tag:theconversation.com,2011:/global/topics/public-health-england-25222/articlesPublic Health England – The Conversation2021-09-13T16:25:04Ztag:theconversation.com,2011:article/1678362021-09-13T16:25:04Z2021-09-13T16:25:04ZCOVID-19: why infection rates among double-vaccinated older adults look worse than they are<p>Recently, ITV journalist Robert Peston caught COVID, despite being double vaccinated. This set Peston wondering how common it is for the fully vaccinated to get the disease. His analysis is now complete. </p>
<p>The <a href="https://www.itv.com/news/2021-09-11/peston-covid-infections-higher-in-doubled-vaxxed-aged-40-79-than-for-non-vaxxed">headline is fairly alarming</a>: “Data shows infections high among double vaxxed for those aged 40 to 79.” Although, perhaps not as alarming as the <a href="https://www.express.co.uk/news/uk/1489970/robert-peston-itv-coronavirus-news-latest-infections-rise-double-vaxxed-delta-variant">Daily Express</a>: “Peston lifts lid on Covid horror as infections spike in double-vaxxed 40 to 79-year-olds.”</p>
<p>So has Peston lifted a lid on COVID horror? Let’s take a closer look at those figures.</p>
<p>Peston’s conclusions are based on <a href="https://www.gov.uk/government/publications/covid-19-vaccine-surveillance-report">newly published</a> data from Public Health England which shows us how many of the new COVID cases, emergency hospital admissions and deaths during the four weeks up to September 5 were among unvaccinated, partially vaccinated, or fully vaccinated people. These numbers give us the first clear indication of how effective COVID vaccines are at protecting people from getting COVID or from suffering serious ill health in those unlucky enough to catch the bug.</p>
<p>On the face of it, the case numbers appear concerning. Of the 554,896 new COVID cases recorded in adults over this period, over half (50.6%) were in people who had already had two vaccine doses. In comparison, just one in five cases were in adults who haven’t yet had a single jab.</p>
<p>But looking at just the raw numbers obscures the fact that 73% of people aged 18 and over in England are already double-jabbed. So it makes more sense to look at case rates: the proportion of unvaccinated and fully vaccinated people who tested positive for COVID. Peston’s concern is that even when we do this, in 40- to 79-year-olds, case rates are higher in fully vaccinated groups. Does that mean that the delta variant has overcome the protection of vaccines for older adults?</p>
<h2>We don’t know how many people are in England</h2>
<p>In short, no. The crucial factor that Peston’s analysis has missed is that, in order to estimate these case rates, we need to know exactly how many vaccinated and unvaccinated people there are in the country. </p>
<p>Counting the number of fully vaccinated people is relatively simple – we know how many doses of vaccine have been delivered. But counting the number of unvaccinated people is surprisingly hard. The best way we have to do this is to take the number of people we have vaccinated away from the total population of the country. Except we don’t actually know how many people there are in England.</p>
<p>There are two main sources we could use for these figures: population estimates from the Office for National Statistics (ONS), and figures from NIMS, the National Immunisation Management Service. The latest available ONS figures are based on the 2011 census, adjusted for births, deaths and estimated migration. NIMS figures, which are used in planning the vaccination programme, are based on GP records. Inconveniently, the figures don’t agree. ONS estimates there are 44.5 million adults in England, while NIMS has a higher figure of 49.5 million.</p>
<p>Both of these figures are definitely wrong, at least to some extent. The ONS figure is for mid-2020 and so doesn’t capture the large number of excess deaths we have seen during the pandemic. Meanwhile, NIMS data can count the same person several times if they have changed GP practices but still appear on the books of their old surgery. And both sources are unlikely to fully capture the effect that both Brexit and the pandemic have had on migration.</p>
<p>Why does this difference matter? Well, where we have high vaccination coverage, it means we are very uncertain about how many unvaccinated people there are. Over 39 million adults have received at least one vaccine dose. NIMS figures suggest that leaves 10 million unvaccinated, while ONS says it’s just 5 million – a full 50% lower. The PHE figures that Peston has highlighted use NIMS population estimates. If instead we calculate these figures using ONS estimates, then the concern he highlights disappears, and case rates in all ages below 80 become substantially lower in the fully vaccinated.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/420834/original/file-20210913-13-1r7vohq.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/420834/original/file-20210913-13-1r7vohq.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/420834/original/file-20210913-13-1r7vohq.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/420834/original/file-20210913-13-1r7vohq.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/420834/original/file-20210913-13-1r7vohq.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/420834/original/file-20210913-13-1r7vohq.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/420834/original/file-20210913-13-1r7vohq.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/420834/original/file-20210913-13-1r7vohq.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Choice of population data makes a big difference.</span>
<span class="attribution"><span class="source">Public Health England and NHS England. Analysis by Colin Angus</span></span>
</figcaption>
</figure>
<p>While there are good reasons why PHE use NIMS figures, most commentators agree that ONS estimates are likely to be closer to the true population for all but the oldest age groups. As a result, the real story in this data is that it is very likely that being fully vaccinated does reduce your chance of catching COVID. More importantly, other data in the same report shows that rates of emergency hospital admission and death are hugely lower for the fully vaccinated across all age groups. </p>
<p>The rapid development of several highly effective COVID vaccines is one of the greatest scientific success stories of modern times. Questions about waning immunity and booster jabs are still to come, but we shouldn’t let uncertainty about exactly how many people there are in the country distract us from how well the vaccines are continuing to do their job.</p><img src="https://counter.theconversation.com/content/167836/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Colin Angus does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Counting the number of unvaccinated people is surprisingly hard.Colin Angus, Research Fellow in the Sheffield Alcohol Research Group, University of SheffieldLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1636712021-07-14T10:24:24Z2021-07-14T10:24:24ZMost COVID deaths in England now are in the vaccinated – here’s why that shouldn’t alarm you<p>More vaccinated people are dying of COVID than unvaccinated people, according to a recent <a href="https://www.gov.uk/government/publications/investigation-of-novel-sars-cov-2-variant-variant-of-concern-20201201">report from Public Health England</a> (PHE). The report shows that 163 of the 257 people (63.4%) who died of the delta variant within 28 days of a positive COVID test between February 1 and June 21, had received at least one dose of the vaccine. At first glance, this may seem alarming, but it is exactly as would be expected. </p>
<p>Here’s a simple thought experiment: imagine everyone is now fully vaccinated with COVID vaccines – which are excellent but can’t save all lives. Some people who get infected with COVID will still die. All of these people will be fully vaccinated – 100%. That doesn’t mean vaccines aren’t effective at reducing death.</p>
<p>The risk of dying from COVID <a href="https://www.bmj.com/content/370/bmj.m3259">doubles</a> roughly every seven years older a patient is. The 35-year difference between a 35-year-old and a 70-year-old means the risk of death between the two patients has doubled five times – equivalently it has increased by a factor of 32. An unvaccinated 70-year-old might be 32 times more likely to die of COVID than an unvaccinated 35-year-old. This dramatic variation of the risk profile with age means that even excellent vaccines don’t reduce the risk of death for older people to below the risk for some younger demographics. </p>
<p><a href="https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/997418/Variants_of_Concern_VOC_Technical_Briefing_17.pdf">PHE data</a> suggests that being double vaccinated reduces the risk of being hospitalised with the now-dominant delta variant by around 96%. Even conservatively assuming the vaccines are no more effective at preventing death than hospitalisation (actually they are likely to be more effective at preventing death) this means the risk of death for double vaccinated people has been cut to less than one-twentieth of the value for unvaccinated people with the same underlying risk profile. </p>
<p>However, the 20-fold decrease in risk afforded by the vaccine isn’t enough to offset the 32-fold increase in underlying risk of death of an 70-year-old over a 35-year-old. Given the same risk of infection, we would still expect to see more double-vaccinated 70-year-olds die from COVID than unvaccinated 35-year-olds. There are caveats to that simple calculation. The risk of infection is not the same for all age groups. Currently, infections are <a href="https://www.dailymail.co.uk/news/article-9769177/Covid-cases-England-THIRTEEN-times-higher-young-people-compared-60s.html">highest in the youngest</a> and lower in older age groups.</p>
<h2>Think of it as ball-bearing rain</h2>
<p>One way to imagine the risk is as a rain of differently sized ball bearings falling from the sky, where the ball bearings are the people that get infected with COVID. For simplicity’s sake, let’s assume there are roughly equal numbers of ball bearings in each age group. In each age category, there is also a variation in the size of the balls. The balls representing the older groups are smaller, representing a higher risk of death. </p>
<p>Now imagine there’s a sieve that catches many of the balls. Most people who get COVID will not die (most balls get caught in the sieve). But some of the smaller balls fall through. The older you are, the more likely you are to fall through the holes. The balls that make it through the first sieve are hugely skewed towards older age ranges, represented by the smaller ball bearings. Before COVID vaccines came along, the people that fell through the holes represented the people who would die of COVID. The risk was massively skewed towards older people.</p>
<p>Vaccination provides a second sieve underneath the first, to prevent people from dying. This time, because we haven’t vaccinated everyone, it’s the holes in the sieve that are of different sizes. For older people who’ve had both doses, the holes are smaller, so many ball-bearings are stopped. The vaccines will save many of those who would previously have died. </p>
<p>For younger people the holes in the vaccine sieve are currently bigger as they are less likely to have received both doses and so more likely to fall through the sieve.</p>
<p>If all the filtering were just done by the second sieve (with no skew in risk of death by age, represented by the first sieve), then we might expect younger unvaccinated people to account for a larger proportion of the deaths. But it isn’t. The first sieve is so hugely biased towards older people that even with vaccination, more of them slip through the second sieve than the younger unvaccinated people. Given the UK’s vaccination strategy (vaccinate older, more vulnerable people first), you would expect high proportions of the people who die from COVID to have been vaccinated. And that is exactly what we see in the data. </p>
<p>The fact that more vaccinated people are dying than unvaccinated people does nothing to undermine vaccine safety or effectiveness. In fact, it’s exactly what we’d expect from the excellent vaccines, which have already saved tens of thousands of lives.</p>
<p><em>Correction: An earlier version of this article stated: “The report shows that 163 of the 257 people (63.4%) who died within 28 days of a positive COVID test between February 1 and June 21, had received at least one dose of the vaccine.” It should have read: “The report shows that 163 of the 257 people (63.4%) who died of the delta variant within 28 days of a positive COVID test between February 1 and June 21, had received at least one dose of the vaccine”.</em></p><img src="https://counter.theconversation.com/content/163671/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Christian Yates does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The latest UK data shows that nearly two-thirds of people who died of COVID between February 1 and June 21 had been vaccinated.Christian Yates, Senior Lecturer in Mathematical Biology, University of BathLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1615512021-05-26T17:30:49Z2021-05-26T17:30:49ZCOVID vaccine weekly: both vaccine doses needed for good protection against B16172 variant<p>It’s been a concerning few weeks in the UK, with the B16172 variant first taking hold and then spreading to become dominant. This more infectious form of the virus, initially identified in India, is what we’re now going to have to live with – unless it is out-competed by another variant in the future.</p>
<p>Worryingly, experts had <a href="https://theconversation.com/q-a-indian-coronavirus-variant-what-is-it-and-what-effect-will-it-have-159269">predicted</a> that B16172 might be able to escape some of the effects of vaccines, which if true would threaten to derail the UK’s plans to finish lifting restrictions from the end of June. However, Public Health England (PHE) has looked at the ability of various variants to evade immunity, and says that the UK’s vaccines remain effective against the variants circulating, including B16172.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/q-a-indian-coronavirus-variant-what-is-it-and-what-effect-will-it-have-159269">Q+A: Indian coronavirus variant – what is it and what effect will it have?</a>
</strong>
</em>
</p>
<hr>
<p>On the surface, this looks like good news. But delve a bit deeper, and things get more complicated, <a href="https://theconversation.com/b16172-variant-the-uk-needs-to-brace-for-more-cases-despite-vaccine-effectiveness-161455">says</a> Paul Hunter, professor of medicine at the University of East Anglia. PHE’s research found little drop-off in protection against B16172 among people who were fully vaccinated. But among those who have received just one dose, protection is considerably lower against B16172 compared to the previously dominant one, B117.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/b16172-variant-the-uk-needs-to-brace-for-more-cases-despite-vaccine-effectiveness-161455">B16172 variant: the UK needs to brace for more cases, despite vaccine effectiveness</a>
</strong>
</em>
</p>
<hr>
<p>Plus, we can be pretty confident that B16172 is more infectious than earlier variants. This will magnify the effect of any drop in protection, meaning the UK could be about to witness a new spike in cases. Any prospect of a third wave arriving could have serious implications for the final stage of reopening in June. </p>
<hr>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/320716/original/file-20200316-18073-ruhw8b.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/320716/original/file-20200316-18073-ruhw8b.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/320716/original/file-20200316-18073-ruhw8b.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/320716/original/file-20200316-18073-ruhw8b.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/320716/original/file-20200316-18073-ruhw8b.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/320716/original/file-20200316-18073-ruhw8b.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/320716/original/file-20200316-18073-ruhw8b.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption"></span>
</figcaption>
</figure>
<p><em><strong>This is our weekly round-up of expert information about the <a href="https://theconversation.com/uk/topics/covid-vaccines-96571">COVID-19 vaccines</a>.</strong> <br>
The Conversation, a not-for-profit group, works with a wide range of academics across its global network to produce evidence-based analysis and insights. Get more regular updates from trusted experts by <a href="https://theconversation.com/uk/newsletters/the-daily-2">subscribing to our free newsletter</a> .</em></p>
<hr>
<p>However, there’s an important caveat here, <a href="https://theconversation.com/coronavirus-so-many-variants-but-vaccines-are-still-effective-161222">argues</a> Luke O'Neill, professor of biochemistry at Trinity College Dublin. PHE’s analyses are concerned with the risk of infection. But really, the most important question when considering the effects of variants breaking through vaccine protection is not whether someone gets infected, but whether they become severely ill or die.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/coronavirus-so-many-variants-but-vaccines-are-still-effective-161222">Coronavirus: so many variants, but vaccines are still effective</a>
</strong>
</em>
</p>
<hr>
<p>So far, we don’t have an answer to whether B16172 causes more severe illness, or if vaccines still offer protection against severe illness if they fail to stop people developing COVID-19 symptoms. But, given the amounts of antibodies the vaccines typically get people to generate – as well as how effective they are at stimulating the immune system’s T cell response – it’s a reasonable prospect that they’ll remain highly effective at blocking the worst effects of COVID-19.</p>
<p>As Paul Hunter <a href="https://theconversation.com/b16172-variant-the-uk-needs-to-brace-for-more-cases-despite-vaccine-effectiveness-161455">notes</a>, we should have a better sense of how B16172 is affecting hospitalisation and death rates in the next few weeks. If these remain unaffected, then it’s far more likely that the UK’s exit from lockdown will be unaffected too. </p>
<hr>
<p><em>Get the latest news and advice on <a href="https://theconversation.com/uk/covid-19">COVID-19</a>, direct from the experts in your inbox. Join hundreds of thousands who trust experts by <strong><a href="https://theconversation.com/uk/newsletters/the-daily-2">subscribing to our newsletter</a></strong>.</em></p><img src="https://counter.theconversation.com/content/161551/count.gif" alt="The Conversation" width="1" height="1" />
New, early-stage research suggest that B16172 does have some ability to escape the effects of vaccines.Rob Reddick, Commissioning Editor, COVID-19Licensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1566152021-03-19T11:29:36Z2021-03-19T11:29:36ZHow effective is the first shot of the Pfizer or Moderna vaccine?<figure><img src="https://images.theconversation.com/files/411570/original/file-20210715-52849-4vv9ib.jpg?ixlib=rb-1.1.0&rect=152%2C73%2C3234%2C2360&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Make that second appointment and get your final dose for full protection.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/detail-photo-of-the-back-of-a-covid-19-vaccination-record-news-photo/1316475438">MediaNews Group/Reading Eagle via Getty Images</a></span></figcaption></figure><p>Maybe you’ve postponed your second COVID-19 vaccine appointment, whether because of scheduling hassles or general reluctance. But how safe are you after just a single dose?</p>
