October 24th 2001 - Thistle Hotel, Cardiff

Mrs Ann Hemingway, Welsh Member of the FSA Board and Chair of the Advisory Committee for Wales opened the workshop by welcoming delegates to this first workshop in a series working towards producing a strategy to improve diet across Wales.

She emphasised the participative nature of the event and the need for the strategy to be developed in an open and transparent way, building sustainable partnerships with those who will be involved in its delivery and execution, and engendering a sense of shared ownership.[Slides from this and other presentations are appended in Annex B]

Health in Wales: Why we need a nutrition strategy

Dr Ruth Hall, the Chief Medical Officer for Wales, outlined the major health problems being faced by people living in Wales (coronary heart disease, cancer and obesity) and presented evidence pointing to diet and nutrition as being fundamental in determining the risk of these diseases.

Statistically, heart disease is responsible for the majority of deaths in Wales, and whilst mortality rates are steadily decreasing towards the National Assembly’s health gain target for 2002, they vary by more than threefold across the country and are substantially higher than in many other European countries, including England. Significant reductions in mortality can be achieved through improved diet as demonstrated by a programme implemented in North Karelia, Finland. Cutting down on saturated fat intake, eating oily fish such as salmon and mackerel, and increasing fruit and vegetable consumption have all been proven to reduce the risk of heart disease. Obesity is a major contributory factor in the incidence of coronary heart disease, cancer and diabetes, and more than half of the adult population of Wales is overweight or clinically obese. Cancer is the second most common cause of death in Wales, again with rates varying by more than twofold across Wales. It is estimated 25% of all cancer deaths are attributable to poor diet, particularly low intake of fruit and vegetables.

Poor diet not only has health consequences, but also has economic repercussions. People from communities experiencing the highest levels of social disadvantage are most often those whose diet is inferior, with resulting higher levels of these chronic diseases. National Assembly action to improve diet includes various initiatives such as the Welsh Network of Healthy Schools Schemes and the Community Food Initiative.

The need to work in partnership with the NHS, local authorities and voluntary and independent sectors was seen as crucial to the success of the strategy, and its development was timely given the proposed structural changes within the NHS and the shift in emphasis from disease treatment to its prevention through health promotion. Accordingly, education and training in health promotion were seen as an essential feature of the NHS plan for Wales.

Ms Suzi Leather, the Deputy Chair of the FSA, presented an overview of the Agency’s remit in respect of nutrition encompassing an outline of the Agency’s strategic nutrition framework; the factors influencing people’s eating habits; and action, planned or in place, to modify these. She commended the Welsh Executive of the Agency for moving ahead with its own Nutrition strategy and valued the contribution this would make to the UK operation.

A fundamental plank of the Agency’s nutrition work was in securing a sound evidence base for action. The FSA spends ¿6 million on nutrition research programmes and surveys each year, and more emphasis was now being placed on addressing the behavioural barriers to healthy eating. Taking the 5 main areas influencing population behaviour where intervention might effect changes in dietary habits: knowledge, life skills, social influences, access and stimulus to promote behavioural change, Ms Leather summarised current FSA activities under each of these headings.

With regards to knowledge, children, particularly in the 12-18 age group, were seen as the prime target, and the Agency was involved in numerous cross-government initiatives and promotional campaigns such as the Healthy Schools Programme and the BNF’s CD-ROM for secondary schools. Life skills are important to enable the knowledge acquired about healthy eating to be put into practice. With this in mind, the FSA were looking into making food labelling more user friendly and understandable and were evaluating the effectiveness of cooking classes. Social influences were seen as increasingly important given the high rates of food consumption outside the home. Educating caterers on healthier food choices is covered in a guide ‘Catering for Health’, developed to support catering lecturers, by the FSA in conjunction with the Department of Health and BNF. This will impact not only on the restaurant/entertainment market, but also on school, hospital and work canteens. The FSA are in discussion with the retail sector to develop a Retailers’ Charter to improve the range and ‘healthiness’ of food available in shops, and the issue of access was regarded as paramount in deprived areas. Finally, the FSA were working with Local Authorities, the NHS and the voluntary sector to effect behavioural change by supporting community initiatives and other activities to raise the profile of nutrition.

