‘Fat but fit’ – Lessons in the language of a press release

This week a paper from the EPIC-CVD which I co-authored was published in the European Heart Journal. Unfortunately the article was subsequently promoted in the press with the headline ‘Fat but fit’ still risk heart disease, encouraging a belief that physical activity offers no heart health benefit to those that are overweight.

This headline is misleading because most people understand ‘fit’ to mean physically activity, however the paper didn’t measure physical fitness. Instead it measured metabolic health (ie, high blood pressure, cholesterol and blood glucose) which some term ‘medical fitness’, and is often shortened to ‘fitness’. Hence the confusion.

What the paper really shows is that being overweight and having poor metabolic health both contribute to increasing risk of coronary heart disease (CHD), or a heart attack, to put it more simply. If you group people based on their weight status and metabolic health then the risk of having a heart attack increases in the following order:

 

 

 

 

 

 

To provide some context to these numbers, we know that having a heart attack is more common in older people – that risk increases with age by about 10% per year. Being overweight and healthy notionally makes you 2 ½ years older (in terms of heart disease risk) than a normal weight and healthy person. Whilst being obese and unhealthy notionally makes you 15 ½ years older!

My take home message from these figures is that having poor metabolic health is much worse than being overweight or obese on its own; however people carrying excess weight still don’t get off scot-free. So, if you can improve your metabolic health (whether you are normal weight or overweight or obese) you can substantially reduce your risk of CHD. Equally if you can reduce your weight (whether you have good or bad metabolic health) you can reduce the likelihood of a heart attack even further.

What about being fit, ‘physically active’ fit?  

If you are overweight and are physically active then this will more than likely be good for your health – we know that physical activity has beneficial effects on metabolic health. The long-standing fat-fit hypothesis states that the health benefits of being physically active can cancel out the increased risk of being overweight, so it’s possible to live just as long if you are fat as long as you are fit. Does our work say anything about that idea? Not really, not without a lot of inference and assumptions. You’d need a study of physical fitness and weight and metabolic health to get to the bottom of that one (a study like this).

What is apparent from this analysis is that grouping people based on continuous measures of health is spurious. If you look at the ‘apparently healthy’ overweight or obese group you’ll see that their blood pressure, cholesterol, blood glucose, etc are actually still higher than the supposedly equally healthy normal weight group. To me this suggests that metabolically healthy obesity doesn’t really exist, not long-term. The people in the healthy obese group just didn’t quite meet the cut-offs for being defined as ‘unhealthy’ yet, suggesting it’s only a matter of time before they cross over to the unhealthy group.

So what’s the point of putting people in boxes, we are all individuals after all, with our own unique profile of risk factors. I’d say let’s try and keep continuous risk factors continuous and aim for lowering them across the whole range using whatever methods have been shown to work in the past. Physical activity and diet can both help in different ways, to either improve metabolic health or promote weight loss, so aiming for a healthier lifestyle is as important as it ever was.

This blog was written by Dr Laura Johnson, a Lecturer in Public Health Nutrition in the Centre for Exercise, Nutrition and Health Science, School for Policy Studies.

 

 

 

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Back to school for MyHeart Beat

Dr Laura Johnson, is a Nutritional Epidemiologist and Senior Lecturer in Public Health Nutrition. Her research focuses on establishing the role of overall dietary and eating patterns in the prevention and treatment of obesity, diabetes and coronary heart disease as well as understanding the factors that influence food intake and appetite control. In this blog, she reflects on a recent visit to Malaysia to research adolescent lifestyle in conjunction with the MyHeart Beat project.

In April, this year I went back to school, some things were just the same as I remembered but others were very different, mainly because I was in school in Malaysia. I had found myself in Kuala Lumpur for work and I was visiting schools to find out exactly how big a task we had taken on for our new collaborative research project MyHeart Beat (Malaysian Health and Adolescents longitudinal Research Team Behavioural Epidemiology and Trial).

MyHeart Beat is funded by the UK Medical Research Council and Academy of Sciences Malaysia (Newton Ungku Omar Fund). The project aims to explore how changes to diet and physical activity could improve heart health in Malaysian adolescents. It’s a collaboration between researchers in the University of Bristol’s Centre for Exercise, Nutrition and Health Sciences and the University of Malaya’s Faculty of Medicine. Our aim is to find ways for Malaysian teens to be more active and eat better, which will help them in the future to avoid obesity, type 2 diabetes, and cardiovascular disease, chronic conditions that are affecting ever increasing numbers of people in Malaysia.

MyHeart Beat builds on MyHearts (Malaysian Health and Adolescents longitudinal Research Team study) an excellent project by researchers at the University of Malaya, in collaboration with researchers from Queen’s University of Belfast, who have spent the last 5 years following more than 1000 teenagers from the age of 13 to 17 years in 3 Malaysian states. MyHearts has collected detailed information on diet, activity, lifestyle and health and has shown that 15% of adolescents are overweight and a further 9% are obese. Physical inactivity is rife (64% of teens are inactive) and breakfast habits are erratic (25% of teens never or only occasionally eat breakfast). We’re planning more analyses of this rich data to find out about the patterns of behaviour related to obesity and heart health.