<p><a href="https://scholar.google.com/citations?user=6yMIM1MAAAAJ&hl=en">As an immunologist</a>, I hear this question frequently – and the answer has changed as new genetic strains of the coronavirus become more common. <a href="https://covid.cdc.gov/covid-data-tracker/?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fcases-updates%2Fvariant-proportions.html#variant-proportions">By the beginning of July 2021</a>, the <a href="https://www.cdc.gov/coronavirus/2019-ncov/variants/variant-info.html">delta variant</a> had become the most dominant strain of SARS-CoV-2 circulating in the U.S.</p>
<p>The Moderna and Pfizer mRNA vaccines weren’t designed specifically to ward off the delta variant. While overall they still <a href="https://www.cdc.gov/coronavirus/2019-ncov/vaccines/effectiveness.html">provide excellent protection</a> after the full two doses, new research suggests <a href="https://doi.org/10.1038/s41586-021-03777-9">a single dose provides less immunity</a> against the coronavirus strains that are out there now than it did against the original strain.</p>
<p>Bottom line: Two shots are way better than one.</p>
<figure class="align-center ">
<img alt="Nurses prepare to give medical workers vaccines." src="https://images.theconversation.com/files/390402/original/file-20210318-21-1xg2fuo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/390402/original/file-20210318-21-1xg2fuo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/390402/original/file-20210318-21-1xg2fuo.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/390402/original/file-20210318-21-1xg2fuo.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/390402/original/file-20210318-21-1xg2fuo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/390402/original/file-20210318-21-1xg2fuo.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/390402/original/file-20210318-21-1xg2fuo.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Medical workers receive vaccination against COVID-19 on Dec. 20, 2020, in Tel Aviv.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/medical-workers-vaccinate-medical-stuff-members-against-news-photo/1230224367?adppopup=true">Amir Levy/Getty Images</a></span>
</figcaption>
</figure>
<h2>How well had the vaccines been working?</h2>
<p>Soon after the Pfizer COVID-19 vaccine was authorized in December 2020, researchers in Israel found that a <a href="https://doi.org/10.1016/S0140-6736(21)00448-7">single dose was highly effective</a> in one medical center’s thousands of vaccinated health care workers. A single dose reduced the rate of infection by up to 85% after four weeks post-shot compared to those who were not vaccinated.</p>
<p>This real-world finding was consistent with an analysis <a href="https://doi.org/10.1056/NEJMoa2034577">of Pfizer’s clinical trial data</a> reported in 2020 in the New England Journal of Medicine. In that study, the 52% protection from the first dose included infections that occurred in the first 12 days after vaccination, when one would not expect the vaccine to have had time to generate protective antibodies.</p>
<p>Another real-world study of adults ages 70 and older conducted by Public Health England in early 2021 determined that <a href="https://doi.org/10.1136/bmj.n1088">a single dose of the Pfizer vaccine was 61% effective</a> at preventing symptomatic disease 28 days after vaccination. Two doses increased effectiveness to 85%-90%.</p>
<h2>So, what’s changed?</h2>
<p>Essentially, it comes down to new variants. Scientists are particularly concerned about the delta variant because it <a href="https://www.nytimes.com/2021/07/15/briefing/delta-variant-spread-contagious.html">appears to be especially contagious</a>.</p>
<p>All of the vaccines for COVID-19 <a href="https://doi.org/10.1038/s41586-021-03738-2">generate antibodies against the spike glycoprotein</a> on the surface of the coronavirus. If you encounter the coronavirus after you’ve been vaccinated, these antibodies protect you by binding to the spike on its surface, preventing the virus from entering your cells to cause an infection.</p>
<p>The problem is that the delta variant can evade some – but not all – of the antibodies generated by the current vaccines.</p>
<h2>How well do vaccines protect against delta so far?</h2>
<p>It looks like the delta variant is relatively resistant to the anti-spike antibodies vaccination generates. This change is what makes it all the more important to get the second dose of an mRNA vaccine.</p>
<p>The first shot <a href="https://doi.org/10.1038/s41577-020-00479-7">introduces your body</a> to the virus’s spike protein so your immune system can start to produce targeted antibodies and immune cells. <a href="https://theconversation.com/why-it-takes-2-shots-to-make-mrna-vaccines-do-their-antibody-creating-best-and-what-the-data-shows-on-delaying-the-booster-dose-153956">The second shot</a> gives your body another chance to practice mounting that immune response against COVID-19. The second dose triggers the creation of more anti-spike antibodies, and these are more effective at protecting you because they bind more tightly to the viral spike if they encounter it.</p>
<p>In a study published in the journal Nature in July, researchers tested serum from the blood of 16 recent Pfizer vaccine recipients in France. After the first dose of the mRNA vaccine, serum from <a href="https://doi.org/10.1038/s41586-021-03777-9">only two of the 16 vaccinated people neutralized the delta variant</a> of the virus. The good news, though, is that after the second vaccine dose, serum from 15 out of 16 people neutralized the delta variant.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/411572/original/file-20210715-25-1hqj2pl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="masked people walk past a public Christmas tree" src="https://images.theconversation.com/files/411572/original/file-20210715-25-1hqj2pl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/411572/original/file-20210715-25-1hqj2pl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/411572/original/file-20210715-25-1hqj2pl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/411572/original/file-20210715-25-1hqj2pl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/411572/original/file-20210715-25-1hqj2pl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/411572/original/file-20210715-25-1hqj2pl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/411572/original/file-20210715-25-1hqj2pl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The delta variant started gaining a foothold in the U.K. at the end of 2020.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/pedestrians-wearing-a-protective-face-covering-to-combat-news-photo/1229735590">Tolga Akmen/AFP via Getty Images</a></span>
</figcaption>
</figure>
<p>Out of the lab and in the real world, Public Health England has collected data on all symptomatic cases of COVID-19 in the country in which the coronavirus was genetically sequenced. Of the 1,054 cases of delta infection through the middle of May 2021, a preliminary analysis that has not yet been peer-reviewed found that <a href="https://doi.org/10.1101/2021.05.22.21257658">one dose of the Pfizer vaccine was 33% effective</a> at preventing symptomatic infection. Protection rose to 88% after two doses. Those protection levels for delta are lower than what they found for the older alpha variant: 51% effectiveness after dose one and 93% after dose two.</p>
<p>A smaller preliminary study from Canada that also has not yet been peer-reviewed identified a <a href="https://doi.org/10.1101/2021.06.28.21259420">similar level of protection</a>. In 165 people with delta infection, researchers found 56% protection from symptomatic infection with one dose of Pfizer and 87% with two. Importantly, researchers calculated that protection from hospitalization or death from delta after even a single dose was 78% for Pfizer and 96% for Moderna.</p>
<h2>Am I protected?</h2>
<p>You are well protected if you have completed your vaccination: two doses of the Pfizer or Moderna or the single-dose Johnson & Johnson vaccine. If you have had only one of the two required doses of the mRNA vaccines, then you should finish vaccination by getting the second shot. That will raise your COVID-19 protection from what <a href="https://doi.org/10.1101/2021.05.22.21257658">might be as low as 33%</a> better than an unvaccinated person <a href="https://www.cdc.gov/vaccines/covid-19/effectiveness-research/protocols.html">up to 90%</a>.</p>
<p>[<em>Get our best science, health and technology stories.</em> <a href="https://theconversation.com/us/newsletters/science-editors-picks-71/?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=science-best">Sign up for The Conversation’s science newsletter</a>.]</p>
<p>The picture is more complicated if you are immunocompromised. Studies have found that <a href="https://doi.org/10.1126/sciimmunol.abj1031">some immunocompromised patients</a> <a href="https://doi.org/10.7326/M21-1451">don’t produce antibodies</a> after vaccination. In these cases, some studies suggest that <a href="https://doi.org/10.7326/L21-0282">booster shots may offer hope</a>, with a third dose of an mRNA vaccine triggering a protective antibody response.</p>
<p>For mRNA vaccines against COVID-19, the <a href="https://www.cdc.gov/coronavirus/2019-ncov/vaccines/faq.html">CDC recommendation remains the same</a>: For Pfizer, get two doses 21 days apart, and for Moderna, get two doses 28 days apart. Sticking to the schedule and getting both doses means you will have very high levels of protection once your body has time to build immunity.</p>
<hr>
<p><em>Editor’s note: Since this article was initially published on March 19, 2021, the coronavirus has continued to mutate. This updated version reflects research as of July 2021 suggesting that a single dose of the Moderna or Pfizer COVID-19 vaccine is not enough to reliably ward off infection. The recommendation remains to receive the full course of two shots.</em></p><img src="https://counter.theconversation.com/content/156615/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>William Petri receives funding from National Institutes of Health, the Gates Foundation and Regeneron.</span></em></p>An immunologist explains that you get some protection from the first dose of the mRNA vaccines but you need two to build up strong immunity, particularly to newer coronavirus variants.William Petri, Professor of Medicine, University of VirginiaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1447032020-08-20T10:55:14Z2020-08-20T10:55:14ZHeatwaves are an invisible killer – and the UK is woefully unprepared<p>The COVID-19 pandemic continues to cause suffering around the world, but another killer has silently struck in summer 2020. With relatively little by way of official warning or advice on how people can stay safe, recent heatwaves may have cost thousands of lives across the UK and western Europe. And these extreme weather events are arriving more often and in longer, deadlier bouts.</p>
<p>Most deaths during heatwaves occur out of sight and among those who are <a href="https://www.metoffice.gov.uk/public/weather/heat-health/?tab=heatHealth&season=normal">most vulnerable</a>, such as the elderly and those with pre-existing health conditions. Because heatwaves aren’t something we can see or touch – and are often greeted with joy – it’s difficult for people to <a href="https://www.sciencedirect.com/science/article/pii/S1462901118313649">understand the risk</a> they pose.</p>
<p><a href="https://www.metoffice.gov.uk/about-us/press-office/news/weather-and-climate/2020/heatwave-continues-august">In mid-August 2020</a>, the UK saw the longest stretch of daytime temperatures above 30°C since 1976, as well as the hottest August day (36.4°C) since the deadly 2003 heatwave. Throughout 2020, there have also been <a href="https://www.dailymail.co.uk/news/article-8614935/Heatwave-Britain-bake-100F-temperatures-today-Met-Office-issues-flood-warnings.html">16 “tropical nights”</a>. These occur when night time temperatures stay above 20°C, which used to be <a href="https://socialmetwork.blog/2020/08/07/a-journey-through-hot-british-summers/">rare in the UK</a>. There were 44 recorded between 1960 and 2000, but there have been 84 since 2000. The number of heatwaves each decade has also risen on average by one and a half per decade since 1960.</p>
<p>The three heatwaves the UK experienced in 2019 led to <a href="https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/841320/PHE_heatwave_report_2019.pdf">892 deaths</a>. The last time the record temperatures of August 2020 were reached in 2003, <a href="https://link.springer.com/article/10.1007/s00484-018-1518-2">more than 2,000 people died</a> in the UK.</p>
<p>Climate change is projected to raise average temperatures in the UK by <a href="https://www.metoffice.gov.uk/binaries/content/assets/metofficegovuk/pdf/research/ukcp/ukcp18-fact-sheet-temperature.pdf">5°C by 2070</a>, making the kind of temperatures seen in the mid-August heatwave of 2020 the norm for summers of the future. That could amount to a daunting public health crisis, and one which few people are talking about.</p>
<p>For every 1°C above a daily average temperature in the summer months, the UK currently sees a 2% rise in the <a href="https://ehjournal.biomedcentral.com/articles/10.1186/s12940-017-0322-5">death rate</a>.</p>
<h2>Beating the heat</h2>
<p>Up to 5,000 people could die each year as a result of <a href="https://www.theccc.org.uk/wp-content/uploads/2019/07/Outcomes-Heat-preventable-deaths-case-study.pdf">heat in the UK</a> by 2050. Elsewhere, longer and hotter heatwaves are likely to wreak havoc on infrastructure built in a cooler past. Railway tracks <a href="https://www.theguardian.com/business/2019/jul/25/why-the-heatwave-is-disrupting-the-uk-railways">will buckle</a>, <a href="https://www.independent.co.uk/news/uk/home-news/hammersmith-bridge-closed-heatwave-safety-concerns-london-a9669476.html">bridges will sag</a> and reservoirs could dry up. More than 300 households in West Sussex went without water <a href="https://www.bbc.co.uk/news/uk-england-sussex-53748040">for five days</a> this summer.</p>
<p>Despite all this, heatwaves don’t even carry a Met Office weather warning, like rain, wind or snow. In the government’s <a href="https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/644968/UK_National_Risk_Register_2017.pdf">national risk register</a>, heatwaves are described as being more likely to occur than coastal and river flooding, and the scale of the damage they cause is similar. But from 2000 to 2019, there have been 68 journal articles published on heatwaves in the UK, versus 1,766 on floods. The amount of research attention and funding that heatwaves receive compared to flooding is tiny, even though extreme heat can trigger storms which themselves cause flash flooding. </p>
<p>Many researchers, including me, think the UK government’s handling of heatwaves is inadequate. As Bob Ward, policy director of the Grantham Research Institute on Climate Change at the London School of Economics <a href="https://www.theguardian.com/uk-news/2018/jul/26/uk-woefully-unprepared-for-deadly-heatwaves-warn-mps">said in 2018</a>: “The lack of communication by government departments and agencies about the risks of heatwaves is contributing to the death toll every year.”</p>
<p>England has the <a href="https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/888668/Heatwave_plan_for_England_2020.pdf">heat health plan</a> to coordinate relief efforts during heatwaves. It’s an emergency response run by Public Health England (which is in the process of <a href="https://theconversation.com/changes-to-public-health-bodies-must-be-based-on-evidence-and-reflection-not-scapegoating-144603">being dismantled</a> by the government) and informed by Met Office forecasting. When a heatwave is expected, warnings are sent to hospitals and care homes to take necessary precautions, like deploying fans and air conditioning. </p>
<p>The plan is only used from June 1 to September 15. If three consecutive days with hot temperatures pass outside those dates, there’s no emergency response mandated by the heat health plan. Nor would an event outside those dates even qualify for the official definition of a heatwave. But as <a href="https://www.carbonbrief.org/media-reaction-uks-record-breaking-winter-heat-in-2019">February 2019</a> proved, heatwaves can arrive in the UK outside of official British summertime.</p>
<figure class="align-center ">
<img alt="A spinning fan sits on a windowsill." src="https://images.theconversation.com/files/353829/original/file-20200820-20-13ml1mr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/353829/original/file-20200820-20-13ml1mr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/353829/original/file-20200820-20-13ml1mr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/353829/original/file-20200820-20-13ml1mr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/353829/original/file-20200820-20-13ml1mr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/353829/original/file-20200820-20-13ml1mr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/353829/original/file-20200820-20-13ml1mr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The UK’s heat health plan should go further to help adapt to extreme heat.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/fan-motion-between-potted-plants-providing-557419942">Tim Roberts Photography/Shutterstock</a></span>
</figcaption>
</figure>
<p>The heat health plan only covers England, and since it’s an emergency response that’s only enacted in the health sector, the plan doesn’t allow for adaptations where they’re most needed to save lives. Overheating occurs in 20% of UK homes <a href="https://www.sciencedirect.com/science/article/pii/S0301421510000273">during a normal summer</a> and it can lead to potentially fatal <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)32596-6/fulltext">heat stroke</a>. This is the cause of most preventable heatwave deaths and it demands an <a href="https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/7604/2185850.pdf">adaptation plan</a> from the government that includes retrofitting homes and building new housing that doesn’t overheat.</p>
<p>Workplaces also need a legal maximum temperature at which people can stop working during bouts of extreme heat. In Latin America, working throughout heatwaves has been linked to <a href="https://cjasn.asnjournals.org/content/11/8/1472">kidney disease</a>.</p>
<p>Heatwaves will continue to grow in intensity, duration and frequency without action on climate change. An emergency response once one has been declared is not enough. As extreme heat becomes routine, we must adapt our homes, roads and other infrastructure to save lives.</p><img src="https://counter.theconversation.com/content/144703/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Chloe Brimicombe receives funding from NERC through the SCENARIO DTP. She is a PhD Student at the University of Reading in partnership with ECMWF, the Walker Institute and Evidence for Development. She is affiliated with Christian Aid, through the Prophetic Activist Scheme. </span></em></p>Extreme heat could kill 5,000 people each year in the UK by the 2050s.Chloe Brimicombe, PhD Candidate in Climate Change and Health, University of ReadingLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1446032020-08-17T15:47:07Z2020-08-17T15:47:07ZChanges to public health bodies must be based on evidence and reflection, not scapegoating<p>The chaos caused by coronavirus will last far beyond the discovery of effective medical treatments. Our social and political structures have been tested and, in many instances, found to be unprepared for this pandemic. </p>
<p>It is therefore not surprising that questions have been asked of official bodies such as the <a href="https://www.bbc.co.uk/news/world-us-canada-53327906">World Health Organization</a> and, in the UK, <a href="https://www.reuters.com/article/us-health-coronavirus-britain-phe/public-health-england-to-be-scrapped-and-replaced-by-new-body-telegraph-idUSKCN25B0ZN">Public Health England</a>. The US has announced that it will withdraw from the World Health Organization, and now UK health secretary Matt Hancock has said that the government will replace Public Health England with a new body.</p>
