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 UKs 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:
This topic is most closely linked to:
1. What are the key issues?
Breastfeeding rates are amongst the lowest in England and the gap between Stockton-on-Tees and England is widening.
At all ages, the proportion of people who are overweight and obese is higher than England. Only one in five adults eats a healthy diet.
People in vulnerable groups and those with low incomes are at increased risk of having malnutrition from diet-related illness.
There are high rates of dental decay in children, which will be significantly influenced by diet. There is a four-fold difference in decay rates between the best and worst wards.
2. What commissioning priorities are recommended?
Commission services to improve children’s diet during early years of life, focusing on families living in wards of deprivation.
Increase promotion and uptake of the national Healthy Start initiative, in particular vitamin supplements, to both professionals and the target audience.
Previous commissioning priorities
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, there are still several areas of concern.
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).
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
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 (BAPEN, 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.
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.
Mothers in low socioeconomic position continue to have a strong impact on patterns of infant feeding (NHS 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.
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. 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.
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).
Many areas of dietary concern for people in lower socioeconomic groups were similar to that of the general population; but the following were more marked:
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)
People suffering mental ill health
Depression increases the risk of mortality by 50% and doubles the risk of coronary heart disease in adults (DH, 2011). 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.
4. What is the level of need in the population?
Healthy eating adults
Local data on the nutritional intake of the Stockton-on-Tees population is very limited as dietary surveillance is complicated and expensive.
About 58% of babies in Stockton-on-Tees get the best start in life by being breastfed at birth, significantly lower than the 75% in England. Although rates have tended to increase in Stockton-on-Tees, greater increases are seen in comparable areas and the gap is widening. In 2014/15, Stockton-on-Tees had the seventeeth lowest breastfeeding initiation rate of 262 local authority districts in England (NHS England, 2015). 64 local authorities failed to meet data quality standards.
By the time babies are six to eight weeks old, only about three in ten are being breastfed, less than the proportions breastfed in England and the North East. Of the mothers who start breastfeeding in Stockton about half have stopped by the time their baby is 6-8 weeks old compared with 56% in England. In 2014/15, Stockton-on-Tees had the twelfth lowest breastfeeding rate at 6-8 weeks of 150 local authority districts in England with recorded data (176 failed to meet data quality standards).
Within Stockton breastfeeding initiation ranges from less than 40% in Stainsby Hill and Roseworth wards to 85% in Northern Parishes ward. Most wards in Stockton have breastfeeding initiation rates below the England average. There are ten of Stockton’s 26 wards where less than half of mothers initiate breastfeeding (Source: Tees Public Health / North Tees and Hartlepool NHS Trust).
Stockton has a low rate of breastfeeding initiation and of the mothers who do initiate breastfeeding, a higher than average proportion stop breastfeeding before their baby is 2 months old.
In terms of Mosaic groups, more births are to women in group ‘O’ (Families in low-rise social housing with high levels of benefit need) than any other group. This group has the lowest level of breastfeeding initiation at just one in every five births and by 6-8 weeks as few as one in nine infants are being breastfed.
Using the Mosaic 'types' shows that the highest number of births is in Type O69 (Vulnerable young parents needing substantial state support), where over 80% of babies are not breastfed at all.
5. What services are currently provided?
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 lifestyle behaviour, including dietary habits.
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.
Health Trainer programme
Community cooking sessions
The regional Better Health at Work Awards encourage employers in the North East to consider how they can improve the health of their workforce. Stockton on Tees council lead on the development of the award by and introducing the award to local businesses and supporting them to achieve it. Implementing and promoting healthy eating is an integral part of the scheme.
Community Growing Schemes
There are a variety of growing schemes in the borough, delivered in schools and in the community. They are delivered by various organisations, targeting different population groups.
There are a number of food banks across the borough delivered by a number of different organisations, some having defined access criteria such as only accessible to substance misusers.
