EHJ September 2004, pages 268-271
Diet-related disease has replaced smoking as the number one public health threat. Stuart Spear looks at how colleagues in Wales and Scotland are tackling the problem and asks whether England is slipping behind with its food and health action plan

The public health time bomb is primed and someone has to defuse it, fast. That is the message from a growing number of public health campaign groups who fear that an under-resourced and overstretched Department of Health is just not up to the job of addressing the enormous public health crisis facing us from diet-related disease, which is set to pose an even larger public health threat than smoking ever did.

The statistics are terrifying. One third of adults will be obese by 2020, by which time one-in-two children will also be obese if current trends increase. Children are drinking on average 4.7 litres of soft drinks a week, providing them with a surplus 8,000 calories a month if they are eating proper meals. And that is before we even start looking at the high sugar, salt and starch foods being thrown their way.

At present, cardiovascular disease is claiming 20,000 lives a year, a third caused by poor diet. Cancer claims 30,000 lives a year, over 7,000 of which could be saved if people were eating the right foods. These figures are set to rocket if obesity rates are not stemmed, as are the costs to the National Health Service which the government currently puts at over £2bn a year.

This is the reason for increasing disquiet about the slow pace at which government is responding to this impending crisis. There are also growing concerns about the lack of imaginative ideas coming out of the DoH to tackle diet-related disease compared to other countries, including Scotland and Wales . Campaigners believe that while decreasing salt, fat and sugar content in foods is key, the DoH is focusing too much on nutrition to the exclusion of more innovative strategies.

As the government has already launched its five-a-day policy and has started providing fresh fruit to schools, all eyes are now on the food and health action plan which is expected to be wrapped up in the health white paper, now scheduled for November. But so far public health groups, including the CIEH, have been unimpressed with what they have seen during two phases of consultation leading up to the launch. "What the DoH has produced so far is more a nutrition strategy than what we would call a food and health action plan," said Jenny Morris, CIEH policy officer.

Consumer awareness is one area where pressure groups, including the CIEH, believe the DoH is failing to properly grasp the nettle, limiting its campaign to the five-a-day initiative and information on the Food Standards Agency website. The CIEH believes a far more targeted and co-ordinated strategy is needed if behavioural changes are really going to come about. "We should be looking very closely at the experience of other countries, such as the US to identify innovative approaches," points out Ms Morris. "To be truly effective, all awareness campaigns, whether central, regional or local require well co-ordinated action between stakeholders with the appropriate targeting of messages."

Advertising food products, especially to the young, has become an increasingly high-profile issue producing a stand-off between government and public health campaigners who want to see an outright ban on adverts for unhealthy foods during children's viewing hours. They see the DoH line that a better balance is required with healthier foods being advertised, as pandering to pressure from the food industry.

The alliance for better farming and food, Sustain, and the CIEH, also believe that the DoH has failed to place nutrition and health in the context of sustainable development. In Sustain's response to the government's most recent food and health consultation exercise, it points out that sustainability is only mentioned once in the Choosing health choosing a better diet document. To many, the lack of references to sustainable development seems surprising given that the whole idea of a food and health action plan was born out of the Curry commission report on food and farming published two years ago, which had sustainability at its core.

But probably where the DoH comes in for most criticism, is when its proposals and the speed at which change is taking place is compared to what is going on in Scotland and Wales . The Welsh Assembly commissioned the FSA four years ago to consult on how best to improve the health of the nation through diet. The Welsh health audit revealed specific population groups most at risk from diet-related disease. In its food and wellbeing document it focuses on low-income families, young people and children, pregnant women and middle-aged men as being at the highest risk.

Where critics believe the joint Welsh Assembly and FSA nutrition strategy differs from its English counterpart, is that it drills down into the community providing focused delivery mechanisms. An example is the food and fitness health promotion grant scheme, which funds 27 projects across Wales looking at increasing levels of physical activity and healthy eating. Most of the projects started this year and range from developing menus in luncheon clubs for the elderly to make them healthier, to cook and eat sessions for youth clubs. Another example, in Cardiff , is where elderly volunteers are trained up to teach their peers about healthy eating.

While similar projects can be found in England , public health campaigners point to the way Wales has managed to co-ordinate its initiatives into coherent policies aimed at targeting specific groups at risk from diet-related disease. Also, by monitoring initiatives centrally, it is easier to pick out those that succeed and duplicate them across the country. To help achieve this, a community food network has been set up, putting community groups in contact with each other.

