Big Lottery Fund.

Boyd Orr.

Caraher M.

Chadwick E.

Dowler E.

Engels F.

Le Gros Clark F.

Martin Caraher

Mitchell J.

Nelson M.

Oliver S.

Rowntree BS

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Food and health promotion: Lessons from the field

Caraher, M.

City Research Online

Caraher, M. (2008). Food and health promotion: Lessons from the field. Health Education Journal, 67(1), pp. 3-8. doi: 10.1177/0017896907086155 City Research OnlineOriginal citation: Caraher, M. (2008). Food and health promotion: Lessons from the field. Health Education Journal, 67(1), pp. 3-8. doi: 10.1177/0017896907086155 Permanent City Research Online URL: http://openaccess.city.ac.uk/7880/ Copyright & reuseCity University London has developed City Research Online so that its users may access the research outputs of City University London's staff. Copyright © and Moral Rights for this paper are retained by the individual author(s) and/ or other copyright holders.  All material in City Research Online is checked for eligibility for copyright before being made available in the live archive. URLs from City Research Online may be freely distributed and linked to from other web pages. Versions of researchThe version in City Research Online may differ from the final published version. Users are advised to check the Permanent City Research Online URL above for the status of the paper.EnquiriesIf you have any enquiries about any aspect of City Research Online, or if you wish to make contact with the author(s) of this paper, please email the team at publications@city.ac.uk. 1 The Health Education Journal occasionally invites selected academics to write a guest editorial or position paper on a topic of their choice.  Food health promotion developing research and evaluation based on practice: lesson from the orchard.   Dr Martin Caraher Associate Dean /Reader in Food and Health Policy Centre for Food Policy City Community and Health Sciences Northampton Square  City University London EC1V OHB +44 (0)20 7040 4161 m.caraher@city.ac.uk <mailto:m.caraher@city.ac.uk>  Writing in 1939 Le Gros Clark and Titmuss 1 warned of the dangers facing the UK in relation to its food supply, they highlighted the dangers from a food system that had moved from small urban populations drawing sustenance ‘from their surrounding countryside’ to a central supply system controlled by a smaller and smaller number of companies. They also pointed out the challenges to national food security in the light of the forthcoming War as well as the fact that policy in the inter-war period had failed to plan for such an eventuality. Earlier, in 1936, Boyd Orr 2 had pointed out concerns over the role of poverty in relation to healthy diet, a process begun a century before by people such as Chadwick, Engels and Seebohm Rowntree. 3 4 5 During the War and in the immediate post-war period some of the inequality issues were addressed through rationing. Now again, we are facing a national food problem albeit that the underlying drivers are different but the headline issues are similar namely issues of food supply and over-reliance on food from overseas, health concerns, control & management of the food trade and dispersal to the community. The detail of the concerns has changed in that we are concerned with diet related non-communicable diseases (DRNCDs), obesity, the control of the food chain by a small number of operators, food miles, food access and food poverty; yet we still lack a coherent policy approach.  .  What has health promotion done to contribute to these issues and their solutions? In the global economy many things have changed which health promotion practice has not kept pace with.6 7 Lest I be accused of being overly pessimistic there is a need to acknowledge positive things have been achieved with food and health and there are beacons of good practice. Look at the school meals situation (ala Jamie Oliver) and the growth of local food networks and systems, all offer promise. Yet even here these must be contrasted with recent evaluations of the English fruit and vegetable scheme (SFVS), 8 a Food Standards Agency report on low incomes 9 and the failure of health promotion to contribute to solutions. The SFVS evaluation of the school fruit scheme showed no overall improvements in the diets of children. Closer analysis shows that the scheme had an impact within the setting of the school but this impact was muted by other activities in the environment such as food advertising/promotion, food availability and siting of food  2 outlets. So you can be successful in the setting you are working in and have some ‘control’ over -such as a school- but the gains here may be offset by issues outside the setting and your control. This does not mean that health promotion interventions are not successful in their own right but that there are a myriad of things happening in the wider social and economic environment which have an impact and which small-scale health promotion projects cannot influence to any great degree. A Food Standards Agency official commenting in a press release on the findings of a report into diet and low income said the findings ‘suggests that the dietary pattern of people on low incomes is the same as the general population, although some areas of their diets are slightly worse’ and goes on to say that the gap is ‘not as big as some feared’,10 this jars with the experience of many health promotion workers working with those living in poverty and on low incomes. What such research does not detail is the effect that day-to-day living on the margins has on families and individuals and the struggle that they engage in to make ends meet. 11  12That the ‘gap is not as big as some feared’, skirts over the issue that there is an inequity and the report does not address the inputs necessary to address these gaps. The figures for food security, from the report, read alarmingly for a modern developed country, with 36% indicating that they could not afford to eat balanced meals with 22% reducing or skipping meals, and 5% reported not eating for a whole day, because they did not have enough money to buy food. The FSA takes the view that ‘this study did not identify any direct link between dietary patterns and income, food access or cooking skill’ and that the findings from the study will be used ‘to help inform their policy making in areas of diet, nutrition and health – in particular those departments with responsibility for lifestyle issues such as smoking and drinking’. 