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Social determinants of health and health inequalities: focus on nutrition

Gwen Nightingale

Deputy Director, Obesity and Food Policy (job-share)

Department of Health, England

Presentation to High Level Group - 4 May 2015

Significant health inequalities exist in England

• The life expectancy gap is 9 years for men and 7 years for women

between the most and the least deprived areas, with a gap in expected

years in good health of 19 years.

• Average healthy life expectancy is only 52 years in the most deprived

deciles, and it exceeds 67 years (State Pension age by 2028) only in the

three least deprived deciles.

• People in unskilled occupations have 60 per cent higher prevalence of

long term conditions (LTCs) than those in professional occupations, and

more deprived people are more likely to have two or more LTCs and from

a younger age. Long term conditions account for around 70% of total

health and care spend in England.

• Diabetes is two to three times more prevalent in the most deprived areas

than in the least deprived, and two to six times more prevalent in South

Asian groups than the general population. Treating type II diabetes costs

the NHS £8.8 billion per year.

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Inequalities in England

Reducing health inequalities is enshrined in law

A legal requirement was introduced in 2013 to have regard to the need to

reduce health inequalities across the health system - including for Ministers

themselves.

The Secretary of State for Health must:

• have regard to the need to reduce inequalities between the people of

England with respect to the benefits that may be obtained by them from

the health service;

• include in his annual report on the performance of the health service in

England, an assessment of how effectively he has discharged his duty to

have regard to the need to reduce inequalities;

• set out in a letter to NHS England, which is published and laid before

Parliament, his assessment of how it has discharged its duty to have

regard to the need to reduce health inequalities, based on NHS England’s

annual report.

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Inequalities in England

Our approach: Working with industry has led to healthier

product availability, benefitting all groups

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1. Working with industry

Organisations signing up to the Responsibility Deal have committed to take

action voluntarily to improve public health through their responsibilities as

employers, as well as through their commercial actions and their community

activities. Over 700 partners have signed up.

Examples include:

600 million kcals removed from Tesco Finest and Everyday Value sandwiches

Britvic plan to stop selling full sugar Fruit Shoot saving 2.2 billion kcals.

Further examples of changes

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1. Working with industry

Sugar-free Pepsi Max to be offered to cinema goers as default. All branding will be Pepsi Max.

250 kcal cap on single serve confectionery

The partnership specifically targeted fruit and vegetable

consumption – where inequalities exist

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1. Working with industry

• Lower income homes eat less

fresh fruit, Vegetables and oily

fish

• Through the voluntary

agreement, the Association of

Convenience Stores (ACS)

pledged to promote fresh fruit

and vegetables. The ACS is a

trade organisation for 'symbol'

stores, eg Costcutter, NISA, and

individual local shops, often

found in the most deprived

areas.

Working with industry has led to healthier product availability,

benefitting all groups - Salt Reduction

In 2014 we introduced a revised set of salt reduction targets that challenge

industry to reduce further the amount of salt in 76 categories of food by

December 2017.

Since the start of the Responsibility Deal, around 75% of the retail market

and 65% of major high street restaurants and contract caterers have

committed to reduce salt. This includes all the major supermarkets, many big

manufacturing brands, restaurant chains and contract caterers.

Some examples under this pledge:

• McCain has reduced added-salt in its product portfolio by 22%,

• Heinz has achieved up to 50% salt reductions, and

• Sainsbury’s has removed 2.5 tonnes of salt per year from own brand

products.

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1. Working with industry

Schools play an important role

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2. Action on obesity

• The School Food Standards severely restrict foods high in fat, salt and sugar, as

well as low quality reformed or reconstituted foods. They ensure that pupils always

have healthy options for their school lunch.

• Every pupil in reception, year 1 and 2 attending a state-funded school is now entitled

to a nutritious, free school lunch.

• Children aged four to six attending a fully state-funded infant, primary or special

school, are entitled to receive a free piece of fruit or vegetable each school day.

• Pupils attending pre-school, nursery, primary or secondary school are eligible for

subsidised milk.

• In the new national curriculum, learning about food is a key component for every

pupil up to the age of 14. Pupils in primary schools will learn about healthy eating

and a good, balanced diet. In secondary schools, the teaching of food is

compulsory for 11- 14 year olds and all pupils will learn about nutrition and diet.

• The School Sports Premium, School Games and the Change4Life School Sports

Clubs programme ensure all children have the opportunity to take part in sport and

be physically active

Local government also plays a significant role

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2. Action on obesity

• Local government has responsibility for public health and takes this

into account when exercising its licensing and planning duties.

• This is an opportunity to recognise that more deprived areas tend to

have a higher concentration of food outlets that are unhealthy and

take action to influence future development and change the

balance.

