November 21 2001 - Metropole Hotel, Llandrindod Wells

Mrs Joy Whinney, Director of FSA Wales and Chair of the Nutrition Strategy Steering Group opened the proceedings by setting out the background to the inception of a nutrition strategy for Wales and outlining the rationale behind selection of the ‘socially disadvantaged’ as a priority group for action. The main issues for consideration by delegates were to define more precisely the populations encompassed by the term ‘socially disadvantaged’, and to identify the barriers to healthy eating experienced by these people with a view to formulating practical and workable solutions that would progress towards a series of targets for improvements in diet and health. [Slides from this and other presentations are appended in Annex B].

Nutrition inequalities: The need for action

Sally Cavanagh, food poverty project officer from Sustain described food poverty as ‘the inability to acquire or consume an adequate quality or quantity of food’.

In the UK, this could affect 1 in 4 of the population, and studies have shown benefit levels and the minimum wage to be insufficient to financially support a healthy diet given that food was perceived to be a flexible budget item by many low-income consumers.

Furthermore, there were limitations to physical access through loss of local, independent stores, lack of car ownership and inflated cost of ‘healthy food’ where it was available locally.

Finally, low-income consumers were disadvantaged through their lack of practical cooking skills, understanding of food labelling and nutrition, and susceptibility to advertising.

Whilst the Government and other agencies were working towards addressing these issues through neighbourhood renewal, the minimum wage, public health strategy etc., a range of policy options involving consultation with communities, commitment from Government and co-ordinated action at all levels was necessary to reduce the level of food poverty.

The Sustain Food Poverty Project aims to improve access to food by people on low-income through a networking system where members can share experience e.g. on community food initiatives.

It also involves a community mapping element which uses participatory appraisal techniques to enable local communities to analyse their local food economies and work with local policy makers to develop appropriate action plans.

The recently launched Food Justice Campaign, based on a Sustain policy document Food Poverty: Options for the New Millennium, aims to secure a duty on Government to draw up and implement a national action plan for eradicating food poverty within 15 years.

Policy options identified in this report include: increase of the minimum wage, introduction of better transport systems, charitable status for local community shops, greater emphasis on cooking skills in the national curriculum, clearer food labelling and tougher regulation of food advertising.

In order to achieve the best outcomes for disadvantaged groups, it was important to recognise the diversity of needs and problems experienced by different communities.

Shirley Doyle, food and health advisor from St Mellon’s Healthy Living Centre gave a practical example of a project set up to improve the health of a community through addressing nutritional issues amongst others.

To put this in context, she started by sharing her experience of working in a clinical situation with the associated time constraints, long duration before follow-up appointments and poor uptake of dietary advice unless patients were already motivated.

By contrast, this project offered the opportunity for alternative ways of working with the emphasis on community involvement.

The St Mellons Healthy living Centre is situated at a large housing estate on the outskirts of Cardiff with a disproportionate number of lone parents, children and residents on benefits, whose lifestyles were a cause for concern.

As it is in its initial stages, the focus thus far has been on building trust, self esteem and confidence, whilst breaking down barriers and taking on board the issues presented by the community.

Links have been formed with supermarkets, local sports clubs and Sure Start, community mapping is ongoing, school action groups are in place and ‘cook and taste’ sessions have been successfully organised.

Given the level of illiteracy, it has been essential to be innovative in the way the healthy eating message is conveyed e.g. through use of Dictaphones instead of printed material when conducting surveys.

There is huge potential for project such as these to effect lifestyle changes, and whilst funding for this particular project currently exists for the next 5 years, there is an obvious need to take a longer term approach in achieving dietary change and related health benefits.

The main themes captured from this session are described below:

Q: Is there a role for the media in getting the healthy eating message across?

A:A recent consumer survey showed that TV is a preferred method of conveying healthy eating messages by some groups, however, there are inherent problems in generating media interest in dietary issues. Whilst the public are aware of these messages, the route to success lies in stimulating cultural change, for instance through work schools.

Q:Given the evidence from developing countries that women often forgo eating in deference to male household members, has there been any analysis of gender differences when doing community mapping?

A:Generally this has not been examined, but at a local community level differences arise from issues such as access, and action is then targeted on this basis. Women do however have a fundamental role in determining the dietary intakes of their family through shopping and catering for them.