I’ve previously explored patterns of food intake associated with obesity and shown that it’s a combination of high-fat, low fibre and energy density that is important rather than any single aspect of diet. Key foods part of an obesogenic dietary pattern in the UK include fruits, vegetables, and high-fibre bread (not eating enough of them) and white bread, crisps, sweets, and processed meat (eating too much of them). We expect the most common foods eaten in Malaysia to be different to the UK but in principle whatever foods there that make a diet energy dense, low in fibre and high in fat are still likely to be those most important for preventing obesity. In MyHeart Beat we will apply the same method for finding patterns of behaviour (reduced rank regression, RRR). RRR is a statistical technique that, for dietary patterns, adds up intakes of all foods after giving some foods more emphasis than other (by giving pattern loadings). RRR works out how much emphasis to give different foods by trying lots of options until it settles on the one where foods are combined in such a way that the energy density, fibre and fat content of the whole diet can be predicted best. You end up with pattern loadings (numbers) for each food and the larger the loading the more important that food is for predicting the obesogenic features of diet. Using the loadings, it’s then possible to rank foods in order of importance and identify exactly what foods to change to make diets less likely to lead to obesity. With our analyses, we hope to find out not only what the most important foods are but also what activities are best for maintaining health throughout adolescence. Once we know what the high-risk behaviours are we can start working out ways to help teenagers to change.

Although, even when you know what to change you then have the task of working out how to change it. There are many different routes we can take to change behaviour; the sheer number of options can be challenging but is also what makes the project fascinating. The MyHeart Beat team has lots of experience trying to change behaviour in children in the UK, Europe and Malaysia. For changing diet we’ve attempted intensive programs led by dietitians as well as computer based courses supervised by teachers. Innovative strategies we’ve tried for increasing physical activity have included after school clubs led by teaching assistants; dance workshops and harnessing the power of social networks to spread positive physical activity messages. In Malaysia, the MyBFF@school program (My Body is Fit and Fabulous) has been designed specifically to help overweight and obese adolescents control their weight and provides a valuable platform on which to build a broader program that could help all adolescents stay healthy.

A starting point for designing an intervention is simple logistics. What is even possible to change within Malaysian schools? So that’s what brought me to Kuala Lumpur, to visit schools and see for myself how life works for adolescents at school over there. I realised that the biggest difference compared with my school in the UK was the timing. In Malaysia, school starts at 7 am and ends at 1 pm, break time is for 20 minutes between 0930-1030 (depending on which year you are in) and this is the time when the cafeteria is open for hot meals and cold drinks.

The school canteen offers lots of fried and sweet snacks like burgers, sausages, chicken and samosas, not so different to school food I remember. But more traditional meals, made of rice, noodles, eggs, fish or meat with sauce, were also for sale.

Some schools had fruit snacks suggesting it may be possible to alter the range of foods available. There were vats of ice-cold drinks like fruit squash and Milo and iced tea, all sugar-sweetened. Water wasn’t freely accessible but water bottles were sometimes brought in from home.

Touring the rest of the school, I saw that there were plenty of spaces for physical activity, a school gym, hall, basketball courts and a playing field. But the heat was high as was the humidity, I was sweating just standing still! I had no desire to be physically active in those conditions, which made me wonder what the kids thought about that.    

That leads me back to what MyHeart Beat aims to do in the next 18 months. We plan to find out what staff and students think about different options for changing diet and activities – because ultimately it’s the people whose behaviour you are trying to change that know best what will work for them. We’re also aware of some local initiatives by state nutrition divisions starting this year to make improvements to the school food supply e.g. in Perak, parents/teachers are asked to report if the canteen is selling unhealthy food. To find out more about what the adolescents, teachers and Ministry of Education officials think about what can and should change, we’re planning some interviews and focus groups to ask them directly. From this we’ll work out the options that will be most feasible for changing. Then we’ll develop an intervention (set of changes) that we hope will improve diet and physical activity and ultimately cardiovascular and metabolic health. Our approach follows the UK Medical Research Council (MRC) recommendations for designing interventions. We hope that by building on a strong evidence base and crucially talking to the local people, we’ll ensure the intervention we design will be a success.

Towards the end of 2018 we’ll be taking our intervention out to some schools to test it out. This small pilot project is the ultimate aim of all of the different parts of the project and will tell us if the plans we’ve made will work in practice. I’m looking forward to visiting Malaysia again at that stage, and getting some more fabulous hospitality from the MyHeart Beat researchers over there!

To Shooka, Shafina and Fadzrel, Terima Kasih (Thank You) for having me.

 

 

 

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If all the evidence points to a Mediterranean diet… Why do UK Dietary Guidelines insist on a low-fat diet?

Dr Angeliki Papadaki, Lecturer in Public Health Nutrition at the Centre for Exercise, Nutrition and Health Sciences, School for Policy Studies, argues on the need for UK dietary guidance to loosen the low-fat advice and embrace higher-fat but healthier dietary patterns, like the Mediterranean diet.

olive-oil-photoI come from Crete. I grew up in a house where everything revolved around the kitchen. Most of my childhood memories involve my mother preparing meals from scratch, using olive oil. Meals were accompanied with vegetables and we had a legume soup (like lentils, beans, chickpeas) twice a week. All of them were a pleasure to eat; they just needed olive oil and a slice of bread to scoop up the juices to receive a cook’s highest reward: empty plates.

I’ve lived in the UK for 10 years and I still can’t enjoy vegetables or salad unless I prepare them myself. They are boiled and boring, with uninspiring dressings, and no tomato sauce or sautéing with olive oil and onions to give them some flavour. It’s no wonder that 70% of adults in the UK do not eat enough fruits and vegetables and that on average they consume 14g of legumes a day (half the amount consumed in the traditional diet of Crete).

