- B&NES has a higher than national known level of fruit and vegetable consumption, but it is still low.
- There is a relationship between healthy eating and areas with lower incomes. In addition food prices are rising at a signfiicant rate, with a 23% rise in vegetable prices and 11% rise in fruit prices between 2006 and 2009
- More than 1 in 10 sheltered housing tenants are likely to be at risk of malnutrition (approx 200 in B&NES). Hospital admissions for malnutirtion have increased significantly between 2004-6 and 2009-11, but this may relate to improved diagnosis.
A healthy diet is essential for good health and wellbeing and poor diet and malnutrition is linked to a wide variety of health conditions including depression, fatigue and various cancers. Children and older people are particularly at risk from the effects of poor diet.
What does the data say?
Unicef’s 2013 healthy eating by children in rich countries comparative overview 1
In Unicef’s 2013 healthy eating by children in rich countries in rich countries comparative overview, Unicef compares 29 of the world’s most advanced economies. It considers the two following measures:
- Percentage of children aged 11,13 and 15 who eat breakfast every day
- Percentage of children aged 11,13 and 15 who eat fruit daily
According to Unicef’s report in the UK, just over 60% of children aged 11, 13 and 15 eat breakfast every day, this is mid table. More than 50% of children eat breakfast every day in all 29 countries except Romania and Slovenia. Only in the Netherlands and Portugal does the percentage of children who eat breakfast every day exceed 80%.
The Unicef’s report indicates that in the UK, just under 40% of children aged 11, 13 and 15 eat fruit daily, this is mid table. There are nine countries where over 40% of children are thought to eat fruit daily, with the highest proportions being in Denmark, Canada, and Portugal. The only countries in which fewer than 30% of children eat fruit every day are Finland and Sweden – plus the three Baltic countries, Estonia, Latvia and Lithuania.
It is important to note that one of the limitations of these league tables is that internationally comparable data on children’s lives is not sufficiently timely. Between the collection of data in a wide variety of different settings and their publication in quality-controlled, internationally comparable form, the time-lag is typically two to three years. This means that most of the statistics on child well-being used in this report, though based on the latest available data, apply to the period 2009–2010.
Fruit and veg consumption - UK household purchases of fruit and vegetables were 1.8% lower in 2014 than in 2013, a reduction of 11.4% since their peak in 2006 (see figure 1). 2
Figure 1: UK trend in purchases of fruit and vegetables 3
Nationally around 26% of adults consume 5 portions or more of fruit and vegetables a day, there is little difference between men and women and in general the percentage increases slightly with age. 20% of children (aged 5-15) consume 5 or more portions of fruit and vegetables a day. There does not seem to be a trend by age of child4
Bath and North East Somerset generally has a higher than national known fruit and veg consumption prevalence in England. Estimates suggest that around 30% of the population of Bath and North East Somerset consume 5 pieces of fruit and veg a day (26% England). Lyncombe has the highest model based estimate percentage of 38% consumption of fruit and veg and of those that are known, Twerton has the lowest at 19% consumption of 5 pieces of fruit and veg a day5
There were large rises in food prices between June 2007 and February 2009. This included a 23% rise in vegetable prices and an 11% rise in fruit prices. All food price rises put pressure on food shopping choices6
Percentage consuming 5 fruit and vegetables a day is higher in areas of lower deprivation7
Vegetarians - 2% of the national population are vegetarian
Fat consumption - Total fat provided 34-36% of food energy across all age groups. Intakes were very similar to the previous survey for adults but lower than previous surveys for children and toddlers. The DRV for total fat is that the population average intake should provide no more than 35% of food energy intake.