<p>Things could have been much worse. SARS-CoV-2 is not as lethal as other epidemic viruses, such as HIV or Ebola. Indeed, the fact that the virus is relatively benign for the majority of people is why it has <a href="https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200629-covid-19-sitrep-161.pdf?sfvrsn=74fde64e_2">spread so successfully</a>. Although many have suffered and died, the pandemic is likely to affect many more in terms of <a href="https://www.bmj.com/content/369/bmj.m1994">mental health</a> or complications due to <a href="https://www.nejm.org/doi/full/10.1056/NEJMms2009984">delayed medical care</a>, while a great amount of suffering will also probably be caused by the <a href="https://www.research.ox.ac.uk/Article/2020-04-07-the-economic-impact-of-covid-19">subsequent economic chaos</a>. These are the issues that need addressing in future responses.</p>
<p>An optimist would hope that, while we must acknowledge that many have suffered, the political and social repercussions of the pandemic could be broadly positive – using the experience of this virus to ensure we are much better prepared for future, possibly more serious, viruses. But this requires that those in power take a longer-term view.</p>
<h2>More pandemics are inevitable</h2>
<p><a href="https://www.gov.uk/government/collections/chief-medical-officer-annual-reports">Every year</a> the UK’s chief medical officer publishes an independent report outlining future health risks. The World Health Organization also regularly publishes reports of likely <a href="https://www.who.int/news-room/feature-stories/ten-threats-to-global-health-in-2019">future threats</a>. Pandemics have always featured prominently in these reports. Likewise academics <a href="https://www.ncbi.nlm.nih.gov/books/NBK54171/">regularly study and reflect</a> on previous outbreaks. Although the specifics of SARS-CoV-2 and COVID-19 could not be predicted, the occurrence of a pandemic virus with significant international effects <a href="https://www.kcl.ac.uk/learning-to-be-less-surprised-by-surprises-like-covid-19">was not a surprise</a>.</p>
<p>History was not the only predictor of this pandemic. From a biological perspective, we know that viruses are a fundamental part of life. Infectious diseases cause considerable human misery, and yet viruses are also significant evolutionary drivers. Viruses are also the most abundant biological entities on Earth and may even be responsible for the <a href="https://www.frontiersin.org/articles/10.3389/fmicb.2019.00523/full">origins of life itself</a>.</p>
<p>If the existence of viruses is <a href="https://link.springer.com/book/10.1007/978-94-007-4899-6#about">fundamental for life</a>, it is important that we learn to live with them. There will never be a post-virus world. The majority of viruses are harmless to humans, but at the same time we need to expect, and plan for, a significant minority being responsible for a great deal of disease (<a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1994798/">including 15% of cancers</a>). The big challenge is therefore to create systems and processes that are able to predict, plan for, and then deal with viral infections including future pandemics.</p>
<p><a href="https://www.who.int/health-laws/topics/governance-decentralisation/en/">Much has been written</a> about the advantages of centralised or decentralised health systems. What is clear is that different health systems have reacted and adapted to COVID-19 in <a href="https://theconversation.com/coronavirus-around-the-world-conversation-authors-on-lessons-from-different-countries-139808">different ways</a>. There have been many failures but also many successes. Although there is a temptation to compare internationally by looking at infection or death rates, such comparisons do not take into account the complexity of the situation caused by very different cultures, political arrangements and systems of health care.</p>
<h2>Planning for the future</h2>
<p>Within the UK there has been a separation between personal health care provision, which was broadly the responsibility of the National Heath Service (NHS), and epidemiological or public health concerns that mostly fell under the remit of Public Health England (PHE). While both the NHS and PHE are technically separate, they both fall under the Department of Health and Social Care, with many clinical and scientific staff working across both organisations.</p>
<p>Logically, it makes sense to distinguish between personal health care and population-level health concerns. Over recent years, the NHS has become increasingly decentralised so as to better respond to localised health concerns. The same level of decentralisation would not make sense for the purposes of health surveillance, which must consider broader national and international concerns. But at the same time, a balance is needed.</p>
<p>Consider the introduction of lockdowns. Initially, a national lockdown <a href="https://www.gov.uk/government/speeches/pm-address-to-the-nation-on-coronavirus-23-march-2020">was implemented</a> as a response to the nationwide epidemic, but following this experience, the strategy is now to implement <a href="https://www.gov.uk/government/collections/local-restrictions-areas-with-an-outbreak-of-coronavirus-covid-19">regional lockdowns</a>. While national-level planning is still needed with respect to controlling borders and a few other arrangements that are necessarily centralised, there does seem to be an increasing acknowledgement that perhaps the UK’s response was initially a bit <a href="https://theconversation.com/coronavirus-why-we-need-local-models-to-successfully-exit-lockdown-138358">too centralised</a> and thus did not sufficiently take into account the needs of different populations across the UK.</p>
<p>A second example is the implementation of the “test and trace” process. While identifying community infections and limiting transmission is a key part of epidemic control, the practicalities of organising such a system have turned out to be <a href="https://theconversation.com/coronavirus-why-did-england-ignore-an-army-of-existing-contact-tracers-140825">significantly more complex</a> than was initially expected.</p>
<p>Although the technology for an automated system does exist and is being <a href="https://www.sciencemag.org/news/2020/05/countries-around-world-are-rolling-out-contact-tracing-apps-contain-coronavirus-how">developed in various places</a>, it seems that such technology is better suited to private development using market forces rather than through centralised governance. Implementing manual tracing while encouraging the development of appropriate technologies seems to be the only workable approach, something that may also be better suited to local rather than national arrangements.</p>
<p>It is vitally important that long term lessons are learned from the SARS-CoV-2 pandemic. Of course, the initial response should be dealing with the outbreak as it happens, but once the early repercussions subside, we must take careful stock of what has happened so as to better prepare for the future. </p>
<p>This process will involve a considerable amount of reflection that will probably take many years. What must be avoided is the tendency to just replace processes or organisations without first working out what failings have occurred and why they happened. It is vital that new arrangements are based upon solutions to actual problems rather than the short-term political need to look as if something is being done.</p><img src="https://counter.theconversation.com/content/144603/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Simon Kolstoe is an academic at the University of Portsmouth and also the independent chair of Public Health England's Regulation and Governance Group. The opinions expressed in this article are entirely his own and do not represent the views of the University of Portsmouth or Public Health England.</span></em></p>De-funding Public Health England is not the answer – we need to learn lessons from the coronavirus response before making radical decisions.Simon Kolstoe, Senior Lecturer in Evidence Based Healthcare and University Ethics Advisor, University of PortsmouthLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1408252020-06-18T12:50:39Z2020-06-18T12:50:39ZCoronavirus: why did England ignore an army of existing contact tracers?<p>The coronavirus contact tracing app for England will <a href="https://www.theguardian.com/society/2020/jun/17/nhs-covid-19-contact-tracing-app-no-longer-a-priority-says-minister">not be rolled out until winter</a>, the minister responsible for overseeing it has said. Meanwhile, the <a href="https://www.nhs.uk/conditions/coronavirus-covid-19/testing-and-tracing/nhs-test-and-trace-if-youve-been-in-contact-with-a-person-who-has-coronavirus/">NHS Test and Trace</a> system, in which individual contact tracers follow up with people who have been in close proximity to positive cases of COVID-19, has been plagued by difficulties. </p>
<p>The New York Times has <a href="https://www.nytimes.com/2020/06/17/world/europe/uk-contact-tracing-coronavirus.html?action=click&module=Top%20Stories&pgtype=Homepage">reported</a> that despite the UK having had nearly 300,000 cases of the disease and more than 40,000 deaths, some contact tracers have not yet spoken to a single person.</p>
<p>But when the coronavirus pandemic broke out, there was already a group of people who were very well prepared to help the government’s tracking efforts – the NHS workers who carry out contact tracing in cases of sexually transmitted infections. </p>
<p>In the world of sexually transmitted infections, contact tracing is known as <a href="https://ssha.info/wp-content/uploads/ssha-guidance-on-partner-notification-aug-2015.pdf">partner notification</a>. The task of health advisers, employed in sexual health clinics since the 1950s, is to support people who have been diagnosed with sexually transmitted infections to get their sexual contacts tested and treated as well. </p>
<p>They work with other highly trained professionals who are also used to having difficult conversations with people who have been exposed to infection, in the health protection teams of Public Health England and local government Environmental Health Departments.</p>
<h2>Contact tracing for sexual health</h2>
<p>So what happens in sexual contact tracing, and what are the lessons for coronavirus? </p>
<p>First, a contact tracer builds a risk assessment of the “index patient” – the person who has just been diagnosed with a sexually transmitted infection, say gonorrhoea or syphilis, and may be very distressed. They may not even believe the test result.</p>
<p>This discussion, in person or by phone, involves sharing highly personal information. It requires trust – in the person, in their competence and in the institution that will be holding their information. The contact tracer explores with the patient who else has been exposed to the infection. How they can be contacted. Do they already know of the diagnosis? How likely is it that transmission took place? Did they use a condom (and if so, was it used correctly)? </p>
<p>Some “high value” patients will have many contacts needing to be tested and treated and may also need other forms of care. Someone with many sexual partners may need a hepatitis B vaccination and pre-exposure prophylaxis to stop them contracting HIV. </p>
<p>At the end of the consultation, there needs to be a clear plan for what will happen next and when, and clarity on what support will be offered. Very importantly there needs to be an open door to return quickly and disclose something too sensitive for a first conversation. Speed is of the essence. </p>
<p>Clinics routinely take part in local and national audits of their effectiveness, and <a href="https://www.ncbi.nlm.nih.gov/books/NBK261433/">wide-ranging research</a> confirms the importance of contact tracing in the control of sexually transmitted infections.</p>
<h2>Lessons for coronavirus</h2>
<p>Coronavirus contact tracing aims to prevent onward transmission by isolating people. It also seeks to alert people who have been exposed to an infection so they can get tested and reduce their risk of illness or complications. </p>
<p>However, unlike in cases of sexually transmitted infections, self-protection through treatment isn’t possible after exposure to coronavirus, making contact tracing more challenging. The person contacted may have little to gain from the warning and they may be seriously disadvantaged by an instruction to self-isolate. </p>
<p>In this case, the value of a case in reducing the <a href="https://theconversation.com/coronavirus-is-the-r-number-still-useful-138542">R number</a> will need to be assessed terms of who they are at risk of exposing. Are they in a large and crowded household? Are they in a job where social distancing is difficult? Are housemates particularly vulnerable to severe illness? What are they afraid of and how can they be supported? </p>
<p>Contact tracing must support the individual in making the best decisions, and for some the news they have been exposed will be very distressing. They may fear for the life of a household member or vulnerable contacts and have financial worries. As a result of a phone call, a whole household may need support with a range of financial, physical and mental health issues. </p>
<p>And how do we measure its effectiveness? This remains a challenge even for sexual contact tracing, which has been taking place for decades.</p>
<h2>A missed opportunity</h2>
<p>So what kind of infrastructure is needed for coronavirus contact tracing to be a success? The UK’s network of sexual health clinics is unique as a locally embedded public health infrastructure with experience in contact tracing operations. Together with Environmental Health and Health Protection Departments, these should have been an ideal basis for a new system to track coronavirus. </p>
<p>Their mutual links and networks cross the NHS, including GPs, hospitals and laboratories, which give their staff a trusted place from which to start difficult conversations and collect sensitive information. Also, importantly, they are linked to other health services. </p>
<p>Building on its existing infrastructure, Germany used previously underfunded local health offices in its much-praised coronavirus response, ramping up the contact tracing function of its <a href="https://www.ft.com/content/cc1f650a-91c0-4e1f-b990-ee8ceb5339ea">Gesundheitsämters</a> - local government authorities similar to our Environment Health and Health Protection units. </p>
<p>England has to date taken a different route, choosing instead to develop a new, national, dedicated contact tracing system run by the private provider SERCO, which <a href="https://www.theguardian.com/business/2020/may/20/serco-accidentally-shares-contact-tracers-email-addresses-covid-19">accidentally leaked</a> the email addresses of 300 contact tracers in May. </p>
<p>Most of the recruited coronavirus contact tracers are entirely new to the role and lack the support of professionals experienced in these tricky issues. They also lack the networks into GPs and other local NHS services that can support households in a time of stigma, strain and fear. </p>
<p>It’s a shame that this existing workforce of experienced contact tracers was overlooked in the government’s coronavirus strategy when all the UK and international evidence points to the benefits of integrating contact tracing with existing public health structures. But the fight against COVID-19 is a marathon, not a sprint - there’s still time to build coronavirus contact tracing into the DNA of NHS and public health services.</p><img src="https://counter.theconversation.com/content/140825/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jackie Cassell is employed at the Brighton and Sussex Medical School, and receives research funding from the National Institutes for Health Research. She holds an honorary contract with Public Health England which is not funded. She is a member of the British Association of Sexual Health and HIV, a Fellow of the Royal College of Physicians and the Faculty of Public Health. She is a member of the Liberal Democrats.</span></em></p>Contact tracing for sexual health has been taking place in England for many years. Why was this workforce ignored in the coronavirus response?Jackie Cassell, Professor of Primary Care Epidemiology, Honorary Consultant in Public Health, Brighton and Sussex Medical SchoolLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1348242020-03-26T11:58:31Z2020-03-26T11:58:31ZNot perfect but positive – the UK response to coronavirus<p>Over the past couple of weeks, the UK government has received unwavering criticism for its response to COVID-19. Several faultfinders have unleashed their uninhibited condemnation of the COVID-19 strategy. Many concerns are warranted. Most would agree that the response and its communication have been far from perfect. But if the UK is to successfully scale this epidemiological monolith, we must yield hope from its successes.</p>
<p>One of the most ubiquitous criticisms has been on the shift in strategy, seen by some as premature and defeatist. The UK started out with intensive community testing and contact tracing. Almost overnight, these measures became heavily restricted. Diagnostic testing focused on hospitalised patients, and contact tracing focused on only complex situations or high-risk settings. This change was not surrender, though. It represented a humbling acceptance of the virus outpacing the capacity to test and trace. It was an adjustment to protect the most vulnerable. It signalled a need to mobilise the public and buy time to prepare for a full 12-round fight.</p>
<p>The dearth of testing is a particular bugbear for many. Some have likened this ostensibly laissez-faire approach to going into a fight blindfolded. Government officials, though, have maintained that scaling up diagnostic testing, although currently planned, <a href="https://www.ft.com/content/fce110fc-6eaf-11ea-89df-41bea055720b">needs time</a>. A comparison is often made to South Korea and China: heralded as role models for both large-scale testing and successful outbreak response.</p>
<p>Technology is more firmly embedded in the health systems of Asian countries and these societies. The liberal use of CCTV, credit card and GPS mobile phone data was fundamental to South Korea’s ability to test and trace so <a href="https://theconversation.com/coronavirus-south-koreas-success-in-controlling-disease-is-due-to-its-acceptance-of-surveillance-134068">widely and efficiently</a>. It is unfair to use these tech-savvy behemoths, battle-scarred but bettered from previous epidemics of Sars and Mers coronaviruses, as a benchmark. Nonetheless, ongoing operations to <a href="https://www.theguardian.com/world/2020/mar/25/uk-coronavirus-mass-home-testing-to-be-made-available-within-days">scale up testing and a new antibody test on the horizon</a> merit optimism for the UK.</p>
<p>Subsequent measures, such as voluntary self-isolation, household quarantine, increasing hospital capacity and social distancing, have all bolstered the protective armoury. The plan for <a href="https://www.gov.uk/government/publications/guidance-on-shielding-and-protecting-extremely-vulnerable-persons-from-covid-19/guidance-on-shielding-and-protecting-extremely-vulnerable-persons-from-covid-19#what-do-we-mean-by-extremely-vulnerable">shielding 1.5 million extremely vulnerable people</a> is commendable. Unheard of in most other countries, it is emblematic of a nuanced response led by public health experts.</p>