The argument that olive oil, as one of the most important Mediterranean diet foods, helps the consumption of higher amounts of vegetables and legumes is not new. Yet UK dietary guidance has a long tradition of recommending a low-fat diet. Up to recently, the Eatwell Plate recommended to “eat just a small amount of foods high in fat” and made only one reference to olive oil: “When you’re cooking, use just a small bit of unsaturated oil such as sunflower, rapeseed or olive, rather than butter, lard or ghee”.greek-salad-photo

Granted, the revised Eatwell Guide differentiates unsaturated oils from other high-fat foods, but still emphasises that these foods “should be limited in the diet”, without defining this limit. Again, olive oil comes third in line, after vegetable and rapeseed oil. To contrast this, the Mediterranean diet recommendations suggest that olive oil should be the main source of fat in the diet and used in every main meal. A recent randomised controlled study showed that for each 10 g/day increase in extra-virgin olive oil consumption, cardiovascular disease incidence and mortality decrease by 10% and 7%.

The concern about moving from a low-fat diet recommendation to a higher-fat one (even with the ‘right’ fats) might come from fear of promoting obesity. Yet, despite the advice to limit fats, more than half adults in the UK are overweight or obese. At the same time, diabetes is on the increase and heart disease is one of the most common causes of death. In contrast, and despite its higher fat content, the Mediterranean diet does not cause weight gain, and even if some heart disease risk factors are higher in Mediterranean countries, actual diagnosis of the disease is lower than in the UK. High-fat diets were recently shown to improve risk factors for heart disease among people with diabetes, compared to low-fat diets. The Spanish landmark PREDIMED study also recently showed that following a Mediterranean diet, with high amounts of olive oil (≥4 tablespoons recommended every day), reduces risk of cardiovascular events by 30%, compared to a low-fat diet usually recommended for the prevention of cardiovascular disease.

Traditional Greek dip tzatziki

The EU recently invited its Member States to “promote healthy eating, emphasising health promoting diets, such as the Mediterranean diet”. The US Dietary Guidelines have also recently recommended the Mediterranean diet as an example of a healthy eating pattern. The National Institute for Health and Care Excellence, after reviewing the evidence for its draft public health guideline on maintaining a healthy weight, recommended to “follow the principles of a Mediterranean diet, which is a diet predominantly based on vegetables, fruits, beans and pulses, wholegrains, fish and using olive oil instead of other fats”. After review by the Public Health Advisory Committee however, this recommendation was not included in the final guidance, exposing a resistance of UK experts to the Mediterranean diet recommendations.

Yet we know that the Mediterranean diet is tastier and easier to comply with compared to a low-fat diet. We know that, with appropriate nutrition education, it can be transferable to Western populations. Perhaps we need to show its effect on health through randomised controlled trials in the UK before we see UK dietary guidance embrace its recommendations, similar to what our US counterparts did.

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Growing the conversation: how to make Bristol a Child Friendly city

Close up of little boy in canvas shoes drawing with chalks on the sidewalk

Debbie Watson reports as The Bristol ‘Child Friendly City’ Network ran the first Child Friendly Symposium as part of the 2015 Thinking Futures festival.

Inspired by global UNICEF guidelines, the Child Friendly City’s Network aim is to bring together a wide range of partners to campaign strategically and deliver grass roots projects that support child friendly environments. The Child Friendly Symposium brought together around 20 children and young people, as well as 80 adults who worked for and with this demographic, from all over Bristol.

Mayor George Ferguson opened the event and emphasised the need for cities to actively consider children and young people, whether in urban planning decisions, allocation of community resources or in the respect afforded to our youngest citizens. He said: “A child-friendly city is a healthy, happy, liveable and playable city”.

The symposium then saw short presentations delivered by Bristol academics: Dr Angie Page on children’s activity levels and public health outcomes; Dr Helen Manchester on a project which explored young people’s cultural engagement in Bristol; and Dr Debbie Watson on a project which co-developed research capability and awareness with Room13 Hareclive children and artists.

But the main event saw child-led participatory activity to engage adults in the room. Together they made creative banners, highlighting what needs to change in Bristol for it to be truly child friendly. These banners were then showcased, sharing many powerful and provocative messages.

Giving young people from Room 13 Hareclive, Hartcliffe and Felix Road Adventure Playground, Easton, a contributing role in the symposium was an important statement of intent. Harnessing this potential is what Child Friendly Cities (CFC) are all about, holding true to the principle that ‘if a city is successful for children it will be successful for all people’.

“The Thinking Futures Bristol Child Friendly City Symposium was a great opportunity for us to bring together representatives from different backgrounds in the city to share an equal platform: children and young people, academics, organisations working with children and young people, arts and cultural organisations, Bristol’s mayor and Bristol City Council officers.”

We heard compelling arguments from different perspectives – research, local government and children themselves – about why it’s so important for Bristol to be more child friendly. Children and adults identified key calls for change in the city such as ‘free bus travel for children’, ‘safer streets’ and ‘believe and trust in us’, which we all endorsed. It was good to see children and young people, many of them from more disconnected parts of Bristol, sharing thoughts and ideas with academics and practitioners, and vice versa.

This event in partnership with the University of Bristol really helped to raise the profile of Bristol CFC and to consolidate and move on our agenda within the city. We’re excited by the possibility of further collaborative work with academics.” – the Child Friendly City network.

The event is part of a wider strategy to grow the conversation in Bristol, beyond immediate partners and interested parties. Already, impact can be seen across the city through press releases, media coverage, and new partnerships. Bristol and other cities have already been in touch, with potential collaborations stretching as far as Sweden. In late February these interested parties came together at a seminar hosted by Cardiff University’s Children’s social care research and development centre (CASCADE), opened by Dr Sally Holland, the children’s commissioner for Wales.
Ongoing local campaigning includes: a proposal for research impact funding to tackle one key issue with children in the city; organising a young people’s Mayoral hustings in May; and an international conference hosted in Bristol, for the city to truly lead on child friendly policy and practice.

