Obesity and Sugar – Successive governments have failed to act despite the warnings

The Scientific Advisory Committee on Nutrition (SACN) report out on Friday 17th makes recommendations on sugar and fibre consumption.  Inevitably the recommendations on sugar got the most attention, with a call for us to reduce our intake by half.

2020health’s top messages:

  • Our 2014 report Careless Eating Costs Lives’ top message is that there is no sobesitythumbnailingle solution and unless a comprehensive strategy is put in place, levels of obesity will still rise.
  • Of crucial importance is prevention and early intervention. A holistic strategy is urgently needed for children and should be a top priority.
  • The evidence tells us that once an adult is obese, the vast majority remain obese. 0.5% of men will return to normal weight; and just under 1% of women [1]. The best evidenced treatment for obesity is bariatric surgery.

Our take – clinical and political

  1. Whilst updated research is necessary, this is unhelpful if it leads to piecemeal ‘solutions’ to a complex and multi-faceted problem.
  2. We are mystified as to why taxpayer’s money was used to produce another report telling us that sugar causes tooth decay and that people who eat too much sugar put on weight.
  3. The recommendations on fibre intake will be difficult for anyone to consume. The example given is: 30g of fibre a day could be achieved, for example by consuming ALL of the following in a day: five portions of fruit and vegetables, two slices of wholemeal bread, a portion of high fibre breakfast cereal, a baked potato and a portion of whole wheat pasta.
  4. Successive governments have failed to act despite the warnings. This is the biggest    public health failure of our time.

Julia Manning, CEO of 2020health said: This report tells us what we already know, and it isn’t the obesity strategy that we desperately need. There is no single solution to obesity and whilst many people do eat too much sugar, this advice needs to be part of a cross-cutting hard-hitting obesity strategy. We have called for a cross-departmental obesity task-force, and for all policy to be considered in the light of what it will mean for the public’s health. We still haven’t got the action we require to tackle this enormous problem.

[1] http://www.bbc.co.uk/news/health-33551498 reporting from the American Journal of Public Health

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NHS Costs and charging: Publicity, shame and complexity

Commenting on today’s press about Jeremy Hunt has created waves with his new plan to state the cost of medicines on the label and with his comment last night (July 2nd) on Question Time that he is not opposed to charging patients for missed NHS appointments. The story is covered here.

2020Health’s top messagesChaging the culture 2010

  • Our short paper ‘Responsibility in healthcare: changing the culture’ (2010) recommended publicising the cost of medicines, devices and A&E attendance
  • We all need reminding to use NHS resources wisely – advertising the costs of treatment or missed treatment would help inform us
  • Flat fines for missing NHS appointments would hit those with the most complicated lives

Our take – clinical and political

2020health does not want to see anyone deterred from seeking medical advice when they feel they need it; flat fines for missed appointments may have this unintended consequence.

We value things more when we know what they are worth – especially the Brits who are more interested in value for money that European counterparts

All Political Parties should support schemes to reduce waste in the NHS

Some in the press have called this idea ‘shaming’ – feeling shame is important – shame means we feel we have done wrong and are more likely to redress a situation and try better next time.


Julia Manning, CEO of 2020health said: “We would not want to see a child who has just left care, or someone who is homeless, being told they can’t’ rebook an appointment until they have paid a fine. However we agree that we value things more when we know what they are worth and we recommended five years ago that we start publicising the cost of medicines on the packet. We think this will lead to a reduction in waste.”

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Questions that need an answer: Mental Illness

As the statistics below demonstrate, the need for treatment, prevention and early intervention for people who experience different mental illnesses is acute, yet services are still woefully under-resourced. We encourage you to ask these questions at all opportunities and campaign for a sea-change in provision for those who experience mental illness. See our latest Reports related to this field.


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No one is empowered if the truth is not shared

The new statutory duty of candour was introduced for NHS bodies in England (trusts, foundation trusts and special health authorities) from 27 November 2014, and will apply to all other care providers registered with CQC from 1 April 2015. Today the guidance is being introduced for individual professionals.