<p>Pandemic response requires a whole-of-government approach. An unprecedented £330 billion package of loan guarantees for businesses was <a href="https://www.politico.eu/article/uk-sets-out-330-billion-coronavirus-business-loan-package/">recently announced by the new Chancellor Rishi Sunak</a>. Without this, the success of public health measures such as self-isolation and closing businesses would be threatened. With it, the health effects of economic contraction will be offset. This, one of the largest economic packages of its type in the world, is a bold step by a surefooted government.</p>
<p>This crisis has seen the NHS come into its own. A national recruitment effort has kicked into gear, with<a href="https://news.sky.com/story/coronavirus-4-500-retired-doctors-and-nurses-sign-up-to-battle-covid-19-pandemic-11961685"> 4,500 recently retired professionals dusting off their stethoscopes</a>. <a href="https://www.theguardian.com/world/2020/mar/25/astonishing-170000-people-sign-up-to-be-nhs-volunteers-in-15-hours-coronavirus">Half a million members of the public</a> have also signed up to volunteer for the NHS. Doctors from across all specialities are being redeployed. Staff rotas and wards have been redesigned to accommodate the anticipated surge in patients. A 4,000-bed hospital (with a whopping 500 ventilators) is being created in the <a href="https://www.bbc.co.uk/news/health-52018477">ExCel Centre in London</a>.</p>
<h2>Primed and ready</h2>
<p>The public health workforce is also primed. Public Health England, with multiple technical cells, continues to immerse the national strategy in scientific expertise. Health protection teams are preventing outbreaks in institutions and providing evidence-based guidance to healthcare professionals. Local authority public health teams are delivering vital support to community groups, businesses and individuals.</p>
<p>The public is now largely united in their recognition of this threat. Most are heeding advice, taking care of the vulnerable, and staying at home. For those who are not, the government has strengthened enforcement. A palpable sense of common purpose is swelling.</p>
<p>There may have been uncertainties, mistakes and delays along the way. But we now find ourselves at a critical juncture. It is reassuring that the man at the helm, Chris Whitty – a serendipitous appointment to chief medical officer – is operating within his bailiwick. We can and should look forward with optimism. This is the defining crisis of our lifetimes. Let it not be defined by suffocating despair, but solidarity, support and hope.</p><img src="https://counter.theconversation.com/content/134824/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Vageesh Jain works in a local government public health team in London</span></em></p>Let’s stay united in the face of this threat.Vageesh Jain, NIHR Academic Clinical Fellow in Public Health Medicine, UCLLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1279432019-12-12T12:42:56Z2019-12-12T12:42:56ZNon-alcoholic drinks: how healthy are they?<figure><img src="https://images.theconversation.com/files/306588/original/file-20191212-85428-58vqd0.jpg?ixlib=rb-1.1.0&rect=51%2C155%2C5760%2C2845&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/beautiful-girl-drinking-beer-653164258">Merla/Shutterstock</a></span></figcaption></figure><p>A few years ago, alcohol-free beers and wine were a rarity. And what was available was pretty execrable. Today, the <a href="https://www.telegraph.co.uk/news/2018/04/29/sales-nanny-state-low-alcohol-beers-soaring-figures-show/">market is booming</a> and you can order a pint of alcohol-free IPA, with all its rich hoppiness, or a glass of “de-alcoholised” merlot that actually tastes like wine, not jumped-up grape juice.</p>
<p>In the UK, a drink can be classed as alcohol free if it has less than 0.05% ABV (alcohol by volume). This is considerably less than alcohol-containing versions (beer has about 4-5% and wine around 13%). Given the negative effect, alcohol can have on your health, particularly over the long term, alcohol-free beer and wine are certainly healthier options. But does that mean they’re good for you?</p>
<p>Not everyone is aware that alcoholic drinks contain calories. A standard glass of wine, for instance, has nearly as many calories as a jam doughnut, and that’s just from the alcohol it contains. But how does a glass of alcoholic-free wine compare?</p>
<h2>Free sugar</h2>
<p>There are different sugars in the diet. One type we need to be careful of, and that we tend to have too much of, is <a href="https://www.nutritionsociety.org/papers/definition-free-sugars-uk">“free sugar”</a>. This term is used to describe the sugar that is added to food or drink, or the type that’s found in fruit juices, honey and syrup. </p>
<p>UK guidelines suggest that adults should get <a href="https://www.gov.uk/government/publications/sacn-carbohydrates-and-health-report">less than 5% of their daily calories from free sugars</a>, which works out to about six or seven teaspoons of sugar. That should be the most you get from all the food and drink that you have on an average day.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/306601/original/file-20191212-85376-xrj1jy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/306601/original/file-20191212-85376-xrj1jy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/306601/original/file-20191212-85376-xrj1jy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/306601/original/file-20191212-85376-xrj1jy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/306601/original/file-20191212-85376-xrj1jy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/306601/original/file-20191212-85376-xrj1jy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/306601/original/file-20191212-85376-xrj1jy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Your daily allowance of free sugar.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/six-pieces-sugar-metal-spoon-on-1108531499">Andrei Metelev/Shutterstock</a></span>
</figcaption>
</figure>
<p>A pint of alcohol-free lager contains one and a half teaspoons of free sugars – a quarter of your recommended maximum in just one glass. If you polish off a bottle of alcohol-free chardonnay over lunch, you’ve had eight teaspoons. And in some cases, that may even be more than its alcohol-containing alternative. </p>
<p>With soft drinks, as with alcohol-free beers and wine, the sugar content varies from product to product. A glass of lemonade contains about two teaspoons of free sugar, while the same amount of cola is nearer five. If you want to avoid sugar completely, you might prefer water or sugar-free versions of soft drinks.</p>
<p>In the UK, Public Health England challenged the food and drink industry to reduce the sugar content of their products by 20% before 2020. And last year the government introduced a sugar tax. As a result, the average sugar content of these drinks has <a href="https://www.gov.uk/government/publications/sugar-reduction-progress-between-2015-and-2018">decreased by 28%</a> as manufacturers look to reformulate their products to make them healthier. But some drinks, such as milkshakes, fruit juices and smoothies, aren’t affected by the levy – and neither are alcohol-free drinks.</p>
<h2>Perspective needed</h2>
<p>Health cannot be quantified by any one aspect of nutrition. The sugar or calorie content of a drink you have doesn’t necessarily make it, or you, unhealthy. The bigger picture of your life is more important than a snapshot. And the role of a drink in your health depends on how much and how often you have it, as well as what else you’re eating or drinking.</p><img src="https://counter.theconversation.com/content/127943/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ali Hill does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Alcohol-free wine and beer can be high in sugar, but that doesn’t mean you shouldn’t enjoy the occasional sin-free bevvy.Ali Hill, Course Leader in Applied Human Nutrition, Solent UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1068912019-01-02T09:00:04Z2019-01-02T09:00:04ZDry January: a convenient distraction for the alcohol industry<figure><img src="https://images.theconversation.com/files/248428/original/file-20181203-194925-1jph3mx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">shutterstock</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/221168854?src=IaWpGaLwAf1FXdGlOxphqA-1-29&size=medium_jpg">Brian Goodman/Shutterstock</a></span></figcaption></figure><p>Six years on and Dry January is more popular than ever, but does quitting booze for a month actually make a difference to your life? Looking at the <a href="https://alcoholchange.org.uk/get-involved/campaigns/dry-january">Dry January</a> website, managed by Alcohol Change UK, you’re left in little doubt: you can lose weight, save money, sleep better and have more energy. There is certainly evidence to support the negative effects of alcohol on all these things, but does that mean Dry January causes these positive effects?</p>
<p>To figure out the true benefits of Dry January, you need to think about <a href="http://eprints.whiterose.ac.uk/137043/">what you do</a> when you give up alcohol for a month. For instance, do you start doing other healthy things, like take more exercise or eat healthier food? If you do, then that’s great, but the positive effects you will experience are not solely due to temporarily quitting alcohol. </p>
<p>Despite its popularity, the impact of Dry January on health has not been robustly investigated. The most <a href="https://academic.oup.com/eurpub/article/27/5/929/4209886">recent attempt</a> in 2017 did not look at whether people made other healthy lifestyle changes when they gave up booze. But a more significant problem is the number of participants who dropped out. While the study results looked positive, they could be misleading, particularly if those who dropped out did so from feeling worse as a result of quitting drinking.</p>
<p>The research was also sponsored by Public Health England, the same group that endorses the Dry January campaign. An independent evaluation would avoid a perceived conflict of interest. </p>
<h2>Inconvenient truth</h2>
<p>Rather than viewing Dry January as a threat to their business, the alcohol industry views it as a neat distraction from an inconvenient truth. Although alcohol consumption is declining overall, 4.4% of the population account for <a href="https://www.theguardian.com/society/2018/jan/22/nearly-one-third-of-alcohol-sold-in-england-drunk-by-4-of-population">more than 30%</a> of all the alcohol sold in the UK. But Dry January is not aimed at high-risk drinkers, as Alcohol Change UK makes clear. It would be potentially life-threatening for people in this group to suddenly stop drinking. They need specialist support to reduce their alcohol intake if they are to avoid harming their health or, worse, dying. </p>
<p>Abrupt alcohol withdrawal <a href="https://theconversation.com/alcohol-withdrawal-can-be-deadly-heres-why-96487">can kill</a>. So there is a real danger that these campaigns play well with the alcohol industry as they distract attention from a group of people who are at the greatest risk of dying prematurely due to alcohol. This is not a product image you’d want to draw attention to. In this way, Dry January might cause more harm than good, because it attracts those least at risk of developing problems due to alcohol, while neatly distracting attention from those at the greatest risk. The alcohol industry is <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/add.14216">adept at influencing</a> policy to protect their business model. </p>
<p>Unfortunately, Public Health England recently faced <a href="https://www.theguardian.com/society/2018/sep/21/public-health-england-review-drinkaware-website-guidance">criticism</a> for its own relationship with the industry. It joined <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3992896/">Drinkaware</a>, an organisation funded by the alcohol industry, in an “alcohol-free days” campaign that many experts believed was an ill-judged tie up. The campaign’s message appeared to minimise the risks associated with excessive drinking, based on a self-assessment drinking tool. </p>
<p>Those facing the greatest risks to their health as a result of drinking alcohol get the least in the way of services compared to those with more modest risks from alcohol consumption. Alcohol treatment services continue <a href="https://www.bbc.co.uk/news/uk-england-44039996">to be cut</a>, while alcohol-related harm continues to rise. This is a classic example of the <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(71)92410-X/fulltext">inverse care law</a>, which describes a situation where those who most need medical care are least likely to receive it. </p>
<p>There is a health apartheid as low-risk drinkers are served by campaigns like Dry January and high-risk drinkers are denied support. This is demonstrated <a href="https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(17)32866-0.pdf">by differences</a> in social groups – those from the most socially deprived groups are the most likely to die due to alcoholic liver disease.</p>
<figure class="align-<image id= zoomable">
<a href="https://images.theconversation.com/files/247773/original/file-20181128-32230-19bya6w.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/247773/original/file-20181128-32230-19bya6w.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/247773/original/file-20181128-32230-19bya6w.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=534&fit=crop&dpr=1 600w, https://images.theconversation.com/files/247773/original/file-20181128-32230-19bya6w.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=534&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/247773/original/file-20181128-32230-19bya6w.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=534&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/247773/original/file-20181128-32230-19bya6w.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=672&fit=crop&dpr=1 754w, https://images.theconversation.com/files/247773/original/file-20181128-32230-19bya6w.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=672&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/247773/original/file-20181128-32230-19bya6w.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=672&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Number of deaths from liver disease by age and social deprivation.</span>
<span class="attribution"><span class="source">Lancet</span></span>
</figcaption>
</figure>
<p>Alcohol <a href="https://www.bmj.com/content/363/bmj.k4370">is a drug</a> that happens to be legally regulated, and like all drugs, there are vested interests that control access to credible information about the health risks. Robust evaluation of the Dry January campaign is overdue. Millions of participants need a more accurate idea of whether or not they should bother (popularity should not be used as a proxy for effectiveness). Money would be better spent on those who need support the most and on tackling the root causes of excessive drinking.</p><img src="https://counter.theconversation.com/content/106891/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ian Hamilton reviews research grants for Alcohol Change UK. </span></em></p>There’s no credible evidence that Dry January is good for your health. But it’s certainly good for on group: the alcohol industry.Ian Hamilton, Associate Professor, University of YorkLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/898762018-01-11T10:14:45Z2018-01-11T10:14:45ZSugar: six easy ways to encourage children to eat less<figure><img src="https://images.theconversation.com/files/201420/original/file-20180109-36019-9uxc8x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Tempted...</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/diet-kids-sad-unhappy-child-reaches-768409303?src=BpJU09cVlGpRKTyemTSiPw-1-0">Sharomka/Shutterstock</a></span></figcaption></figure><p>A new campaign from Public Health England is urging parents to <a href="http://www.bbc.co.uk/news/health-42411474">limit snacks for children</a> to two a day, and 100 calories a piece. The aim is to reduce kids’ sugar consumption – according to <a href="https://www.nhs.uk/change4life/food-facts/sugar#y923EBPuvyUuzyF8.97">PHE data</a>, children eat on average 10kg of sugar every year, with about half of this coming from sugary drinks and snacks.</p>
<p>This is definitely an important initiative, but any parent will tell you that getting little ones to swap cereal bars for celery is no easy task. You could explain again and again how eating too much sugar can lead to health problems like obesity and tooth decay, but that doesn’t mean children will fully understand why snacking on sweet treats can be a problem.</p>
<p>Though encouraging children to eat healthy snacks isn’t as easy as clearing out the cupboards, that doesn’t mean it’s an impossible feat. Here’s how to make it less of a labour.</p>
<h2>1. Be creative</h2>
<p>There are only so much vegetable sticks and hummus that anyone can eat before it gets boring, so you will need to get a bit creative with the snacks on offer. But this is not about going over the top with Pinterest-worthy creations either. <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1651-2227.2011.02409.x/full">Bright colours</a> and interesting textures will do the trick, as well as pairing already <a href="http://jn.nutrition.org/content/143/7/1194.short">well-liked flavours with new tastes</a>.</p>
<h2>2. Stock up with different choices</h2>
<p>Variety can help as well. Rather than just having single snacks to hand, get a couple of alternatives ready. Again, these don’t need to be presented on a platter, the idea is to give them <a href="https://www.ncbi.nlm.nih.gov/pubmed/27062194">the autonomy to choose</a>. </p>
<p>Have pots of plain yogurt or fromage frais in the fridge, nuts and raisins ready to be scooped out in handfuls, or some oven roasted vegetable crisps with a small amount of dip waiting in the cupboard. </p>
<figure class="align-left zoomable">
<a href="https://images.theconversation.com/files/201486/original/file-20180110-46715-ljfn4u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/201486/original/file-20180110-46715-ljfn4u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/201486/original/file-20180110-46715-ljfn4u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=900&fit=crop&dpr=1 600w, https://images.theconversation.com/files/201486/original/file-20180110-46715-ljfn4u.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=900&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/201486/original/file-20180110-46715-ljfn4u.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=900&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/201486/original/file-20180110-46715-ljfn4u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1131&fit=crop&dpr=1 754w, https://images.theconversation.com/files/201486/original/file-20180110-46715-ljfn4u.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1131&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/201486/original/file-20180110-46715-ljfn4u.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1131&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Snack suggestions.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/school-lunch-box-snacks-kids-over-698716126?src=gEcP4tIxDZ9dgVeVd-l3Jw-1-65">Dado Photo/Shutterstock</a></span>
</figcaption>
</figure>
<h2>3. Avoid sugary drinks</h2>
<p>Parents hear over and over that even seemingly healthy drinks can often hide numerous teaspoons of sugar in them. While fizzy drinks are generally regarded as the most unhealthy options, fruit juice and smoothies aren’t <a href="https://www.theguardian.com/society/2016/mar/23/fruit-juices-smoothies-contain-unacceptably-high-levels-sugar">as healthy as they seem either</a>. </p>
<p>Flavoured water and squash <a href="http://www.telegraph.co.uk/foodanddrink/healthyeating/11504822/How-your-healthy-flavoured-water-contains-more-sugar-than-cola.html">can also contain sugar</a> so that leaves plain water as <a href="https://theconversation.com/under-threes-need-water-and-milk-not-sugar-loaded-drinks-32347">the best option</a> for children to drink. Though many kids will say they don’t like the taste, adding a squeeze lemon or orange, or infusing a large jug with mint and strawberries will help change their minds. </p>