3 It is heartening that those on low incomes are taking on board the healthy eating messages and acting on them and also that cooking knowledge/skills may not be barriers to healthy eating for the poor, something we showed in this journal nine years ago. 13 14 The areas of food access remains more contentious and reporting that the dominant means of access is through supermarkets and therefore the poor are like the rest of society does not make it easy or easier for them.15 Research from people such as Dowler show that the poor can cope but have to expend more energy and resources to do so. 16 Does all this herald a return to health education type programmes with the downstream focus on information, attitudes and individual choice? Of course choices are ultimately individual but these individual choices are influenced by a wide range of other influences such as income, geography and culture. That the poor have the same problems as other groups in the population is not unique what is unique- and disturbing- is that the solutions to the problem are seen as within the remit of lifestyle and not structure.    Of course what both of these two examples of national evaluation and research show is that data of this nature does not address the impact of locality and the struggle that living in poverty bring with them. This is where health promotion practice and research and evaluation have a part to play. Food projects based on and which uphold health promotion principles have many benefits and can impact on wide range of criteria. 17 18 19   We are currently seeing less funding and support for food projects at a time when food issues have never been more important. This increased concern over food is partially driven by food scares of both a chronic and acute nature; salmonella in chocolate, rising  3 levels of diabetes, and a food system that contributes to unhealthy eating and ultimately to obesity, are among the many to reach the headlines. The response of government is muted with the state seemingly unwilling to step in to promote and protect the health of its citizens at a structural level of policy development eg the banning of advertising or the introduction of food taxes and subsidies. 20 21  There is also an expectation that projects at a local level will deliver on goals which are not supported by activities or policy upstream.   These dilemmas have contributed to the lack of a comprehensive evidence base for health promotion and food as has the emphasis on scientific and individual rationality at the expense of family and communities. Systematic reviews are generally taken to be the gold standard but still need interpretation and application to the work context and setting. Many research reviews are based on the principle of evidence based clinical practice and as such have what is called high internal validity (what they measure and find is accurate for the setting under study) but often poor application to the real world (poor external validity). For example the research evidence on the benefits of consuming five fruit and vegetables a day are incontrovertible but the ways in which you can achieve this are less clear. This is where health promotion can contribute with a focus on practice, the translation of research into practice and the subsequent evaluation of this is of the utmost importance. We need to encourage and develop a clear and unambiguous evidence base of and for health promotion practice and move away from research that offers nothing more than descriptions of process.   Health promotion practice suffers from a lack of evidence-based, well-designed intervention projects.22 23  This introduces the dilemma for local food based health promotion projects, do nothing or intervene? One way of addressing this is by adopting what Robinson and Sirard call a solution-orientated approach.24 This means that past orientation or lack of evidence of cause can be overruled in favour of future orientation. In essence, this moves the focus of future work away from developing more descriptions of the problem to working on solutions and hence the importance of generating practice-based evidence. This is evidence that arises from actually trying to solve a problem from first principles.  There is a dilemma for health promotion with the temptation that we should simply focus on smaller and smaller settings where we can influence the situation. This would as a strategy, be disastrous and may not address issues of inequality. Health promotion work of a similar strand in an area or region could combine to develop more robust interventions and evaluations sharing both set-up costs and expertise in both management and evaluation areas. In research and evaluation terms this would allow a critical mass to be built up of interventions and thus allowing the findings to speak with authority. This is not to be confused with a call for more quantitative research on food and health promotion but for more robust health promotion research and evaluation which addresses the issues of implementation.   The FSA report on food and low income, referred to earlier, highlights the finding that nutritional intakes of all income groups are below recommended levels and gaps between  4 those on low incomes and other groups remain. This at worst highlights the need for a universalist approach to healthy eating with all groups, regardless of income, targeted. The danger with such an approach is that it widens the inequality as those groups who are more affluent can act and can afford to adopt their lifestyles. A selectivist approach runs the danger of stigmatising groups targeted and of the inequality gap increasing as the poor still lack the resources (social and financial) to act on the issues.  