2020health’s Top Messages:

  • Honesty and integrity are essential to trust
  • Candour is crucial for both public and professionals – building trust and learning from mistakes only happens with honesty and integrity
  • No one is empowered if the truth is not shared

Our concerns – clinical and political:

Whilst the first two principles of candour could be applied proactively, it is clear from principle three onwards that this right to candour only exists retrospectively for patients. But what about our right to all the information and options up front?

2020health wants to see the right for the public to be more fully informed of their options for treatment as well as potential risks shared AHEAD of making choices, including treatment options not available on the NHS.

2020Health fringe meeting at the Conservative Party Conference 2014 entitled "Can we trust in Health Technology". Photography by DFphotography.co.uk

Julia Manning, CEO of 2020health said: “Candour is crucial for both public and professionals, and the sooner mistakes are recognised and addressed, the better for all. Building trust and learning from mistakes only happens with honesty and integrity. However we want to see this duty go further, and for informed consent ahead of treatment to be more comprehensive in terms the sharing of choices of treatment, including treatment not available on the NHS. The we will have honesty on all sides.”

You can hear Julia’s comments on Candour on BBC Radio London94.9 this morning (You can hear the clip on 2020health’s webpage)


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First impressions of an NHS conference

Guest Blog by Simon Bottery, Director of Policy and External Relations, Independent Age

Screen Shot 2015-06-24 at 10.50.13Older people, as we know, are huge users of the NHS. People aged 65 or over account for one in six of the population but one in two
hospital bed days and 60 per cent of the one billion medical items prescribed every year. So as an older people’s charity, Independent Age has been looking hard at how we can best help people navigate the complexities of the NHS. It was that spirit of enquiry that took me to last month’s NHS Confederation conference in Liverpool. The Confederation is made up of the organisations that plan, commission and provide NHS services and I was keen to see how we could best engage with them.

I’m not sure I’m much better informed on that question but I did find the conference fascinating, not least for the evident differences between the NHS sector and that group of services with which it is so frequently urged to integrate – social care. What follows is a series of first impressions, some of them perhaps poorly-evidenced, under-considered, naïve or just plain wrong. But maybe some of them will strike a chord.

  • It felt as though there were a lot more planners and perhaps commissioners at the conference than there were providers. Within the first 24 hours, I felt I was drowning under a weight of organisational acronyms and system charts. A typical breakout session would have a title like ‘Challenges in transforming care collaboration: new models of innovation’ and would feature two or three earnest professionals worrying about their organisations structure and culture. You may think I’m exaggerating but the full list of sessions is here http://bit.ly/1B2M6CQ : have a look. One cause – or possibly effect – of that focus on planning and commissioning was a relative lack of examples of actual service delivery. There were a few, often impressive, contributions from GPs in particular, outlining how their practices worked within their communities but I would have loved to have heard more, about and from a much wider range of services. It was ironic that perhaps the most powerful plenary presentation came from Brigadier Kevin Beaton OBE of the Military Medical Service who spoke, with Lt Col Maggie Durrant, about experiences in Iraq, Afghanistan and Ebola. But the strength of this presentation was at least in part because it was so atypical to normal NHS service delivery (which drew the wry observation from Brigadier Beaton that the Ebola clinic was one service that CQC had decided it did not need to inspect directly).
  • Probably as a consequence of the lack of service providers, it was quite hard to find the patients’ perspective. In fact as delegates were making their way home, the local Liverpool Echo was running a story about a pensioner ‘trapped’ in his flat because of a faulty lift, and the effect on his health and wellbeing. I thought ruefully that this seemed one of relatively few occasions on which service users – ‘patients’ – came into clearly into view during the conference. For the rest, end users were largely represented as statistics and data. That felt very different from a typical social care event, where the involvement of service users and often the inclusion of them in service planning (‘co-production) is becoming more mainstreamed. Perhaps tellingly, the only time I heard the term ‘co-production’ used was when NHS Confederation Chief Executive used it to describe how the NHS Five Year Forward View was put together – but he meant that it was co-produced by the six umbrella bodies in the NHS Confederation – rather than with service users. Screen Shot 2015-06-24 at 10.47.18



