Shetland Public Health Annual Report 2015 Food...Mood boosting foods 46 Local examples 47 Impact of poverty on healthy eating and mental health 47 BUT WHY CAN IT BE SO DIFFICULT TO

Shetland Public Health Annual Report 2015

Food and

Health

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Public Health Annual Report 2015

FORWARD

This year’s Public Health Annual Report is about what we eat and how it affects our

health. Along with physical activity (the theme of last year’s report), alcohol and

tobacco, our eating habits are a major factor in our wellbeing, and in the

development, or prevention, of health problems.

Food and diet are complex issues. We know that what we eat affects our health: too

much of some foods, or too little of others. We have to eat to survive, but there are

lots of different factors that influence what foods we choose to eat. In fact sometimes

there may be no choice. For many people, the availability and cost of food severely

limits what they can and can’t eat. For others, medical conditions such as life

threatening allergies dictate what they can and can’t eat. We are all also influenced

by our own culture and traditions, lifelong habits and beliefs about food and diet.

Tackling diet-related health issues needs action on numerous levels. Accurate and

relevant information that can help us make healthy choices is a starting point.

However, the amount of information that there is available to us about diet and

nutrition can be daunting and confusing. The public health profession strives to give

people sound advice based on scientific evidence. But this is often distorted,

confused, or dismissed by the media, the food industry and pressure groups who

want to challenge the evidence or are pursuing their own agenda.

Information is not enough: as well as knowledge, we need the skills to be able to put

it into practice. And we need an environment that supports healthy choices. This can

and must be achieved through national policy and legislation; and local support and

action; on issues such as farming and land use, food production, the role of retailers,

public services and the voluntary sector.

Efforts to improve diet can also have other positive impacts at a community or

population level; for example encouraging individuals and communities to ‘grow your

own’ has the potential to support carbon reduction, improve community

cohesiveness, increase physical activity, help develop skills and tackle inequalities.

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In this Public Health Annual Report, we look at some of the key issues; along with

local data and information where possible, under the following themes:

• How food affects our health

• What makes up a healthy diet

• Diet and mental wellbeing

• Why it can be so difficult to eat healthily

• And what we can do about it.

Make the healthy choice the easy choice

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Acknowledgments

My thanks for all their hard work in the production of this report go to Elizabeth Robinson, Dr Susan Laidlaw, Elsbeth Clark, Nicola Balfour, Lauren Peterson, Jill Hood, Astryd Jamieson, Chloe MacIsaac, Jim Taylor, Lucy Ward, Wendy Hatrick, Jen Grant, Kim Govier, Andy Hayes, David Kerr, and Erin Tait

Angela Nunn of the Salvation Army

Cullivoe, Burravoe and Mid Yell Schools

Dr Sarah Taylor Director of Public Health, NHS Shetland

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CONTENTS

HOW DOES FOOD AFFECT OUR HEALTH? 7

Obesity, Type 2 Diabetes and Heart Disease 7

Being Underweight 14

Vitamin and mineral deficiencies 17

How diet and food affects your teeth 20

Food Allergies and Intolerances 23

WHAT MAKES A ‘GOOD’ DIET? 31

Eatwell plate 33

Good and bad fats 34

Eat Less Sugar: – hidden sugars 35

Eat Less Salt 36

Eat more fibre 37

Understanding food labels 41

FOOD AND MENTAL WELLBEING 43

Why diet matters 43

Mood boosting foods 46

Local examples 47

Impact of poverty on healthy eating and mental health 47

BUT WHY CAN IT BE SO DIFFICULT TO EAT HEALTHILY? 51

Vending machines 53

Food deserts 54

Food poverty in Shetland 59

TAKING ACTION! 64

A tax on sugar? 64

5


Early Nutrition: Healthy Start 67

Challenging the Myths 70

We Are Equal Project 75

Tackling Obesity: Looking to the future 78

Appendix 1 NHS Shetland Public Health and Health Improvement Activity Report

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CHAPTER 1:

HOW DOES FOOD AFFECT OUR HEALTH?

The food we eat can affect our health in many ways. The first thing most people

probably think of is how our diet can affect our weight, and the health problems that

can come with being overweight or obese. People who are very underweight can

also have significant health problems. We probably don’t think about that so much in

our own communities (except that lots of us and young people in particular can be

affected by all the media images of thin fashion models), but we are well aware of the

consequences in other parts of the world where there is famine, war or natural

disasters that lead to food shortages, hunger and starvation. But people who are of a

healthy weight can also have health problems caused by their diet and the food they

eat.

Nutrition is increasingly being recognised as a major factor in chronic disease.

Scientific evidence shows that changes in diet can have significant effects on health,

both positive and negative, throughout life. The increase in chronic diseases due to

poor diet and decreased physical activity, especially amongst poorer people, is a

global concern (WHO, 2003).