Perhaps the best approach is to combine both approaches with a whole population or universalist approach being supplemented by a targeted or selectivist approach to ensure inequalities do not widen.   So what can HP do? This journal has been a forum for the voice of both health promotion practitioners and researchers seeking a radical approach to health promotion. As a group we have not always been our own best critics or advocates. My suggestion is that health promotion needs to address three areas: Firstly adopt the motto of the environmental movement and think global while acting local, often called ‘glocalisation’, this should involve looking both ways at the one time, while helping participants learn new skills and knowledge also allowing them to understand, question and advocate about the ways the global food system influences their choice and decisions.  Secondly evaluation and research needs to be core to health promotion activity and develop more robust approaches and move away from mere descriptive narratives of process. Academics and practitioners should work together to develop new learning from programmes and this may mean less individual evaluations and more grouping of projects and resources.  This should address the ‘projectitis’ of a host of health promotion activity and ensure sharing of resources to maximum benefit. This would allow sharing across a range of activities and areas. Evaluation and research on food-based activities is traditionally weak, too many evaluations that I see are tagged on at the end of a project and/or lacking rigour and there are too many small scale evaluations (an individual cooking project) we need to combine to have a critical mass of projects and develop programme evaluation. Thirdly be clear that our activities contribute to food equity and reducing inequalities and all research and evaluation should address this.   Health promotion clearly has a role to play in addressing food inequity and helping inform policy for the future.                                                        1 Le Gros Clark F, Titmuss RM. Our Food problem and its relation to our national defences. London: Pelican Books, 1939.   2 Boyd Orr. Food Health and Income; A survey of Adequacy of the Diet in Relation to Income. London: MacMillan and Co, 1936. 3 Chadwick E. Report on the Sanitary Condition of the Labouring Population of Great Britain 1842. Edinburgh: Edinburgh University Press, 1965.  5                                                                                                                                                  4 Engels F. The Condition of the Working Class in England. Harmondsworth: Penguin Classics,  (1845)1987. 5 Rowntree B S. Poverty: A Study of Town Life. Centennial edition. Bristol: The Policy Press, 2000. 6 Caraher M. Coveney J. Lang T.  Food, Health and Globalisation: Is Health Promotion Still Relevant? In Scriven A.  Garman S. (Eds) Promoting Health: Global Perspectives. London, Palgrave Macmillan, 2005, 90-105. 7 Labonte R, 1998 Healthy public policy and the World Trade Organisation: a proposal for an international health presence in future world trade/investment talks. Health Promotion International, 1998; 13: (3): 245-256. 8 Big Lottery Fund. 5 A Day Programme and School Fruit and Vegetable Scheme: findings from the evaluations. Big Lottery Fund Research. 2007: Issue 27. 9 Nelson M. Erens B. Bates B. Church S.  Boshier T.  Low income diet and nutrition survey. London; Food Standards Agency, 2007. 10 FSA Press Release. FSA publishes findings of the Low Income Diet and Nutrition Survey Sunday 15 July 2007, Accessed 30/7/07 http://www.food.gov.uk/news/pressreleases/2007/jul/lidns  11 Dowler E. Turner S. with Dobson B.  Poverty Bites: food, health and poor families. London: Child Poverty Action Group, 2001. 12 MItchell J. Editorial A poor explanation for a poor diet. The Food Magazine, 2007: Issue 78; July September, p 2 13 Caraher M., Dixon P. Lang T.  Carr-Hill R.  Barriers to accessing healthy foods: differentials by gender, social class, income and mode of transport. Health Education Journal, 1998: 57 (3): 191-201. 14 Lang T. Caraher M.  Food poverty and shopping deserts: What are the implications for health promotion policy and practice. Health Education Journal, 1998: 58 (3); 202-211. 15 Reisig VMT.  Hobbiss A. Food deserts and how to tackle them: a study from one city’s appraoch. Health Education Journal, 2000; 59, (2): 137-149. 16 Dowler E. Factors affecting nutrient intake and dietary adequacy in lone-parent households.  London: MAFF, 1995. 17 Caraher M. Dowler E. Food projects in London: lessons for policy and practice – A hidden sector and the need for ‘more unhealthy puddings......sometimes’. Health Education Journal, 2007; 66 (2): 188-205 18 Caraher M, Cowburn G. A survey of food projects in the English NHS regions. Health Education Journal, 2004; 63 (3): 197-219. 19 Dowler E. Caraher M. Local Food Projects: the New Philanthropy?  Political Quarterly, 2003; 74 (1): 57-65. 20 Caraher M. Landon J. Dalmeny K. TV advertising and children: Lessons from policy development. Public Health Nutrition, 2006; 9, (5): 596–605. 21 Caraher M.Cowburn G. Taxing food: implications for public health nutrition. Public Health Nutrition, 2005; 8, (8): 1242–1249.  22 Oliver S. Peersman G.  Using Research for Effective Health Promotion. Buckingham: Open University Press, 2001.   23 Peersman GV. Oakley AR, Oliver S. Evidence based health promotion? Some methodological challenges.  International Journal of Health Promotion and Education, 1999; 37, (2): pp 59-6 24 Robinson TN.  Sirard JR.  Preventing Childhood Obesity: A Solution-Oriented Research Paradigm Am J Prev Med, 2005; 28(2S2): 194-201. 

Food and health promotion: Lessons from the field

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