Healthy Choice Partnership – Healthy Catering Award
This scheme is designed and delivered by Stockton on Tees Borough Council Trading Standards to help businesses, who supply ready to eat food, to provide healthy catering by encouraging the use of fresh ingredients, healthy preparation and the use of clear sign-posting of healthier options on menus.
Infants, Children and Young People
Healthy Start scheme
The Department of Health Healthy Start scheme provides free vouchers to spend on milk, plain fresh and frozen fruit and vegetables, infant formula milk and vitamins. The national scheme is available to women during pregnancy and for one year following birth of their child and to children until their fourth birthday, who are in receipt of certain welfare benefits or under 18 years old.
Stockton on Tees Borough council has funded the expansion of the scheme since 1st April 2015 so that all pregnant women, women who choose to breastfeed and children from around six months to their fourth birthday receive Healthy Start vitamins.
Weaning (moving from breast or formula milk to introducing solid foods)
School aged children and young people
Primary school lunch time meals are provided by Stockton Borough Council. All meals provided by the Local Authority (LA) meet the nationally set School Food Standards. Several secondary schools are also provided with lunch time meals by the LA.
6. What is the projected level of need?
If current trends continue, breastfeeding rates at 6-8 weeks will remain at about 30% in Stockton-on-Tees. The Stockton-on-Tees rate is increasing slightly whereas England is static, marginally narrowing the gap between breastfeeding rates locally and nationally, but the gap between Stockton-on-Tees and the North East could increase.
7. What needs might be unmet?
Interventions for families such as antenatal classes (including breastfeeding), breastfeeding support groups and weaning groups are often not attended by those most in need. Their need for appropriate support is not being met.
There is a lack of uptake of preventative services particularly by those at most risk of diet-related disease.
As the Healthy Start scheme is significantly under utilised for vitamin supplements there is a need to raise the awareness of the scheme, particularly in relation to the vitamin element, both with professionals and families.
With the increase in adults living in supported living accommodation there will be an increase in the need for support and education about diet.
8. What evidence is there for effective intervention?
National Institute for Health and Clinical Excellence (NICE)
Behaviour change at population, community and individual levels (PH6)Maternal and child and nutrition. (PH11)
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)
Nutrition Support in Adults. (CG32)
Postnatal Care. (CG37)
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
Interventions to Promote Breastfeeding
The UNICEF Baby friendly Initiative (BFI) suggests the following core practices in maternity and community services.
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.
Children and Young People
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.
Story et al (2008). Creating healthy food and eating environments: Policy and environmental approaches.
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
9. What do people say?
Stockton-on-Tees Borough Council commissioned a consultation with women and midwives regarding infant feeding choices and how to improve support for women who choose to breastfeed. The consultation was conducted by Curb Office Ltd in 2013. The main findings were:
General dietary habits of adults
Stockton Borough Council consulted with 363 residents through the Local Authority Viewpoint survey in September 2013. Some of the main findings related to diet and nutrition were:
10. What additional needs assessment is required?
Audit of practices in care settings in relation to identifying malnutrition and processes followed when malnutrition is identified.
Projection of future needs and obstacles for a healthy diet.
Name: Claire Spence
Job Title: Health Improvement Specialist
phone: 01642 528475
Local strategies and plans
NHS Tees Breastfeeding Strategy 2010-2015
North Tees and Hartlepool Breastfeeding Action Plan
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.
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.
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
Hannula, L; Kaunonen, M; Tarkka, MT, (2008) A systematic review of professional support interventions for breastfeeding. Journal of Clinical Nursing 17(9):1132-43
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
O' Neill M, (2005). Putting food access on the radar.
NHS Information Centre, (2010). Infant Feeding Survey 2010
NICE (2011). Food Allergy in Children and Young People (CG116)
NICE (2011). Postnatal Care (CG37).
NICE (2010) Prevention of cardiovascular disease.
NICE (2008). Maternal and child and nutrition.
NICE (2006). Nutrition Support in Adults (CG32).
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
Scientific Advisory Committee on Nutrition (SACN, 2008). The Nutritional Wellbeing of the British Population
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.