Diet and nutrition

Good nutrition has a key role to play both in the prevention and management of diet-related diseases such as cardiovascular disease (CVD), cancer, diabetes and obesity (WHO, 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 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.

In the UK, the poorer people are, the worse their diet, and the more diet-related diseases they suffer from. This is known as food poverty. Poor diet is a risk factor for the UK’s major causes of death: cancer; coronary heart disease (CHD); and diabetes. It is only recently that the immense contribution it makes to poor health has been quantified: poor diet is related to 30% of life years lost in premature death and disability (De Rose et al, 1998).

Tackling food poverty is recognised as key to achieving government targets on reducing inequalities; reducing illness from cancer and CHD; and improving the health of children and older people. However, action needs to be more than health professionals giving advice to individuals. It must change the ‘food environment’ – that is, accessibility, affordability, culture – in which people live (O’Neil M, 2005).

Poor diet is a major health risk. It contributes to:

 

  • almost 50% of CHD deaths
  • 33% of all cancer deaths
  • increased falls and fractures among older people
  • low birth weight and increased childhood illness and mortality
  • increased dental disease in children.

This topic is most closely linked to:

 

 

Last updated: 2015-12-02 10:18:19
[+] Expand all

1. What are the key issues?

Breastfeeding rates are amongst the lowest in England and the gap between Hartlepool and England is widening.

At all ages, the proportion of people who are overweight and obese is higher than England.  Only half of adults eat a healthy diet. (53.5% of adults consuming 5 portions of fruit and vegetables per day, Public Health Outcomes Framework, 2015)

There is low uptake of vitamin supplements through the Healthy Start scheme.

People in vulnerable groups and those with low incomes are at increased risk of having malnutrition from diet-related illness.

There is inconsistent advice on optimal nutrition from professionals.

There is a high concentration of fast-food take-away outlets per head of population.

Last updated: 02/12/15

2. What commissioning priorities are recommended?

2012/01
Implement evidence-based best practice to maximise breastfeeding initiation and continuation.  Ensure appropriate support services are in place and that health professionals are appropriately trained to provide support and consistent advice throughout antenatal and postnatal periods. Amended from 2012, remains a priority.

2012/03
Increase promotion and uptake of the national Healthy Start initiative, in particular vitamin supplements, to both professionals and the target audience. Amended from 2012, remains a priority.

2012/04
Ensure targeted support and increase Health Check uptake for those identified as most at risk of malnutrition.  This includes tackling wider determinants by providing debt advice, improving housing conditions and ensuring access to affordable food. Amended from 2012, remains a priority.

The following commissioning priorities are new for 2015:

2015/01

Improve children’s diet during early years of life alongside work to promote healthy weight.

 

2015/02

Prevent and support the management of diabetes through a healthy diet.

 

Other priorities that are not necessarily related to commissioning include:

2012/02
Promote healthy eating, making use of national campaigns and brands, and develop joint working with key sectors, such as planning and transport departments, to ensure the potential for physical activity and healthy eating is maximised, including the use of health impact assessments to address the causes of obesity. Remains a priority.

2012/05
Develop consistent and integrated strategies among all health and social care providers to detect, prevent and treat malnutrition.  Make appropriate training available to staff in all settings so that they have a common basic knowledge of nutrition and the skills to promote a nutritionally adequate diet. Remains a priority.

2012/06
Ensure that good quality and healthy food is provided by working with local public sector service providers, such as schools, hospitals, and prisons. Remains a priority.

2015/03

Support the delivery of cookery training, especially for priority groups in line with the emerging evidence base.

 

2015/04

Work with partners to improve healthy cooking practices and healthy food provision in retail outlets and reduce the proliferation of fast food take away outlets.

Last updated: 02/12/15

3. Who is at risk and why?

Nationally, there have been positive changes in the diet of British people over 15 years (Scientific Advisory Committee on Nutrition, SACN, 2008).  However, the latest data from the National Diet and Nutrition Survey shows that overall, the UK population is still consuming too much saturated fat, added sugars and salt, and not enough fruit, vegetables, oily fish and fibre (Public Health England 2014).  Additionally, there are still several areas of concern.

 

Age
Infants, children and young people

Rates of breastfeeding have increased for all age groups nationally (Health & Social Care Information Centre, 2010).  However, young mothers have 50% lower breastfeeding initiation rates and are then less likely to continue breastfeeding compared to older mothers.

It is estimated that 30% of hospital admissions would be avoided for each additional month of full breastfeeding and that 100% of full breastfeeding among 4-month-old babies would avoid 56% of hospital admissions in babies who are younger than 1 year (UNICEF, 2012).

The diets of under-fives in the UK are too low in vitamins A and C, iron and zinc and, for some groups of children, vitamin D.  Children’s diets also contain too few fruits and vegetables, too much of the type of sugars that most contribute to tooth damage, and too much salt (Caroline Walker Trust, 2006).

Children are eating too many unhealthy snacks.  Nearly three in ten secondary school pupils are snacking on crisps, sweets or fizzy drinks three or more times a day (British Heart Foundation, 2011)

Children aged 11-18 have low iron intake, predominantly among girls where 46% have a mean daily intake below the recommended amount. This has implications for growth and development, and an increased risk of iron deficiency anaemia (Whitton et al. 2011).

Dietary habits seem to be set at an early age and seldom improve spontaneously (Frémeaux et al, 2011).