OBESITY, TYPE 2 DIABETES AND HEART DISEASE

Obesity, type 2 diabetes and heart disease are all examples of potentially

preventable conditions where diet plays a key part. They are also linked to each

other and to physical inactivity, smoking and other related diseases such as high

blood pressure. And it is those who are most disadvantaged or deprived, who are

more likely to have these risk factors, the resulting diseases and suffer complications

from them.

The epidemiology (patterns) of these conditions in Shetland is similar to the rest of

the country (ISD, 2015). If we know the quantities and distribution of people with

various health conditions throughout Shetland, we can be more effective at designing

services to meet the needs of specific local areas and groups of people.

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The statistical data presented here is taken from data held at GP practice level1. It

shows where populations registered with local practices sit in comparison with each

other and in some cases in comparison with the Shetland and Scottish averages.

Obesity

Obesity is about having too much body fat; usually 20% or more above the ideal

weight for an individual. Maintaining a healthy weight is about balancing the energy

we consume in the form of calories, and the amount we burn off. Obesity at a simple

level is caused by eating more calories than we are using through physical activity.

However, relative over-eating is a complex business, and there are a range of

psychological, physiological, social, environmental, cultural, medical and genetic

factors that can also affect an individual’s weight and their relationship with food. The

interplay between these factors is complex and, in some instances, difficult to define.

So, tackling obesity and weight problems in individuals and communities cannot be

separated from tackling the social, physical and policy environment that we live in.

And reducing weight problems is as much about shifting cultural attitudes and social

norms as it is about helping individual people to adopt healthier eating and activity

levels. We need to be able to talk about obesity and weight in a healthy and

supportive way for individuals, and in a political way to make change in the factors

that contribute to the problem in modern society.

For a population to tackle obesity, we need to take action at a range of levels, we

need to see obesity as more than a medical problem that is just the business of the

NHS. Action on weight needs to recognise the relationship with, and influence of,

health, emotional and social influences and inequalities.

And at an individual level, to avoid or reduce obesity we need to eat a healthy

balanced diet and be more physically active.

Obesity increases the risk of type 2 diabetes and is also a risk factor for coronary

heart disease, breast cancer, bowel cancer and stroke.

1 QOF (Quality Outcomes Framework) is the system used in general practice to measure activity and fund GPs for a range of services that focus on prevention and early intervention to improve the health of patients.

8


Body mass index (BMI) is a formula used to measure and classify people according

to their weight and height. The higher the BMI, the heavier the person is for their

height, and vice versa. Although generally a high BMI means that an individual is

overweight or obese, occasionally it is due to a high proportion of muscle because

this is heavier than body fat, so a high muscular proportion can mean a person is

categorised as being overweight or obese even though they do not have excess

body fat.

The figure below shows obesity prevalence ( number of patients) across the GP

areas in Shetland. Yell, Hillswick and Unst have a higher proportion of obese people

in their practices compared to the other Shetland practices. This is however, just a

guide, as there a number of reasons why one practice may appear to have a higher

proportion of obese patients compared to another. For example, the more patients

that you weigh, the more obese people you are likely to find. And where small

numbers are concerned, data must be interpreted with caution as what appears as a

big difference may represent just a few people.

Overweight is classified as follows: -

Overweight – BMI = 25 – 29.9

Mildly obese – BMI = 30 – 34.9

Moderately obese – BMI = 35 – 39.9

Morbidly obese – BMI = 40+

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Chart 1: Shetland practice data: Obesity prevalence

The prevalence of obesity in Shetland which is statistically significant is shown in the

funnel chart, below. This takes into account the different sizes of population in the

practice areas. Yell, Unst, Whalsay, Bixter and Hillswick have a statistically

significantly higher prevalence of obesity.

Chart 2: Shetland practice data funnel chart: Obesity prevalence 2013/14

Nb The number of Bixter and Whalsay patients with obesity are very close, so their markers overlap

0

5

10

15

20

25

30

2004 - 05 2005 - 06 2006 - 07 2007 - 08 2008 - 09 2009 - 10 2010 - 11 2011 - 12 2012 - 13 2013 - 14

Rate

per

100

Pat

ient

s

Obesity Prevalence 2007 - 14 by Practice

Bixter Health Centre Brae Health Centre Hillswick Health Centre Lerwick Health Centre

Levenwick Health Centre Scalloway Health Centre Unst Health Centre Walls Health Centre

Whalsay Health Centre Yell Health Centre

Unst

Walls

HillswickYell

Bixter

Whalsay

Brae

Levenwick

ScallowayLerwick

0

2

4

6

8

10

12

14

16

18

20

0 1000 2000 3000 4000 5000 6000 7000 8000 9000 10000

Patients per 100 practice population Overall Patient rate

Lower control limit Upper control limit

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Some individuals may be categorised as clinically overweight, but still appear fit,

active and feel healthy. However, obesity is a risk factor for other conditions which

can become chronic and debilitating, such as type 2 diabetes and heart disease.