For more information:

Towards a child-friendly city

The Child Friendly City network consists of University of Bristol academics and grassroots organisations Architecture Centre, Playing Out, and Room13 Hareclive.

Debbie Watson is Reader in Childhood Studies in the Centre for Family Policy and Child Welfare.

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An engaging pilot study: How the PLAN-A study has been built on participant input.

Plan A logoDr Mark Edwards, from the Centre for Exercise, Nutrition and Health Sciences, discusses the value of participant inclusion in project implementation.

Physical activity is a big problem in the UK. We’re not doing enough of it. Lots of evidence suggests that when people are more active they are also healthier, have a greater sense of wellbeing, and help reduce their risk of future disease. So, why isn’t everybody active? This is a difficult question. We could ask why some people still smoke or why we don’t all eat a healthy diet. The potential answers to these questions are complex and multifaceted.

We do know a few things about physical activity however; firstly, females are less active than males at all ages. Secondly, adolescence is a key time when females become less active and the divide between males’ and females’ activity widens; around the beginning of secondary school. Thirdly, when adolescents stop being active, it becomes even more difficult to (re-)engage them. Fourth, being physically active is not a simple as it seems: the choice and ability to be active is wrapped in myriad social and psychological factors.

The PLAN-A team, led by Dr Simon Sebire at the University of Bristol’s Centre for Exercise, Nutrition & Health Sciences, hope to advance our understanding of how we can increase the physical activity of girls during early adolescence. We are testing the feasibility of increasing the activity levels of Year 8 girls (aged 12-13) through a ‘peer-led’ concept that has proved successful in reducing adolescent smoking rates (www.decipher-impact.com/). The basic concept of PLAN-A is: 1) ask all Year 8 girls in a school to nominate who they think are the most influential girls in their year, 2) recruit the top 15% of the girls nominated to attend a training course to be a peer-supporter, 3) train peer-supporters to recognise the importance of being active, how they can overcome barriers commonly faced by teenage girls and incorporate more activity into their friends’ lives, and how to communicate effectively, and 4) send the girls  back to their peer groups to informally encourage their peers to be more active.

A central belief that underpins PLAN-A is that the people taking part – the girls whose behaviour we are trying to change and, to a lesser extent, the trainers who will train the girls – are best placed to know what will work for them. Despite having a diverse range of experience in our team, we are not Year 8 girls, and as such can only go so far to develop an educational experience that meets their expectations. If the PLAN-A intervention is to help increase the physical activity levels of Year 8 girls, it needs to reflect what they find important, speak their language, engage and enthuse and inspire them to encourage their friends to be active. As such, we have continuously engaged our “end users” in the design of the PLAN-A study, as can be seen in the following narrative.

Our stakeholder engagement started when the grant application was being written. A group of adolescent girls from the DECIPHer ALPHA (Advise Leading to Public Health Advancement) group took part in a focus group and gave valuable feedback on the design of a peer-led activity intervention. The intervention we designed expressly adhered to the girls’ suggestions that the training should focus on health, vitality and enjoyment. The girls also wanted the training to equip them with practical skills. We took what the girls said and edited the training and recruitment materials in light of this.

Before we conducted the ‘feasibility’ study we wanted to explore the materials and training we had developed in light of the DECIPHer ALPHA group’s suggestions with more year 8 girls. We hoped that this would provide a further opportunity to tailor the intervention to their preferences. A school in Wiltshire kindly allowed us to pilot the whole of the PLAN-A intervention with their Year 8 girls. As such, we tested the recruitment, peer nomination, pupil briefings and training with these girls. The process was interesting, a little reassuring, and hugely constructive. Children can be good critics!

In total we conducted six focus groups with the Year 8 girls. The first two focus groups sought feedback on our proposed peer-supporter recruitment and training materials, including the study logo. We mainly wanted to know if what we were proposing appealed to Year 8 girls. Although we weren’t too far off, we redesigned elements of the intervention and then invited the girls to two more focus groups to check whether we had done what they asked. Following a few more revisions based on their input, we felt we were ready to rehearse the intervention.

We ran a pilot recruitment drive, which entailed a presentation to all Year 8 girls and an information pack for themselves and their parents. This went well and 95.7 % of girls in the year wanted to take part. We then conducted the peer nomination with the year group. This provided the chance to test the nomination process out. Again, this went smoothly and a few days later we invited the girls who had been nominated as peer supporters to a briefing session. As they suggested in the earlier focus groups, the girls were reminded of the kudos of being identified as one of the most influential people in their year group. Of the 14 girls who were nominated, 12 attended the training.

In the meantime we trained our PLAN-A trainers – the two people who would be training the peer supporters. The trainers received a training course (run by study staff) and then delivered the peer supporter training. We had an experienced observer sit in and watch the training to help identify any issues that may not be apparent to the trainers (and to also check that everything flowed as planned). Immediately after the training, we interviewed each trainer and conducted two focus groups with the girls who took part. We wanted a ‘warts and all’ account of their experience with PLAN-A, and that’s what we got!