Young adults aged 19-24 years

The Scientific Advisory Committee on Nutrition (2008) found that:

 

  • Almost all (98%) young adults in this age group consumed less than the minimum recommended intake of fruit and vegetables. Mean consumption was 1.6 portions per day.
  • This group exceeded the maximum recommendation of added sugar (11% of food energy) with mean intakes sugar at 16% food energy. The main source was soft drinks with the average intake being 8-9 cans each week.
  • Almost one-third of women in this age group have a low vitamin D status.
  • Over 40% of young women had an iron intake below the recommended level.
  • One-fifth of young men had a salt intake above 15g per day; the recommended maximum is 6g.

Adults aged 65 years and over living in institutions
There is evidence of low intake 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. Malnutrition was found to affect more than 1 in 3 adults on admission to hospitals, more than 1 in 3 adults admitted to care homes in the previous 6 months, and 1 in 5 in adults on admission to mental health units in the UK (British Association for Parental and Enteral Nutrition, 2010). Most of those affected were in the high risk category. Malnutrition is common in all types of care homes and hospitals, all types of wards and diagnostic categories, and all ages.  According to the report, much of the malnutrition present in institutions originates in the community.

Gender
Almost one-third of women aged 19-24 have a low vitamin D status.

Over 40% of young women had an iron intake below the recommended level.

One-fifth of young men had a salt intake above 15g per day; the recommended maximum is 6g.

Some men, following divorce, consume a poor diet (e.g. living on “Pot Noodles” and takeaway food) due to their lack of cooking skills (Eng et al. 2005).

Socioeconomic status
Women from disadvantaged groups have a poorer diet and are more likely either to be obese or to show low weight gain during pregnancy and their babies are more likely to have a low birth weight. Mothers from these groups are also less likely to take folic acid or other supplements before, during or after pregnancy (Food Standards Agency, 2009).

Mothers in low socioeconomic position continue to have a strong impact on patterns of infant feeding (Health and Social Care Information Centre, 2010). Incidence of breastfeeding remains higher amongst mothers in managerial and professional occupations. However across the UK as a whole, breastfeeding rates increased in all socioeconomic groups (Health and Social Care Information Centre).

Nationally, breastfeeding rates amongst mothers in routine and manual occupations increased from 65% in 2005 to 74% in 2010, therefore narrowing the gap between the highest and lowest socioeconomic groups.

Mothers in lower socioeconomic groups are more likely to introduce solid foods earlier than recommended and their children are at a greater risk of both ‘growth faltering’ (that is, they gain weight too slowly) in infancy and obesity in later childhood (Armstrong et al, 2013). In addition, average daily intakes of iron and calcium are significantly lower, and rates of dental caries are significantly higher among children from manual groups compared with those from non-manual groups (Gregory et al. 1995; Health and Social Care Information Centre, 2015).

About 39% of people from low income groups report that they worry about having enough food to eat before they receive money to buy more. Similarly, about one-third (36%) report that they cannot afford to eat balanced meals. Overall, one-fifth of adults in low income groups report reducing the size of, or skipping, meals. Five per cent report that, on occasion, they have not eaten for a whole day because they did not have enough money to buy food (Food Standards Agency, 2008).

 

People have adopted a wide range of strategies to try and manage shortfalls in household income, and using food banks is often the last resort (Lambie-Mumford et al. 2014; Perry et al. 2014). However, more people are using them to make ends meet and the evidence suggests that need is driving demand, not supply (Cooper, Purcell & Jackson, 2014). Research in West Cheshire suggests that 47% of referrals to food banks were the result of problems with social security benefits with a further 20% the result of low, insecure incomes and 11% due to debt (Spencer, Ogden & Battarbee, 2015).

Many areas of dietary concern for people in lower socioeconomic groups were similar to that of the general population (Scientific Advisory Committee on Nutrition, 2008); but the following were more marked:

 

  • Average consumption of fruit and vegetables was lower with the average daily intake being 2.5 for women, 2.4 for men, 2 for girls and 1.6 for boys.
  • Intakes of added sugar, especially amongst children and saturated fats were above current recommendations.
  • Intakes of dietary fibre fell below current recommendations.
  • Evidence of inadequate nutritional status for iron, folate and vitamin D.
  • A substantial proportion of men and women were overweight or obese.

Ethnicity
People from South Asian and African-Caribbean communities tend to have a greater prevalence of vitamin D deficiency, which is thought in part to be due to darker skin tone (SACN, 2008).

Compared with white Europeans, South Asian children reported a higher mean intake of total energy, total fat, polyunsaturated fat and protein whilst carbohydrate (particularly sugars), vitamins C and D, calcium and iron were lower. These differences were larger for Bangladeshi children (Donin et al. 2010).

Compared with white Europeans, Black African and Black Caribbean children had lower intakes of total and saturated fat, fibre, vitamin D and calcium. (Donin et al. 2010)

Vulnerable groups
Learning disabilities
People with a learning disability have a greater prevalence of health problems. It is well established that they are nutritionally vulnerable. Historically, many people with a learning disability lived in long-stay hospitals where many nutritional problems occur. These problems can include the following; underweight (this leads to less resistance to infections and less resistance to pressure sores); overweight; constipation; dehydration and specific nutrient deficiencies. The main other issue cited is the higher prevalence of obesity and underweight in this population (The Caroline Walker Trust, 2007).