Type 2 Diabetes

There are two types of diabetes: type 1 (10% of all cases) and type 2 (90%). Type 1

diabetes is caused by the immune system killing the cells that produce insulin. This

is incurable and results in needing to take insulin injections for the rest of your life

along with blood glucose monitoring and having a healthy diet. Type 1 diabetes is

usually diagnosed in childhood and is not preventable, though many of the

complications can be prevented by good management.

Often linked to obesity, type 2 diabetes, is, however, usually preventable. Type 2

diabetes is largely caused by lifestyle factors although there is a genetic component.

People who are overweight or obese are significantly more likely to develop type 2

diabetes. Like type 1 diabetes, it also affects the production of insulin in the body.

However, its effects can be limited, and often the disease itself managed, by diet and

weight loss. Sometimes people also need medication to control type 2 diabetes. We

are seeing an increase in type 2 diabetes generally in the adult population because

of a rise in obesity. Both types of diabetes can result in complications including

blindness, amputations and heart disease; but the risks of these can be reduced by

controlling the level of sugar in the blood with insulin (for type 1) or diet and (where

necessary) medication (for type 2).

The Scottish Diabetes Survey 2014 reported that at the end of 2014, there were 1082

people in Shetland with diabetes: 4.7% of the population. Of these, 956 people had

type 2 diabetes and 123 had type 1 (three had another type - some rare variations or

those unclassified).

Heart Disease

Coronary heart disease (CHD) kills more people in Scotland than any other disease,

and generally affects men more than women. The disease is caused by fatty

deposits building up in the coronary arteries, often caused by poor diet (particularly

one high in saturated fats), smoking, and inactivity. In some people there is a strong

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genetic component and other conditions can increase the risk including obesity,

diabetes and high blood pressure. Psychological factors may also play a part. CHD

is more common in the over 50s, although becoming more common in younger

people due to increasing obesity. CHD is a long term condition but may present as a

very acute problem (e.g. heart attack or angina). Symptoms are usually chest pain

and breathlessness. CHD can result in death, either suddenly after a heart attack or

following years of poor health.

The risk of CHD can be reduced by stopping smoking, doing more physical activity,

and having a better diet. If CHD develops then it can be managed through lifestyle

changes along with medication and sometimes surgery. However chest pain and

breathlessness may make exercising difficult and so professional support with

cardiac rehabilitation may be necessary to build up physical activity in a safe way.

The prevalence of CHD in Shetland’s communities from the GP practice data is

shown in the graph below. The red and black arrows show the Scottish and Shetland

averages respectively.

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Chart 3: Shetland practice data: Coronary Heart Disease prevalence

The graph demonstrates that Yell and Hillswick appear to have a far higher

prevalence of CHD than the other Shetland practices, and also than the Scottish

average. This may relate to higher levels of obesity that we see in these areas.

0

1

2

3

4

5

6

7

8

9

10

2004 - 05 2005 - 06 2006 - 07 2007 - 08 2008 - 09 2009 - 10 2010 - 11 2011 - 12 2012 - 13 2013 - 14

Rate

per

100

Pat

ient

s

CHD Prevalence 2004 - 14 by Practice

Bixter Health Centre Brae Health Centre Hillswick Health Centre Lerwick Health Centre

Levenwick Health Centre Scalloway Health Centre Unst Health Centre Walls Health Centre

Whalsay Health Centre Yell Health Centre Shetland Scotland

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BEING UNDERWEIGHT

Most health messages about diet and weight tend to focus on eating too much or

being overweight. However, being underweight can also affect health both now, and

in the future. There are lots of reason why someone might be underweight, which is

defined as a BMI of 18.5 or less.

Sometimes a specific illness can make you lose weight, even if you have a normal

appetite, such as gut conditions, type 1 diabetes, and cancers. Mental health

problems such as depression often affect appetite, and periods of stress and anxiety

can also lead to a decreased appetite. It is quite common for older people to lose

their appetite and eat less, even if they have no health problems. People who are

very active, and who do not consume enough calories to replace the energy they

burn can also become underweight. Sometimes weight loss is due to a specific

eating disorder such as anorexia nervosa or bulimia.

Being underweight can affect your immune system, making you more likely to catch

colds, flu and other bugs. Women may stop having periods, and this can then affect

fertility. If you are not consuming enough calories then you will feel tired and lacking

in energy. If you are not eating enough food as part of a healthy balanced diet, then

you are likely to be missing out on the nutrients that keep us healthy. For example,

calcium is needed for strong healthy bones and if you do not have enough then you

are at increased risk of osteoporosis when older. This can lead to fragility fractures,

where bones can break easily. Being underweight can be a particular problem

amongst older people, and can significantly impair quality of life. It increases the risk

of infection and falls, which can lead to hospital admission and even death.