Alcohol consumption - Around 12,500 cancers in the UK each year are linked to alcohol. Alcohol consumption increases the risk of oral (oral cancer includes cancers of the oral cavity, pharynx excluding nasopharynx and lip), laryngeal, oesophageal, breast, bowel and liver cancer. Risk of cancers of the upper aerodigestive tract (oesophagus, oral cavity, pharynx and larynx) increases linearly with quantity of alcohol consumed above 25g/day. Someone drinking 100 g/day has a 4-6-fold increased risk of these cancers compared to light or non-drinkers. Smoking and drinking heavily in combination increases risk of cancers of the upper aerodigestive tract up to 80-fold, and in developed countries, smoking and alcohol consumption combined have been estimated to account for 75% of all upper aerodigestive cancers. Also has correlations with other cancers such as liver, bowel, colon, rectal and breast cancer8
Older people - are often at increased risk of food poisoning and malnutrition; they experience major transitional life events and suffer from medical ailments, which can all affect their food purchase, preparation and consumption behaviours. This in turn can influence their overall health and wellbeing9
Premature deaths - An estimated 70,000 premature deaths in the UK could be avoided each year if UK diets matched nutritional guidelines
Quality adjusted life years - In 2008 that if our diet matched the national nutritional guidelines the health benefits to individuals would be £20 billion each year in quality adjusted life years. 10
People who are malnourished may experience a range of negative effects on their body as a result of a lack of nutrients in the body. Their symptoms may include one or more of the following:
- Impaired immune response
- Impaired thermoregulation
- Breathing difficulties
- Poor libido (sex drive) and fertility problems
According to NHS Direct, the three most likely causes of malnutrition in the UK are an inadequate diet, stomach or intestinal conditions, and alcohol dependency11
Malnutrition affects 23% of people under 65. This increases to 32% over the age of 65.
Those who are admitted to hospital over the age of 80 are twice as likely to become malnourished than those under the age of 50
In 2006, the estimated cost of malnutrition to the NHS was £7.3 billion a year12
Table 2: All hospital admissions in B&NES for malnutrition by age category (first 4 diagnosis codes) s=suppressed at <5
Figure 1: Number of hospital admissions for malnutrition 2009-2011 by age in B&NES residents13
Figure 1 indicates that there are significantly higher numbers of hospital admissions for malnutrition for patients aged 75+. Table 2 also suggests that there has been a recent increase in the number of diagnoses of malnutrition. Given the national evidence for an under-recording of malnutrition this may be due to increased diagnosis rather than increased prevalence.
Malnutrition in Sheltered housing in Wiltshire and B&NES (n-1353) 12% of individuals were ‘at risk’ of malnutrition (7% medium and 5% high) with those greater than 80 years of age (n = 740) having a significantly greater prevalence of malnutrition (14%) than those less than 80 years of age (9%)
More than 1 in 10 tenants are therefore at risk of malnutrition (equates to around 200 people in B&NES)14
Malnutrition is common in all population and patient groups across all age groups. In the community over 10% of older people aged over 65 years in the UK are affected by malnutrition but as many as 30% of residents in care may be malnourished
Malnourished patients stay in hospital for much longer, are three times as likely to develop complications during surgery and have a higher mortality rate. Illness is frequently associated with under-nutrition and the King’s Fund Centre’s Report showed that appropriate nutrition support confers clinical benefit
Evidence suggests that the prevalence of malnutrition is higher in older adults in long term care as many who enter residential care are undernourished due to poverty; social isolation, psychological problems, effects on appetite of illness or medication, and swallowing difficulties15
Studies on dietary intake of the elderly population show an average decrease in the intake of most nutrients with age16
In the UK, malnutrition risk has been identified in 20% - 60% of hospital admissions to medical, surgical, elderly and orthopaedic wards. Although malnutrition is common in hospital admissions, it has been reported as undiagnosed in up to 70% of cases17
Nutrition Screening Week Survey 201018
Malnutrition (medium + high risk according to the Malnutrition Universal Screening Tool [MUST]) 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 care homes the percentage of residents who were considered to have malnutrition: Under 70 years old - 22%; 70-84 years 36%; over 85 years 41%. Overall 37% (N = 821)
In hospitals -‘Malnutrition’ was common in all age groups and diagnostic categories, but it was significantly more common in women (36%v 32%), who were also older than men, in subjects aged 65 years and over than under 65 years (39 v 28%), and in certain diagnostic categories compared with others (e.g. gastrointestinal disease (48%) and neurological disease (34%) versus cardiovascular disease (23%) and musculoskeletal conditions (24%)). ‘Malnutrition’ was present in a higher proportion of patients with respiratory disease than in 2008 and 2007 (42% v 37% and 32%)
The subjects in care homes were older than those in hospitals and mental health units, more than 40% of them being 85 years and over and among those with a ‘MUST’ score 50% were over 85 years. The prevalence of ‘malnutrition’ increased with age but it was not significantly related to duration of stay (up to 6months).
Women were older and had a greater prevalence of ‘malnutrition’ than men (41% v 30%).