<h2>4. Don’t forbid but do control</h2>
<p>As research has repeatedly shown, forbidding foods makes them <a href="http://www.sciencedirect.com/science/article/pii/S0195666307002668">even more attractive</a> for children. In fact, the power of forbidden foods is so strong, it has even been suggested that it <a href="http://www.sciencedirect.com/science/article/pii/S0195666308001499">works on healthy foods</a>, like fruit. </p>
<p>The occasional biscuit or chocolate bar will not jeopardise a child’s eating health habits, so long as it is just one or two every once in a while. As a rule of thumb, try not to keep sugary snacks in the home, avoid offering them if the kids don’t ask for them, and limit the quantity offered if they do. Explain to them why it is important to limit those foods, too, as teaching them about their own health will work better in the long run than just saying no without explanation. </p>
<p>Keep in mind that the 100 calorie recommendation is a rough guide to help parents quantify sugar. Nuts, for example, are a healthy snack choice but a portion size is often more than 100 calories.</p>
<h2>5. Start thinking about meals, too</h2>
<p>While snacks are easier to target through public health campaigns, remember that reducing sugar consumption should be done holistically. If half of childrens’ total sugar consumption comes from sugary drinks and snacks then it is obvious that meals account for the other half. Start thinking about moderating desserts after meals and sugary breakfasts as well.</p>
<h2>6. Eat healthy as a family</h2>
<p>Children learn from what they <a href="https://www.ncbi.nlm.nih.gov/pubmed/15003137">see adults doing</a>, so it is important that parents also make healthy choices. Research shows that children who participate in frequent family meals are <a href="http://www.sciencedirect.com/science/article/pii/S0002822310018316">more likely to eat fruit and vegetables</a>, and they have more healthy eating habits overall that <a href="https://www.ncbi.nlm.nih.gov/pubmed/25485670">can continue in adult life</a>. Apply the same rules to everyone in the family, and the children won’t be the only ones learning a valuable lesson.</p>
<p>Kicking the sugar habit may be tricky to begin with, but following this simple advice will help make food a positive experience for you and your little ones.</p><img src="https://counter.theconversation.com/content/89876/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Sophia Komninou does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>A child nutritionist gives her advice.Sophia Komninou, Lecturer in Infant and Child Public Health, Swansea UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/754752017-03-31T12:22:37Z2017-03-31T12:22:37ZPublic Health England’s new guideline for the food industry is unlikely to curb obesity<figure><img src="https://images.theconversation.com/files/163283/original/image-20170330-15603-1qtm9jk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/281338736?src=YrdYnvzbxwiMnVZBm_SZCA-1-1&size=medium_jpg">roberaten</a></span></figcaption></figure><p>Public Health England (PHE) has <a href="https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/604336/Sugar_reduction_achieving_the_20_.pdf">published new guidelines</a> for the food industry, setting out approaches manufacturers can take to reduce the amount of sugar children consume. The guidelines challenge the industry to cut sugar content in nine food categories, including breakfast cereals, puddings and confectionery, by 20% by 2020, and by 5% this year. Are these guidelines fit for purpose, or are they too little, too late?</p>
<p>Obesity rates in the UK have <a href="https://www.noo.org.uk/NOO_about_obesity/adult_obesity/UK_prevalence_and_trends">risen dramatically over the past 20 years</a>, leading to around one in four people being obese. Although these increases have slowed in recent years, an upward trend still continues. More worryingly, rates of childhood obesity have increased greatly, so that around <a href="http://www.bbc.co.uk/news/health-37859484">one in five 11-year-olds are now obese</a>. These increases are worrying because obesity is a significant risk factor for a number of chronic diseases including type 2 diabetes, cancer and heart disease.</p>
<p>The government spends <a href="http://www.telegraph.co.uk/news/2016/06/07/more-spent-on-treating-obesity-related-conditions-than-on-the-po/">more money each year on obesity than it does the police or fire service</a>. So identifying ways to prevent or reverse obesity are vital to the health and wealth of the UK.</p>
<h2>Not a one-strategy problem</h2>
<p>There are many factors that could explain the global rise in obesity rates, but it is widely accepted that the main cause of obesity is an imbalance between calories consumed and calories expended. We obtain our calories from the macronutrients in our food and drink, namely fats, protein and carbohydrates, including sugars. Global sugar consumption has <a href="http://www.sucden.com/statistics/4_world-sugar-consumption">almost doubled since 1980</a> and around 170m tonnes will be consumed in 2016-17. This has almost certainly contributed to the increased obesity levels we now see, with research showing that consumption of sugar-sweetened drinks <a href="http://www.sciencedirect.com/science/article/pii/S0140673600040411">is associated with obesity in children</a>. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/163444/original/image-20170331-31729-a2z5vg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/163444/original/image-20170331-31729-a2z5vg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/163444/original/image-20170331-31729-a2z5vg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/163444/original/image-20170331-31729-a2z5vg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/163444/original/image-20170331-31729-a2z5vg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/163444/original/image-20170331-31729-a2z5vg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/163444/original/image-20170331-31729-a2z5vg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Global sugar consumption has almost doubled since 1980.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/380183302?src=cIWru9inFkvXAROVurQKxg-1-45&size=medium_jpg">Alf Ribeiro/Shutterstock.com</a></span>
</figcaption>
</figure>
<p>So it is easy to see why so many people are concerned about sugar – and why it has become a big news story in the past few years. It is, however, dangerous to become fixated on single factors in the quest to reverse the rise of obesity levels. Body weight is a complex issue, governed by internal factors including hunger and metabolism, and external factors such as food availability and economic development. </p>
<p>Reducing the causes of obesity down to a single factor has a poor precedent. For 30 years, official recommendations on diet were to limit dietary fat, <a href="https://www.theguardian.com/society/2016/may/22/official-advice-to-eat-low-fat-diet-is-wrong-says-health-charity">a policy that has been described as “disastrous”</a>. Are we making the same mistake with sugar?</p>
<p>Although sugar consumption has increased, we are eating too many calories overall. A report in 2014 suggested that <a href="http://www.dailymail.co.uk/femail/article-2722815/Daily-calorie-intake-countries-world-revealed-surprise-U-S-tops-list-3-770.html">the UK has the world’s sixth-highest daily calorie intake</a>. This is possibly because many people are thought to <a href="http://www.bbc.co.uk/news/health-36988065">significantly underestimate the number of calories they eat each day</a>. </p>
<p>At the same time, the amount of time children spend watching television or using computers <a href="http://www.bbc.co.uk/news/technology-32067158">has almost doubled</a>, while only 66% of men and 56% of women <a href="http://www.sustrans.org.uk/policy-evidence/the-impact-of-our-work/related-academic-research-and-statistics/physical-activity">get the recommended levels of exercise each week</a>. Collectively, these findings show that we eat too much and don’t exercise enough. Cutting sugar consumption will help, but it is unlikely to be a silver bullet for obesity.</p>
<h2>A start, but not enough</h2>
<p>A major issue with the new PHE guideline is that they are voluntary. There is no legal requirement for food manufacturers to reduce the sugar content of their food – they are, after all, guidelines and not law. It remains to be seen how many manufacturers will take the guidelines seriously and whether any changes they make to recipes or serving sizes will have an impact on people’s weight in the long term. </p>
<p>I welcome the new guidelines because they put pressure on food makers to reduce the sugar content of their products, but they can only form a small part of what needs to be a broader approach to solving the obesity crisis.</p><img src="https://counter.theconversation.com/content/75475/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>James Brown does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Body weight is a complex issue and going after one culprit is not enough.James Brown, Lecturer in Biology and Biomedical Science, Aston UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/699472016-12-22T17:55:41Z2016-12-22T17:55:41ZHow reliable is the Eatwell Guide, the official chart of what foods you should be eating?<figure><img src="https://images.theconversation.com/files/149027/original/image-20161207-25768-fboave.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/pic-530297125/stock-photo-piece-of-fresh-sea-northern-salmon-on-a-wooden-background-with-vegetables-before-cooking.html?src=CPPYxwfOwx0HjIeto-qyFw-1-6">ILEISH ANNA/Shutterstock.com</a></span></figcaption></figure><p>The Eatwell plate was a visual guide, in pie-chart form, of the government’s recommended intakes of specified food groups. The chart remained largely unchanged for 20 years. But in October 2014, Public Health England announced that it would update the plate in the light of <a href="https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/547050/government__dietary_recommendations.pdf">new recommendations</a> on sugar and fibre from the government’s Scientific Advisory Committee on Nutrition. </p>
<p>Following the announcement, Kremlin Wickramasinghe and I <a href="https://theconversation.com/official-healthy-food-guide-hasnt-changed-in-20-years-five-things-that-need-updating-33265">wrote an article</a> for The Conversation arguing that the Eatwell plate actually needed a complete overhaul. We argued that the food groups shown in the plate should be revised, that healthier and less healthy foods within food groups should be identified and very unhealthy foods should not be shown at all. In addition, the angles of the segments of the plate – showing how much of each of the food groups we should eat – should be changed and the environmental sustainability of foods as well as their healthiness should be taken into account.</p>
<p>In March 2016, PHE finally launched an updated Eatwell plate – now called the Eatwell Guide.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/148941/original/image-20161206-25727-1bfsmi7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/148941/original/image-20161206-25727-1bfsmi7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/148941/original/image-20161206-25727-1bfsmi7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=430&fit=crop&dpr=1 600w, https://images.theconversation.com/files/148941/original/image-20161206-25727-1bfsmi7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=430&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/148941/original/image-20161206-25727-1bfsmi7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=430&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/148941/original/image-20161206-25727-1bfsmi7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=540&fit=crop&dpr=1 754w, https://images.theconversation.com/files/148941/original/image-20161206-25727-1bfsmi7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=540&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/148941/original/image-20161206-25727-1bfsmi7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=540&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The Eatwell Guide.</span>
<span class="attribution"><a class="source" href="https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/528196/Eatwell_guide_600dpi.jpg">Public Health England</a></span>
</figcaption>
</figure>
<p>So did Public Health England (PHE) take up our recommendations? In some ways, yes. PHE has slightly revised the food groups and they have stopped showing very unhealthy foods (the old Eatwell plate infamously displayed a can of cola). They have commissioned some <a href="https://www.carbontrust.com/media/672635/phe-sustainable-diets.pdf">calculations</a> on the environmental sustainability of the Eatwell Guide diet and it’s certainly an improvement. But most importantly they have changed the angles of the segments of the pie chart to take into account all of the government’s nutrient recommendations – not only the new recommendations on sugar and fibre, but also all the old recommendations for, in particular, fat, saturated fat and salt. </p>
<p>In 2014 we also suggested that the segment for meat, fish and alternatives needed to be smaller than it had been because of the growing evidence for the detrimental effects of meat consumption on health, particularly red and processed meat. But in this we were wrong. It was 12% of the pie in the old <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1365-277X.1995.tb00326.x/abstract">Eatwell plate</a> and is still 12% of the pie in the new Eatwell Guide. Twelve percent turns out to be correct because, while we do indeed need to cut down on meat more than we thought 20 years ago, we also need to compensate for that reduction and get our protein from vegetarian alternatives such as beans and pulses. A fifth of our current diet comes from meat, fish and alternatives, so the new Eatwell Guide indicates we still need to reduce that consumption by nearly a half. </p>
<p>All the other angles of the pie chart have changed. The fruit and vegetable segment has increased from 33% to 39%. The bread, other cereals and potatoes segment has increased from 33% to 37%. The fatty and sugary foods segment has been reduced from 8% to 4%. And, controversially, the segment representing milk and dairy foods has nearly halved – from 15% to 8%.</p>
<h2>A more scientific approach</h2>
<p>These angles have been calculated in a much more transparent and scientific way than they were for the old Eatwell plate where they were essentially a guess. The process involved a technique called optimisation modelling: a computerised way of finding a combination of foods that meets all the nutrient recommendations while at the same time being closest to current dietary habits.</p>
<p>Optimisation modelling means that the recommendations for the different food groups can be broken down into their component parts. For example, although the Eatwell Guide recommends a reduction in meat, fish and alternatives by nearly a half, we show in a new <a href="http://bmjopen.bmj.com/cgi/content/full/bmjopen-2016-013182?ijkey=Uo55Bu2X5HD3ukv&keytype=ref">paper in BMJ Open</a> that for this to happen we actually need to reduce our red and processed meat consumption by 80%, to no more than 15g day, and we should increase our consumption of the beans and pulses by 86% to 26g a day. </p>
<p>The Eatwell Guide has changed the name of the meat, fish and alternatives group to “beans, pulses, fish, eggs, meat and other proteins”, but otherwise doesn’t make it clear that eating less meat and more beans and pulses is what is required for a healthy diet which meets the government’s nutrient recommendations. </p>
<p>Our paper also shows that while we need to reduce our overall intake of milk and dairy foods by nearly a half from current levels of 14% to 8% this should be accomplished by reducing our cheese consumption by 85% to no more than 3g a day. But semi-skimmed and skimmed milk consumption should rise slightly from 120 to 127ml a day.</p>
<p>Optimisation modelling resolves some other thorny questions. Can sugary drinks be a component of a healthy diet? The answer is yes, but at only 60g a day this means we should be reducing our consumption to a can a week. Do we need to cut down on fruit juice? Again, yes – by about 50%.</p>
<p>The Eatwell Guide provides all of us with a clear indication of what foods we should be eating. It boils down to eat less meat and processed foods and more plant-based foods, but these new analyses also flesh out what this means precisely. And, for the first time, the recommendations are based on sound science.</p><img src="https://counter.theconversation.com/content/69947/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Mike Rayner 's research centre - the British Heart Foundation Centre on Population Approaches for Non-Communicable Disease Prevention - received funding from Public Health England to carry out the analyses involving non-linear programming that are reported in this article. His salary is part-funded by the British Heart Foundation. </span></em></p>After 20 years, Public Health England finally released a revised Eatwell Guide – here’s what changed.Mike Rayner, Professor of Population Health, University of OxfordLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/649722016-09-09T10:26:46Z2016-09-09T10:26:46ZDrugs fatalities overtake car fatalities for the first time<figure><img src="https://images.theconversation.com/files/137080/original/image-20160908-25249-1ct7wc5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-276472910/stock-photo-man-injecting-himself-with-a-small-hypodermic-needle-possibly-administering-medication-for-a-disease-such-as-diabetes.html?src=NLK3gv9RXwwEBCFGAW-lgA-1-0">NAS CREATIVES/Shutterstock.com</a></span></figcaption></figure><p>Seven years ago, <a href="http://articles.latimes.com/2011/sep/17/local/la-me-drugs-epidemic-20110918">fatalities from opiates</a> overtook fatalities due to road accidents in the US. Sadly, the same phenomenon is now playing out in England. The latest figures from the Office for National Statistics (ONS), show that last year, 1,732 people died in <a href="https://www.gov.uk/government/statistics/reported-road-casualties-in-great-britain-main-results-2015">traffic accidents in the UK</a> compared with <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/deathsrelatedtodrugpoisoninginenglandandwales/2015registrations">1,989</a> who died due to opiates in England alone.</p>
<p>New psychoactive substances, referred to as “legal highs”, have <a href="https://theconversation.com/stories-about-legal-high-deaths-are-bound-up-in-media-hysteria-24360">received significant media attention</a>, and deaths due to these drugs have risen by 40%, but opiate deaths now outnumber legal-high deaths by 19 to 1, despite a <a href="https://www.gov.uk/government/statistics/drug-misuse-findings-from-the-2015-to-2016-csew">steady decline</a> in opiate use in England and Wales over the last decade.</p>