People of normal weight, or even some who are overweight, may also miss out on

important nutrients if their diet does not include a balance of the essential food

groups.

Eating Disorders

People with eating disorders have an abnormal attitude towards food and their weight

which makes them change their behaviour and eating habits (NHS Inform, 2015).

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They affect women, particularly young women, more than men and affect patients

physically, psychologically and socially. The most common eating disorders are:

• anorexia nervosa – trying to keep weight as low as possible, by not eating

and/or exercising excessively;

• bulimia –trying to control weight by binge eating and then deliberately being

sick or using laxatives (medication to help empty their bowels);

• binge eating – when someone feels a compulsion to overeat.

Around one in 250 women and one in 2,000 men develop an eating disorder at some

point in their lives. The condition usually develops around the age of 16 or 17.

Bulimia is more common than anorexia, especially in women (90% of cases) and

develops slightly later (late teens). Binge eating is hard to define and measure:

affecting both sexes, it usually appears in the 30s and 40s (NHS Choices, 2015).

The chart below shows how many people in Shetland have, or have had an eating

disorder or suspected eating disorder. There are far more females than males,

mostly in the 15-24 year old age group. The very small number of men may reflect a

reluctance of men to seek help, and possibly under-diagnosis, as well as a generally

lower prevalence of eating disorder in the male population.

Chart 4: All patients with a diagnosis of eating disorder recorded on the GP practice database – EMIS (August 2015).

15

http://www.nhsinform.co.uk/health-library/articles/a/anorexia-nervosa/

http://www.nhsinform.co.uk/health-library/articles/b/bulimia/

http://www.nhsinform.co.uk/health-library/articles/b/binge-eating/


Eating disorders are complex, and not just about a desire or external pressure to be

thin. There are a number of risk factors that often combine to make someone more

likely to develop an eating disorder. These include:

• having a family history of eating disorders, depression or substance misuse

• being criticised for their eating habits, body shape or weight

• being particularly fixated with being slim, especially if combined with external

pressure to be thin, for example ballet dancers, models or athletes

• certain personal characteristics, for example, having an obsessive personality

or low self-esteem; or being anxious or a perfectionist

• traumatic experiences, such as sexual or emotional abuse or the death of

someone special

• family and relationship difficulties

• stressful situations, for example problems at work, school or university.

Eating disorders can lead to severe physical problems due to malnutrition,

particularly anorexia nervosa. A quarter to a third of people with anorexia do not

respond to treatment and 5% die from their illness (NHS Inform, 2015).

Female Athletic Triad (FAT)

Female Athletic Triad is a recognised syndrome sometimes seen in individuals (both

men and women) who are physically training or exercising hard and restricting

dietary intake. Symptoms include:

• amenorrhea (being without a period for three months)

• decreased bone mineral density (fragile bones)

• low energy availability (including disordered eating).

In addition to weight loss, individuals may also suffer fatigue and low energy, have

slow injury healing, more inflammation, anxiety, low self-esteem and/or depression,

anaemia, bradycardia (slower than normal heart rate), chronic aches and pains.

These symptoms can have many causes, but is worth considering them as a

possible consequence of excessive physical activity and diet control (Nadolsky, S

2015; Warren, M.P et al. 1999).

16

http://www.nhsinform.co.uk/health-library/articles/d/depression/


VITAMIN AND MINERAL DEFICIENCIES

Vitamins and minerals are essential nutrients that your body needs in small amounts

to work properly. Most people should be able to get all the nutrients they need by

eating a varied and balanced diet. There are fat soluble vitamins and water soluble

vitamins; this is one of the reasons why it is important to have some fat in the diet: to

get the fat soluble vitamins which include vitamins A,D,E,K. Water soluble vitamins

include vitamin C, B and folic acid. Minerals include calcium and iron; and there are

also trace elements such as iodine which are needed in very small amounts.(NHS

Choices , 2015).

Not having enough of these nutrients can cause significant health problems: but

having too much (e.g. taking too many vitamin supplements) can also be unhealthy.

However sometimes vitamin

supplements are necessary, for

example during pregnancy and for

young children (there is some

further information on this in

Chapter 5 (Healthy Start section).

Vitamin D is a good example: it is

necessary for the body to absorb

calcium and so essential for bone

health. Our bodies metabolise

vitamin D from sunlight but in this

country there is not enough

sunlight for this to happen during the winter months, and so we have to rely on

vitamin D from our food. Some particularly vulnerable groups are recommended to

have Vitamin D supplements:

• all children aged six months to five years old

• all pregnant and breastfeeding women

• all people aged 65 and over

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• people who are not exposed to much sun, such as people who cover up their

skin for cultural reasons or those who are housebound or confined indoors for

long periods

• people with darker skins such as people of African-Caribbean and South Asian

origin.