• Local government also administer the National Child Measurement

Programme – which measures over a million children every year in

Reception and Year 6. It provides robust public health surveillance

data on child weight status at a local authority level.

Change 4 Life is aimed at families with children 5 to 11

years old to eat well and move more

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3. Change 4 Life

The Change4Life programme is an evidence-based social marketing campaign. It

supports everyone in making simple changes to adopt a healthier diet and increase

their physical activity. The most recent January 2015 Change4Life ‘Sugar Swaps’

campaign has more than 380,000 people signed up.

Change4Life has enjoyed considerable success to date

• As of January, 1,495,106 families had joined Change4Life, accounting for

2,514,643 people

• 220,000 primary school children participated in sport as part of the Change4Life

Sports Clubs in schools; independent evaluation showed that 38,000 more

children are getting their 60 Active Minutes every day, directly attributable to

Change4Life Sports Clubs16

• Over 200 national organisations have collectively provided £52 million of in-kind

support to the programme

• Over 70,000 local supporters, including schools, general practices, charities and

leisure centres, have joined, reporting that they collectively deliver 380,000 hours

of unpaid time17 to the movement each year.

• 56% of community venues (such as schools, local authority services, the NHS,

childminding, charities and small businesses) display Change4Life materials at no

cost

• The campaign has garnered over £90 million of free media coverage

• The brand is well liked and trusted by the public. In five years, Change4Life has

established itself as an engaging, trusted brand capable of inspiring positive

change at scale, within families

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3. Change 4 Life

The Programme

• NHS Health Check is a risk assessment and management programme for

preventing heart disease, diabetes and other non-communicable diseases

(NCDs) for people aged 40-74

• Key components are risk assessment and / or risk management and reduction

actions e.g. referral to either lifestyle or clinical interventions

• Programme potential includes preventing at least 650 premature deaths and

1,600 heart attacks / strokes each year and detecting at least 20,000 cases of

diabetes or kidney disease earlier.

• Key metrics are offers made and take up of NHS Health Check. The real test of

success will be contribution to NCDs prevention through health improvement

and follow-up of conditions identified.

• Local government administers the Health Check.

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The NHS Health Check has huge potential … 4. NHS Health Checks

… especially in relation to health inequalities

• Many local authorities focus on encouraging take up in high risk and

communities with deprivation.

• East London serves one of the most ethnically diverse and socially deprived

populations in the UK with very high rates of premature cardiovascular

disease particularly among South Asians. A study showed that South Asian

and black African/Caribbean people were more likely than white people to

attend an NHS Check. Older people over 60 years were more likely to

attend than younger people. Women were more likely to attend than men

and attendance was more likely in the most deprived quintile.

• We are testing the impact of behavioural insight and marketing

interventions on improving uptake.

• Further evaluation of the programme is underway.

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4. NHS Healthchecks

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The Troubled families programme was launched in 2012 with the aim of turning

around the lives of 120,000 troubled families through the support of a family support

worker. The programme is being expanded to support up to 400,000 additional

families between 2015-2020 and will include a new health strand and focus.

5. Family interventions

The Troubled Families Programme and the Family Nurse Partnership

Programme target services at families

• Families who are targeted by the programme have multiple issues related to

employment, education, crime, housing, child protection, parenting or health

• Research found that over half (53%) of troubled families had a current record of

obesity, rising to 93% between the ages of 35 and 54.

• Over 105,000 families have had their lives turned around

The Family Nurse Partnership is a voluntary home visiting programme for first time

young mums, aged 19 or under (and dads). A specially trained family nurse visits the

young mum regularly, from early in pregnancy until the child is two.

The programme is underpinned by an internationally recognised robust evidence

base, which shows it can improve health, social and educational outcomes in the

short, medium and long term, while also providing cost benefits.

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Healthy Start aims to help give

families the very best start in life.

Available to pregnant women or those

with a child under 4, the Healthy Start

scheme helps buy basic foods like

milk or fruit. Coupons are also

available to swap for free vitamins

suitable for pregnant women,

breastfeeding women and children

aged 6 months to 5 years old. The

programme also links to healthy

lifestyle advice.

Further support is available to women and families on

low incomes 5. Family interventions

Further information

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Gwen Nightingale and Maeve Walsh:

nightingalewalsh@dh.gsi.gov.uk

Websites

Change for life http://www.nhs.uk/change4life/Pages/change-for-life.aspx

Responsibility deal https://responsibilitydeal.dh.gov.uk/

NHS Health checks http://www.healthcheck.nhs.uk/

Troubled families https://www.gov.uk/government/policies/helping-troubled-

families-turn-their-lives-around

Family Nurse Partnerships http://fnp.nhs.uk/

Healthy Start https://www.healthystart.nhs.uk/