Having put into place measures to promote healthy eating practices, the FSA pledges to continuously evaluate and monitor these to ensure that action is sound, cost-effective and practical with positive and sustained outcomes for a healthier diet.

Professor Robert Pickard, a member of the FSA Advisory Committee for Wales and the Nutrition Strategy Steering Group, reviewed the recommended balance of foods in the diet and compared this to data on dietary intakes from research and surveys. The definition of a balanced diet in the UK is based around the Committee on the Medical Aspects of Food Nutrition Policy (COMA) recommendations. Sources of evidence to assess dietary intake compared to these recommendations included international and UK research on diet and health, surveys of diet and nutritional status and expert advice from Advisory Committees such as the Advisory Committee for Wales (ACW) and the Scientific Advisory Committee on Nutrition (SACN). Of these, the National Food Survey (DEFRA and formerly MAFF), National Diet and Nutrition Surveys (FSA and DH), and the Welsh Consumer Survey (FSA) were the main sources of evidence examined. With the exception of the latter, the Welsh population was under-represented in these surveys, so data on UK trends was presented.

As a population, we are now eating less fat, salt, and sugar, and more fibre and starch. Whilst this seems encouraging, it has taken 10 years to reduce our fat consumption by 2% and with another 2-3% to go it can be assumed it will be a further 10 years before we reach the UK target for intake. Nutritionists are also trying to promote fruit and vegetables as a central part of our diet, and although this is being taken on board by higher income groups, lower income groups are now eating less of these foodstuffs than they did 20 years ago.

Looking at the nutritional requirements at different stages of life, in pregnancy, poor nutrition can lead to low birth weight with increased risk to the offspring of chronic diseases like heart disease and diabetes in later life. Folate intake is also implicated in incidence of neural tube defects. Dietary habits acquired as children are continued into adulthood. There are big differences in the pattern and types of foods eaten between by children of different socio-economic groups, and 47% of children state fruit and vegetables are their least favourite food. This is borne out in the dietary survey data. Activity patterns show children spend 65% of the time engaged in ‘low energy activities’. This inactivity combined with poor diet did not bode well for future adult health. One problem with conveying the healthy eating message to children is the time lapse before the consequences of poor diet could be seen. For the elderly, the ability to absorb vitamins and minerals is reduced, particularly vitamin B12, and fish and meat consumption should be increased to compensate for this. Recent research has also found that DHA, an omega fatty acid found in oily fish, can dramatically improve the functioning of the nervous system.

In the final analysis, whilst much attention is paid to our outward physical appearance, we need to encourage people to think more about their ‘inner beauty’, or health, through improved diet and nutrition.

Mrs Joy Whinney, Director of FSA Wales and Chair of the Nutrition Strategy Steering Group, summarised the evidence on diet and health relating to Wales, and outlined the priority groups identified by the Steering Group with the rationale for their choice. Whilst the ultimate aim of the Strategy is to improve nutrition across the whole population of Wales, there is a need to reduce the inequalities in diet and health prevalent in Wales and to catch up with the best in Europe. It follows that there has to be consensus on where directed effort could have the biggest effect. Using dietary inadequacy, risk of consequent ill-health and amenability to behavioural change and maintenance as criteria for their selection, the Steering Group identified four main priority groups: infants, children and young children; the socially disadvantaged; women of childbearing age, particularly pregnant women; and men, particularly middle-aged men.

For infants, children and young people, good habits acquired in childhood confer health benefits into adulthood. The Bangor University 'Food Dudes' project has shown the potential for effecting change in the dietary habits of children, and the healthy eating message can conveniently be conveyed through the education system and wider community setting. Whilst FSA Wales and the National Assembly already have a number of education initiatives underway, it was recognised that there was a need to streamline and sustain efforts directed at children by various organisations to best effect.

The evidence showed that socially disadvantaged groups in Wales have poorer diets and higher incidence of major chronic diseases. Such health and nutritional inequalities arise from a variety of economic, environmental and knowledge barriers such as lack of income, access and basic skills. These root causes needed to be tackled in order to bring about improvements in diet.

In view of the potential health risks in later life conferred by low-birth weight, improvement in the nutritional status of pre-natal and pregnant women would have a double bonus, impacting on both mother and child. Health professionals have increased access to women during pregnancy, and this combined with heightened awareness of nutrition affords potential for influencing short and longer-term dietary habits of this group.