Calcium and Osteoporosis

Calcium has a number of functions in the body. These include

• helping to build strong bones and teeth

• regulating muscle contractions, including

heartbeat

• ensuring that blood clots normally

Not getting enough calcium in your diet can lead to

rickets in children or osteoporosis in later life. Vitamin D works with calcium to keep

bones healthy. If we do not metabolise or take in enough vitamin D we cannot absorb

the calcium we need to keep our bones healthy.

Osteoporosis is a condition

that weakens bones, making

them fragile and more likely to

break. It affects around three

million people in the UK and

more than 300,000 people

receive hospital treatment for

fractures every year as a

result of osteoporosis. Bones

are at their thickest and

strongest in early adult life but you gradually start losing bone density from around

the age of 35. This affects everyone, but some people lose their bone density more

quickly because they have osteoporosis. It is more common in women and in older

age groups. There are a number of conditions that can increase the risk of

osteoporosis, including not having enough calcium and vitamin D (NHS Choices,

2015). Women are more at risk because of hormonal changes, both naturally through

18

http://www.nhs.uk/conditions/Rickets/Pages/Introduction.aspx

http://www.nhs.uk/conditions/Osteoporosis/Pages/Introduction.aspx


the menopause and also if they stop having periods due to excessive weight loss for

example. So women who are very thin and not eating enough are at particular risk

both because of hormonal changes and malnutrition.

Anaemia

There are different types of anaemia, but iron deficient anaemia is the most common.

Iron helps to make red blood cells, which carry oxygen around the body. The

main symptoms of iron deficiency anaemia include tiredness and lack of energy;

being breathless, heart palpitations (feeling heart beat rapidly) and looking pale. In

men and older women, the most common cause is bleeding in the stomach or

intestines. This can be caused by taking non-steroidal anti-inflammatory drugs

(NSAIDs) such as aspirin; stomach ulcers, or cancer of the stomach or bowel. In

younger women of reproductive age, the most common causes of iron deficiency

anaemia are heavy periods and pregnancy (as your body needs extra iron for your

baby). Unless pregnant, it's rare for iron deficiency anaemia to be caused just by a

poor iron intake. However, if you do have a lack of iron in your diet and develop a

condition such as a bleeding ulcer, then you will be more likely to develop anaemia

(NHS Choices, 2015).

19

http://www.nhs.uk/conditions/Heart-palpitations/Pages/Introduction.aspx

http://www.nhs.uk/Conditions/Anti-inflammatories-non-steroidal/Pages/Introduction.aspx

http://www.nhs.uk/Conditions/Anti-inflammatories-non-steroidal/Pages/Introduction.aspx

http://www.nhs.uk/conditions/Peptic-ulcer/Pages/Introduction.aspx

http://www.nhs.uk/conditions/Periods-heavy/Pages/Introduction.aspx


HOW DIET AND FOOD AFFECTS YOUR TEETH

The foods you choose and how often you eat them can have a huge effect on your

teeth. If you consume too many sugar filled foods (fizzy juice, sweetened fruit drinks,

biscuits, cakes and sweets); foods that appear healthy but contain lots of sugar (dried

fruits, cereal bars, fruit juices, smoothies); or other food with hidden sugars (such as

some ready meals, processed foods and often low fat foods), then you are putting

your teeth at a greater risk of tooth decay. Tooth decay damages your teeth and

leads to fillings or even extractions. The good news is that tooth decay is entirely

preventable1.

The ‘Stephan curves’ below illustrate what happens in your mouth each time you eat:

these examples would be for a young child. They show how the choice and

frequency of the foods you eat affects the number of ‘acid attacks’ your teeth

experience (Health Scotland, 2012). In the first example the teeth are under frequent

sugar attack, with little time for recovery in between.

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The second example shows less sugar attacks and more time for teeth to be

repaired. This is the pattern we should all be aiming for: no more than 3 to 4 daily

“acid attacks”, with plenty of “rest-time” for saliva to repair the damage done by

eating sugar.

Shetland is making excellent progress on improving oral health. The latest National

Dental Inspection across NHS Boards identified that the number of Shetland children

starting school with tooth decay was 19.1% compared to the national average of

31.8% (ISD, 2014). Children in particular are taking on board the messages around

good oral hygiene, such as brushing twice a day. However, making dietary changes

seems to be more challenging for folk.

Generally, as a population we consume too few fruit and vegetables, fish and starchy

carbohydrates, but too many foods high in fat, salt and sugar. This dietary imbalance

increases the risk of developing chronic diseases such as obesity, heart disease,

certain cancers, type II diabetes, as well as tooth decay (Health Scotland , 2012).

Eating smaller amounts of foods and drinks that are high in sugar, and snacking less

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in between meals are ways we can eat more healthily to reduce our risk of tooth

decay, and overall health and wellbeing.

The World Health Organisation recommends that we should all aim to reduce our

sugar intake so that added sugars make up less than 10% of the energy (calories)

we get from food and drink each day (WHO, 2015). Added sugars are sugars and

syrups that are added to foods when they are processed or prepared. Sugars occur

naturally in fruit and milk, and we don’t need to cut down on these sugars. However!