People suffering mental ill health
Self-neglect and disorganised lifestyles may be a symptom of mental health needs and may result in malnutrition. The 2007 National Nutrition Screening Week found 19% of adults admitted to mental health units were ‘malnourished’. Poor nutrition has been associated with a number of mental illnesses such as depression (Dipnall et al, 2015).

Depression increases the risk of mortality by 50% and doubles the risk of coronary heart disease in adults. People with schizophrenia or bipolar disorder have higher rates of obesity, abnormal lipid levels and diabetes. They are also less likely to benefit from public health programmes and mainstream screening (Department of Health, 2011).

 

Other Areas

There is increasing concern about the consumption of energy drinks in adolescents and young adults (particularly males), especially in terms of sugar content, impact on behaviour including increased risk taking and substance misuse and adverse effects affecting the cardiovascular and neurological systems (Ali et al. 2015; Sanchis-Gomar et al. 2015). A survey by the European Food Safety Authority (2013) found that 21% of UK adults were high chronic consumers of energy drinks (European average 12%), with an equivalent figure of 19% in adolescents (European average 12%).  The average consumption for adolescents in the UK was 3.1 litres per month, the highest in Europe (average 2.1 litres). Concerns over behaviour have led some schools to ban them whilst others have gone further by encouraging local shops not to sell them to students. However, robust evidence in relation to behaviour is sparse or non-existent.



 

Last updated: 02/12/15

4. What is the level of need in the population?

Healthy eating adults
The nationally produced Public Health Outcomes Framework provides local authority level data on healthy eating for adults. The 2014 data for Hartlepool shows 53.5% of adults eating at least 5 portions of fruit and vegetables per day, the same as the England average. 

Deprivation

Hartlepool is ranked as the 18th most deprived local authority area nationally (Index of Multiple Deprivation, 2015).  As a consequence, those living in the most deprived areas may face additional barriers to accessing and consuming a healthy diet. Evidence would suggest that locally this is the case due to the high rates of obesity and physical inactivity in these areas.

Breastfeeding
Breastfeeding initiation in Hartlepool is significantly lower than England.  Although rates have tended to increase in Hartlepool, greater increases are seen in comparable areas and the gap is widening.  In 2014/15, breastfeeding initiation rates were 49.6% in Hartlepool (one of the lowest rates nationally) compared to 74.3% in England. 

By the time babies are six to eight weeks old, only about one in five (20%) are being breastfed, less than half the proportion seen in England as a whole. 

Breastfeeding rates vary considerably within Hartlepool.  In Manor House and De Bruce wards, fewer than one-third of mothers initiated breastfeeding, compared with more than two-thirds in Rural West ward (Source: Tees Public Health / North Tees and Hartlepool NHS Trust).

Using the Mosaic social segmentation classification shows that the highest proportion of babies are born into families living in areas typified by Types ‘O’ and ‘K’, where fewer than 30% of babies are breastfed at birth.  Significant numbers of babies are born into families living in areas typified by Mosaic Types ‘E’ and ‘F’, where breastfeeding is initiated for about half of all births.

Using the Mosaic 'types' shows that the highest number of births is in Type O69, where over 80% of babies are not breastfed at all.

 

Healthy Start

Nationally collated data indicates that uptake of the Healthy Start scheme overall is progressing well in Hartlepool, with 81.7% of those eligible (n=1,489) taking part. Eligible beneficiaries are those who qualify to apply for Healthy Start (e.g. at least 10 weeks pregnant or have a child under four years old and the family gets: Income Support, or Income-based Jobseeker’s Allowance, or Income-related Employment and Support Allowance, or Child Tax Credit). Beneficiaries become entitled, once their completed Healthy Start application form has been processed and approved by the Healthy Start Issuing Unit.

 

Healthy Start Vitamins uptake is calculated based on the number of eligible children/mothers, multiplied by 1.5 per quarter (this gives you the potential number of drops/tablets consumed each quarter). Uptake is expressed as a percentage of the number of vitamins reimbursed over the potential number of vitamin reimbursement by the Healthy Start recipients in that area. This is based on the Healthy Start Reimbursement forms collected from local authorities, charities or Trusts. No forms were received for Hartlepool in 2014/15 therefore there is no data in relation to Healthy Start Vitamins uptake for the area.


School meals

School meals in Hartlepool meet the new National School Food Standards for school lunches set by the Government.  In 2014/15, school meal up take in primary and special schools in Hartlepool (70%) was higher than England (44%) and the North East (60%).  Uptake in secondary schools (61%) is also higher than both the regional and national averages (45% and 38% respectively).  Hartlepool has 29% of primary school children and 23% of secondary school children who are eligible for free school meals, higher proportions than England.

 

 

 

 

Last updated: 02/12/15

5. What services are currently provided?

Primary care
One-to-one consultations on nutrition and dietary advice are available within primary care. General practices also carry out brief interventions, particularly as part of the Tees Healthy Heart Check programme, to improve adults’ lifestyle behaviour including dietary habits.  The Hartlepool Health Trainer Service also provide weekly weight management clinics in some GP practices.

Antenatal care

Community midwifery services provide antenatal advice on dietary intake and supplements including folic acid and vitamin D.

 

Secondary care
North Tees and Hartlepool NHS Foundation Trust Nutrition and Dietetic Department provides specialist support for children, young people and adults, including diabetes and other long-term conditions, allergy advice and prevention of malnutrition.

