Assess Life, Health and Wellbeing in the London Borough of Bexley Listening to you, working for you

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1 Joint Strategic Needs Assessment Chapter 20 Diet and Nutrition Assess Life, Health and Wellbeing in the London Borough of Bexley Listening to you, working for you

2 CHAPTER 20 DIET AND NUTRITION 20.1 Introduction Good nutrition has a key role to play both in the prevention and management of dietrelated diseases such as cardiovascular disease, cancer, diabetes and obesity (World Health Organisation, 2003). Healthy eating during childhood and adolescence is vital as a means to ensure healthy growth and development and to set up a pattern of positive eating habits through into adult life. The promotion of evidence-based healthy eating messages is fundamental. Alongside this, it is necessary to ensure that guidelines concerning a nutritionally adequate diet are implemented to help prevent diet-related deficiencies and malnutrition in vulnerable infants, children and adults. Current dietary recommendations have been consistent for a number of years (SACN, 2008a) with the Eatwell Plate being the recommended pictorial representation of the recommended balanced diet (Food Standards Agency, 2008). Source: The Eatwell Plate developed by the Food Standards Agency It has been estimated that if diets matched nutritional guidelines, around 70,000 deaths in the UK could be prevented each year and that the health benefits (in terms of quality adjusted life years (QALYs) would be as high as 20 billion each year (Cabinet Office, 2008). General dietary guidelines for adults do not apply to children under 2 years. It is recommended that babies should be offered a gradually increasing amount and variety of solid foods, in addition to milk, from 6 months. This should include meat, fish, pulses, vegetables and fruit without added salt or sugar. Introducing solid foods too early or too late is undesirable. Between 2 and 5 years the timing and extent of dietary change is flexible. By 5 years, children should be consuming a diet consistent with the general recommendations for adults (Department of Health, 1994b). 1

3 20.2 Bexley s Diet and Nutrition Headlines There is very little robust data on local food intake It is likely that the overall dietary patterns described in the national picture for the general population, low income groups and black and minority ethnic groups and children are similar for the Bexley population The recently published Health Profile for Bexley estimates that healthy eating patterns for adults in the borough are better but not significantly different than the England average 30.5% of the Bexley adult (16+) population consume 5 or more portions of Fruit and Vegetables per day compared to a national average of 28.7% Model based consumption of fruit and vegetables in Bexley by ward ( ) highlights areas to the south where fruit and vegetable consumption is highest (32-37% of population consuming 5+ portions per day) compared to areas to the North and east where only 25-28% consume 5+ portions per day) In 2010 Bexley had 78 fast food outlets per 100,000 population (178 in total) this is the equal to the national average but significantly higher the comparator authorities of Milton Keynes (56 per 100,000 population) and Swindon (59 per 100,000 population) 20.3 The National Picture Adults in the UK tend to eat a diet that is too high in saturated fat, salt and added sugars, and low in fruit, vegetables, whole grains and oily fish (NHS Information Centre 2009, Food Standards Agency, 2001). This tends to be true for children who have a proportionally higher dietary intake added sugars and saturated fats (Cabinet Office, 2008). However there have been positive changes in the nation s diet over the last 15 years including a fall in fat and saturated fat intakes, and in the consumption of red meat, processed meat and meat-based dishes and an increase in fruit and vegetable consumption. Improving the diet of the general population in line with dietary recommendations would therefore have significant health benefits as described above. Results from the first year of the National Diet and Nutrition Survey (Food Standards Agency 2010) shows that diet and nutrient intakes of the UK population were largely similar to findings from previous assessments of diet in Great Britain, for all age groups studied. However, there were some indications of trends in intake moving towards recommendations and guidelines for healthy eating. For example results showed some reduction in intake of saturated fatty acids, although mean intakes were still higher than recommended. Trans fatty acid intakes were also lower than in the past and fell within recommended levels. Non-milk extrinsic sugars (NMES) intakes were reduced from past surveys for all groups except adult women. NMES intakes on average remained considerably higher than recommended. There was some evidence of an increase in consumption of fruit, and to a lesser extent vegetables, in children, but there was little change in adults. 2