  • Ah, that plenary session with the six umbrella bodies. It seemed to this outsider to be a fairly uncontroversial idea – putting the chief executives of the CQC, Monitor, NHS England, Public Health England, Health Education England and the NHS Trust Development Authority – on stage together. But what they ended up saying was unfortunately rather less memorable than the immediate visual impression they created: the lack of diversity in six white, middle-aged men. After an initial attempt to humour through it by imagining the group as the ‘world’s most unlikely boy band’, chair Anita Anand admitted: “It’s rather white and ‘suity’ up here, isn’t it?”  Would it be any better if we put together the leaders of umbrella bodies in social care or the voluntary sector? At least a little, I’d like to think. Diversity was more evident in other sessions but even then it gave pause for thought. Surely no speaker at a social care or voluntary sector conference – even a total outsider – would begin his speech by saying ‘What a pleasure it is to be on stage with four lovely ladies’. But that’s exactly what one senior manager from an IT company said at the start of a ‘Tomorrow’s World’ session on technological change.
  • Despite all that talk about integration of health and social care, there wasn’t really that much evidence of its importance at the conference. NHS England chief executive Simon Stevens mentioned the ‘triple integration’ – primary/secondary, physical/mental and health/#socialcare. Health Secretary Jeremy Hunt spoke about the need to ‘integrate at pace’ health and social care. A session about the radical plans in greater Manchester again touched on integration.  But truthfully there was little too in the way of attendance or input from the social care, housing and voluntary sectors. There was at least one session involving a non-profit housing association, Home Group, and Stroke Association were exhibitors but this was far from mainstreamed. I don’t think we can blame the NSH confederation for that though – the opportunity to engage is there.
  • Rather than integration of health with social care, what seemed more immediately focusing minds was the reality of linking one part of health to another. The overwhelming impression gained from three days with the NHS confederation was of sheer scale and complexity of the different trusts and member bodies, leading to the almost inescapable question as to whether, in reality, there is any such thing as the NHS. Psychologists talk about our tendency towards ‘reification’ – to regard or treat an abstraction as if it had concrete or material existence. The NHS felt an abstraction rather than a single body in any meaningful way. Attempts to create that sense of unity didn’t always succeed totally. NHS Confederation chief executive Rob Webster got a round of applause for his assertion that ‘what gets us out of bed in the morning is the same, whether you’re a porter or a chief executive’. Sharing that on Twitter, drew one response: ‘Bollocks. What chief executive has to worry about whether he can afford to eat next week?’. It’s a fair point, isn’t it?
  • But for all the confusion and fog, I did genuinely take away a lot from confed. I gained even greater respect for the clinicians who work in the NHS and – genuinely – for the managers and commissioners who have to make sense of its complexities.  I met lots of people including many from organisations who I can imagine working with in future. Above all, I learnt a huge amount about the NHS, not least the realisation that I had known very little to begin with and that a very steep learning curve lies ahead. I also picked up quite a few aphorisms to be dropped into conversation (my favourite, delivered by Dr Paul Grundy, who was an architect of the Obamacare reforms, is: ‘If you want to herd cats, you’re going to have to move the food’.) Finally, I must say that Confed did live up to its billing as a tremendous source of freebies from the many organisations that exhibit. Pedometers, fans, data sticks – you name it, it was probably on offer somewhere. Free rucksack, anyone?
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NDPP – Potential game-changing programme to delay or stop onset of Type 2 diabetes

Guest Blog by Louise Ansari, Director of Prevention, Diabetes UK

Louise AnsariMost readers of 2020Health will be concerned about the rising tide of diabetes – some may even have heard that there is a new push on prevention. As Diabetes Week 2015 begins, here’s some more detail on the heralded National Diabetes Prevention Programme (NDPP), jointly being developed by NHS England, Public Health England and Diabetes UK

A few facts and figures first. It’s announced this week that 3.3 million people in the UK now have diagnosed diabetes – and another 590,000 people have undiagnosed Type 2 diabetes. It’s a staggering and shameful fact that someone is diagnosed every three minutes, especially when evidence exists that up to 80 per cent of cases of Type 2 diabetes are preventable, or at least onset can be delayed by up to five years.