<p>Of course, opiates are not the only problem – deaths due to cocaine have reached the highest on record at 320, increasing by nearly 30% since last year – but opiates are what we should really be focusing on. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/137200/original/image-20160909-13363-1uib24s.PNG?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/137200/original/image-20160909-13363-1uib24s.PNG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=377&fit=crop&dpr=1 600w, https://images.theconversation.com/files/137200/original/image-20160909-13363-1uib24s.PNG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=377&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/137200/original/image-20160909-13363-1uib24s.PNG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=377&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/137200/original/image-20160909-13363-1uib24s.PNG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=474&fit=crop&dpr=1 754w, https://images.theconversation.com/files/137200/original/image-20160909-13363-1uib24s.PNG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=474&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/137200/original/image-20160909-13363-1uib24s.PNG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=474&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Drug deaths.</span>
<span class="attribution"><span class="source">Office for National Statistics</span></span>
</figcaption>
</figure>
<h2>Premature and preventable</h2>
<p>Drug-related deaths of males outnumber those of females by three to one and 60% of deaths occur in 30- to 49-year-olds – compared with an <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/lifeexpectancies/bulletins/lifeexpectancyatbirthandatage65bylocalareasinenglandandwales/2015-11-04">average life expectancy</a> for the rest of the population of 80. </p>
<p>Health complications resulting from drug use do not entirely explain this inequality in life span. A range of factors are likely to be involved. Purity and quality of heroin are not as critical, borne out by <a href="http://onlinelibrary.wiley.com/doi/10.1111/add.13516/full">decades of research</a>. Rather it is the risk of accidental overdose by more experienced and tolerant heroin users. Equally, combining heroin with alcohol and or a benzodiazapine such as diazepam <a href="http://www.sciencedirect.com/science/article/pii/S0376871612002785">increases the risk of death</a>. In 1993, one in four deaths were attributed to combining alcohol with opiates; this has now reached one in two. </p>
<p>In 2010, the newly elected Conservative government introduced a <a href="https://www.gov.uk/government/publications/drug-strategy-2010">new treatment strategy</a>. The policy emphasised the importance of achieving abstinence from drugs rather than merely reducing the harm they can cause. This recovery agenda may have inadvertently contributed to the rise in drug deaths. Unfortunately, even if abstinence is achieved, the <a href="http://bit.ly/2cbURiS">odds of relapsing</a> are high. Abstinence <a href="http://www.bjmp.org/files/2013-6-1/bjmp-2013-6-1-a601.pdf">reduces the ability</a> to tolerate previously manageable doses of heroin, resulting in an overdose for some. </p>
<h2>Treatment risk</h2>
<p>Treatment does reduce mortality. A <a href="http://www.nta.nhs.uk/uploads/trendsdrugmisusedeaths1999to2014.pdf">recent report</a> showed that most opiate deaths were of people not in treatment. Treatment usually involves providing a substitute drug with the aim of weaning the individual off heroin. Methadone and buprenorphine are commonly used to do this. But there are two critical factors, retaining people in treatment and what happens when treatment finishes. The month following treatment is particularly important as a person’s tolerance to opiates will have reduced, increasing the risk of overdose <a href="http://onlinelibrary.wiley.com/doi/10.1111/add.13087/full">if the person relapses</a>. Following up people at this critical stage could help reduce the risk of fatality. </p>
<p>But the challenge is how to engage those who are not in treatment. Attracting this group requires a more radical approach. <a href="https://theconversation.com/why-australia-needs-drug-consumption-rooms-53215">Drug consumption rooms</a> provide a safe place for people to use their drugs, providing clean syringes for those who inject heroin. These facilities have an impressive record of reducing fatalities due to drug use. And, just as important, they are the first step towards engaging a marginalised group into health and social care. We don’t need any more evidence as to their value – we need what politicians crave: <a href="http://www.tandfonline.com/doi/abs/10.3109/14659891.2016.1143049">public support</a>.</p>
<p>Naloxone can also temporarily reverse the effects of an opiate overdose. Making this drug available to opiate users and their families offers the potential to reduce fatalities. Scotland has pioneered this by implementing a <a href="http://onlinelibrary.wiley.com/doi/10.1111/add.13265/pdf">national naloxone policy</a> and new regulations in England have <a href="https://www.gov.uk/government/publications/widening-the-availability-of-naloxone/widening-the-availability-of-naloxone">allowed this approach to be mirrored</a>. This development gives workers and heroin users access and permission to administer naloxone when an overdose occurs.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/137083/original/image-20160908-25260-hhapzw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/137083/original/image-20160908-25260-hhapzw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/137083/original/image-20160908-25260-hhapzw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/137083/original/image-20160908-25260-hhapzw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/137083/original/image-20160908-25260-hhapzw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/137083/original/image-20160908-25260-hhapzw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/137083/original/image-20160908-25260-hhapzw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Naloxone can reverse the effects of an opiate overdose.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-418417357/stock-photo-layton-utah-march-11-2016-vial-of-naloxone-drug-which-is-used-for-opiate-drug-overdose-it-is-now-available-to-patients-without-a-prescription-or-over-the-counter.html?src=HeShWLVmobUTJtghilzrNw-1-0">PureRadiancePhoto/Shutterstock.com</a></span>
</figcaption>
</figure>
<h2>A glimpse into the future?</h2>
<p>The US has witnessed a 200% rise in prescription-opiate deaths since the millennium, driven by <a href="http://onlinelibrary.wiley.com/doi/10.1111/ajt.13776/full">increasing availability and lower costs</a>. The regulatory and marketing environments differ in the US and the UK. In the UK, open marketing of opiates is prohibited and there are stricter controls and monitoring of prescribing. But current drug control measures are outdated and <a href="http://www.tandfonline.com/doi/abs/10.3109/14659891.2014.980861">easily circumvented by the internet</a>.</p>
<p>So we need to carefully monitor the use and misuse of a range of prescription drugs such as tramadol. Tramadol is an analgesic used for moderate to severe pain. Prescriptions for tramadol rose dramatically over the <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/deathsrelatedtodrugpoisoninginenglandandwales/2015registrations">last decade</a>, as did deaths thought to be the result of misusing the drug. This prompted new regulations which came into force last year with the aim of curbing tramadol-related deaths. This year’s ONS data shows that one year after the introduction of these regulations deaths have reduced, but we will need to see if this trend continues.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/137202/original/image-20160909-13345-2cdpp9.PNG?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/137202/original/image-20160909-13345-2cdpp9.PNG?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/137202/original/image-20160909-13345-2cdpp9.PNG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=366&fit=crop&dpr=1 600w, https://images.theconversation.com/files/137202/original/image-20160909-13345-2cdpp9.PNG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=366&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/137202/original/image-20160909-13345-2cdpp9.PNG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=366&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/137202/original/image-20160909-13345-2cdpp9.PNG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=460&fit=crop&dpr=1 754w, https://images.theconversation.com/files/137202/original/image-20160909-13345-2cdpp9.PNG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=460&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/137202/original/image-20160909-13345-2cdpp9.PNG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=460&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Tramadol deaths.</span>
<span class="attribution"><span class="source">Office for National Statistics</span></span>
</figcaption>
</figure>
<p>A clear measure of the UK government’s ambition to reduce inequality is <a href="http://www.huffingtonpost.co.uk/clare-bambra/theresa-may-health-inequalities_b_11716312.html">halting the rise in drug overdoses</a>. Avoidable fatalities due to drugs serve as a barometer of how equal our society is and how we respond to individual vulnerability. We all lose out when an individual dies this way.</p>
<p>Public Health England has responded to the trend in drug fatalities, publishing <a href="http://www.nta.nhs.uk/uploads/phe-understanding-preventing-drds.pdf">several recommendations</a>. There are some welcome aims but they could be bolder. The time has come to introduce drug consumption rooms – it’s a life or death decision.</p><img src="https://counter.theconversation.com/content/64972/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ian Hamilton is affiliated with Alcohol Research UK.. </span></em></p><p class="fine-print"><em><span>Mark Monaghan does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Opiates have emerged as a significant threat to public health in the UK.Ian Hamilton, Lecturer in Mental Health, University of YorkMark Monaghan, Lecturer in Crimimology and Social Policy, Loughborough UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/630652016-08-08T16:35:04Z2016-08-08T16:35:04ZFestival drug checking is here, but it now needs to be expanded across the country<figure><img src="https://images.theconversation.com/files/132482/original/image-20160729-25650-1ejz3rm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/cat.mhtml?lang=en&language=en&ref_site=photo&search_source=search_form&version=llv1&anyorall=all&safesearch=1&use_local_boost=1&autocomplete_id=&search_tracking_id=DgKqHgo0-LvUf1_w8CWuTQ&searchterm=nightclub&show_color_wheel=1&orient=&commercial_ok=&media_type=images&search_cat=&searchtermx=&photographer_name=&people_gender=&people_age=&people_ethnicity=&people_number=&color=&page=1&inline=65675167">Radyukov Dima/Shutterstock.com</a></span></figcaption></figure><p>A step towards <a href="https://www.unodc.org/ddt-training/treatment/VOLUME%20D/Topic%204/1.VolD_Topic4_Harm_Reduction.pdf">safer drug use</a> came about recently with the UK’s first drug-checking service at the Secret Garden Party festival. Operated by <a href="http://wearetheloop.co.uk/">The Loop</a> charity, the service provided <a href="http://www.rsc.org/publishing/journals/prospect/ontology.asp?id=CMO:0000763&MSID=b815601h">hi-tech</a> analyses of drugs submitted by festival-goers. </p>
<p>In addition to the known toxic effects of street drugs, users are exposed to risks arising from the uncertainties of the illegal market. In the UK, for example, there are ecstasy tablets circulating that contain <a href="https://www.theguardian.com/society/2016/jun/15/ecstasy-mdma-warning-after-pills-found-with-double-or-triple-doses-in-uk">harmfully high</a> doses of MDMA and other more dangerous drugs, such as <a href="http://www.dailyrecord.co.uk/news/scottish-news/dangerous-batch-green-rolex-pills-8395201#8toXRAkFEdMhAwqB.97">PMA/PMMA</a>. Drug-checking projects like The Loop’s provide an immediate picture of the range of products circulating on a particular site. And, if run well, they can provide important information to both users and on-site medical support services who may have to respond to drug emergencies. </p>
<p>The analysis of street drugs in the UK is <a href="http://www.wedinos.org/">not new</a>. <a href="http://www.emcdda.europa.eu/themes/new-drugs/early-warning">Systems have been in place</a> for several years that identify and share information on emerging and potentially harmful drugs among professional networks, and there is a demand for <a href="http://volteface.me/students-safe-drug-test-kits/">home testing</a> kits (although some have limited <a href="https://www.youtube.com/watch?v=0MbNJYoHDz8">usefulness</a>). The Loop’s approach at the festival differed from other UK projects in that people submitting drugs were provided with information about their drug content and general advice about reducing drug harms. They were also offered information about where to get more help if they wanted it. </p>
<p>Users then had the option to safely dispose of their drugs, but if they decided to take them, they would at least be better informed. This mirrors existing approaches elsewhere in Europe, where drug checking is much more firmly established, and where <a href="http://newip.safernightlife.org/pdfs/standards/NEWIP_D_standards-final_20.12-A4.pdf">guidelines</a> have been published that identify the best characteristics of high-quality programmes. </p>
<p>Importantly, whereas previous drug-checking services, in places like Manchester’s <a href="https://www.theguardian.com/society/2013/dec/01/drug-testing-warehouse-project-nightclub">Warehouse Project</a>, were done below the radar, the Secret Garden Party initiative had the full support of Cambridgeshire Police, meaning that The Loop could work with users without fearing legal consequences. This reflects the increasing pragmatism of some police forces in their responses to drug-related harms.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/132477/original/image-20160729-25624-1wrwxka.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/132477/original/image-20160729-25624-1wrwxka.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=664&fit=crop&dpr=1 600w, https://images.theconversation.com/files/132477/original/image-20160729-25624-1wrwxka.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=664&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/132477/original/image-20160729-25624-1wrwxka.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=664&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/132477/original/image-20160729-25624-1wrwxka.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=834&fit=crop&dpr=1 754w, https://images.theconversation.com/files/132477/original/image-20160729-25624-1wrwxka.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=834&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/132477/original/image-20160729-25624-1wrwxka.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=834&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The Loop’s drug-checking programme in action at the 2016 Secret Garden Party.</span>
<span class="attribution"><span class="source">Steve Rolles</span>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<h2>A promising pilot project</h2>
<p>Although the work undertaken at the Secret Garden Party was encouraging, and there is <a href="https://theconversation.com/six-reasons-australia-should-pilot-pill-testing-party-drugs-34073">emerging evidence</a> that on a small scale at least, drug-checking projects can positively affect drug-users’ behaviour and reduce harm, it is uncertain whether they can be implemented on a large enough scale to benefit public health.</p>
<p>It’s one thing to be able to operate in a single festival, working on a one-to-one basis with a relatively small and captive audience. But drug use also takes place outside such settings. It is often opportunistic rather than planned, and users will differ in their abilities to understand and act on information about drugs that is issued more widely. How do we reach these settings and users, and is it even affordable to roll out such programmes nationally? </p>
<p>Getting the message out about drug risks is <a href="http://www.nta.nhs.uk/Drug-alerts-and-local-drug-information-systems.aspx">difficult</a>, and <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2351959/">can</a> <a href="http://www.ncbi.nlm.nih.gov/pubmed/7480618">backfire</a> if not done well. You can argue that in a field with limited resources, there might be other priorities, such as tackling the UK’s <a href="http://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/deathsrelatedtodrugpoisoninginenglandandwales/2015-09-03">record high</a> number of opiate-related deaths. It’s also a sad truth that even if there were comprehensive drug-checking coverage, <a href="http://www.ncbi.nlm.nih.gov/pubmed/20104506">because so many people use them</a>, there will always be deaths resulting from recreational drug use, and so these approaches should not be seen as the whole solution.</p>
<p>Still, The Loop’s work is important as it shows that it is feasible to operate drug-checking in the UK in a way that is acceptable to users and the police. Also it can motivate people to reflect on their drug use and the potential harms to which they are being exposed. Considering the ineffectiveness of <a href="http://bmjopen.bmj.com/content/5/9/e007449.full">some</a> of the most <a href="http://www.ncbi.nlm.nih.gov/pubmed/20011993">popular</a> responses to drug use, novel approaches such as drug-checking are likely to be highly salient as they intervene in close proximity to actual drug use episodes, and are worthy of further support and investigation.</p>
<p>The challenge now is to better understand through research how drug-checking might complement a <a href="http://www.ncbi.nlm.nih.gov/pubmed/26888408">wider range</a> of activities. It’s early days of course with regards to UK projects, but it’s worth reflecting on recent experiences in the Netherlands. </p>
<p>Over Christmas 2014, the Dutch Drugs Information and Monitoring System, a community-based drug-checking system, identified distinctively designed ecstasy tablets containing high doses of the harmful drug PMMA. A comprehensive response was initiated and a national communication campaign launched to warn users about the potential threat. The response included users and dealers, police, drugs services, health and medical systems, and international professional networks. No Dutch fatalities were subsequently reported and the tablets did not appear in the Dutch market again. Tragically, over the same period, people in the UK who took ecstasy tablets with the same design, died.</p>
<p>The Loop relies on the work of volunteers and collaboration with festival organisers and police. But for this type of work to be taken to the next step will require support from government, agencies such as Public Health England, and research funders. The Home Office’s official response to the Secret Garden Party project has been <a href="http://www.bbc.co.uk/newsbeat/article/36881070/first-ever-festival-to-test-users-drugs">consistent</a> with their policy stance, which is that the priority should be to prevent people from using drugs altogether. Nevertheless, we will be seeing <a href="http://www.newsandstar.co.uk/news/latest/Kendal-Calling-to-offer-drugs-testing-service-6e20d8af-d801-4e9a-8134-7d2276b8145d-ds">more drug-checking projects</a>, and they will play a valuable part in future strategies to reduce drug-related harm.</p><img src="https://counter.theconversation.com/content/63065/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Harry Sumnall receives funding from a number of relevant research charities and councils, including NIHR-PHR and the European Commission. He is a member of the Advisory Council on the Misuse of Drugs (ACMD), and a Trustee of the UK prevention charity Mentor UK, but this article represents his personal views only. </span></em></p><p class="fine-print"><em><span>Amanda Atkinson is the coordinator of the UK Focal Point EMCDDA Early Warning System on NPS based at LJMU. This article presents her personal views only. </span></em></p><p class="fine-print"><em><span>Emma Begley does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>If people are going to take drugs, wouldn’t it be better if they knew what was in them?Harry Sumnall, Professor, Liverpool John Moores UniversityAmanda Atkinson, Senior researcher, Liverpool John Moores UniversityEmma Begley, Research assistant, Liverpool John Moores UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/608742016-06-23T09:46:33Z2016-06-23T09:46:33ZIn a bid for the perfect profile pic, young men are increasingly turning to steroids<figure><img src="https://images.theconversation.com/files/127545/original/image-20160621-13036-1t0giaj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/cat.mhtml?lang=en&language=en&ref_site=photo&search_source=search_form&version=llv1&anyorall=all&safesearch=1&use_local_boost=1&autocomplete_id=&search_tracking_id=fvWkq8poNeynySuEkugwbA&searchterm=gym%20mirror&show_color_wheel=1&orient=&commercial_ok=&media_type=images&search_cat=&searchtermx=&photographer_name=&people_gender=&people_age=&people_ethnicity=&people_number=&color=&page=1&inline=8486536">Kzenon/Shutterstock.com</a></span></figcaption></figure><p>The Crime Survey for England and Wales estimates that around 60,000 people are using steroids to gain muscle, to become leaner and fitter, or to get stronger. But <a href="http://www.ipedinfo.co.uk/resources/downloads/SIEDs%20Survey%20report%202014%20FINAL.pdf">academics and experts who work with steroid users</a> believe the real figure is much higher – probably in the hundreds of thousands. </p>
