfeedingPO.pdf

• e.g. Scandinavian experience 98 breastfeeding
  rates (71 England, 54 NI), four types
  intervention
• Problem based information
• mother to mother support groups
• increase paid maternity leave and guaranteed
  return to work
• maternity ward practices toward mother-infant
  contact and autonomy

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Workplace intervention alcohol and diet HDA
Choosing Health Briefing 2004http//www.hda-onlin
e.org.uk/downloads/pdfs/choosing_health/CHB19-alco
hol_diet-14-7.pdf

• Three out of four good quality studies show
  positive effects of healthy-eating interventions
  in the workplace, with decreases in blood
  cholesterol of between 2.5 and 10.
• List of characteristics of an effective work
  place intervention

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Future HDA publications

• December 2005
• The National Healthy Schools Standard and
  Extended Schools
• March 2005
• Public health evidence briefing compendium
• An analysis of training provision in relation to
  the implementation of breastfeeding initiation
  and duration (website only)
• June 2005
• Health guide for Sure Start practitioners
  nutrition, smoking cessation and accidental
  injury
• October 2005
• Initiation and duration of breastfeeding
  (effective action briefing)
• Nutrition and low-income women in pregnancy (with
  focus on low birth weight) (evidence review)

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Other useful contacts and resources

• nutrition and food poverty a toolkit for those
  involved in developing or implementing a local
  nutrition and food poverty strategy. Dr Vivienne
  Press, National Heart Forum 2004
• http//www.heartforum.org.uk/
• House of Commons Health Committee report
  Obesity May 2004
• http//www.publications.parliament.uk/pa/cm200304/
  cmselect/cmhealth/23/23.pdf
• Scientific Advisory Committee on Nutrition
• http//www.sacn.gov.uk/
• Food Standards Agency
• http//www.food.gov.uk/
• National Institute for Clinical Excellence
• http//www.nice.org.uk/

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In conclusion, after all confusion of conflicting
evidence, the answer...

• The Japanese eat very little fat and suffer fewer
  heart attacks than the British or Americans.
• The French eat a lot of fat and also suffer fewer
  heart attacks than the British or Americans.
• The Japanese drink very little red wine and
  suffer fewer heart attacks than the British or
  Americans.
• The Italians drink excessive amounts of red wine
  and also suffer fewer heart attacks than the
  British or Americans.
• The Germans drink a lot of beers and eat lots of
  sausages and fats and suffer fewer heart attacks
  than the British or Americans.

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• Conclusion...
• Eat and drink what you like. Speaking English is
  apparently what kills you!

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• Rob Howard
• Senior Practice Development Officer
• Health Development Agency
• East Midlands Region
• Government Office for the East Midlands
• The Belgrave Centre
• Stanley Place
• Talbot Street
• Nottingham
• NG1 5GG
•  
• Tel [phone]
• Mobile [phone]
• email rob.howard_at_hda-online.org.uk