In hospital the malnutrition was found in 28% of patients under 60 years, 32% in those aged 60-79 years and 44% in those 80 years and over. It was 37% greater in patients aged 65 years and over than those under 65 years (39% v 28%)
Figure 2: Percentage of patients in hospital with malnutrition by age category
Malnourished elderly people run a dramatically increased risk of fracturing their neck of femur, usually by falling due to a lack of strength 19
Local hospital admissions data for diagnoses relating to ICD codes for Rickets and other vitamin D deficiency showed less than 5 incidents of an admission for someone aged under 18 in the last 5 years. All cases where rickets appeared as a secondary diagnosis were for elderly persons as a result of other ailments such as Crohns, Renal disease and Coeliac’s disease. 20
What does the community say?
The Child Health-Related Behaviour Survey developed by the Schools Health Education Unit (SHEU) is designed for young people of primary and secondary school age. The surveys have been developed by health and education professionals, and cover a wide range of topics. Data arising from the survey can be used to help inform planning and policy decisions as well being used in the classroom as the stimulus for discussion with young people. These surveys are carried out every two years.
When considering the results of the Child Health-Related Behaviour Survey in B&NES it is worth bearing in mind the level of participation in the survey, and thus how representative the responses are likely to be of children in B&NES as a whole. For more information see the Child Health-Related Behaviour Survey section in Children and Young People.
As well as the local B&NES results, comparisons are made with national/aggregate figures from all the surveys conducted by the Schools Health Education Unit (SHEU) in the previous year from their publication “Young People into 2013”. The national sample used for the 2013 comparison consists of 43,014 young people aged 10 to 15.
The Child Health-Related Behaviour Survey in B&NES in 2013 asked a number of questions relating to diet and nutrition.
Healthy choices - In 2013 when secondary school children in B&NES in year 8 and 10 were asked whether they considered their health when they chose what to eat:
- 14% (12% in 2011) of boys and 20% (also 20% in 2011) of girls responded that they ‘very often’ or ‘always’ consider their health when choosing what to eat.
- 16% (19% in 2011) of boys and 9% (8% in 2011) of girls responded that they ‘never’ consider their health when choosing what to eat.
The Child Health-Related Behaviour Survey also tried to establish whether there were any differences between secondary school children that are likely to be from a more deprived background. To do this it found out the numbers of secondary school year 8 and 10 respondents that were eligible for the pupil premium.
The pupil premium is additional funding given to publicly funded schools in England to raise the attainment of disadvantaged pupils and close the gap between them and their peers.
Pupil premium funding is available to both mainstream and non-mainstream schools, such as special schools and pupil referral units. It is paid to schools according to the number of pupils who have been:
- registered as eligible for free school meals at any point in the last 6 years
- been in care for 6 months or longer 23
10% (247) of year 8 and 10 respondents in 2013 were eligible for the pupil premium.
A higher proportion of the secondary school pupils eligible the pupil premium (PP) responded that they never considered their health when they chose what to eat, 21%, compared to the 11% of children that were not eligible for them. 24
Fruit and vegetables - In 2013 when primary school children in B&NES in year 4 and 6 were asked how many portions of fruit and vegetables they ate yesterday:
- Only 5% of pupils responded that they didn’t have any portions of fruit or vegetables to eat on the day before the survey.
- 31% of pupils responded that they had at least 5 portions of fruit and vegetables to eat on the day before the survey, this is virtually the same as the response in 2011, when it was 32%, and slightly higher than the national SHEU rate of 28%.
In 2013 when secondary school children in B&NES in year 8 and 10 were asked how many portions of fruit and vegetables they ate yesterday:
- Only 7% of pupils responded that they did not have any portions of fruit or vegetables to eat on the day before the survey, lower than the national SHEU rate of 11%.
- 20% of pupils responded that they had at least 5 portions of fruit and vegetables to eat on the day before the survey, slightly higher than the national SHEU rate of 17%.
- The response rate by secondary school pupils in 2013 in B&NES to these questions was very similar to 2011.
A higher proportion of the secondary school pupils eligible the pupil premium (PP) responded that they did not have any portions of fruit or vegetables to eat on the day before the survey, 14%, compared to the 6% of children that were not eligible for them. 25
Breakfast - In response to questions about what the primary school pupils had eaten before lessons in the morning:
- 90% of pupils said that they had had a conventional breakfast, comprising of toast, cereal or porridge.
- Only 2% of pupils responded that they didn’t have anything to eat or drink before lessons on the day of the survey. This is lower than the national SHEU rate of 7%.
- 4% had only had a drink, slightly lower than the national SHEU rate of 6%
- The response rate by primary school pupils in B&NES to these questions is very similar to that in 2011.