Q:There is considerable commercial influence on our diets through advertising aimed at children and vending machines in schools encouraging products high in fat, sugar and salt. How can we work with the food industry to better guide children’s food choices?

A:The panel acknowledged this was an important issue. Whereas Sustain support a ban on advertising to children, and would like to see more balanced promotions, the Food Standards Agency is working with industry on a voluntary basis for change. It was felt that the National Assembly should top up schools’ income to avoid them having to rely on money from vending machines, and this might be more cost effective in the long term given the associated health benefits.

Q:There is an argument that provision of free school meals for all children could lead to improvements in the health of the entire population, particularly the socially disadvantaged. What is the potential for such action?

A:It was felt that the issues of concern in relation to free school meals were their nutritional content, and poor uptake by those entitled. Action was needed to overcome the stigma associated with free meals and there was scope for introduction of policies and incentives to improve uptake, for instance through avoiding separate queues for free meals, and introduction of smart card systems with bonuses for healthy choices. It was recognised this would be easier to enforce in primary schools, and that older children are more subject to peer pressure and often have the option to eat outside of the school grounds during lunchtime.

Q:With time pressures on professional parents, it is inevitable that more convenience foods are eaten. Is there any evidence to suggest that the diet of higher income groups is also getting worse?

A:It would seem that those on higher income compensate for increased intake of convenience foods through eating more fresh fruit and vegetables in addition, and have the option of choosing ‘premium’ fresh and pre-packed foods. Even so, a consumer attitudes survey showed that these groups were still not eating the government recommended amounts of fruit and vegetables.

Q:Lack of cooking skills, menu planning and budgeting are all barriers to healthy eating. How can we reinstate these for children through the curriculum, voluntary organisations etc.?

A:There are several ongoing projects in Wales, both in schools and through voluntary organisations such as the WI, and youth workers. The National Assembly has funded some cooking skill projects, which have proved successful and effective, but there is scope for extension of this to all schools as part of the strategy. Sustain are also piloting a ‘Grab 5’ project to promote fruit and vegetables to schools in England.

Q:Do we have any information on the proportion of income spent on food by households with differing income levels?

A:Lynne Kennedy was aware of data on this and agreed to provide it to the secretariat following the event. Whilst there is a range of estimates in the literature, official estimates available as part of the routine data supplied by the Family Expenditure Survey (HMSO) indicate low-income families spend 21% of their total income on food, compared to the national average of 17%.

Defining the ‘socially disadvantaged’

It was apparent from the first of the group sessions, that our working title 'the socially disadvantaged' needed to be changed to avoid patronisation and to reflect the range of different populations being considered. There were a range of suggestions including ‘the socially excluded’ and ‘communities in need’, however, the most apt in view of the range of groups being considered was 'low-income and other vulnerable consumers'. This reflects inclusion of not only those financially constrained, but also other ‘pockets’ of deprivation across a multitude of sub-populations who may experience problems of access, specifically: the disabled and chronically ill, the elderly, lone parents, rural communities, ethnicity minority groups, young people (particularly men), and people with low educational attainment.

As regards the low-income component, disposable income was seen to be the major constraint, and we need to find out more about percentage of income available to spend on food and transport to shops in relation to family income . Reference to the ‘poverty line’ or ‘deprivation index’ could be used to identify populations affected.

The target setting exercise threw up many similar ideas to those offered at the 24th October workshop although there was some dissension over the feasibility of dietary changes in the short term. There was, however, a perceived need to have ‘quick win’ targets, which would allow celebration of success and stimulate motivation towards longer-term goals.

Short-term targets

• To increase intake of fruit and vegetable by a practicable amount in the first instance with a longer-term aim of achieving the government recommended ‘5 portions a day’.
• To increase uptake of nutritious free school meals and to work towards removal of their associated stigma.
• To improve the nutritional content of meals provided in schools, private care homes, hospitals and prisons.
• To reduce fat, sugar and salt intakes through healthier mass catering practices.
• To provide simpler, more easily understood food labelling.
• To increase uptake of free school milk.
• To identify and develop existing community schemes.
• To expand the baseline evidence through further research/surveys/community mapping.
• To create funding streams to aid community schemes.
• To give cooking skills more teaching time in the school curriculum.
• To extend the numbers of fruit tuck shops and breakfast clubs in schools.
• To introduce fiscal incentives to make healthy food accessible.