More than 20,000 people with diabetes die before their time every year. The condition is a leading cause of preventable sight loss in people of working age and is a major contributor to kidney failure, heart attack, and stroke. As well as the human cost, diabetes accounts for around 10 per cent of the annual NHS budget – £10 billion a year.

Many whole-society measures are necessary, including reformulation of food and drink products to reduce sugar and fat, and a reduction in portion size. Whole population health could improve if such measures were taken systematically. But we know as well from five international randomised control trials that high risk people who go through a programme focussing on improving diet and exercise will significantly reduce their risk of getting Type 2 diabetes.

That’s where NDPP comes in. We will deliver at scale, an evidence based lifestyle change programme focused on lowering weight, increasing physical activity and improving the diet of those individuals identified as being at high risk of developing Type 2 diabetes.

The singular aim of the programme is to reduce people’s risk of developing Type 2 diabetes across England. This will improve the health of the nation whilst at the same time relieve the system of a major financial burden, both in reducing costs of day to day diabetes management, but also potentially reducing the much higher costs of managing complications such as limb amputation.

The NHS Health Check programme will provide a key referral route into the programme – many GPs already say they wished they had a programme to refer people onto once the Health Check shows them to be at high risk. There will also be other referral routes into the programme – all based around a NICE validated risk score, and pharmacists, GPs and community groups will all play a key role here. Often GPs will already have identified individuals at high risk and will have information on their systems enabling them to refer into the NDPP.

The NDPP is undertaking a review of existing diabetes prevention programmes to establish an evidence base of effective interventions, and this will be published later in the summer. We are currently working with seven local ‘demonstrator sites’ (Birmingham South and Central CCG, Bradford City CCG, Durham County Council, Herefordshire CCG/LA, Medway CCG/LA, Salford CCG/LA and Southwark Council and CCG) to learn practical lessons from delivery, testing and evaluation approaches.   The demonstrator sites will pilot new approaches and help co-design the service. We’re also setting up reference groups of experts to inform clinical design, and patients to inform the design from a user experience perspective. During 2015/16 we are hoping to target up to 10,000 people to participate in an intervention. Procurement planning is also underway for future national roll-out, as is planning for evaluation of the scheme, to provide the robust evidence of efficacy here that was shown in international trial

The NDPP has the potential to be a truly game-changing programme, reducing pressure on the system, helping people regain better health, and delay or stop a diagnosis of Type 2 diabetes, a progressive and ultimately severe condition

Diabetes UK home page

If you want to receive regular information on the NDPP please email diabetesprevention@phe.gov


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French Lessons that can really help

As the challenge of an increasing obesogenic population shows no sign of going away, the deluge of diet regimes, fitness regimes and research that either condemns or promotes certain foods over another continues to flow. How do we begin to make sense of it all?

Our guest blog on Monday highlighted the valuable role dietitians can play in helping us navigate this deluge and support us all to live healthier lives, drawing upon theiobesitythumbnailr high level of skill and expertise in food and nutrition.

One of the concluding themes from 2020health’s recent report ‘Careless eating costs lives’ was that our health needs change depending on where we are in the life cycle so understanding our dietary needs throughout life is paramount.  The focus needs to shift from a particular diet to ‘our diet’ and an improved understanding of food and what it means to eat a nutritious healthy diet.

Coupled with this is the need to help make healthy choices easier. Simply reinforcing messages about poor choices will not work. People need to be educated to understand what constitutes good choice so they can take steps to change their behaviour.

So how might the specialized skills and expertise of the dietician be more effectively utilized within the health and social care system? 

With the general shift towards community based care and a focus on integration of services, one approach would be to make greater use of dieticians within the community setting and increasing ‘touch points’ with dieticians within the GP surgery.