Once whole fruits are processed into items such as smoothies, fruit juices or dried

fruits, then the sugar is no longer contained within the structure of the fruit and can

cause damage to teeth – so we do need to watch how much we have of these

(Health Scotland, 2012).

There are a number of ways to help everyone to reduce the amount of sugar in their

diet; some of these are discussed further in later chapters.

Clearer food labelling and media advertising: Just how ‘healthy’ are products

marketed as a ‘healthy option’ such as smoothies, yoghurts, snack bars, and

breakfast cereals? Such products often contain surprisingly high amounts of sugar,

but the labelling and advertising mislead us into thinking they are a healthy option.

A wider range of healthy affordable foods in rural shops: Our rural shops face

many challenges, including competition with supermarkets, a smaller customer base,

and changing shopping patterns of customers. However, the people who shop in

their local shops should be able to access fresh, healthy, affordable food.

Changes to food placement in supermarkets and shops: How often do we see

fruit next to the counter or checkout, or vegetables at the end of the isles? Or see

bottles of water and milk predominantly displaying in fridges at places such as the

cinema instead of a small corner of a bottom shelf (or not at all!)? To encourage

healthy eating behaviours, shops and leisure facilities could help to make foods like

fruit and vegetables visible and easy to reach (convenient), enticingly displayed

(attractive), and appear like an obvious choice (normal). With these principles there

are endless ways we can lead people to make healthier choices (Wansink, 2015).

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FOOD ALLERGIES AND INTOLERANCES

Adverse reactions to foods are often called many different names including food

hypersensitivity, food intolerance, food allergy, and many other medical and non-

medical terms.

These names can cause a lot of confusion and many people will believe that they

have a food allergy or intolerance when this is not actually the case. Around 30% of

people believe they are allergic or intolerant to one or more foods, but it is estimated

that only 5-8% of children and 1-2% of adults have a true food allergy. Food

intolerances are more common, although it is difficult to estimate how many people

are affected as food intolerances can be difficult to diagnose because there are only

a few reliable tests.

Reported rates of food allergies and intolerances have risen sharply over the last 20

years. It is not known why rates are increasing, but with these increases comes a

wider awareness of food allergies and intolerances as well as plenty of conflicting

information which can make it difficult to know if you or a family member are affected.

Food allergy

A food allergy is a reaction produced by the immune system (the body’s defence

system against illness and infection) when it encounters a normally harmless

substance (ie proteins in particular foods) and mistakenly treats it as a threat. The

body then begins to ‘fight off’ the proteins and this reaction produces the symptoms

of an allergic reaction. Symptoms can affect different areas of the body at the same

time and common symptoms include:

• an itchy sensation inside the mouth, throat or ears

• an itchy red rash (known as urticaria or hives)

• swelling of the face, around the eyes, lips, tongue and roof of the mouth

(known as angioedema)

• vomiting

• stomach ache

• diarrhoea.

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Depending on the severity of the allergy, symptoms can occur anytime from a few

seconds after eating the food up to several hours. In the most severe cases

symptoms such as shortness of breath, throat constriction and breathing difficulties

may develop rapidly. This is known as anaphylaxis and can be life threatening, so

requires urgent medical attention.

Almost any food can cause an allergic reaction, but there are a handful of foods that

cause approximately 90% of reactions. In adults and children, the foods that most

commonly cause an allergic reaction are:

• milk - children are usually allergic to

proteins found in cow’s milk.

• eggs

• peanuts

• tree nuts

• soya

• wheat

• fish

• shellfish

• celery

• mustard

• sesame seeds

• fruit and vegetables

People who have food allergies generally will always have a bad reaction even if they

come into contact with a very small amount of the foodstuff they are allergic to.

Food intolerance

Food intolerances are more common than food allergies and can be harder to

diagnose. There is no immune response to the food eaten but the food intolerances

can be caused by several different factors including increased sensitively to the

chemicals that are produced naturally or added into food. Some food intolerances,

such as lactose intolerance, can be caused by a lack of the enzyme needed to break

down food so it can be absorbed into the body. This makes the problem food difficult

24


to digest and results in typical symptoms. In some cases there is no identifiable

physical cause for the symptoms of food intolerances although a person’s lifestyle

and their dietary choices can affect the severity of the symptoms experienced.

Common symptoms people experience with food intolerances are

• diarrhoea,

• bloating and stomach cramps

• skin problems such as eczema.

Usually reactions are delayed and symptoms may take several hours, even several

days to appear. They are usually triggered by larger amounts of food whereas with a

food allergy even small amounts can cause a reaction

Although not life threatening, food intolerances can make the sufferer feel extremely

unwell and can have a major impact on working and social life. Since it is possible to

be intolerant to several different foods at the same time it becomes very difficult to

determine whether food intolerance is the cause of chronic illness, and which foods

may be responsible.

