Healthy eating: an NHS priority A sure way to improve health outcomes for NHS staff and the public Aseem Malhotra, 1,2 Mahiben Maruthappu, 3 Terence Stephenson 4 Tackling the obesity epidemic and its asso- ciated adverse health consequences is one of today’s important public health chal- lenges. Obesity directly costs the National Health Service (NHS) about £6 billion per year. Direct and indirect costs of diabetes are estimated to be £24 billion and are likely to double over the next 20 years. 1 Some fundamental misunderstandings among the medical and healthcare com- munity and lay public inhibit the imple- mentation of effective interventions. Our decisions about the food we buy and what we eat are often automatic and made without full conscious awareness. 2 For example, despite wanting to lose weight, we’re still tempted to buy the brightly packaged chocolate bar at the checkout till. The lifestyle hierarchy places diet as a powerful common determinant of cardio- vascular disease, obesity, type 2 diabetes and several cancers. 3 The Lancet Global Burden of Disease Study reports that poor diet contributes to more disease than phys- ical inactivity, smoking and alcohol com- bined. 4 Recent scientific advances support a number of specific dietary targets to be prioritised for the prevention of cardiovas- cular disease. Several are aimed at increas- ing consumption of healthy foods, with a number to reduce the consumption of harmful ones. The α-linoleic acid, poly- phenols and omega-3 fatty acids found in abundance in nuts, fruit, vegetables, olive oil and oily fish rapidly exert positive health effects by attenuating thrombosis and inflammation, 5 and it is estimated that increasing population consumption of fruit and vegetables by one portion per day and nut consumption by two servings a week would prevent 5.2 million deaths from cardiovascular disease globally within just 1 year. 6 Conversely, the con- sumption of trans-fats commonly found in fast food can rapidly increase C-reactive protein and other inflammatory markers within weeks. 7 Reducing consumption of sugary drinks by 15% would prevent 180 000 people from becoming obese in the UK in the same time period and save £275 million for re-investment in the NHS. 8 Real progress towards combating the obesity epidemic and diseases associated with diet will only start once a root cause —the need for a healthier food environ- ment—is understood. The success of the junk food industry depends on the avail- ability of their products to anyone, any- where, at any time. Tackling the obesity burden requires collective action, and there is no single silver bullet, but there is an established hierarchy of effectiveness. The Centres of Disease Control health impact pyramid shows that, by changing the context—that is, the food environment —so that individuals’ choices about what to eat default to healthy options will have a far greater impact on population health than counselling or education. Healthy choice must become the easy choice. 9 Changing the context of smoking by insist- ing on smoke-free buildings has had a huge impact on reducing smoking preva- lence and improving health. Within just 1 year of the introduction of smoke-free legislation in Scotland, there was a 17% reduction in admissions for heart attacks and a 6% decrease in out-of-hospital cardiac deaths. 10 The Boorman Report demonstrated that better staff health and well-being is asso- ciated with better organisational perform- ance and improved patient outcomes. 11 The NHS is the primary interface with ‘health’ for most of the population, and so the workforce environment and the atti- tudes to health and well-being and diet of NHS staff can impact on health promo- tion. However, the oversupply of cheap, high-energy but nutrient-poor food and drink even pervades the institutions that should be promoting positive health mes- sages—our hospitals. Confectionary, crisps and sugary drinks are available to staff and patients through vending machines in hos- pital corridors and to bed-bound patients via hospital trolleys. Also, many hospitals have high-street fast-food franchises on site. Thus acceptability and consumption of such foods is legitimised by being in a healthcare setting. Moreover, reduced availability of healthy food options limits choice for many NHS staff, half of whom are estimated to be overweight or obese. 12 Educating people about healthy eating is difficult when the food environment is so unhealthy. Strategies that prevent excessive weight gain for children and adults by reducing consumption of unhealthy foods should be welcomed. However, focusing only on weight loss by any means is a missed opportunity and so potentially harmful. Health practitioners should move beyond the traditional, well-intentioned but limited dietary advice—to ‘eat less and move more’—and be more specific and evidence based. Regular physical activity consisting of a 30 min brisk walk per day has tremendous cardiovascular, bone and musculoskeletal benefits, but the link to obesity is weak 13 and its benefits are undermined by poor dietary habits. A recent longitudinal cohort study involving 175 countries showed that, for every add- itional 150 sugar-based kilocalories con- sumed daily (typical of a can of cola) compared with calories from another source, there was an 11-fold increase in the prevalence of developing type 2 dia- betes independent of body mass index and physical activity levels. 14 You can’t outrun a bad diet. Rapid weight loss and regain is detri- mental to health. Such ‘weight cycling’ contributes to hypertension, insulin resist- ance and dyslipidaemia resulting in increased mortality risk and worse cardio- vascular outcomes. The weight loss indus- try, which promotes calorie restriction rather than good nutrition, generates US $58 billion in revenue annually in the USA even though long-term follow-up studies (up to 5 years) show that most people on rapid diets regain much of the lost weight; about two-thirds do not achieve health benefits and put on weight whether or not they maintain their diet or exercise pro- gramme. 15 In contrast, with advice on a low-fat diet, the PREDIMED primary pre- vention randomised controlled trial, which included 7500 high-risk individuals ini- tially free of cardiovascular disease, found that an energy-unrestricted Mediterranean diet (41% total fat) supplemented with extra-virgin olive oil or nuts achieved a 30% reduction in major cardiovascular events, with event reduction occurring even within 3 months. 16 A key finding from analysis of PREDIMED subgroups showed that dietary intervention achieved 1 Department of Cardiology, Frimley Park Hospital, Surrey, UK; 2 Academy of Medical Royal Colleges, London, UK; 3 NHS England, London, UK; 4 Institute of Child Health, UK Academy of Medical Royal Colleges, London, UK Correspondence to Dr Aseem Malhotra, Academy of Medical Royal Colleges, 10 Dallington Street, London, EC1V 0DB; aseem_malhotra@hotmail.com Malhotra A, et al. Postgrad Med J December 2014 Vol 90 No 1070 671 Editorial on June 11, 2020 by guest. Protected by copyright. http://pmj.bmj.com/ Postgrad Med J: first published as 10.1136/postgradmedj-2014-133103 on 16 November 2014. Downloaded from