Where appropriate health professionals in the acute and community settings are trained to identify those patients who are suffering from malnutrition, or are at risk, using the Malnutrition Universal Screening Tool (MUST). The Trust has a High Impact for Nutrition Group to ensure processes are followed and improved if needed. The community setting will be using this model to increase capacity.

Community services
Community Midwifery Services provide antenatal advice on diet and supplements, including folic acid and vitamin D.   Weight monitoring is also carried out at booking appointment to help assist risk level.

Mental health and learning disabilities

Tees, Esk and Wear Valleys NHS Foundation Trust cover a wide range of mental health, learning disability and substance misuse services. The dietetic team are implementing two pathways of care for malnutrition and weight management. 


In-patient food provision is monitored to ensure that menus provided for in-patient settings meet the nutritional guidelines and needs of the client group.  Healthy options are promoted using a traffic light food labelling system together with the provision of health promotion education groups and sessions for people with learning disabilities.

Health Trainer Service
Health Trainers help adults to develop healthier behaviours and lifestyles. The service offers practical support and signposting to appropriate services to help clients change their own behaviours by making informed choices and goals.  Typically, the service encourages people to eat more healthily, manage weight if appropriate and to drink sensibly.  The service also refers and signposts clients to services help people to stop smoking, participate in increased physical activity, undergo an NHS Health Check or support with mental health / debt management and other issues.

EDAN / Type-2 Diabetes prevention and support

Nutritional support is provided alongside physical activity as part of a prevention and support programme for clients at risk of, or diagnosed with, Type-2 Diabetes.  Delivery is provided through Hartlepool Borough Council Public Health (Sport & Recreation and Health Improvement).

Substance misusers
Drug and alcohol support services offer breakfast and brunch clubs as a way to engage substance misusers. Support is provided if needed with cooking and shopping skills to support service users in living independently.



Voluntary sector
Families First operate a health bus which is used to carry out health audits and lifestyle advice.
Hartlepool Mind provide a 6-week programme that addresses emotional and psychological factors for weight management as well as lifestyle improvements to provide long-term solutions.

Café 177 A healthy bistro run for young people by young people.




Breastfeeding support

Antenatal support sessions are provided by maternity services.  Following discharge from the midwifery service, locality health visiting teams and children’s centres support mothers further with breastfeeding and infant feeding.

 

Families in it Together Hartlepool (FiiT Hart)

Bespoke one-to-one family weight management programme incorporating physical activity and nutirional / behavioural support, provided by Hartlepool Borough Council Public Health (Sport & Recreation and Health Improvement).


Healthy Start scheme
The scheme provides pregnant women, new mothers and young children with free Healthy Start vitamins, which can reduce the risk of health problems associated with vitamin deficiencies (for example, rickets and spina bifida). Women supported by Healthy Start are entitled to free vitamins during pregnancy and until their child is one year old, while children aged from six months to their fourth birthday are also eligible.
 

Weaning programmes/advice
The Health Visiting service provides weaning advice when appropriate and when requested by parents.  Children’s Centres also offer advice and structured weaning programmes which support parents by providing safe and practical advice.


Learning Disabilities
General practices carry out annual health checks on patients registered with a learning disability and a Health Facilitator supports practices.

A DVD (Eat Well, Live More) has been developed by people with learning disabilities which is proving to be a valuable resource to educate clients with a learning disability and their carers.
 

Workplace initiatives

 The regional Better Health at Work Award encourages employers in the North East to consider how they can improve the health of their workforce.  Implementing and promoting healthy eating is an integral part of the scheme including the development of a healthy eating policy.

 

HBC Environmental Health (alongside Planning) are working with several established fast-food take-away outlets to promote healthier cooking and catering practices, including low-fat / low-salt / low-sugar menu options (sharing of good practice and healthy recipes between outlets), provision of water, and restricted salt shakers in fish and chip outlets, and mapping of A5 hot food take away outlets, to inform the planning process.

 

 

Last updated: 02/12/15

6. What is the projected level of need?

Breastfeeding at 6-8 weeks is forecast to increase slightly, based on historical data.  However, the rate is increasing more slowly than that seen in the North East, thus widening the gap.

Other emerging nutritional deficiencies may also increase locally, and with the elderly population predicted to increase, the prevalence of malnutrition may also increase subsequently impacting on local NHS services and health costs.

 

Last updated: 02/12/15

7. What needs might be unmet?

 

Training and building capacity

There is increased demand for the Health Trainer service, which is currently the only provider of diet and nutrition advice in the community at the tier 1–2 level of intervention. Therefore there is a need to review referrals and pathways to meet current and future demand.
 

There is a need for capacity and capability building in Hartlepool for frontline staff to ensure every contact maximises the health improvement opportunity, and to ensure consistent nutrition advice and support, particularly for those who care for vulnerable children and adults.


There is no consistent approach to educational needs and standards of practice for nutritional care and support in care settings, particularly linked to malnutrition.


Demand for cooking skills development and practical advice on healthy eating is high, but meeting this demand is subject to available staffing resources, funding and facilities.

 

Breastfeeeding
For breastfeeding, there are unmet needs for:

 

  • A universal model of antenatal information giving/contact with pregnant women delivered by health visiting teams to identify and act upon barriers to healthy feeding choices for babies.
  • An increase in the capacity of health professionals to be able to support women with breastfeeding in the first two weeks after delivery when Hartlepool has its greatest ‘drop off’ in the numbers breastfeeding.
  • A comprehensive paid peer support programme (NICE 2008a, 2008b, 2006)
  • Multiple ‘Breastfeeding Welcome’ venues, both statutory and private retail, in Hartlepool.
  • More ‘local’ breastfeeding support groups.