<p>Needle-exchange clinics across the UK report that steroids users are a growing group and, in some cases, even exceed other illegal drug-using groups. Recently, <a href="http://www.irishtimes.com/life-and-style/people/ireland-s-steroid-boom-among-young-gym-goers-1.2671574">Merchants Quay Ireland</a>, the largest needle-exchange clinic in Ireland, reported that over the past two years 50% more people have come to the service for needles and other equipment to inject steroids. </p>
<p>What is even more alarming is that a significant number of young men are consuming a range of performance and image enhancing drugs, including steroids and human growth hormone. While the use of steroids has traditionally been limited to professional athletes, bodybuilders, soldiers and police, it is increasingly becoming a mainstream choice for young men looking to bulk up or lose weight.</p>
<h2>Distorted body image</h2>
<p>A rising number of young people are <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3986904/">unhappy with the way they look</a>. Although social pressure to conform to idealised beauty standards is nothing new, the growth of social media sites such as Instagram, Snapchat and Facebook has <a href="http://www.sciencedirect.com/science/article/pii/S2352250X15002249">exacerbated this focus on appearance</a>. Young people spend several hours a day using social media, <a href="http://is.muni.cz/el/1423/podzim2014/PSY221P121/um/Perloff2014.SocialMediaEffectsBodyImage.BID.pdf">interacting with and comparing themselves with their peers</a>, often in the pursuit of the perfect profile picture or to increase their number of followers and “likes”.</p>
<p>While it is widely known that a distorted body image affects many females, there is growing evidence that males are under similar pressure – not to be thin but to be muscular. Television programmes such as “<a href="http://www.channel4.com/programmes/obsessed-with-my-body">Obsessed with my body</a>” and “<a href="http://www.bbc.co.uk/programmes/b06svrw2">Dying for a six pack</a>” illustrate that there is a huge growth in male teenage vanity, from boys seeking to “get ripped” in the gym to men having invasive plastic surgery. For instance, <a href="http://www.theprivateclinic.co.uk/blog/2016/02/08/how-2015-was-the-year-for-cosmetic-plastic-surgery-in-the-uk">the number of men opting for cosmetic surgery</a> has almost doubled in the past decade in the UK, from 2,440 treatments in 2005 to 4,614 in 2015. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/127561/original/image-20160621-13025-136xzd6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/127561/original/image-20160621-13025-136xzd6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/127561/original/image-20160621-13025-136xzd6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/127561/original/image-20160621-13025-136xzd6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/127561/original/image-20160621-13025-136xzd6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/127561/original/image-20160621-13025-136xzd6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/127561/original/image-20160621-13025-136xzd6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">In pursuit of ‘likes’.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/dl2_lim.mhtml?src=ooKgsXaIM8u3Tk5BZdVdJQ-2-60&clicksrc=download_btn_inline&id=172002716&size=medium_jpg&submit_jpg=">Linda Moon/Shutterstock.com</a></span>
</figcaption>
</figure>
<p>There is mounting concern in the UK among healthcare professionals that males suffer from poor body image and its subsequent detrimental effects on health, well-being and confidence. For example, an <a href="http://www.ncb.org.uk/media/861233/appg_body_image_final.pdf">All-Party Parliamentary Group on Body Image</a> reported that there are high levels of body image dissatisfaction among adults and young people in the UK. It is estimated that roughly two-thirds of adults suffer from negative body image and that 34% of adolescent boys have been on a diet to change their body shape or to lose weight.</p>
<p><a href="http://www.bbc.co.uk/newsbeat/article/34307044/muscle-dysmorphia-one-in-10-men-in-gyms-believed-to-have-bigorexia">In the UK</a> and <a href="https://theconversation.com/anabolic-steroids-a-serious-global-health-problem-amid-boom-in-cosmetic-use-24238">in other countries</a> there is an alarming rise in obsessive weight training, with young men spending large amounts of money on <a href="http://www.ncbi.nlm.nih.gov/pubmed/18091024">supplements</a>, exhibiting <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3986904/#B9">abnormal eating patterns</a> and, for some, even the use of steroids and other image enhancing drugs such as <a href="https://en.wikipedia.org/wiki/Clenbuterol">clenbuterol</a> (to lose weight) and <a href="https://en.wikipedia.org/wiki/Melanotan_II">melanotan II</a> (tanning agent). </p>
<h2>Not safe</h2>
<p>Steroid use can cause major health problems including liver malfunction, heart problems and skin infections. They can cause psychological disturbances too, such as dependence, depression and body-image disorders. Also, in the UK there is <a href="https://www.gov.uk/government/news/steroid-users-at-risk-of-hiv-hepatitis-b-and-hepatitis-c">evidence of HIV among steroid users</a>, with an HIV prevalence of 1.5% in men who inject steroids, which is comparable to that in those who inject heroin, amphetamine and other street drugs. </p>
<p><a href="http://www.sciencedirect.com/science/article/pii/S0376871610004072">Several studies</a> show that steroid users often use other enhancement drugs, such as human growth hormone and weight-loss drugs, and recreational or psychoactive substances, such as cocaine and ecstasy. Mixing drugs can be harmful. For example, taking oral steroids and alcohol can cause liver damage. And, so-called “roid rage” can be exacerbated by mixing steroids and psychoactive substances, such as cocaine and amphetamine (speed).</p>
<h2>Helping steroid users</h2>
<p><a href="http://www.theguardian.com/society/2015/jul/19/health-workers-urged-to-increase-help-for-anabolic-steroid-users">Health workers</a> and <a href="http://www.cph.org.uk/SteroidConference2016/">academics</a> in the UK are urging organisations and politicians to increase help for steroid users. <a href="http://www.nta.nhs.uk/uploads/providing-effective-services-for-people-who-use-image-and-performance-enhancing-drugs.pdf">Public Health England</a> has also advised local councils and healthcare professionals to engage more effectively with young men using these substances. But it is difficult to reach this group as they often don’t see themselves as drug users. As such, users, especially younger ones, tend not to use local services because of the stigma of being seen as a drug injector. </p>
<p>To make matters worse, GPs often <a href="http://www.drugs.ie/resourcesfiles/ResearchDocs/Europe/Research/2015/Steroids_and_Image_Steroid_Image_Enhancing_Drugs_2013_Survey_Results_FINAL.pdf">lack the specialist knowledge</a> to meet the needs of people who use steroids. This forms a significant barrier for users to get the help they need. Instead, they tend to turn to the internet or their friends in the gym for advice. </p>
<p>What is needed are specialist steroid clinics run by local councils. As well as providing needles and syringes, such clinics should also provide education and health checks for steroid users. </p>
<p>There are some prevention and harm-reduction initiatives in the UK, such as the <a href="http://www.wales.nhs.uk/sitesplus/888/page/75064">Steroid Educational Toolkit</a>, the <a href="http://inef.ie/?p=6691">SMART method</a>, the <a href="https://humanenhancementdrugs.com/">Human Enhancement Drug website</a>, <a href="http://www.ninezerofive.org/">Nine Zero Five</a> and several <a href="http://www.mylife4me.co.uk/services/needle-exchange.php">needle exchange clinics</a> that provide such services. </p>
<p>Still, prevention and harm reduction measures lag far behind those for alcohol and other street drugs, not just in the UK but <a href="http://apo.org.au/resource/understanding-and-responding-rise-steroid-injecting-australia-recommendations-national">in most countries</a>. The government needs to address the needs of this rapidly growing drug-using population and include steroid users in health interventions.</p><img src="https://counter.theconversation.com/content/60874/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kyle J.D. Mulrooney holds an Erasmus Mundus Fellowship for the joint doctoral programme, the Doctorate in Cultural and Global Criminology (DCGC), and receives funding from the Educational, Audiovisual and Cultural Executive Agency of the European Union.</span></em></p><p class="fine-print"><em><span>Katinka van de Ven does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>A growing number of young men are using steroids, but there are few public services to help this vulnerable group.Katinka van de Ven, Lecturer in Criminology, Birmingham City UniversityKyle J.D. Mulrooney, Ph.D. Fellow, Doctorate in Cultural and Global Criminology, University of KentLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/598502016-06-01T12:21:28Z2016-06-01T12:21:28ZForget about fats – it’s processed food we should be worried about<figure><img src="https://images.theconversation.com/files/124346/original/image-20160527-869-153bkdu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/cat.mhtml?lang=en&language=en&ref_site=photo&search_source=search_form&version=llv1&anyorall=all&safesearch=1&use_local_boost=1&autocomplete_id=&searchterm=food%20factory&show_color_wheel=1&orient=&commercial_ok=&media_type=images&search_cat=&searchtermx=&photographer_name=&people_gender=&people_age=&people_ethnicity=&people_number=&color=&page=1&inline=174437342">Yuangeng Zhang/Shutterstock</a></span></figcaption></figure><p>Last week, the National Obesity Forum caused a <a href="http://www.bbc.co.uk/news/health-36345768">furore</a> by claiming that eating fat, including saturated fat, will help cut rates of obesity and type 2 diabetes. Public Health England hit back, calling NOF’s advice “irresponsible”.</p>
<p>There’s wide agreement that modern diets have led to a rise in illnesses such as coronary heart disease and type 2 diabetes. Like most research, the recent controversy focuses on whether specific nutrients are the cause. </p>
<p>I’m not qualified to decide whether fat is good for you or will help you lose weight. But as a philosopher, and someone who has studied diet and health-related behaviours, I am curious about the question. What we ask determines what sorts of answer make sense. Does it make sense to focus on nutrients such as fat or carbohydrates, for example, or should we reframe the question?</p>
<p>There are many ways to think about the <a href="http://www.cpc.unc.edu/projects/nutrans/whatis">dietary changes</a> in Western societies over the past century or so. Of course, we can think in terms of nutrients: more sugar, more refined carbohydrates, more animal fats, more oils. Another change is in terms of agriculture and animal husbandry: new fertilisers and pesticides, new ways to feed and breed animals, new ways to hasten their growth. A third sort of change starts with an organisational revolution: <a href="https://twitter.com/garrathwilliams/status/735478021352787968">large corporations</a> now dominate our food supplies. </p>
<p>These corporations are armed with factories and laboratories, with brands and trademarks and marketing departments. And they have created a new sort of food: <a href="https://www.researchgate.net/publication/235627891_Profits_And_Pandemics_Prevention_Of_Harmful_Effects_Of_Tobacco_Alcohol_And_Ultra-Processed_Food_And_Drink_Industries">the ultra-processed variety</a>. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/124021/original/image-20160525-25202-g70zp8.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/124021/original/image-20160525-25202-g70zp8.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=567&fit=crop&dpr=1 600w, https://images.theconversation.com/files/124021/original/image-20160525-25202-g70zp8.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=567&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/124021/original/image-20160525-25202-g70zp8.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=567&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/124021/original/image-20160525-25202-g70zp8.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=713&fit=crop&dpr=1 754w, https://images.theconversation.com/files/124021/original/image-20160525-25202-g70zp8.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=713&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/124021/original/image-20160525-25202-g70zp8.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=713&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Why don’t we see cabbages advertised by modern food companies?</span>
</figcaption>
</figure>
<p>Raw ingredients are reduced to pulps and powders and concentrates and extracts. Chemicals are used to emulsify and enhance flavours (some of these familiar, such as salt, others unknown before modern chemistry). New technologies pound and process and bleach and coat, change liquids into pastes or solids, extract the last scraps from animal carcasses, and “fortify” with vitamins lost in earlier stages of processing. </p>
<p>We see appealing pictures of farms and crops on the packaging, but <a href="http://www.4thestate.co.uk/author/joanna-blythman/">we’ve no idea</a> how the products inside came from the baffling lists of ingredients.</p>
<p>Given these enormous changes, how can we discover which aspects of modern diets are damaging to health? I’ve just sketched out three major changes. But each of them involves many factors. So it is enormously difficult to establish which aspects of modern diets have increased rates of some illnesses.</p>
<p>This isn’t to say that conventional questions about different nutrients are unanswerable. Some answers are becoming clear: <a href="https://theconversation.com/sweet-enough-separating-fact-from-fiction-in-the-sugar-debate-21796">lots of sugar</a> isn’t good for us; <a href="http://www.sciencedirect.com.ezproxy.lancs.ac.uk/science/article/pii/S0149291814000538">trans-fats</a> are definitely bad for us. But just focusing on nutrients is a mistake. In particular, there are good reasons to think that modern food processing itself poses health risks.</p>
<p>Some of these problems overlap with concerns about specific nutrients. Adding salt, sugar or fat (sometimes all three) is a good way to make cheap ingredients palatable. Processing foods tends to remove the many micronutrients found in whole foods, and crops from modern industrial agriculture tend to be <a href="http://hortsci.ashspublications.org/content/44/1/15.full">poorer in micronutrients</a> anyhow. </p>
<p>Some problems overlap with concerns about energy intake. Processed foods tend to contain <a href="http://www.wphna.org/htdocs/downloadsdec2012/12-12_WN3_The_Food_System_PDF_SENT.pdf">less water and fibre</a>, so they are more calorie-dense and easier to consume in large quantities. </p>
<p>Alongside convenience, processed foods are carefully engineered for immediate appeal. They are also marketed with every trick in the book (unlike whole foods). All these factors encourage over-consumption. And then we can add suspicions that some aspects of modern food processing – various additives or <a href="http://shelflifeadvice.com/content/whats-our-food-maybe-processing-aids-maybe-not">“processing aids”</a> or chemicals in packaging – pose health risks of their own.</p>
<h2>Don’t focus on specific nutrients</h2>
<p>Focusing on specific nutrients such as fat or cholesterol has often damaged the reputation of whole foods. Many people limit their consumption of eggs, butter or red meat, for example. Processed food companies are in a better position to defend their products, though. Packaging can easily make or insinuate health claims. Margarine might be made who-knows-how with industrial trans-fats, but it can be formulated to be low in cholesterol to reassure us of its health value. The breakfast cereal might be over a quarter sugar, but the packaging emphasises the fibre or vitamin or iron content.</p>
<p>No one can see or taste nutrients themselves. To focus on them means trusting labels and mistrusting your senses. Confused, we pick up a low-calorie fizzy drink, then choose a low-fat yoghurt that contains all the sugar we just tried to avoid. When healthy eating guidelines focus on nutrients, we become more susceptible to the processed food and drink industry. </p>
<p>Claims that “fat won’t make you fat” <a href="http://www.dailymail.co.uk/news/article-3603951/Now-experts-say-eat-fat-combat-obesity-Damning-report-calls-major-overhaul-dietary-guidelines-advises-people-stop-counting-calories.html">make headlines</a>. I think they hide a more important idea also hinted at in the new report. On top of modern industrial agriculture, industrial food processing represents the <a href="http://www.journals.cambridge.org/abstract_S0029665110003903">biggest change to human diets</a> since people began farming. Major food and drink companies compete with one another. But as Carlos Monteiro, a professor of nutrition and public health at the University of São Paulo, <a href="http://www.wphna.org/htdocs/downloadsnovember2010/10-11%20WN%20Comm%20Food%20processing.pdf">remarks</a>, “they all have the same overall policy” – promoting ultra-processed foods. </p>