In response to questions about what the secondary school pupils had eaten before lessons in the morning:
- 72% of pupils said that they had had a conventional breakfast, comprising of toast, cereal or porridge.
- Only 7% of pupils responded that they didn’t have anything to eat or drink before lessons on the day of the survey. This is lower than the national SHEU rate of 13%.
- 3% had a cooked breakfast, very similar to the national SHEU rate of 4%.
- The response rate by secondary school pupils in B&NES to these questions is very similar to that in 2011.
Lunch - When the secondary school pupil respondents were asked what they did for lunch yesterday:
- 35% (32% in 2011) of pupils said that they had a school lunch on the day before the survey. This is lower than the national SHEU rate of 45%.
- 2% said they bought lunch from a takeaway or shop, similar to 2011 when it was 3%.
- 11% (9% in 2011) of pupils responded that they didn’t have any lunch on the day before the survey. This is lower than the national SHEU rate of 14%.
A higher proportion of the secondary school pupils eligible the pupil premium (PP) responded that they had a school lunch on the day before the survey, 62%, compared to the 32% of children that were not eligible for them. 26
Water - When primary school pupils were asked about their water (plain water) consumption: (excludes, do not count tea, coffee, squash type drinks or fizzy drinks):
- Only 4% of pupils responded that they did not drink any water on the day before the survey.
- 34% of pupils responded that they drank at least ‘about a litre’ of water on the day before the survey.
- 95% of pupils responded that they are able to get water at school, while 4% said ‘not easily’.
When secondary school pupils were asked about their water (plain water) consumption: (excludes, do not count tea, coffee, squash type drinks or fizzy drinks):
- Only 9% of pupils responded that they did not drink any water on the day before the survey.
- 31% of pupils responded that they drank at least ‘about a litre’ of water on the day before the survey.
- These are the same as the 2011 results.
Are we meeting the needs?
Much of the malnutrition present on admission to institutions originates in the community. Consistent and integrated strategies to detect, prevent and treat malnutrition should exist within and between all care settings27
Sirona health and care operate an award system called Eat Out Eat Well that rewards food outlets that provide their customers with healthier choices. It has three levels – Bronze, Silver, and Gold, and is symbolised by an apple logo in the shape of a heart. The level of award is based on a scoring system that takes into account the type of food on offer, cooking methods, and how you promote healthy choices to your customers28 in 2013/14, 40 food providers were supported to acheive an Eat Out Eat Well award 29
Sirona Food and Health Service 2013/14 demographic report 30
A team of Food and Health Workers deliver healthy eating 'Cook it' courses. These include Cook It, Family Cook It and Cook It Plus for parents and careers of children and young people up to the age of 17 in order to improve thier diet. HENRY courses are for parents and carers of children aged up to 5 years of age to improve parenting and nutritional skills. The courses are 6 weeks long and 32 were delivered in 2013/14. There were 343 referrals in 2013/14, with 78% of clients aged 45 and over and 70% females.
- 1. Unicef Research (2013) Child well-being in rich countries: A comparative overview, http://www.unicef.org.uk/Images/Campaigns/FINAL_RC11-ENG-LORES-fnl2.pdf (downloaded 31/01/14)
- 2. DEFRA (2015) Food Statistics Book 2015. Governmental Department for Environment, Food and Rural Affairs. (Online) https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/512112/foodpocketbook-2015report-31mar16.pdf (Accessed 21st April 2016)
- 3. DEFRA (2015) Food Statistics Book 2015. Governmental Department for Environment, Food and Rural Affairs (Online) https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/512112/foodpocketbook-2015report-31mar16.pdf (Accessed 21st April 2016)
- 4. NHS Information Centre (2010) Health Survey for England (downloaded 12/04/2012) http://www.ic.nhs.uk/pubs/hse10trends