 

Vulnerable adults and children

Increased support and education for adults who move from a care setting to independent living and those already in supported living is needed as often they lack the resources and knowledge to purchase and eat a balanced diet, particularly for those adults with learning disabilities and mental ill health.


Black and minority ethnic groups

There is a need for targeted healthy eating and weight management services for the BME population.

Healthy Start scheme
As the Healthy Start scheme is significantly under utilised for vitamin supplements there is a need to raise the awareness of the scheme, in relation to the vitamin element particularly, both with professionals and families.

 

Learning Disabilities
There is a need for intensive engagement with people with learning disabilities to develop a greater understanding of healthy eating and weight management.  There is a particular need for increased support and education for adults who move from a care setting to independent living and those already in supported living as often they lack the resources and knowledge to purchase and eat a balanced diet.

It is essential that staff working with people with learning disabilities, in particular the care providers’ workforce, receive basic nutrition awareness and identify champions in areas to enable them to support people with learning disabilities to make healthy meals.  Certain areas such as staff training are currently being addressed via support from the Health Trainer Service.There is also a lack of specialist help available to support people with learning disabilities who are diagnosed with diabetes.

Malnutrition

There is a lack of awareness about the correct use of identification tools for malnutrition and processes followed in community care and social care settings.

Last updated: 02/12/15

8. What evidence is there for effective intervention?

National Institute for Health and Clinical Excellence (NICE) 
Public Health Guidance

Behaviour change at population, community and individual levels (PH6)Maternal and child and nutrition. (PH11)

Prevention of cardiovascular disease. (PH25)

Physical activity and dietary intervention for weight management before, during and after pregnancy. (PH27)

Preventing type 2 diabetes - population and community interventions. (PH35)

Managing Overweight and Obesity among Children and Young People: Lifestyle Weight Management Services (PH47)

Behaviour Change: Individual Approaches (PH49)

 Overweight and Obese Adults – Lifestyle Weight Management (PH53)

Clinical Guidance

Nutrition Support in Adults. (CG32)

Postnatal Care. (CG37)

Obesity: The Prevention, Identification, Assessment and Management of Overweight and Obesity in Adults and Children (CG43). (CG43)

Food Allergy in Children and Young People (CG116)

Lipid Modification: Cardiovascular Risk Assessment and Modification of Blood Lipids for the Primary and Secondary Prevention of Cardiovascular Disease (CG181)

Obesity: Identification, Assessment and Management of Overweight and Obesity in Children, Young People and Adults (CG189)

Department of Health

National Service Framework for Children, Young People and Maternity Services: Maternity Services.

Infant Feeding Recommendation

Healthy Lives, Healthy People: A Call to Action.

Interventions to Promote Breastfeeding

The UNICEF Baby friendly Initiative (BFI) suggests the following core practices in maternity and community services.

 

  • The delivery of an appropriate mix of education and/or support programmes routinely delivered by health professionals, practitioners and peer supporters. This includes:
    • Informal, practical breastfeeding education in the antenatal period, delivered in combination with peer support programmes to women on low incomes.
    • A single session of informal breastfeeding education delivered during the antenatal period, targeting women on low incomes.
    • Practical breastfeeding support from a health professional/practitioner in the early postnatal period.
    • Peer support programmes in antenatal and/or postnatal periods to women on low incomes.
  • Changes to policy and practice within the community and hospital setting including:
  • Supporting effective positioning and attachment.
  • Encouraging unrestricted baby-led breastfeeding.
  • Encouraging the combination of supportive care.
  • Teaching breastfeeding technique and reassurance for women with ‘insufficient’ milk.
  • Peer or volunteer support to be delivered by telephone in late antenatal and early postnatal periods to complement face to face support.
  • Breastfeeding education and support from one professional in the antenatal and early postnatal period.
  • One-to-one, needs-based professional education in the antenatal period and peer support for up to 1 year targeting white, low income women.
  • Media programmes that use local images for specific target groups, including teenagers.

A systematic review of professional support interventions for breastfeeding (Hannula et al, 2008) concluded that:

• Interventions expanding from pregnancy through to birth and the postnatal period were more effective than interventions concentrating on a shorter period.
• Intervention ‘packages’ using various methods of education and support from well-trained professionals were more effective than interventions concentrating on a single method.
• During pregnancy the effective interventions were interactive, involving mothers in conversation
• The BFI approach when combined with ‘hands off teaching’ was effective.
• Interventions that were effective during the postnatal period were: home visits; telephone support and breastfeeding centres combined with peer support.
• Professionals need breastfeeding education and the support of their organisations to act as breastfeeding supporters.
• Mothers benefit from breastfeeding encouragement and guidance that supports their self efficacy, feelings of being capable and empowered and that is tailored to their individual needs.

Children and Young People
One of the biggest challenges when trying to improve the diets of women, children and families is how to help them change their behaviour (rather than just their knowledge and attitudes). NICE guidance (see links above) emphasises that a multidisciplinary approach (involving and supporting the families themselves and the wider community) is the most effective option. It is important that professionals involved adopt a non-judgemental, informal and individual approach based on advice about food, rather than just nutrients.