In general the girls loved the training (and their trainers). The biggest issue was that there was too much writing and not enough moving. The trainers largely agreed with the girls and raised similar issues. We took this feedback and used it to change as many activities as possible to reflect what the girls wanted. We revised the activities and now have a “final” intervention package that targets the intended learning outcomes using much more activity, less writing and sitting, and more role play. We will be delivering the intervention over the next few months and will, once again, seek detailed feedback on how this was received by the people taking part.

 

This project is funded by the National Institute for Health Research [Public Health Research Programme] (project number 13/90/16). The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the NIHR PHR Programme or the Department of Health.

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Can after-school dance increase physical activity levels in adolescent girls?

Russ Jago, Professor of Paediatric Physical Activity & Public Health, reports some surprising findings from research conducted at the Centre for Exercise, Nutrition, and Health.

dancers1-500x240

Adolescent girls who attend after-school dance classes are no more likely to be physically active than those who don’t. This is one of the key findings from Active 7, a research project that aims to find out whether after-school dance sessions can help adolescent girls to engage in moderate levels of exercise.

Physical activity is associated with improved physical and mental health, but many adolescents – and particularly adolescent girls – do not engage in recommended levels of physical activity.  A team, led by staff in the Centre for Exercise, Health and Nutrition at the School for Policy Studies aimed to address this issue by examining whether providing dance programmes at secondary schools led to increases in girls’ physical activity. The study took place in 18 secondary schools. In half of the schools, Year 7 girls were provided with a new after-school dance programme for 20 weeks. Girls in the other “control” schools carried on as normal.

The results were surprising.  Much academic research suggests dance is an appealing form of physical activity amongst teenage girls, that extra-curricular periods are better suited to delivering physical activity interventions, and that interventions based on psychological theory (as Active7 was) have more success than non-theory based interventions. However, we found no difference between the physical activity levels of the intervention and control group girls at the end of the programme, or 6-months later. We also found that only a third of girls attended at least two thirds of the sessions provided in their school.

Our earlier work had suggested that girls enjoy dance and as such the lack of a difference in the physical activity levels of the girls was surprising. This could be due to the intensity of the dance sessions. The goal of the project was to increase ‘moderate to vigorous physical activity’ (MVPA), which gets you sweaty and slightly out of breath. The results found that girls who attended Active7 only took part in 4.7 more minutes of MVPA on session days, and therefore the sessions may not have been intensive enough to impact on MVPA.  Only one-third of the girls met the attendance criteria of attending two-thirds of the sessions, suggesting there may be a need to consider alternative forms of physical activity. A final and third explanation is methodological; accelerometers may not be able to capture the nuanced movements inherent in dance, especially when preparing for performances. Thus, levels of MVPA in sessions may have been underrepresented.

The results have implications for how we think about delivering after-school physical activity interventions. We might need to move beyond delivering standardised forms of extra-curricular physical activity and instead find more novel forms of exercise that offer lots of different types of physical activity. Fortunately, the findings from Active7 provide us with new ways of thinking about designing interventions. Offering participants with sufficient ‘choice’ in the design of the intervention is one potential method uncovered in our analysis, whilst delivering tailored interventions that meet a diversity of schools was also suggested as a future recommendation from girls and school contacts. Thus, future research which examines how to engage girls in activity and focusses on the types of activities that they would like to attend, when they would like to attend and how to maximise physical activity during those sessions, is needed.

The project was funded by the National Institute for Health Research Public Health Research (NIHR PHR) Programme (project number 11/3050/01). The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the NIHR PHR Programme or the Department of Health.

This blog post is based on Jago et al 2015: Effect and cost of an after-school dance programme on the physical activity of Year 7 girls: The Bristol Girls Dance Project, a school-based cluster randomised controlled trial, International Journal of Behavioral Nutrition & Physical Activity, 12:128, 2015

 

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Bridge Learning Campus visit to ENHS

Mark EdwardsRecently a group of Year 8 students from Bridge Learning Campus spent the day with staff in the centre for Exercise, Nutrition, and Health Sciences. Two of the girls (Amy Manning and Jess Martin) were winner and runner-up respectively of the Bristol Bright Night (Healthy Bodies, Healthy Minds) award. As part of their prize Mark Edwards (ENHS) and Chloe Anderson (Centre for Public Engagement) arranged for the girls to visit the health-focused Centre. Mark reflects here on the fun and insightful day that ENHS spent with the girls.

Five girls, accompanied by their Science teacher, Ms Williams, spent the day learning about the research we do and gave us some great insights into the barriers they face to being physically active. Almost all of our work into physical activity is assessed by accelerometers (which give a sophisticated measure of physical activity). Byron Tibbitts from ENHS offered a tour de force of the little red device we use to measure activity. In true Blue Peter fashion, the girls made a rudimentary accelerometer and then did their own mini controlled trial with the real things! The girls not only conducted the experiment with Byron, but then went on to analyse and interpret the data too.

Next up, Emma Solomon, Bex Newell and Rosina Cross (the B-Proac1v team) taught the girls all about blood pressure (a measure used in the BHF-funded study into young children’s physical activity). The girls confirmed our hypotheses that music and physical activity both affect blood pressure levels.

Finally, Kate Banfield built on the work we do in our FAB Kids outreach project to discuss sugar content in drinks. In an illuminating study, the girls were genuinely shocked to see the amount of sugar in drinks commonly consumed by people their age.diagram

After a great lunch in the Refectory we headed back to have a roundtable discussion on the barriers girls face to being physically active. The declining physical activity levels of female adolescents is a real public health concern (and the focus of the Acitve7 and PLAN-A studies), so this gave staff in ENHS a great opportunity to hear about the issues girls face. Mark Edwards and Sarah Harding led the discussion and were hugely impressed with the candid and insightful observations the girls made.