Echoing the Curry report recommendations, Welsh food deserts are being tackled by setting up a minimum of 26 sustainable food co-ops tasked with delivering affordable and healthy foods to disadvantaged communities. "What these co-ops are doing is linking farmers to communities by cutting out the distribution chain," explains Maureen Howell, the Welsh Assembly lead on the food and wellbeing strategy. "We are working with Welsh farmers to build up as much local produce as possible." Development workers set up the projects and then move on once they are up and running.

Work is also on-going in schools, establishing fruit tuck shops and offering free healthy breakfasts to primary school children. A TV campaign launched jointly with BBC Wales has used comedy and drama to encourage healthy eating, along with a helpline and road shows. Early figures show that 1.3 million people tuned in to the BBC programmes while the helpline received over 3,500 calls.

Equally, Scotland appears to be well ahead of England in its strategy having adopted the World Health Organisation model, dovetailing healthy eating initiatives with encouraging physical activity. TV adverts, healthy catering awards, combined with providing nutritious food and health education through schools, make up Scotland 's nutrition strategy. Hundreds of community-based initiatives have been launched, while a food and health council has been established to drive forward and oversee policy.

Of course, in some respects it is unfair to compare Scotland and Wales ' approach to tackling diet-related disease, given that England is dealing with a much larger population and a more complex central government structure. In Wales , it is far easier for the Welsh Assembly to work harmoniously with colleagues from the FSA, while using a coherent delivery mechanism with local health boards coterminous with local authorities.

Geof Rayner, a long-time campaigner and consultant on nutrition and health, former chair of the UK Public Health Association and visiting research fellow at City University , explains: "The problem in England is that there are so many fingers in the policy pie that no one body has a particular remit. You have Defra, the Department for Culture, Media and Sport. You have the Department of Health with lots of working parties, which is overstretched, then you have a whole set of other bodies along with the Food Standards Agency." Mr Rayner goes on to point out that in some cases government ministries appear to have been actively promoting the cause of the problem, like when the DCMS supported Cadbury's Get active chocolate bar promotion.

Mr Rayner and Professor Tim Lang, from the centre for food policy at the Thames Valley University , have in recent months been trying to convince government ministers of the merit of setting up an overarching food and nutrition council, to bring together all the different government departments and agencies, along the lines of the Scottish cross-cutting food and health council.

MPs sitting on the recent House of Commons health committee that reported into obesity agree. They made over 70 recommendations on how best to tackle this public health time bomb, one of which was the setting up of a new council for nutrition and physical activity to "improve coordination and inject independent thinking into strategy".

"You need an integrative body which sets out the picture, has a view of things and which is not so much about delivery mechanisms but is looking for more effective and imaginative initiatives to deliver," explains Mr Rayner. This approach has already been in place for a number of years in countries such as Norway and Finland . In north America , by contrast, food and health councils have been set up on a city or state basis, which Mr Rayner believes could also be adopted here.

This opens up the idea of by-passing central government and launching regional health and food action plans through the regional government departments and regional assemblies. This has already happened in the East Midlands where the partnership assembly, working with the regional office of the DoH, produced Investment for Health, the country's first regional public health strategy, launched in 2003. Born out of an 18-month consultation with local stakeholders, the strategy sets out 16 public health objectives for the East Midlands region. While diet, prevention of cardiovascular disease and reducing cancer rates all figure in the strategy, it provides a far broader public health remit, also covering issues such as sexual health, health at work, food safety and substance misuse.

This in turn has spawned a local public health strategy launched by Derby DC in partnership with the Central Derby and Greater Derby Primary Care Trusts. This sets out 22 key public health objectives highlighting key actions to be taken.

The next phase of the regional strategy is to develop a food and health action plan. "We have done some initial scoping of what's happening within the region in terms of food and health and the action plan will be due out at the end of this year," said Nick Salfield, deputy regional director of public health at the DoH for the East Midlands. He believes that there may be an argument for central government providing broad policy direction and then letting regional government create more specific policy leads for their particular regions. "If the DoH defines too much at the centre then they will be criticised for that. There is some point in having a broad framework and then letting local organisations have choice and flexibility," he told EHJ.

However, some public health groups, like the Royal Society for the Promotion of Health, believe that there is an inherent danger in producing regional public food and health strategies, which may lead to inequalities depending on what region you may live in. "I am not a great fan of regional delivery," explains Alastair McCapra, head of communications for the RSPH.

He believes that the problem is cultural rather than whether delivery is national or regional. "The DoH is well geared up to dealing with the NHS and issuing leaflets to eat more fruit. But the linking of the health agenda with sustainable development has pushed them into territory where they really are not quite clear where they are going. So, with the best will in the world they are finding it hard to take a lead on some of these things," he told EHJ. He added: "Delivery is not the problem - it is the political will to put some bite into all this that is the issue."