As with food allergies people can be intolerant to almost any food, some of the more

common food intolerances are listed below;

• Lactose intolerance - occurs when your body can't digest lactose. Lactose is a

sugar found in milk and dairy products such as yoghurts and soft cheeses.

Lactose intolerance is not the same as a cow’s milk protein allergy

• Wheat intolerance - This is different to coeliac disease which will be discussed

below

• Histamine intolerance – histamine is a chemical that occurs naturally in certain

foods

• Yeast intolerance

• Alcohol intolerance

Diagnosing a food allergy or intolerance

If you suspect that you or a member of your family may have an allergy or

intolerance, this can be diagnosed through NHS services. This may involve

having one or more allergy tests.

25


Many people can mistakenly assume they have a food allergy, when their symptoms

are actually due to a completely different condition. Therefore it is important that your

first step in diagnosing an allergy or intolerance is making an appointment with your

GP. Your GP will ask you questions about the duration, severity and type of

symptoms you experienced as well as what food you had eaten prior to the

symptoms occurring.

If your GP thinks that you have an allergy or intolerance they may refer you for

further tests such skin prick testing, blood tests or

elimination diets.

If an allergy is suspected (where symptoms develop

quickly), skin prick testing (a test where the skin is

pierced and a small amount of food extract is allowed

to come in contact with skin cells) and blood tests are

normally used as these tests help identify specific

foods which cause an immune response and allergic

reaction.

If an intolerance is suspected, (where symptoms

develop much more slowly), then you may be asked to completely eliminate the

suspected problem food from your diet for 2 to 6 weeks, then reintroduce it. If your

symptoms improve when the food is withdrawn and return when the food is

reintroduced then it is likely that you are intolerant to that food. Elimination diets are

also used to identify some less severe allergies. It is important to always consult a

qualified health professional before cutting out key foods from your or your family’s

diet. Your GP may want to refer you to a dietitian to ensure you are able to

completely eliminate the food from your diet without missing out on necessary

nutrients.

Commercial allergy or intolerance-testing kits are available, but their use is not

recommended. Many kits are based on unsound scientific principles. Even if they are

reliable, you should have the results looked at by a health professional.

26


Treating a food allergy or intolerance

There is no treatment to cure a food

allergy. The best way of preventing

an allergic reaction is to identify the

food that causes the allergy and then

avoid it. However, it is best to avoid

making any radical changes to your

or your family’s diet, such as cutting

out particular foods, without first

talking to your GP or a dietitian. It is

especially important to seek medical advice before eliminating any food from a child’s

diet as eliminating certain foods from their diet could cause a nutritional imbalance in

their diet which could affect their growth or development.

A type of medication called an antihistamine can help relieve the symptoms of a mild

or moderate allergic reaction. A higher dose of antihistamines is often needed to

control symptoms. If someone has a severe food allergy and are at risk of

anaphylaxis they are often given a device, known as an auto-injector pen, which

contains doses of adrenaline that can be used in emergencies to treat anaphylaxis.

Many children will grow out of their allergies and intolerances as their bodies and

immune systems mature. Most children who have food allergies to milk, eggs, soya

and wheat in early life will likely outgrow this allergy by the time they start school.

Regular testing or oral challenges (where a child is trialled with a gradually increasing

amount of food and monitored for a reaction) will help determine if a child’s allergy

remains. However this should only be attempted with guidance from a qualified

health professional.

Peanut and tree-nut allergies are usually more persistent and most children with nut

allergies will remain allergic to nuts the rest of their lives. Food allergies that develop

during adulthood, or persist into adulthood, are likely to be lifelong allergies and

therefore those foods will need to always be avoided.

As with food allergy there is currently no treatment to cure food intolerance and the

best way to prevent symptoms is to use elimination diets to identify the cause of

27


symptoms and then avoid the problem food. However unlike food allergies for those

with food intolerance prolonged elimination can build tolerance of the problem food.

Weeks or months of elimination of the problem food can in some cases lead to

reintroduction of the food without causing the return of symptoms. This can be done

by establishing tolerance levels for problem foods; for example eating the food

occasionally or in small quantities may be tolerated, but having the food in large

quantities or on regular basis (e.g. every day) might lead to symptoms recurring. A

dietitian can help you eliminate problem foods and reintroduce them to find out your

tolerance levels.

As with food allergies it is strongly advised that you seek advice from a qualified

health professional before going on a strict elimination diet to try and improve your

symptoms.

Coeliac disease

Coeliac disease is often confused by many people as an allergy or intolerance to

gluten however this is not the case. Coeliac disease is a common digestive condition

where a person has an adverse reaction to gluten. It is an autoimmune condition

where the immune system mistakes substances found inside gluten (a protein found

in wheat, rye and barley) as a threat to the body and attacks them. This damages the

surface of the small bowel (intestines), disrupting the body's ability to absorb

nutrients from food. It is not entirely clear what causes the immune system to act this

way, although a combination of a person's genetic make-up and the environment

appear to play a part. Symptoms of coeliac disease include diarrhoea, bloating and

weight loss and are similar to those of an allergy or intolerance.