4 The specific nutritional concerns vary between groups. These are described in detail in the Nutritional Wellbeing of the Population report (SACN, 2008) and include: Fruit and vegetable intake is below the five-a-day recommendation in all groups Oily fish consumption is below the recommended 1 portion a week in all groups. High average salt consumption. High consumption of soft drinks (particular in children and young people) High consumption of saturated fats (but around the recommended intake of total fat) in all groups High intake of sugars in most groups (particular children and young people and elderly people living in institutions) A substantial proportion of adults exceeded the sensible drinking recommendations making a significant contribution to energy intake Low fibre intakes in all groups Low intakes of vitamins and minerals, including vitamin A, riboflavin, iron, potassium and magnesium in those under 25 years. Low intakes of some micronutrients in older adults aged over 65 years. Evidence of low Vitamin D status in most population age groups A summary of the intake of the general population in comparison with recommended intakes was provided in the SACN report (SACN, 2008). High salt intake is particularly prevalent with 82% of men and 65% of women consuming more than the recommended maximum 6g of salt a day. Reducing salt intake can reduce blood pressure in just 4 weeks (Department of Health, 2010a). Most at risk groups From their analysis, the SACN report (SACN, 2008) identified the following groups as being at particular risk of poor dietary variety and low nutrient intake and biochemical status (SACN, 2008): Children aged 18 years and under Young adults aged years Smokers People in lower socio-economic groups Adults aged 65 years and over living in institutions Black and minority ethnic groups were not identified in the SACN report as analysis by ethnic group was not possible. However there are specific concerns that are described below. Lower socioeconomic status A good picture of the diet and nutrition of low income groups has been obtained from the Low Income and Diet and Nutrition Survey (Food Standards Agency, 2008). On average, low income households and those in the most deprived wards consume less fruit and vegetables, salads, wholemeal bread, wholegrain and high fibre cereals and oily fish and consume more white bread, full fat milk, table sugar and processed meat products. Key findings included: Only 3% of children and 15% of adults reported eating oily fish. 8% of men and 9% of women reported consumption of 5 portions of fruit and vegetables a day. The average number of fruit and vegetable portions eaten daily was: men 2.4, women 2.5. Fruit and vegetable consumption among children was very low, with only 1% of boys and 4% of girls eating five or more portions a day, with average daily consumption being: boys 1.6 and girls 2.0 portions. 3

5 Higher intake of sugar as a proportion of energy and sugary foods. There was a particularly high consumption of non-diet soft drinks, particularly in children. Lower intakes of non-starch polysaccharides (fibre) than the general population (due to the lower consumption of wholewheat foods and vegetables). Similar level of consumption of fats as in the general population. Similar level of consumption of vitamin and minerals with the exception of lower iron intake in women aged years in low income groups compared with the general population. 60% of adults lived in households where it was reported that salt was added during cooking and 30% of men, 22% of women, 13% of boys and12% of girls reported that they always added salt at the table. Children were more likely than adults to consume processed meats such as sausages, coated chicken and turkey, and burgers and kebabs. It has also been found that the diets of the low income population are accompanied by higher levels of smoking, higher alcohol intake and lower physical activity compared with population as a whole (Food Standards Agency, 2008). Food Poverty Food poverty is a term used to describe when a household or individual is unable to obtain a nutritionally adequate diet. Food poverty has also been defined as those households that do not have enough food to meet the energy and nutrient needs of all of their members (DeRose et al, 1998). Food poverty is believed to have four main influences: affordability of healthy food items, awareness of what constitutes a healthy diet; availability of healthy food in a local area; and accessibility to food outlets selling healthy food (Flaherty, S. J, 2008). There is a debate as to whether physical access to affordable food is an important factor in food poverty. A study in Newcastle found that the key predictors of healthy eating overall were dietary knowledge and a healthier lifestyle, rather than physical access to food in shops. Although this research was only done in one city it challenges the assumption that access to food is a significant issue in the diet of low income groups in deprived areas (Food Standards Agency, 2003). However there may be specific groups at a local level who do have issues of access (Flaherty, S. J, 2008). Social Factors affecting food choice A number of points emerged around social factors and food choice from the Low Income and Diet and Nutrition Survey (Food Standards Agency, 2008). Although there were no consistent associations between these and overall diet, results do give a preliminary indication of the relative importance of the different factors. Of the low income population: Men and women with a lower level of educational attainment tended to have a less healthy diet than men and women with a higher level. 30% of men and 29% of women reported that price/value/money available for food was the most important influence on their choice of food. Having more money and/or greater availability of cheaper healthier foods were the factors reported most often that would help to facilitate changes in diet. Overall, 35% of men and 44% of women indicated that they would like to change their diet, while 60% of parents/carers would like to change their children s diet. 39% reported that, in the last year, they had been worried that their food would run out before they got money for more, while a similar proportion (36%) indicated that they could not afford to eat balanced meals. Overall, 22% reported reducing or skipping meals and 5% reported not eating for a whole day, because they did not have enough money to buy food. 4