Middle-aged men typically have poorer diets than women and their risk of heart disease and cancer are much higher. Despite this, there is a general lack of health promotion targeted at men. This may be in part a result of men’s attitude towards safeguarding their health. There is, however, great potential in terms of health gain that could be unleashed with successful intervention directed at this group.

These four groups were put forward for discussion by the workshop participants with a view to seeking opinion on their selection, and to present an opportunity to propose alternative target groups if the consensus was for significantly different groups from those presented.

The main themes captured from this session are described below:

Q: There is suggestion that the 'Retailers Charter' mentioned by Ms Leather might include targets and league tables. What are the speakers view on this?

A: This is at an early stage of discussion but will have the ultimate aim of encouraging retailers to ‘compete for virtue’. The general public are perhaps unaware of the power retailers have in helping consumers make better choices, and whilst retailers are already moving in the right direction, there is still scope for them to do more to improve our diet.

Q: The connection between health and nutrition has been made, but without any mention of teeth and oral structures people use to eat.

A: The panel unanimously agreed this was a significant oversight and endorsed the view that nutrition has ramifications for oral health, and indeed that loss of dental structures can adversely affect food choice, particularly for the elderly. Similarly, there was concern that frequency of exposure particularly to sugar by babies and young children laid them open to future dental disease. There was also an evident social class relationship with tooth hygiene.

Q: The War diet was in many respects a healthy one. It would seem that our generation has lost the cooking skills and innate ability to gauge what makes a good diet.

A: There is a need to be creative rather than prescriptive in the way we educate our children about diet, and cross-curricular coverage and skill training in school would contribute to this. Furthermore, social and psychological support would instil a sense of confidence to put this teaching into practice.

Q: Many schools having limited funds feel pressurised to accept sponsorship money from companies promoting ‘unhealthy’ food items e.g. by collecting vouchers on crisp packets. This is obviously an undesirable practice but will the strategy take account of this?

A:This is an example of the overwhelming burden of advertising. It was suggested that the solution was not to ban such schemes, as schools may indeed rely quite heavily on these additional sources of funds. Instead, there should be a move towards promoting more healthy foods to counteract the effects of ‘junk food’ advertising.

Q: In terms of food prepared outside the home, low income consumers were more likely to encounter establishments selling chips, kebabs and burgers than hotels and restaurants which might provide healthier choices. How will the FSA address this?

A:The ‘Catering for Health’ programme, launched in England by the FSA and the Department of Health, is concerned with the food accessed by all sectors of society and has an important role to play in the teaching of nutrition in catering colleges. Through efforts here it was hoped to raise awareness and educate our chefs etc. to make healthier choices available.

Q: What consideration is being given to pesticides in fruit and vegetables given that we are advocating increasing our consumption of these?

A: The Advisory Committee on Pesticides publishes annual reports on pesticide levels in foodstuffs, which show these to be very low. The FSA have sought expert advice on this at the request of the Department of Health in relation to the free fruit for schools scheme and concluded that the benefits of fruit and vegetable consumption far outweigh any potential risks arising from pesticide contamination.

Q: There has been no mention of the importance of dairy products in childhood nutrition. Where there are schemes in school to promote fruit and vegetable consumption there is often a reluctance to also promote milk. The two should not be mutually exclusive.

A: It was accepted that milk was an important staple of the human diet from birth and it has a crucial role in safeguarding against osteoporosis later in life. With regard to the increasing levels of obesity we are now seeing in our population, there should perhaps be a move towards promoting semi-skimmed milk for the over 5’s.

Q: Given the limited resources available, middle aged men should not necessarily be selected as a priority group given their apparent resistance to change.

A:Quite often, it is the food choices made by the man as ‘head’ of the household that affect the dietary habits of the whole family, so there are further benefits that might be reaped by targeting this group. Also, ill health of men resulting from poor diet has repercussions for the rest of the family as they are often the main if not only source of income. As a group, middle aged men have been under-researched and not effectively targeted in the past.

Q: Whilst we are eating less than we used to, obesity is an increasing problem. To what extent will the Nutrition Strategy be supported by policy initiatives to tackle other factors such as exercise?

A: There are already two Assembly initiatives in progress: coronary heart disease prevention through development of national programmes on physical activity; and a task force being run by the Sports Council looking at issues to do with active lifestyles. There is also scope for improving food labelling to allow estimation of the effort required to ‘burn off’ its energy content.