The final part of the day was always going to be the most nerve racking for the girls. But they excelled. Speaking to a room packed full of academics – scary for even a seasoned prof! – the girls gave a brief presentation on what they learnt throughout the day, with a wonderful practical example of how accelerometers work. The girls then spoke about the barriers they face to being active and presented some possible solutions for getting around them. The key messages we heard were that physical activities need to be FUN! There also needs to be the opportunity for girls-only activity, a chance to try new activities in a welcoming arena, and girls want to dress in whatever they feel comfortable. In making our research effective and getting it to truly speak to the people it is aimed at, it is vital we hear the voices of the girls.

It was a pleasure having the Bridge Learning Campus girls and Ms Williams come in – the girls did themselves, their teachers, and the school proud. We hope that they not only learnt some interesting things about physical activity but also had a good deal of fun too. None of the girls knew anybody who had been to university, and none of them had ever visited a university before. We hope to have inspired them to consider university as a viable option for them when they begin thinking about their future beyond secondary school.DSC_0290

Due to the success of the day, we hope to team up with the Centre for Public Engagement to make this an annual event.

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Capturing the benefits of ‘playing out’

School for Policy Studies academics work with a range of local interests. Playing out is a non-for-profit Bristol based organisation that encourages street play in the UK. Naomi Fuller, from playing out, has written this blog about how their work with the School is helping them to capture the benefits of such activity. 

I stood turning the skipping rope for ages at our last playing out session. Tall ten-year-olds and sturdy toddlers queued to have a go at jumping in as I chanted “Mickey Mouse Built a House” on request. I watched them – some skipping deftly, others stopping and starting with the rope getting tangled, some squatting down to do some chalking close by while they waited and I wondered whether it was possible to unpick what was going on. Of course they were having fun, giggling and trying to hold hands and skip together, then running out of the turning rope to add chalked horns to the rainbow-coloured cow they had drawn together in the middle of the street. But is there any way to measure this activity. And is there any need?PORTRAIT-grandma-skipping-rope.jpg

A conference hosted recently by University of Bristol gave some clear answers to these questions. The event was called “Outdoors and Active: Delivering public health outcomes by increasing children’s active travel and outdoor play”. It gathered people working in local authority public health teams, education and play services to share new research showing beyond doubt that children at playing out sessions are getting more exercise and activity than they would if they were indoors during that same period. Dr Angie Page and Professor Ashley Cooper are lead researchers for the PEACH project, a long term study examining the links between the different physical environments children spend time in and how active they are in them. They and their team have already measured children’s activity levels on their school journeys – whether in cars, on foot or by bike, during the school day and in the after-school period, examining the length of time they spend outdoors and indoors and exactly how much physical exercise they do.

To carry out these studies and gather the data they need, researchers have kitted children out with GPS tracking devices which show precisely their location at every stage of their journey. Children have also worn ‘accelerometers’ which measure the intensity of their exercise and activity. Recently Angie and her research team have turned their attention to street play – visiting playing out sessions to measure the intensity and type of physical activity children are doing. As well as equipping the children with the technical kit, her team interviewed parents and children about their activity patterns and habits.

It’s the levels of ‘moderate to vigorous physical activity’ (MVPA) that are a key focus. Government guidelines are clear: children between five and eighteen need to get at least an hour’s MPVA each day to ensure they are healthy. But very few are managing this and recent figures show just 14% of boys and 8% of girls are doing so. And these levels of inactivity are increasingly worrying for children’s long-term health and wellbeing. During a playing out session MVPA is the energetic play we often see; the skipping, scooting, hopscotch and playing tag as you would expect. But it’s brisk walking and similar types of activity as well and lots of imaginative games would include periods of MVPA as I’ve observed on my own street when make believe wizards and witches take to their broomsticks after huddling over a pretend cauldron for a while. The University of Bristol data shows;

  •  Children are three to five times more active outdoors than indoors
  • Time spent outdoors with friends is linked to an increase in children’s physical activity levels
  • During playing out sessions children spent 30% of their time in moderate to vigorous physical activity (MVPA) and another 15% in light activity.
  • This compares to 5% of time indoors usually spent in MVPA

Holding-one-end-skipping-ropeAngie Page introduced some important questions in presenting these findings. First was the notion of ‘subsitutional replacement’. Put in lay terms the issue is whether the children at the playing out session would have got their physical activity in another place such as their garden or local park if they hadn’t been playing in the street that day. The clear answer was no. The responses from parents and children showed that the playing out session was usually an alternative to a less active option – watching TV or another sedentary indoor activity.

And the other intriguing question was around the idea of ‘compensation’. This is the question of whether being active during a playing out session means children flop on the sofa for longer afterwards and are ironically less active than they would have been normally (as many adults often are after a gym session!). Again the data showed that this did not happen to the children playing out and that they did not have a pattern of doing less activity after playing out to ‘compensate’ for the more vigorous play they had done.

Professor Kevin Fenton, Director of Health and Wellbeing at Public Health England closed the conference by starkly stressing the urgency of improving children’s levels of physical activity and the need to make active play the norm once more. “It’s often said that the environment is an important health service,” said Professor Fenton. And he talked about both green spaces and urban spaces like streets, needing to be seen in this way – as potentially health-giving spaces for those spending time in them. The challenge both for the audience gathered at the conference, and for policy-makers and public health commissioners, is to support the idea of street environments as a ‘health service’ and to act on the growing body of research and data which clearly shows the benefits of street play. The evidence is there – not that anyone who has watched a playing out session has ever doubted it.