Longer-term targets

• To lower dietary cholesterol and obesity levels.
• To reduce incidence of chronic diseases such as coronary heart disease, cancer, and diabetes.
• To align targets with National Strategic Frameworks and new health and well-being strategies.
• To reduce the incidence of dental caries and improve oral health.
• To increase the numbers of new mothers who breastfeed their babies.
• To increase benefit levels.
• To redress the balance of advertising in favour of healthier foods and to secure the co-operation of manufacturers in producing and promoting these.
• To adopt a whole school approach to healthier lifestyle and link dietary modification with physical activity.

Before embarking on a comprehensive action plan, there was a need first to engage communities in raising their awareness of nutrition and health related issues, and in getting them to identify the particular problems they experience when it comes to healthy eating. Such intervention would only be possible if time and effort was expended on fostering the confidence of these communities. Ideally, any resulting action plan would therefore be community led. This would need to recognise the low priority many low-income consumers place on healthy eating when confronted with other more pressing demands on their finances. It would also need to be sustainable and culturally integrated given that many of the current initiatives are isolated and of limited duration.

There was also impetus for having the right health professionals in place to facilitate the process, so, for example, Local Health Groups might have a community nutrition co-ordinator. This was particularly pertinent given the scope for influencing the current NHS review.

Schools were seen as fundamental to effecting dietary change through healthier school meals and schemes such as the Healthy Schools Network, School Nutrition Action Groups (SNAG), and fruit tuck shops and breakfast clubs. Moreover, there was a need to reassess the curriculum content of schools with a view to placing more emphasis on the practical skills required to access a healthy diet i.e. cooking, budgeting, and shopping.

Finally, there was substantial mileage in revisiting ‘best practice’ and applying the lessons learned from this. Taking the barriers to healthy eating identified by the keynote speakers, specific approaches to their remedy suggested could be rationalised according to the barriers they seek to overcome:

Financial barriers could be alleviated through:

• Introduction of credit unions.
• Increase in benefit levels/minimum wage.
• Subsidy of ‘healthy options’ thereby increasing peoples resources to buy these products.
• Availability of smaller portions through retailers to minimise cost and wastage.

Access problems could be addressed through:

• Improvement in transport systems e.g. through community buses, free transport to supermarkets, and community transport to more remote areas.
• planning systems,
• Food co-operatives and farmers markets using seasonal food from local farmers.
• Food box and food community delivery schemes.
• Community cafes.
• Influencing local planning policies to provide local facilities.
• Internet access through local libraries/community centres.

Gaps and realignment of information and skills base could be tackled by:

• Training of health professionals and those working directly with communities.
• Community cooking classes.
• Improved food labelling
• Tougher regulation of food advertising.
• Workplace schemes to inform and promote healthy eating.

A small number of high-level ‘headline indicators’ were favoured in determining progress towards targets with information derived from:

• Rolling dietary surveys.
• Community mapping exercises.
• Baseline data from schools.
• Food retailers.

Organisations involved in delivery and implementation of action

Central and local government, voluntary sector, NHS, FSA, Local Health Groups, Local Authorities, local Chambers of Commerce, Wales Centre for Health, British Retail Consortium.

Summary and closing remarks

Phil Morgan gave a synopsis of what he felt were the main issues that had arisen from the presentations and feedback from the discussion groups. Throughout there had been a broad theme dictating empowerment of communities with targeted local action as the route to success. Organisations needed to work co-operatively to tackle access problems through innovative ways of using planning systems, setting up food co-operatives and credit unions etc. Fruit and vegetable consumption was a major cause for concern, and efforts to rectify this should be reflected in targets which aim to increase intake beyond current levels with the ‘5 a day’ recommendation as the ultimate goal. Improvement in the nutritional content of school meals and increased uptake of free school meals would go some way towards changing children’s diets for the better. The need to simplify food labelling has previously been recognised and there is ongoing work by the FSA to address this. At the local level, efforts to enable communities to access a healthy balanced diet could be streamlined by appointment of a nutrition co-ordinator within Local Health Groups. Such actions, whilst diverse and far-reaching could in the longer-term help in redressing the inequalities in diet and health currently being seen.

Joy Whinney drew the day to a close by thanking speakers, participants and facilitators for their hard work over the course of the day, the outcome of which would be taken away by the Steering Group for consideration in producing the Nutrition Strategy.