- 5. The NHS Information Centre for Health and Social Care (2007) Estimates of consumption of 5 pieces of fruit and veg in Bath & North East Somerset Population (2003-2005) based on demographic characteristics of the area
- 6. ONS (2010) Food Statistics Pocket Book (downloaded 12/04/2012) S:\Policy&Pships\Dev&Support\Research&intelligence\Health and Wellbeing\diet\ defra-stats-foodfarm-food-pocketbook-2010.pdf
- 7. Lakshman, R. et al (2010) Association between area-level socioeconomic deprivation and a cluster of behavioural risk factors: cross-sectional, population-based study, J Public Health doi: 10.1093/pubmed/fdq072 (downloaded 12/04/2012) http://jpubhealth.oxfordjournals.org/content/early/2010/09/29/pubmed.fdq072.full
- 8. Cancer Research UK (2011) Diet, alcohol and cancer in the UK – statistics (downloaded 12/04/2012)http://info.cancerresearchuk.org/cancerstats/causes/lifestyle/diet/
- 9. Bates, B., Lennox, A. & Swan, G. (2008/09) National Diet and Nutrition Survey Headline results from Year 1 of the Rolling Programme, Food Standards Agency/Department of Health
- 10. The Strategy Unit (2008) Food matters, Towards a strategy for the 21st Century, Cabinet Office (downloaded 12/04/2012) http://www.foodsecurity.ac.uk/assets/pdfs/cabinet-office-food-matters.pdf
- 11. HESonline (07/03/2012) Malnutrition http://www.hesonline.nhs.uk/Ease/servlet/ContentServer?siteID=1937&categoryID=970
- 12. Age Concern (downloaded 7/3/2011) Still Hungry to be Heard, Age UK http://www.ageuk.org.uk/Documents/EN-GB/ID9489%20HTBH%20Report%2028ppA4.pdf?dtrk=true
- 13. SUS data (2004-2011) Hospital admissions for malnutrition, B&NES PCT in-house analysis
- 14. Ralph, A.F. et al. (2010) Prevalence of malnutrition in Sheltered Housing Schemes in Wiltshire and Somerset, Proceedings of the Nutrition Society (2010), 69 (OCE2), E206
- 15. Richards, C. et al (2009) Nutrition and Health Policy, Bath and North East Somerset NHS http://www.banes.nhs.uk/SiteCollectionDocuments/About%20Us/Policies%20and%20Procedures/Nutrition%20and%20Health%20policy%20May%202011.pdf
- 16. Salva, A. & Pera, G. (2001) Nutrition and ageing, Screening for malnutrition in dwelling elderly, Public Health Nutrition: 4(6A), 1375±1378 (downloaded 12/04/2012) http://journals.cambridge.org/download.php?file=%2FPHN%2FPHN4_6a%2FS1368980001000386a.pdf&code=5b5d24bc0671256f3d961c531b3262e2
- 17. British Dietetic Association (downloaded 07/02.2012) Malnutrition in hospitals (January 2006) http://www.bda.uk.com/malnutrition_in_hospitals.html
- 18. Russel, C.A. & Elia M (2011) Nutrition Screening Survey In the Uk And Republic of Ireland In 2010, BAPEN http://www.bapen.org.uk/pdfs/nsw/nsw10/nsw10-report.pdf
- 19. Arthritis Research UK (2011) Treatment for malnutrition in the elderly 'could prevent hip fractures' (downloaded 07/03/2012) http://www.arthritisresearchuk.org/news/general-news/2011/june/treatment-for-malnutrition-in-the-elderly-could-prevent-hip-fractures.aspx
- 20. SUS data 2014, hospital admissions relating to rickets ICD codes, B&NES in house analysis
- 21. Schools Health Education Unit (2013) The Health-Related Behaviour Survey 2013, A report for BANES Primary, Bath and North East Somerset Council
- 22. Schools Health Education Unit (2013) The Health-Related Behaviour Survey 2013, A report for BANES Secondary, Bath and North East Somerset Council
- 23. Department of Education (2014) Pupil premium: funding for schools and alternative provision, https://www.gov.uk/pupil-premium-information-for-schools-and-alternative-provision-settings (viewed 11/04/14)
- 24. Schools Health Education Unit (2013) The Health-Related Behaviour Survey 2013, B&NES Secondary Pupil Premium Headline Results, Bath and North East Somerset Council
- 25. Schools Health Education Unit (2013) The Health-Related Behaviour Survey 2013, B&NES Secondary Pupil Premium Headline Results, Bath and North East Somerset Council
- 26. Schools Health Education Unit (2013) The Health-Related Behaviour Survey 2013, B&NES Secondary Pupil Premium Headline Results, Bath and North East Somerset Council
- 27. Russel, C.A. & Elia M (2011) Nutrition Screening Survey In the Uk And Republic of Ireland In 2010, BAPEN http://www.bapen.org.uk/pdfs/nsw/nsw10/nsw10-report.pdf
- 28. http://www.bathnes.gov.uk/services/environment/food-safety/eat-out-eat-well
- 29. Sirona Health Improvement Service Annual Report 2013-14
- 30. Sirona Healthy Lifestyle Service 2013-14 demographic report