A few days after the conference my street played out again and this time as I watched the pink-cheeked skippers, legs blurred as they jumped faster and faster it felt inspiring to realise that what they were doing – so naturally and with so much fun – is part of something increasingly important to researchers and policy makers. You can read more about the University of Bristol’s research findings here. If you want to know how to support street play in your street, or work for an organisation interested in finding out more do get in touch.

This piece was originally posted on the playing out blog.

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How rethinking residential care can help safeguard children against sexual exploitation

In light of how vulnerable looked-after children are to abusers, it’s time to rethink our approach to residential care, argue Tom Rahilly and David Berridge

Tom Rahilly is Head of Strategy and Development, NSPCC, and David Berridge is Professor of Child and Family Welfare, University of Bristol

Not that it has ever gone away, but the government’s recent intervention in Rotherham council brought back into the public eye the horrendous events in which a reported 1,400 children were sexually exploited. The serious case review into sexual exploitation in Oxfordshire shows the problem is not restricted to one area alone. Alexis Jay’s report into Rotherham showed widespread failures. While there were many individual practitioners trying their best, they came up against a wall of denial.

It’s clear that we urgently need to find a better way of safeguarding our most vulnerable children. Children who were abused included those living at home with their families as well as children in care. However, there seems to be a pattern in abusers targeting those who are particularly vulnerable such as in residential care.

Challenge

No-one should under-estimate the challenge of tackling this. Children may yearn for adult affection and be less adept at recognising true motives and exploitation. Numerous girls made comments such as, ‘I know he really loves me’, or, ‘I was special to him’. It is harrowing when individuals will settle for so little, or feel that they are entitled to no better.

Residential care is often misunderstood and most homes work hard to provide stability and boundaries for young people who have led unsettled and troublesome lives. Children arrive with established harmful patterns of behaviour and undesirable contacts. Dealing with this in local, open units is a challenge and residential workers have to be very creative in gathering intelligence, fragmenting social groups and offering alternatives.

Under-professionalised

Despite these efforts, it is clear that there are long-term and structural problems with residential care in England. These relate to role and status. We still expect our most troubled children to be looked after by an undervalued workforce that is the least well qualified, lowest paid and not given the support it needs. In other words a workforce that is ‘under-professionalised’. It doesn’t need to be this way. It is different to this in much of continental Europe.

The government has taken action to address some of the shortcomings. Attention has focused on children placed long distances and the problem of residential homes located in unsafe areas.

There has been a debate about responses to children who go missing. A new set of quality standards is planned. And whilst we need to go further, useful steps have been taken to tighten-up qualifications for the residential sector. This is a reasonable start but, alone, none of this will resolve current problems.

Rethink the nature of residential care

We need to develop a more nuanced, and individual approach to safeguarding children in care; a relational approach. Research shows that it is the relationship that children have with the carer and other professionals that is critical to effective safeguarding. Children need someone they trust; someone that they turn to for support. Alongside improving qualifications – which is critical – we must focus on supporting the quality and stability of the relationships that young people in care have with those there to support and protect them.

Achieving this requires us to rethink the nature of residential care. We must ensure the management of residential care build a positive culture in the home where children and young people know that their needs are understood and that their views and experiences are valued and listened to. We must, for example, eliminate inflexible shift patterns and ways of working that mean that children cannot develop meaningful, trusting relationships over the longer term.

Residential children’s homes as anomalies

Though it may never be the same, residential care should resemble family care as closely as possible.

Most human service professions are now graduate entry: children’s residential homes are, therefore, anomalous. Some councils pay and perceive heads of homes at social worker team leader-level, which seems more commensurate with the level of responsibility and expertise required, but practice remains variable. We are now dependent on a large independent residential sector and the economics of care are a problem.

Hopefully the next government will continue to develop the children’s residential sector, building on the work that has started and based on what we know works. How all this squares with a five-year, average, reduction in council budgets of 37% remains to be seen.

But as the messages from Rotherham and elsewhere have shown us, we cannot afford not to act.

This piece is based on chapter three from the NSPCC’s book, ‘Promoting the wellbeing of children in care’, which was launched om 6/3/15.

This piece was first published on communitycare.co.uk

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From Bristol City to Mexico City: New challenges for obesity research

In this blog, Simon Sebire from the Centre for Exercise, Nutrition & Health Sciences and three PhD students reflect on new avenues of research into childhood physical activity and obesity in Low and Middle Income Countries and the opportunities and challenges this work presents.

New ideas emerge in the least likely places. As I listened to Professor Andy Gouldson present his research to the School for Policy Studies in spring 2014, I was inspired to sketch connections between some of Andy’s concepts (economic development and environmental issues) and my own (the psychology of motivating people to adopt healthy behaviours like being physically active). After the talk, I shared my scribbles with my colleague Prof. Russ Jago, only to find that he had an almost identical set.

Our thoughts had independently been transported from Bristol to Mexico and musings about the potential associations of urban development and rural-urban migration on the lifestyle behaviours of children and their families. This international perspective is not something either of us had previously pursued is but clearly had prompted some scribbling! The Mexico connection was inspired by three CONACyT-funded students, from Mexico, who at the time were studying our MSc in Nutrition, Physical Activity and Public Health and were considering PhDs.

Nearly 1 year on the three students (Ana Ortega Avila, Maria Hermosillo Gallardo and Nadia Rodriguez Ceron) are now PhD students in the School for Policy Studies Centre for Exercise, Nutrition and Health Sciences supervised by Prof. Russ Jago, Dr Angeliki Papadaki and I. They secured further funding from CONACyT to pursue their programme of research to study how various social, psychological and environmental factors might be related to physical activity and nutrition behaviours in children adolescents and their families in Mexico.