Q: Research has proven the potential health benefits in terms of reducing dental caries achievable through fluoridation of water or milk.

A: This was really an issue for the Health Departments rather than for consideration as part of the Nutrition Strategy. The contribution that good dental health makes a to individuals eating a balanced diet was, however, acknowledged.

Q: There are many players in the field working hard to bring about change in dietary habits. The goal is long-term change but this is not supported by long term funding.

A: The panel shared these concerns. The FSA has a huge amount of ongoing research, and evaluation of this and other current initiatives were fundamental in terms of establishing what was effective in changing dietary behaviour.

Plenary Session 2: Feedback from group sessions on priorities, setting and achievement of targets

Discussion from the group sessions are reported using the series of questions appended to the background paper:

1. The priority groups proposed in the strategy are: socially disadvantaged groups; children and young people; middle aged men; and women of childbearing age. Do you broadly agree with these, and if not what other groups would you prioritise?

Socially disadvantaged groups:

• There was unanimous agreement on their selection, but some discussion over the terminology applied. Alternative suggestions included: socially excluded, low income consumers and communities in need.
• This group potentially included a wide range of sub-groups e.g. the elderly, ethnic minorities, disabled people, rural communities, prison inmates.
• Given the scope within this group (and indeed the other groups), the Steering Group should attempt to target those most in need.

Children and young people:

• Again there was unified consensus for selection of this group but with tighter definition on the age range, e.g. should those in higher education be included and would very young children/babies be better placed alongside ‘women of childbearing age’?
• The main focus of effort should be directed towards schools.

Middle-aged men:

• Selection of this group caused the most unease, and whilst the benefits of dietary improvement in this group were undisputed, there was concern at their amenability to change.
• Some delegates thought since no real effort had previously been made to target middle-aged men, they were worthy of attention but should take lower priority than other groups.
• Members of this group may well be picked up in other groups selected e.g. the socially disadvantaged.

Women of childbearing age:

• This group could encompass the majority of the female population so perhaps could be redefined as pre-natal and pregnant women.
• There was general accord for their selection but with particular emphasis on the nutrition of younger mothers.
• resistance to their inclusion was expressed, as this same group is readily targeted by a number of other strategies.

Other groups:

• ideas were to target younger men i.e. <40 years to pre-empt the health consequences of poor diet; and widowers/older men, as they may be vulnerable having possibly never cooked for themselves.
• larly, the elderly were mooted as a distinct priority group, however, given the lack of homogeneity within this population, there was latitude for targeting the needy elderly within the socially disadvantaged group. 'Pre-elderly' people (c.55-75 years) were also perceived to be an under-represented group.

2. What do you see as the main targets for the strategy overall?

Short term targets:

• increase the number of people receiving information about healthy eating through e.g. educational material for schools, leaflets, advertising, internet.
• increase/improve training of health professionals in the field of nutrition, and to increase recruitment to relevant shortage professions.
• increase fruit and vegetable consumption but with an achievable target, not necessarily the recommended 5 portions a day.
• improve food labelling to make it easier for consumers to make healthy choices.
• To widen variety in the diet by extending the numbers of foods eaten from each food group.

Longer term targets:

• To reduce the incidence of dental caries.
• To reduce levels of overweight and obesity.
• To reduce the incidence of coronary heart disease and strokes.
• To reduce the incidence of type II diabetes.
• To reduce the incidence of diet related cancers.
• To reduce the percentage of energy derived from total fat intake.

3. What do you see as the main targets for each of the priority groups and which organisations would be involved?

Socially disadvantaged groups:

• To improve access to healthier food through transport provision, pricing and retailing practices, local availability, and setting up of food co-operatives and credit unions.
• To increase consumption of fruit and vegetables and widen the variety of foods eaten.
• To increase community dietetics teams to meet recommended numbers per head of population.
• To increase involvement of community groups and leaders.

Organisations involved: retailers, schools, local planners, voluntary sectors, 'Sure Start', Local Authorities, Local Health Boards, NHS, health alliances.