Overall, the evidence suggests that dietary interventions which recognise the specific circumstances facing low income families, teenage parents and mothers from minority ethnic or disadvantaged groups are likely to be more effective than generic interventions. NICE suggest that services need to be accessible and applicable to everyone, including those with learning, physical or other disabilities. NICE also emphasise the importance of monitoring and evaluating new interventions.

Knai, et al. (2006). Getting children to eat more fruit and vegetables: A systematic review.

Townsend et al. (2011). The more schools do to promote healthy eating, the healthier the dietary choices by students.

Adults
A systematic review showed the effectiveness of 'paraprofessionals' (trained and supervised community food workers and health trainers) or peer educators who are trained and supervised by nutritionists to deliver education and skill-based programmes to low-income populations. The review found that managers will need to ensure that the intervention has been developed from a theoretical base, has a specific message about increasing fruit and vegetable consumption, and has a component about behaviour change (Cilska et al, 2004).

Story et al (2008). Creating healthy food and eating environments: Policy and environmental approaches.

Pomerleau et al (2005). Interventions designed to increase adult fruit and vegetable intake can be effective: A systematic review of the literature.

 Other documents:

 

Jolly K, Ingram L, Khan KS. et al. (2012). Systematic review of peer support for breastfeeding continuation: meta-regression analysis of the effect of setting, intensity, and timing. British Medical Journal, 344, d8287

 

Kaunonen M, Hannula L. & Tarkka MT. (2012). A systematic review of peer support interventions for breastfeeding. Journal of Clinical Nursing, 21 (13-14), 1943 – 1954

 

Government Office for Science (2007) Tackling Obesities: Future Choices. London: Author

 

Lara J, Hobbs N, Moynihan PJ. et al. (2014). Effectiveness of dietary interventions among adults of retirement age: a systematic review and meta-analysis of randomized controlled trials. BMC Medicine, 12, 60

 

McGill R, Anwar E, Orton L. et al. (2015). Are interventions to promote healthy eating equally effective for all? Systematic review of socioeconomic inequalities in impact. BMC Public Health, 15, 457

 

Moran VH, Morgan H, Rothnie K. et al. (2015). Incentives to promote breastfeeding: A systematic review. Pediatrics, 135 (3), e687 - e702

 

National Obesity Observatory – for a wide variety of publications and information related to obesity

 

Renfrew MJ, McCormick FM, Wade A. et al. (2012). Support for healthy breastfeeding mothers with healthy term babies. Cochrane Database of Systematic Reviews, Issue 5. Art. No.: CD001141

Last updated: 02/12/15

9. What do people say?

General Population
There is a lack of local consultation and data on what people say about diet and nutrition-related issues.   Viewpoint 1,000 is a Hartlepool survey which is carried out regularly throughout the year to consult with local people on a range of issues.   In January 2012 there were questions about healthy lifestyle and the maintenance of a healthy weight.   It will endeavour to find out what people already know and how best to support them in lifestyle change and maintenance of a healthy weight.

A community consultation was carried out as part of the Health Trainer Services review in 2014.  A summary of the results of the consultation are available via the Hartlepool Obesity JSNA here (http://www.teesjsna.org.uk/hartlepool-obesity/)

Breastfeeding
In the past year Hartlepool health visitors collected individual feedback from 844 women, of whom 348 initiated breastfeeding at birth.  117 women ceased breastfeeding before the health visitors primary visit, and gave the following information :

 

  • Exactly how long they breastfed for;
  • If they had stopped breastfeeding and why; and
  • Their recommendations for the type of support that might have helped them.


The findings showed that the peak times for stopping feeding were within the first 4 days of birth and also at day 7.  Common themes in mothers’ responses for ceasing to breastfeed include:

 

  • Positioning and attachment difficulties in the first few days of feeding;
  • A feeling that they were unable to breastfeed, felt to be too difficult;
  • A feeling that the baby couldn’t breastfeed;
  • Painful breastfeeding;
  • Mother’s concern that their baby may not be getting enough milk; and
  • Mother’s concern that she was not producing enough milk.


Many of these concerns involve women’s expectations of what breastfeeding is like in reality, a perception that feeding isn’t going well and an anticipation that a solution could not be found.

This feedback provides vital information on subjects that staff can work with women in the antenatal and early postnatal period to reassure about the early days of breastfeeding, reinforce information on the signs that breastfeeding is going well and advise on local help available for feeding issues.

Women themselves have repeatedly requested:

 

  • More help and support during the earliest days of breastfeeding their child;
  • A ‘Mum to Mum’ peer support programme in both the hospital and community settings;
  • Clearly identified ‘Breastfeeding Welcome’ venues in Hartlepool; and
  • More breastfeeding support groups.


The North East SHA commissioned research with mothers on reasons for their infant feeding choices. The most common reasons for planning to use infant formula were:

 

  • Participants did not like the idea of breastfeeding;
  • Other people can feed the baby;
  • Inconvenient due to mother’s lifestyle;
  • Previous children were fed with infant formula;
  • Participants had breastfed previous children and didn’t like it.


The most common reason for planning to breastfeed was that ‘breastfeeding is best for health of the baby’.

During audit preparation prior to the UNICEF Baby Friendly Initiative, both the women who were bottle feeding, but had initiated breastfeeding and women who were breastfeeding asked for local breastfeeding support groups as they had seen these on the television.


Women and families value the support that is provided by peer groups. This was identified in the final recommendations of the Public Health North East social marketing benchmarking research.