<p>Instead of asking about specific nutrients, we might also ask whether the rise of processed foods has contributed to the rise in diet-related diseases. And perhaps the best health advice is not to obsess about the latest demon nutrient, but to prepare whole foods for ourselves, adapting the old adage: everything in moderation, especially ultra-processed foods.</p><img src="https://counter.theconversation.com/content/59850/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Garrath Williams receives funding from the European Union’s Seventh Framework Programme (as part of the I.Family Study), and has previously received funding from the EU's Sixth Framework Programme (as part of the IDEFICS Study).</span></em></p>Arguing about the pros and cons of fat in our diet takes the focus away from the real nutritional demon: processed foods.Garrath Williams, Senior Lecturer in Philosophy, Lancaster UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/591022016-05-12T13:00:38Z2016-05-12T13:00:38ZLocal takeaways create a double burden for obesity<figure><img src="https://images.theconversation.com/files/122120/original/image-20160511-18157-1ltnfqf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Poor neighbourhoods have more takeaway outlets.</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/cat.mhtml?lang=en&language=en&ref_site=photo&search_source=search_form&version=llv1&anyorall=all&safesearch=1&use_local_boost=1&autocomplete_id=&search_tracking_id=AMsT084965JL8j4WNoHf8Q&searchterm=fish%20and%20chip%20shop&show_color_wheel=1&orient=&commercial_ok=&media_type=images&search_cat=&searchtermx=&photographer_name=&people_gender=&people_age=&people_ethnicity=&people_number=&color=&page=1&inline=256404478">pxl.store / Shutterstock.com</a></span></figcaption></figure><p>People in the UK are spending <a href="https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/485982/familyfood-2014report-17dec15.pdf">more than ever</a> on takeaway food and there’s good reason to believe that this is contributing to the nation’s obesity problem. Two-thirds of UK adults are either <a href="https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/295149/07-1662-obesity-modelling-trends.pdf">overweight or obese</a>.</p>
<p>But the amount of excess weight the nation is carrying isn’t equal. On average, people in socially disadvantaged groups – those less educated or on lower incomes – are more likely to be <a href="http://www.noo.org.uk/LA/impact/education">overweight</a>. This can be explained by the fact that the socially disadvantaged tend to have <a href="http://www.sciencedirect.com/science/article/pii/S019566631500255X">less time for cooking</a>, <a href="http://her.oxfordjournals.org/content/15/2/163.long">less knowledge about healthy eating</a> and <a href="http://nutritionreviews.oxfordjournals.org/content/67/suppl_1/S36.long">less money for healthy food</a>. Levels of takeaway food consumption are also greater <a href="http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=8468256&fileId=S136898001100139X">in disadvantaged groups</a>.</p>
<p>Disadvantage can also be environmental. We know that disadvantaged neighbourhoods tend to have <a href="https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/296248/Obesity_and_environment_March2014.pdf">greater numbers of takeaway outlets</a>. Although all UK neighbourhoods have become less healthy in the last two decades, disadvantaged neighbourhoods have <a href="http://www.sciencedirect.com/science/article/pii/S1353829215000325">become unhealthier fastest</a>. It would seem to make sense then that unequal neighbourhoods could be contributing to unequal waistlines. </p>
<h2>“But I never use my local takeaway”</h2>
<p>This, of course, assumes that neighbourhood food access influences what people eat and how much they weigh. A growing body of evidence suggests that it does. In an analysis, using data on nearly 6,000 people from the Fenland Study in Cambridgeshire, we showed that the greatest neighbourhood exposure to takeaway food was linked to consuming the equivalent of an additional serving of French fries per week and nearly <a href="http://www.bmj.com/content/348/bmj.g1464">doubling</a> one’s odds of obesity.</p>
<p>We might like to believe that we make entirely free choices about what, when and where to eat. And we often hear from people that they never use their local takeaway outlets. But given that we need to buy our food from somewhere, we’re all influenced to some degree by what’s on offer within our environment. For people living or working in areas full of takeaways but short on healthier options, unhealthy choices are likely to be the easiest or only option. Among our Cambridgeshire adults, as many as <a href="https://ijbnpa.biomedcentral.com/articles/10.1186/1479-5868-10-85">47 takeaway outlets</a> were present within just a mile of one person’s home. And growth in the takeaway sector over two decades outpaced that of <a href="http://www.sciencedirect.com/science/article/pii/S1353829215000325">supermarkets</a>, convenience stores and restaurants, so our environment has become more imbalanced towards greater availability of takeaway food. </p>
<h2>Understanding levels of influence</h2>
<p>Our <a href="http://ajcn.nutrition.org/content/early/2016/05/11/ajcn.115.128132.full.pdf+html">new study</a> explores the interplay between social disadvantage and access to neighbourhood takeaway outlets. We used low educational attainment as a marker of social disadvantage – so it’s also an indication of lacking the social, economic, behavioural and psychological resources that might leave people more vulnerable to their environment. For example, less well off consumers are particularly <a href="http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=9994657&fileId=S1368980015000361">price sensitive</a>, and may be disproportionately affected by the lure of takeaways serving large portions at <a href="http://ajcn.nutrition.org/content/79/1/6.full">low prices</a>.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/122122/original/image-20160511-18123-1sklrbh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/122122/original/image-20160511-18123-1sklrbh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/122122/original/image-20160511-18123-1sklrbh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/122122/original/image-20160511-18123-1sklrbh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/122122/original/image-20160511-18123-1sklrbh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/122122/original/image-20160511-18123-1sklrbh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/122122/original/image-20160511-18123-1sklrbh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Cheap, calorific and ubiquitous.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/cat.mhtml?lang=en&language=en&ref_site=photo&search_source=search_form&version=llv1&anyorall=all&safesearch=1&use_local_boost=1&autocomplete_id=&search_tracking_id=sPFijT3IldBsddQkL0XONw&searchterm=kebab%20uk&show_color_wheel=1&orient=&commercial_ok=&media_type=images&search_cat=&searchtermx=&photographer_name=&people_gender=&people_age=&people_ethnicity=&people_number=&color=&page=1&inline=122823118">www.shutterstock.com</a></span>
</figcaption>
</figure>
<p>This picture of the effects of a disadvantageous unhealthy neighbourhood being compounded by social disadvantage came through clearly in our analysis. People with the greatest exposure to takeaway outlets consumed a third more unhealthy takeaway food per day if they were the least educated than if they were highest educated. These differences would add up over a year to an additional consumption of over 4kg of unhealthy food. By comparison, people with least exposure to takeaway outlets consumed only a fifth more takeaway food if they were least educated.</p>
<p>In the paper, we also compared the odds of being obese for those facing this double burden of individual and neighbourhood disadvantage. We found that those least educated and most exposed to takeaways were three times more likely to be obese than the most educated and least exposed. </p>
<p>So while neighbourhood takeaway food access is important in shaping everyone’s diet and weight, the effects seem to be greater for those with less education. This means that where takeaways are most abundant, inequalities in diet and obesity are likely to be amplified. </p>
<h2>What’s the takeaway message?</h2>
<p>The good news is that this situation can be addressed. Fixing the food environment alone isn’t going to cure the obesity crisis, but healthier food choices can be better supported by modifying and shaping the geography of food access across our neighbourhoods. </p>
<p>Our results suggest that if we reduce takeaway access in particular, this will not only benefit all social groups, but will also minimise differences in consumption between social groups. Changing neighbourhoods may seem like a radical step, and there may be challenges, but such efforts are currently underway and are endorsed by <a href="https://www.nice.org.uk/advice/lgb9/chapter/Introduction#nice-recommendations">NICE</a>, <a href="https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/296248/Obesity_and_environment_March2014.pdf">Public Health England</a>, the <a href="https://www.london.gov.uk/sites/default/files/takeawaystoolkit.pdf">Greater London Authority</a> and the <a href="http://www.aomrc.org.uk/doc_view/9673-measuring-up">Academy of Medical Royal Colleges</a>. </p>
<p>Traditional individually-focused efforts, such as improving nutrition knowledge and cooking skills, may also be important but their success will be limited if we continue to live in neighbourhoods that make unhealthy choices the easy and cheap option. The effects of takeaway food outlet access on diet and weight and the implications of this access for social inequalities are now being realised by researchers and public health bodies and constitute a potentially important point of intervention for improving the health of all of us.</p><img src="https://counter.theconversation.com/content/59102/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Thomas Burgoine receives or has received funding from the British Heart Foundation, Cancer Research UK, Economic and Social Research Council, Medical Research Council, the National Institute for Health Research, and the Wellcome Trust under the auspices of the UK Clinical Research Collaboration.</span></em></p><p class="fine-print"><em><span>Pablo Monsivais receives funding from the British Heart Foundation, Cancer Research UK, Economic and Social Research Council, Medical Research Council, the National Institute for Health Research, and the Wellcome Trust under the auspices of the UK Clinical Research Collaboration</span></em></p>It’s not easy to make good food choices when there’s a takeaway on every corner.Thomas Burgoine, Career Development Fellow (Post-doctoral Research Associate), University of CambridgePablo Monsivais, Senior University Lecturer, University of CambridgeLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/552772016-02-29T09:56:11Z2016-02-29T09:56:11ZNHS bed cuts are failing millions of mental health patients<figure><img src="https://images.theconversation.com/files/112953/original/image-20160225-15165-17d1emq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Oleg Golovnev/Shutterstock</span></span></figcaption></figure><p>It is difficult to imagine a time when you would need your family and friends more than when you are really ill. So it’s probably not the best time to be separated and sent hundreds of miles away from everyone you know to a hospital at the other end of the country. Sadly, this is an all too <a href="http://www.theguardian.com/society/2016/feb/09/mental-health-patients-travel-across-uk-for-beds">frequent experience</a> for children and adults with acute mental health problems.</p>
<p>In the UK about <a href="http://media.wix.com/ugd/0e662e_6f7ebeffbf5e45dbbefacd0f0dcffb71.pdf">500 patients a month</a> have to travel more than 31 miles (50km) to access care as acute inpatient beds or services are unavailable in their areas. </p>
<p>A recent report from the <a href="http://www.caapc.info/">independent commission</a>, chaired by ex-NHS chief executive <a href="http://www.parliament.uk/biographies/lords/lord-crisp/3783">Lord Crisp</a>, called for changes to the way services are commissioned to help reduce the number of patients having to travel far and wide to access appropriate health care.</p>
<p>The <a href="http://media.wix.com/ugd/0e662e_15ee6729e0e946c8bf19397791ea2ac2.pdf">report</a>, which is backed by the Royal College of Psychiatrists, recommends that from October 2017, “no acutely ill patient should have to travel long distances to receive care”, as well as the introduction of “a maximum four-hour wait for acute psychiatric care” – in hospital or the community after an initial assessment.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/112951/original/image-20160225-15136-d461dq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/112951/original/image-20160225-15136-d461dq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/112951/original/image-20160225-15136-d461dq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/112951/original/image-20160225-15136-d461dq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/112951/original/image-20160225-15136-d461dq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/112951/original/image-20160225-15136-d461dq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/112951/original/image-20160225-15136-d461dq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A quarter of people in the UK will experience a mental health problem each year.</span>
<span class="attribution"><span class="source">111foto/Shutterstock</span></span>
</figcaption>
</figure>
<p>The Royal College of Psychiatrists has previously set and monitored targets for inpatient ward capacity stating clearly that these wards should operate at no more than 85% bed occupancy. But these wards frequently operate at <a href="http://media.wix.com/ugd/0e662e_15ee6729e0e946c8bf19397791ea2ac2.pdf">well over 100%</a>.</p>
<p>On top top this, psychiatric wards routinely send the least ill inpatient on leave so they can admit another acutely ill person – meaning there is often more than one person allocated to each bed. The profound suffering of people put in this position with psychiatric issues is almost impossible to underestimate. So how did we get to the point where this has become routine practice?</p>
<h2>Community care</h2>
<p>When the <a href="http://www.independent.co.uk/life-style/health-and-families/health-news/the-demise-of-the-asylum-and-the-rise-of-care-in-the-community-8352927.html">large asylums closed</a> some 20 years ago, there was a logical plan to invest in community treatment as an alternative to hospital care. This new community treatment would not only divert individuals from hospital but by intervening early would potentially avoid hospital admissions. </p>
<p>But the money saved from closing down these large and expensive institutions <a href="https://www.england.nhs.uk/mentalhealth/taskforce/">did not follow</a> the patients into the community. This resulted in an under-investment in mental healthcare for decades.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/112617/original/image-20160223-16436-1u9qtwf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/112617/original/image-20160223-16436-1u9qtwf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/112617/original/image-20160223-16436-1u9qtwf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=278&fit=crop&dpr=1 600w, https://images.theconversation.com/files/112617/original/image-20160223-16436-1u9qtwf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=278&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/112617/original/image-20160223-16436-1u9qtwf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=278&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/112617/original/image-20160223-16436-1u9qtwf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=349&fit=crop&dpr=1 754w, https://images.theconversation.com/files/112617/original/image-20160223-16436-1u9qtwf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=349&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/112617/original/image-20160223-16436-1u9qtwf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=349&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Mental health beds cut across England.</span>
<span class="attribution"><span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>What happens now is that the private sector plugs the shortfall in acute mental health beds when the NHS reaches capacity. Although data is not available on the overall cost, one NHS trust reported spending <a href="http://media.wix.com/ugd/0e662e_6f7ebeffbf5e45dbbefacd0f0dcffb71.pdf">£4.8m on 70 patients</a> placed in the private sector in one year. So if the aim of reducing the number of acute psychiatric beds was to save money, then the government has failed. </p>
<p>This mental health bed crisis symbolises a cold and business like response to <a href="http://www.communitycare.co.uk/2014/11/28/deaths-linked-mental-health-beds-crisis-cuts-leave-little-slack-system/">individual suffering</a>, the strategy has been to operate a “just in time” logistics approach to providing acute mental health care. But people aren’t commodities who can be shunted around the country under the guise of efficiency and capacity constraints. </p>
<p>We should be efficient with <a href="http://www.bbc.co.uk/news/health-35653455">taxpayers’ money</a> but we also need to be humane and avoid short-sighted savings, and the NHS should have <a href="http://www.theguardian.com/society/2013/oct/23/mental-health-bed-cuts-ashamed-nhs">sufficient capacity</a> to be able to admit a person in close proximity to where they live. </p>
<h2>Short sighted austerity</h2>
<p>It is clear that acute <a href="http://www.kingsfund.org.uk/sites/files/kf/Paying-the-Price-the-cost-of-mental-health-care-England-2026-McCrone-Dhanasiri-Patel-Knapp-Lawton-Smith-Kings-Fund-May-2008_0.pdf">mental health care is costly</a> to the individual and the state. And that mental illness is <a href="http://www.mind.org.uk/information-support/types-of-mental-health-problems/mental-health-problems-introduction/causes/#.Vs8YMoyLRhA">exacerbated by many factors</a> including substance use and childhood trauma. All of which are malleable. </p>
<p><a href="https://www.rethink.org/media/973932/LOST%20GENERATION%20-%20Rethink%20Mental%20Illness%20report.pdf">Early intervention</a> and taking a long-term view is what Public Health England was designed and set up for. Yet this organisation is facing disinvestment <a href="http://www.kingsfund.org.uk/blog/2015/08/cuts-public-health-spending-falsest-false-economies">to the tune of £200m</a>. Saving this amount now will cost us all dearly in the future, as the prevention of mental health problems is demoted in favour of shrinking public health activity.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/Mnav8Cw7fTA?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
</figure>
<p>When it comes to bed shortages, there is little evidence to support acute in-patient admission beyond its ability to contain and <a href="http://onlinelibrary.wiley.com/doi/10.1111/inm.12044/full">minimise risk</a>. These are not therapeutic environments and for some can introduce an additional risk of danger through exploitation or <a href="http://onlinelibrary.wiley.com/doi/10.1111/jpm.12080/full">unwanted sexual abuse</a>.</p>
<p>Instead, we should be looking closer to home as it is family and carers, not professionals who are our <a href="http://bmjopen.bmj.com/content/4/10/e006108.full">greatest asset</a> in providing continuity and compassion for people with mental health problems. Disconnecting families from their loved ones at the time of acute crisis seems bad enough but we compound this by not listening and involving these families at other stages in the treatment. It is staggering to think that while family work has the greatest evidence base it is the <a href="http://www.mentalhealthcare.org.uk/family_therapy">least practised</a>. But the time has come to change this.</p>
<p>This crisis has gone on for long enough. Mental health bed cuts put <a href="http://www.bbc.co.uk/news/uk-30236927">lives at risk</a> and that needs to change. We need to be as radical as the Victorians were when they introduced asylums for the mentally ill. We need a complete rethink of the way we prioritise and provide mental healthcare so that it is fit for purpose, focusing equally on causes as well as the treatment of mental ill health.</p><img src="https://counter.theconversation.com/content/55277/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ian Hamilton does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Sending mentally ill adults and children long distances for care is unacceptable and must end.Ian Hamilton, Lecturer in Mental Health, University of YorkLicensed as Creative Commons – attribution, no derivatives.