Children and young people:

• To increase consumption of fruit and vegetables, and to widen the variety of foods eaten.
• To reduce consumption of fizzy drinks by children and increase availability of water in schools.
• To increase consumption of dairy produce, particularly milk.
• To improve the nutritional balance of school meals and explore the benefits of extending the use of the 'smart card' scheme.
• To increase awareness and understanding of nutrition through the curriculum.
• To improve practical cooking skills.
• To increase participation in the Welsh Network of Healthy Schools, and to increase the requirements demanded by this scheme.
• To increase promotion and advertising of healthy foods.
• To set up co-ordinated focus groups of young people to discuss healthy eating issues.
• To reduce the incidence of dental caries.
• To decrease the number of packets of crisps eaten.

Organisations involved: youth organisations, schools, school caterers, local education authorities, media, food industry, school milk co-ordinators, post-16 education providers, healthy school co-ordinators, school PSE co-ordinators.

Middle-aged men:

• To increase fruit and vegetable consumption and variety of foods eaten.
• To reduce consumption of saturated fat.
• To commission more research into ways to change dietary habits.
• To investigate potential for novel approaches e.g. through public houses, betting shops, working men's clubs.
• To reduce alcohol consumption, particularly by younger men, to within recommended limits.

Organisations involved: leisure services, employers, public houses, forces, prison authorities, NHS, sports councils and facilities.

Women of childbearing age:

• To increase fruit and vegetable consumption and variety of foods eaten.
• To increase folic acid in the diet.
• To reduce the incidence of low birth weight babies.
• To increase breastfeeding uptake and duration.
• To increase numbers of breastfeeding support groups.
• To increase training of midwives and health visitors to tackle nutritional issues.

Organisation involved: midwives, health visitors, nursery nurses, 'Sure Start', media, voluntary organisations, community development workers.

General comments:

• Whilst the strategy should be inclusive, aiming to improve the diet of all people in Wales, the funding stream should be directed towards the priority groups identified, with the socially disadvantaged and children/young people being most deserving.
• The strategy is timely given that many of the present Better Health: Better Wales targets are set for 2002.
• More targets are needed with more detail than the current 15 Better Health: Better Wales health gain targets.
• There is a need to take account of existing strategies such as National Strategic Frameworks and the primary care strategy to ensure consistency.
• Whilst physical activity is not within the remit of this strategy, it was an important consideration in its success, as diet and exercise together produce the desired health benefits.
• In order to achieve the long-term health benefits listed, long-term funding is required.

Ann Hemingway drew on feedback from reporters from each of the group sessions and the earlier presentations in capturing the key themes arising from the workshop. There was general consensus amongst participants on the priority groups identified, with the possible exception of middle-aged men. The Steering Group will keep the needs of this group under review. There was also some concern that pregnant women were already the focus of great deal of attention and intervention, and to single them out as part of this strategy was not helpful. Whilst the Nutrition Strategy would be directed at the population as a whole, selection of priority groups means a ranking for allocation of limited resources could be established, and it was agreed the socially disadvantaged and children/young people should take precedence. The Steering Group would take on board these observations, and will adjust the priority groups accordingly.

In considering targets, short-term targets were seen as essential in moving the Strategy forward and in celebrating success, and were useful as a means of breaking down longer-term targets into manageable segments. In setting targets it was important to be precise about how these would be measured, for instance, in determining access to and affordability of healthy food. Also, targets should be feasible and part of a continuum with cross-sector involvement, and social and community support if the Strategy is to be successful.

Whilst the long-term targets suggested were necessarily health related, the potential for effecting dietary change in the shorter term provided a more powerful impetus for the Strategy. Similarly, there was scope within the Strategy for novel approaches such as reducing the number of packets of crisps eaten and altering the contents of the 'retail shopping basket' to reflect the healthier option. Increasing fruit and vegetable consumption received universal endorsement but with achievable staged targets working towards the 5 a day recommendation. Finally, professional development of existing and training GPs and other health care professionals to enable more effective delivery of the healthy eating message was seen as essential.

The starting point for the day's discussion was consideration of the aims of the FSA, and the way they supported the development of a Nutritional Strategy for Wales, upheld by a broad range of opinion and delivering real measurable effects on the diet of the Welsh people. The input and material generated by the workshop would now be taken away by the Steering Group for consideration in taking this initiative forward.

Mrs Hemingway thanked the speakers, facilitators, Steering Group members and participants for what had proved to be an extremely informative and productive event.