Women also highlight that embarrassment is a large part of choosing not to breastfeed and not knowing where would be “safe” to breastfeed when in public. 

Last updated: 02/12/15

10. What additional needs assessment is required?

 

  • Audit of identifying malnutrition and processes used when malnutrition is identified in care settings.
  • Analysis of the results of the CQUIN Maternity and Health Visitor Antenatal Contact Pilot.
  • Continuing use of the UNICEF Baby Friendly audit of information given to pregnant women and mothers in the first months of feeding.
  • Continuing health visitor data collection and analysis of results.
  • Analysis of the impact of the peer support pilot.
  • Further insight into the availability of fast food take-away outlets and shops selling affordable, healthy food in Hartlepool, particularly in relation to schools and areas of deprivation (ward mapping).

 

  • An analysis of training needs for those working in care settings and for frontline staff.Needs analysis to determine the level of breastfeeding services that might be required locally and to calculate the cost of commissioning breastfeeding services by:

 

  • identifying indicative local service requirements;
  • reviewing current commissioned activity;
  • identifying future change in capacity required; and
  • modelling future commissioning intentions and associated costs.
  • Develop a better understanding of local beliefs and attitudes to diet and nutrition and use this insight to commission culturally appropriate interventions aimed at improving diet and nutrition in target populations.

 

Last updated: 02/12/15

Key Contact

Name: Steven Carter

Job Title:  Health Improvement Practitioner

e-mail: steven.carter@hartlepool.gov.uk

phone:  01429 523587

 

References

National strategies and plans

Department of Health (2004). National Service Framework for Children, Young People and Maternity Services: Maternity Services.

Department of Health (2004). Infant Feeding Recommendation.

Department of Health (2011). Healthy Lives, Healthy People: A Call to Action.

Scientific Advisory Committee on Nutrition (2015). Carbohydrates and Health. London: The Stationary Office

Local strategies and plans

Public Health North East (2012). North East Infant Feeding Weaning and Nutrition Guidelines

NHS Tees Breastfeeding Strategy 2010-2015

North Tees and Hartlepool Breastfeeding Action Plan

Other references

Ali F, Rehman H, Babayan Z, Stapleton D. & Joshi DD. (2015). Energy drinks and their adverse health effects: a systematic review of the current evidence. Postgraduate Medicine, 127 (3), 308 – 322

Armstrong J, Dorosty AR, Reilly JJ et al. (2003) Coexistence of social inequalities in undernutrition and obesity in pre‑school children. Archives of Disease in Childhood, 88, 671 – 675

British Association for Parenteral and Enteral Nutrition (BAPEN, 2010). Nutrition Screening Survey in the UK in 2007

British Heart Foundation (2011). The real five-a-day? UK kids feast on chocolate, energy drinks and crisps.

Caroline Walker Trust (2007). Eating well: children and adults with learning disabilities

Caroline Walker Trust (2006). Eating Well for Under 5’s in Childcare – Practical and Nutritional Guidelines.

Ciliska, D; Miles, E; O'Brien, M.A; et al, (2004). The effectiveness of community interventions to increase fruit and vegetable consumption in people four years of age and older.

Department of Health (DH), (2011). No health without mental health

DeRose L, Messer E, Millman S, (1998). Who's hungry? And how do we know? Food shortage, poverty, and deprivation.  New York: United Nations University Press.

Dipnall JF, Pasco JA, Meyer D. et al. (2015). The association between dietary patterns, diabetes and depression. Journal of Affective Disorders, 174, 215 – 224

Donin, AS; Nightingale, CM; Owen, CG et al (2010). Nutritional composition of the diets of South Asian, black African-Caribbean and white European children in the United Kingdom: The Child Heart and Health Study in England (CHASE). British Journal of Nutrition, 104, 276-285

Eng, PM; Kawachi, I; Fitzmaurice, G; & Rimm, EB (2005). Effects of marital transitions on changes in dietary and other health behaviours in US male health professionals. Journal of Epidemiology and Community Health, 59, 56-62

Food Standards Agency (2008). Low Income Diet and Nutrition Survey

Food Standard Agency, (2009). Annual Report of the Chief Scientist 2008/09

Frémeaux, AE; Hosking, J; Metcalf, BS et al (2011). Consistency of children's dietary choices: annual repeat measures from 5 to 13 years. British Journal of Nutrition, 106, 725-731

Gregory J, Collins D, Davies P et al. (1995). National Diet and Nutrition Survey: Children aged 1½ to 4½ Years. Volume 1: Report of the Diet and Nutrition Survey. London: The Stationery Office.

Hannula, L; Kaunonen, M; Tarkka, MT, (2008) A systematic review of professional support interventions for breastfeeding. Journal of Clinical Nursing 17(9):1132-43

Health & Social Care Information Centre (2010). Infant Feeding Survey 2010. London: Author

Health & Social Care Information Centre (2015). Child Dental Health Survey 2013, England, Wales and Northern Ireland. London: Author

Herbert K, Plugge E, Foster C & Doll H. (2012). Prevalence of risk factors for non-communicable diseases in prison populations worldwide: A systematic review. The Lancet, 379 (9830), 1975 – 1982

Ji C & Cappuccio FP. (2014). Socioeconomic inequality in salt intake in Britain 10 years after a national salt reduction programme. BMJ Open, 4, e005683

Jolly K, Ingram L, Khan KS. et al. (2012). Systematic review of peer support for breastfeeding continuation: meta-regression analysis of the effect of setting, intensity, and timing. British Medical Journal, 344, d8287