The causes of and response to increasing levels of obesity in low and middle income countries have been the focus of a recent Guardian Global Development Podcast. The podcast draws on the experiences of children, families, health practitioners and campaigners from South Africa and Mexico. In Mexico 73% of men, 69% of women and approximately 35% of adolescents are obese or overweight which is higher than in the USA. It is clear that there is much to be done to both treat those who are already overweight and prevent the development of obesity in young people. However, extrapolating our existing research and knowledge of what we think drives obesogenic behaviours in places like Bristol to the context of people’s lives in Mexico presents a number of challenges.

Ana, Maria and Nadia have a wealth of experience from previously working in Mexico as nutritionists or within the food industry, so I asked them to listen to the podcast and share their insider’s view of the challenges ahead:

Maria referred to the potentially damaging effects of families in Mexico aspiring to an American lifestyle dominated by unhealthy foods and sedentary behaviour:

The blog says that processed foods and junk food are one of the main causes of overweight and obesity increasing in Mexico, which is partially true, but I think it has to do a little bit more with what I call “junk behaviours”. For example, how mums from rural areas prefer to give their children processed foods instead of home-made meals because they heard somewhere that people from USA consumed them, and because Americans always choose right (at least that’s the belief in some parts of Mexico); junk food and processed foods are the way to go for feeding their children.

Ana suggested that this influence may be strongest in regions closest to America and highlighted the broader problems associated with researching an issue which is geographically diverse:

Mexico is among the largest countries in the world geographically and demographically (118 million people); where differences in dietary pattern exist between rural and urban areas or between north, central and south regions.I have always lived in the northwest and the influence of the U.S.A. is visible in a lot of aspects in our life compared to the centre or south of the country. Our dietary patterns are based on American food choices and less on the Mexican traditional diet.

Ana, Maria and Nadia all added that the potential mismatch between perceptions of wealth and health may be making being overweight an aspiration:

Ana: In my experience as a nutritionist there are a number of cultural misconceptions among population when it comes to healthy nutrition. For example, being a little overweight still means you are healthy and well-nourished whereas being thin means you are unhealthy or sick. People don’t see overweight as a problem, on the contrary, they see it as something normal.

Nadia suggested that such perceptions may prevent parents from identifying obesity as a potential health problem in their children:

I think the healthy body image is distorted as family, friends or in the streets, the most common thing is to see someone obese; and that is really concerning because how will they do something to improve their health if they don’t even think there’s a problem. 

Ana, Maria and Nadia reflected on the challenges of applying our physical activity and nutrition research findings which are largely based on evidence from developed countries such as the UK or USA to the context of middle income countries such as Mexico. A good example is parents’ perceptions of safety when letting their children play outside of the home. In UK research, including some in Bristol by my ENHS colleagues, we tend to focus attention on the presence of traffic or children’s risk of injury while unsupervised. In contrast, perceptions of safety in Mexico are measured nationally with questions including those related to the risk of kidnap, existence of violent gangs in the neighbourhood, armed robbery and frequency of firearms shootings. 73.3% of the participants in the 2014 National Survey on Victimization and Perception of Public Safety (ENVIPE) in Mexico reported not feeling safe in their local areas. In addition to the safety implications of conducting research in this context, it is clear that current measures of parents’ perceptions of their child’s safety to be active outside the home will not be sufficient and Nadia has plans to develop a new tool.

In addition, the political landscape challenges us to consider different ways in which our research may be best able to impact on health policy:

Ana: The political context in Mexico is complex, the government is dealing with high levels of insecurity and corruption, events that prevent the government from focusing on other matters such as the implementation of new health policies.

Maria believes that more is needed to be done to educate policy makers in addition to the public: There is a huge educational barrier, both governmental and individual, which makes difficult to take seriously the obesity and overweight problem.

Nadia: All those factors are completely different to high-income countries, and makes the context a complex matter to understand when almost all the research has developed in a completely different contexts with a wider range of opportunities to change or create policies that have a real impact in the population’s health. 

In summary, over the last year or so, I have been transported from Bristol city to Mexico City thanks to a fortuitous combination of research daydreaming and inspiring MSc (now PhD) students.  As a supervisor, my initial conversations with our new students has forced me out of my research comfort zone, an experience which has been echoed and reported by researchers in the International Physical Activity and the Environment Network in Latin America. Undoubtedly, our success in co-producing research which could have international impact will require us to work together to combine our collective knowledge to understand the context and key drivers of obesity-related behaviour change in Mexico.

Thanks to Ana Avila Ortega, Maria Hermosillo Gallardo and Nadia Rodriguez Ceron for their contributions.

  • Ana’s PhD focusses on the development of a social media intervention to reduce consumption of sugar-sweetened beverages in  Mexican older adolescents
  • Maria is studying the associations between urbanicity in Mexico and lifestyle behaviours and the influence of the rural urban transition on family health.
  • Nadia’s PhD focusses on the environmental and social correlates of physical activity in children in Mexico City.

Dr Simon Sebire is Lecturer in Physical Activity & Exercise Psychology in the Centre for Exercise, Nutrition & Health Sciences (ENHS) in the School for Policy Studies.The results of the 2014 Research Excellence Framework (REF) confirm the Centre’s international reputation for research excellence within the field of physical activity, nutrition and health. ENHS was rated 1st overall in the UK.

 

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