6 Children aged 18 years and under In addition to the information given above, it is also worth noting the main findings from the SACN Report (2008) show that the following are key areas where nutritional recommendations are not being met amongst children: Fruit & vegetables - Children aged 4-18 years consumed less than the recommendation for people aged over 5 years. Oily fish - All age groups consumed well below the recommendation. Non-milk extrinsic sugar (NMES) - On average all age groups exceeded the recommendation ( 11% food energy), with mean intakes up to 19% of food energy; the main source of which was soft drinks. Vitamin A- 10% of children aged 1½-18 years had intakes below the minimum recommended amount. Vitamin D - Children aged less than 5 years had a mean intake from food at 18% of the recommended amount and 12% of children aged years had low biochemical vitamin D status. Iron-16% of children under 5 years and 47% of girls aged years had iron intakes below the minimum recommended amount. Other Minerals - Large proportions of females aged years had mineral intakes falling below the minimum recommended amounts for magnesium (52%), potassium (28%), calcium (22%), zinc (24%) and iodine (12%). Smaller proportions of males in this age group had intakes below the LRNI for magnesium (24%), potassium (12%), calcium (11%), zinc (12%) and iodine (2%). Supplements 20% of children aged 1½-4½ years were reported to be taking non-prescribed supplements, mainly vitamins A, C and D and multivitamins. It should be noted that that new national policy now means that every child in reception, year 1 and year 2 in state-funded schools will receive a free school lunch from September Adults aged 65 years and over living in institutions There is evidence of low intakes and status for a number of vitamins and minerals for older people living in institutions. In October 2006, the Food Standards Agency issued nutrient and food-based guidance for UK institutions. The Nutrition Screening Survey (BAPEN, 2008) found that 42% of recently admitted residents in care homes were malnourished How does Bexley compare? Bexley like most areas has a lack of dietary and nutritional information about its local population. It is likely that the overall dietary patterns described in the national picture for the general population, low income groups and black and minority ethnic groups and children are similar for the Bexley population. With Bexley having higher prevalence of obesity than the national estimates for both children and adults we can assume that dietary behaviours may be poorer than the national picture. The recently published Health Profile for Bexley estimates that healthy eating patterns for adult are better but not significantly different than the England average (APHO, 2013). However this is based on the Health Survey for England ( ) which only asks about fruit and vegetable intake. This shows that 30.5% of the Bexley adult (16+) population consume 5 or more portions of Fruit and Vegetables per day compared to a national average of 28.7%. 5

7 There are stark differences however in fruit and veg consumption across wards. Model based consumption of fruit and vegetables in Bexley by ward, , highlights areas to the south where fruit and vegetable consumption is highest (32-37% of population consuming 5+ portions per day) compared to areas to the North and east where only 25-28% consume 5+ portions per day) Source GLA (2013) Fast food outlets The availability of cheap and ready unhealthy foods (such as fast food takeaway outlets) increases the risk of a diet based on high consumption of sugar, saturated fat and salt. Studies have found that an increased density of fast food outlets is directly related to increased Body Mass Index and that having a fast food outlet within 160m of school is associated with a 5% increase in obesity (J. Vigna, SD et al 2010). In 2010 Bexley had 78 fast food outlets per 100,000 population (178 in total) this is the equal to the national average but significantly higher the comparator authorities of Milton Keynes (56 per 100,000 population) and Swindon (59 per 100,000 population) 6