Kaunonen M, Hannula L. & Tarkka MT. (2012). A systematic review of peer support interventions for breastfeeding. Journal of Clinical Nursing, 21 (13-14), 1943 – 1954

Knai, C., Pomerleau, J., Lock, K. & McKee, M. (2006). Getting children to eat more fruit and vegetables: A systematic review. Preventive Medicine, 42, 85-95

Lambie-Mumford H, Crossley D, Jensen E, Verbeke M & Dowler E. (2014). Household Food Security in the UK: A Review of Food Aid. London: DEFRA

Lara J, Hobbs N, Moynihan PJ. et al. (2014). Effectiveness of dietary interventions among adults of retirement age: a systematic review and meta-analysis of randomized controlled trials. BMC Medicine, 12, 60

McGill R, Anwar E, Orton L. et al. (2015). Are interventions to promote healthy eating equally effective for all? Systematic review of socioeconomic inequalities in impact. BMC Public Health, 15, 457

Moran VH, Morgan H, Rothnie K. et al. (2015). Incentives to promote breastfeeding: A systematic review. Pediatrics, 135 (3), e687 - e702

National Institute of Health and Clinical Excellence (2006). Behaviour Change at Population, Community and Individual Levels (PH6). London: Author

National Institute of Health and Clinical Excellence (2006). Nutrition Support in Adults: Oral Nutrition Support, Enteral Tube Feeding and Parenteral Nutrition (CG32) . London: Author

National Institute of Health and Clinical Excellence (2008). Maternal and Child Nutrition (PH11). London: Author

National Institute of Health and Clinical Excellence (2010). Prevention of Cardiovascular Disease at Population Level (PH25). London: Author

National Institute of Health and Care Excellence (2010). Weight Management Before, During and After Pregnancy (PH27). London: Author

National Institute of Health and Care Excellence (2011). Food Allergy in Children and Young People: Diagnosis and Assessment of Food Allergy in Children and Young People in Primary Care and Community Settings (CG116). London: Author

National Institute of Health and Care Excellence (2011). Preventing Type 2 Diabetes: Population and Community-Level Interventions (PH35). London: Author

National Institute of Health and Care Excellence (2013). Managing Overweight and Obesity among Children and Young People: Lifestyle Weight Management Services (PH47). London: Author

National Institute of Health and Care Excellence (2014). Behaviour Change: Individual Approaches (PH49). London: Author

National Institute of Health and Clinical Excellence (2014). Lipid Modification: Cardiovascular Risk Assessment and the Modification of Blood Lipids for the Primary and Secondary Prevention of Cardiovascular Disease (CG181). London: Author

National Institute of Health and Care Excellence (2014). Obesity: Identification, Assessment and Management of Overweight and Obesity in Children, Young People and Adults (CG189). London: Author

National Institute of Health and Care Excellence (2014). Overweight and Obese Adults - Lifestyle Weight Management (PH53). London: Author

National Institute of Health and Clinical Excellence (2014). Quality Standard for Nutrition Support in Adults (QS24). London: AuthorNHS Information Centre, (2010). Infant Feeding Survey 2010

O' Neill M, (2005). Putting food access on the radar.

ONS (2011). Fertility assumptions: 2010-based national population projections.

Pomerleau, J., Lock, K., Knai, C. & McKee, M. (2005). Interventions designed to increase adult fruit and vegetable intake can be effective: A systematic review of the literature. Journal of Nutrition, 135, 2486-2495

Public Health England (2014). National Diet and Nutrition Survey: Results from Years 1 to 4 (combined) of the Rolling Programme for 2008 and 2009 to 2011 and 2012. London: Author

Renfrew MJ, McCormick FM, Wade A. et al. (2012). Support for healthy breastfeeding mothers with healthy term babies. Cochrane Database of Systematic Reviews, Issue 5. Art. No.: CD001141

Sanchis-Gomar F, Pareja-Galeano H, Cervellin G, Lippi G, Earnest CP. (2015). Energy drink overconsumption in adolescents: implications for arrhythmias and other cardiovascular events. Canadian Journal of Cardiology, 31 (5), 572 – 575

Scientific Advisory Committee on Nutrition (SACN, 2008). The Nutritional Wellbeing of the British Population

Spencer A, Ogden C & Battarbee L. (2015). #cheshirehunger - Understanding Emergency Food Provision in West Cheshire. Chester: West Cheshire Food Bank

Story, M., Kaphingst, K.M., Robinson-O’Brien, R. & Glanz, K. (2008). Creating healthy food and eating environments: Policy and environmental approaches. Annual Review of Public Health, 29, 253-272

Townsend, N., Murphy, S. & Moore, L. (2011). The more schools do to promote healthy eating, the healthier the dietary choices by students. Journal of Epidemiology and Community Health, 65, 889-895

UNICEF (2012). Breastfeeding reduces hospital admissions.

Whitton, C; Nicholson, SK; Roberts C; et al (2011). National Diet and Nutrition Survey: UK food consumption and nutrient intakes from the first year of the rolling programme and comparisons with previous surveys. British Journal of Nutrition, 106, 1899-1914

WHO (2003) Diet, nutrition and the prevention of chronic diseases.

 



Printed from TEES JNSA Website.
URL: http://www.teesjsna.org.uk/hartlepool-diet-and-nutrition/
Printed: 22/08/2014