Our ‘Careless eating costs lives’ report reviewed many different areas of interventions, which different countries have adopted to try and tackle obesity. One example was EPODE, originating in France, and an acronym for ‘together let’s beat childhood obesity’. The largest national obesity network, EPODE has fostered a multi-stakeholder approach with links established between civil society, the corporate sector, NGOs, academia and institutions.

The EPODE approach endeavours to deliver programmes that create everyday norms and settings for children to eat healthily and play safely and actively. The multi-stakeholder, whole community approach facilitates the development of healthy environments including mapped walking routes, playgrounds and cycle routes. Community involvement discourages opposition and provides individuals with a value in the local environment. Local government is closely involved and a local figurehead is appointed to pioneer projects and motivate the population.

Whilst some speculate as to whether some grand initiative like EPODE could run in the UK, owing to a perceived lacklustre community spirit and local engagement, it does offer an enticing innovative and sustainable approach. It demonstrates how adopting a network framework and nurturing a positive attitude towards effective change might reap health benefits in communities and bring about a reverse in the current trends of societal divide.

There are two key aspects of the EPODE programme which I particularly want to highlight here which are relevant to developing the role of the dietician:

  1. a. Tailoring support to the needs of the community
  2. b. Helping children reconnect with the food system

a) Tailoring support to the needs of the community

The EPODE programme is specifically designed for tailoring to the individual requirements of communities.

Screen Shot 2015-01-14 at 12.11.00Changes in the global food system, including reduced time-cost of food, changes to local environments and increased automation of labour at home and in the workplace contribute to the obesogenic environment (Swinburn et al 2013). An obesogenic environment is an environment which encourages unhealthy eating and insufficient physical activity. Contributing factors are high density of fast food outlets, restaurants and vending machines, and environments that discourage movement, e.g. either by making walking difficult (encouraging car use) or buildings where lifts are prominent and stairs are hidden (BBC News Magazine Monitor  2014).

Whilst current findings do not appear to be based on robust scientific trials, the opportunity for change which EPODE offers is clear,  not only in terms of improving the health of our younger generation, but in building united, healthy communities.

Dieticians and community engagement is nothing new but is under utilized currently. In certain areas of the UK dieticians recognize that it is easier to build a rapport with people when the environment is informal, such as in the community setting of a children’s centre to run Cook 4 Life sessions with mothers.

The dietitian’s skill set positions them to play an invaluable role in any community strategy for building and strengthening healthy communities.  Their specialized training allows them to assess, diagnose and treat diet and nutrition problems at an individual and wider public health level. This knowledge and understanding can then be used to evaluate the specific needs of a community and then translate it into practical lifestyle advice and guidance.

b) Helping children reconnect with the food system

Data from Public Health England indicates that one in 10 kids in England are obese by the time they start primary school. By the time they leave, one in five is obese and a third are overweight.  It is therefore becoming increasingly urgent to help educate from an early age the importance of making healthy lifestyle choices.

EPODE helps to demonstrate the value of reconnecting children with the food system and food supply, by helping to instill a better understanding of what it means to live healthily.  It is never too early to provide the best information to children about the importance of making healthy decisions.  As recommended in ‘Careless eating costs lives’, practical cookery skills and clear food education should form a statutory part of the Key Stage 3 Design & Technology curriculum, under Food Technology.

With their specialized knowledge of diet and nutrition and the skills to synthesis the latest scientific and public health data, dieticians have a critical part to play in the shaping and direction of any food education programme that aims to improve health literacy from an early age.

It is becoming increasingly clear that no one solution will resolve the obesity challenge. It is much more complex because it underpins how we live our daily lives, the environment in which we live and work and how we feel about ourselves.

Amongst the noise of talking ‘organizational change’, integration and collaboration between disciplines and professionals will be crucial.  And amongst the noise of the latest statistics, diet fad or research finding will need to be the voice of the dietician, shining a much needed light on how to make sense of it all and move forward effectively.

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