8 Sep-08 Dec-08 Mar-09 Jun-09 Sep-09 Dec-09 Mar-10 Jun-10 Sep-10 Dec-10 Mar-11 Jun-11 Sep-11 Dec-11 Mar-12 Jun Number of fast food outlets per 100,000 population (2010) Milton Keynes Swindon Medway Bexley Peterborough England Havering Source: Ordnance Survey Interest Map 2010 Children and Young People There is very little evidence at a local level on children s nutrition in Bexley. There is a local packed lunch survey of primary school aged children in Bexley that has been running since This survey shows no change in high fat salt and sugar contents (91% in % in 2012) and significant increases in in fruit and vegetable contents (7% % 2012) and healthy drink contents (26% in % in 2012) Bexley Primary Schools Packed Lunch Survey % of children surveyed who had Vegetable or Salad % of children surveyed who had Fruit % of children surveyed who had High fat, salt or sugar % of children surveyed who had Healthy Drink (Water, Milk or pure unsweetened fruit juice) % of children who have both fruit and vegetables The Children s Food Trust carried out an evaluation of the approach to the provision of food and drink in 80 Bexley early years settings in 2013, reviewing the audit conducted by the local Health Improvement Team on the extent to which 38 recommendations of best practice had been implemented. Half of these recommendations were fully met with a further 14 recommendations were partially met. 7

9 20.5 National policy and evidence of what works Increasing the consumption of fruit and vegetables can significantly reduce the risk of many chronic diseases. Eating at least 5 portions of fruit and vegetables a day is estimated to reduce the risk of deaths from chronic disease, stroke, and cancer by up to 20%. Research has shown that an increase of one portion of fruit or vegetables a day lowers the risk of coronary heart disease by 4% and the risk of stroke by 6%, and can help lower blood pressure. There is a particular emphasis on diet and nutrition in the following Public Health and clinical NICE guidance: NICE (2008): Maternal and child and nutrition. NICE (2010) Physical activity and dietary intervention for weight management before, during and after pregnancy. NICE (2010) Prevention of cardiovascular disease NICE Guidance (2006) Obesity guidance on the prevention, identification, assessment and management of overweight and obesity in adults and children NICE (2008). Lipid Modification. SACN had the following recommendations in its Nutritional Wellbeing of the Nation report (SACN, 2008): Reducing sugar and saturated fats whilst increasing intakes of fats from oily fish, nuts and seeds. Encouraging children to drink low fat milk rather than soft drinks. Promoting diets rich in non-starch polysaccharides (fibre) to reduce the risk of bowel disease. Encouraging people to eat more fish, particularly oily fish, would help to reduce the risk of cardiovascular disease. Reducing alcohol consumption. Vitamin D supplementation in institutionalised older people. Promotion of vitamin D rich foods, outdoor activity and supplementation for high risk groups (darkskinned ethnic minorities, people who cover their skin, young children and pregnant and breastfeeding women) especially during winter months. Continue to promote a balanced nutrient dense diet [e.g. Eatwell Plate model] in the context of a healthy lifestyle particularly targeted at young people, older adults living in institutions and people in lower socioeconomic groups What does this mean for Bexley? 1. Issues for concern and early consideration a. Interventions to improve diet should target deprived groups and other vulnerable groups who have been shown to have the poorest diets, including better understanding of nutrition beliefs to make better use of social media and support for better food purchase and preparation. b. Develop a maternal, infant and child nutrition strategy implementation plan and ensure integrated nutrition interventions through Children s Centres, schools, and other community settings. c. Ensure that evidence based messages and the Eatwell Plate are used to promote consistent messages concerning a nutritionally adequate diet, healthy eating and prevention of obesity, CVD and 8

10 diabetes. d. Work with take-away and other food outlets to improve the nutritional quality of food served. 2. Issues for Monitoring and Review a. Implement fully and audit the Government Food Buying Standard to ensure all food procured by, and provided for, people working in the public sector is in line with dietary recommendations made in the eatwell plate. b. Take forward recommendations in the interim retail planning guidance and in relation to the NICE CVD Prevention guidance to use existing powers to regulate the opening times and number of take-away and other food outlets serving foods high in fat, sugar and salt in given areas and in particular near schools. c. Ensure effective implementation of national free school meals from September 2014 for the target younger age group and further investigate ways to improve the uptake of free school meals for older children. 9