Coeliac disease can be accurately diagnosed with a blood test and biopsy and those

diagnosed with coeliac disease must follow a gluten free diet for the rest of their lives

as any gluten they eat can damage their intestines and cause a recurrence of

symptoms.

The chart below shows how many people in Shetland have coeliac disease. There

are more females than men, especially in the 45-64 year old age group.

28


Chart 5: All patients with a diagnosis of coeliac disease recorded on the GP practice database – EMIS (August 2015).

The similarity in symptoms of conditions like coeliac disease and food allergies or

intolerances is the main reason why it is important to always seek advice from a

qualified health professional before eliminating foods from your diet or going on a

strict diet.

Where to go for more information

If you would like more information on food allergies and food intolerances the

following websites may be helpful

www.nhs.uk/Conditions/food-allergy

www.allergyuk.org/

www.allergyuk.org/food-intolerance/food-intolerance

29

http://www.nhs.uk/Conditions/food-allergy

http://www.allergyuk.org/

http://www.allergyuk.org/food-intolerance/food-intolerance


References

Health Scotland. (2012) Oral Health and Nutrition Guidance for Professionals. Health Scotland, Edinburgh. Information Services Division (2014) Publication Report: National Dental Inspection Programme. [Online] Available from: https://isdscotland.scot.nhs.uk/Health-Topics/Dental-Care/Publications/2014-10-28/2014-10-28-NDIP-Report.pdf?77236574889 [Accessed July 2015]. Information Statistic Division (ISD) (2015) Quality and Outcomes Framework [Online] Available from: www.isdscotland.org [Accessed August 2015]. Nadolsky, s. (2015) Fitness & menstrual health: how to stay lean, healthy, and fit without losing your period. [Online] Available from: www.precisionnutrition.com/fitness-menstrual-health [Accessed August 2015]. NHS Scotland Inform website (2015) [online] Available from:www.nhsinform.co.uk [Accessed September 2015]. NHS Choices website (2015) [online] Available from: www.nhs.uk [Accessed September 2015]. Wansink, B. (2015) Change Their Choice! Changing Behaviour Using the CAN approach and Activism Research. Psychology and Marketing. 32(5) pp486-500. Warren MP, Voussoughian F, Geer EB, Hyle EP, Adberg CL, Ramos RH. (1999) Functional hypothalamic amenorrhea: hypoleptinemia and disordered eating. J Clin Endocrinol Metab. Mar;84(3) pp 873-7 World Health Organisation (WHO) (2003), Diet, Nutrition and the Prevention of Chronic Diseases, WHO Technical Report Series: Report of a Joint WHO/Food and Agricultural Organisation of the United Nations (FAO) Expert Consultation, Geneva: WHO World Health Organisation (2015), Guideline: Sugars intake for adults and children. World Health Organisation, Geneva: WHO. .

30

https://isdscotland.scot.nhs.uk/Health-Topics/Dental-Care/Publications/2014-10-28/2014-10-28-NDIP-Report.pdf?77236574889



http://www.isdscotland.org/

http://www.precisionnutrition.com/fitness-menstrual-health

http://www.nhsinform.co.uk/

http://www.nhs.uk/

http://www.ncbi.nlm.nih.gov/pubmed?term=10084564


CHAPTER 2

WHAT MAKES A ‘GOOD’ DIET?

A common complaint about ‘healthy eating advice’ is that it is too complicated and

too contradictory. Recommendations about the exact quantities of different foods and

food groups may change over time; and there are numerous sources of information,

some of it is based on science but a lot of it is not. Some people believe a vegetarian

diet is the healthiest; others would say the Mediterranean diet; or one low in

carbohydrates, or one high in protein. There is a lot of interest currently in diets that

exclude processed and refined foods and those that limit all carbohydrates, not just

sugar, but don’t worry about (unrefined) fats.

A healthy diet is about both quantity and quality: eating too much of anything is not a

good idea. (Even drinking too much water can cause health problems). But our diet

does need to contain protein, a source of energy, all the essential vitamins and

minerals, fibre and some fat. Even though there may be arguments about the

healthiest diet, they probably all agree on eating less processed foods that are high

in salt and refined sugar and fat.

31


Healthy Eating Tips

(www.healthyshetland.com)

Healthy eating doesn't have to be difficult - it usually just means making some small changes.

Making changes gradually means you are more likely to stick with them - try changing one

thing at a time. Here are some simple tips to help you keep on track with healthy eating:

• Base your meals on starchy foods – these are foods that will fill you up. Choose

whole grain varieties when you can.

• Eat lots of fruit and vegetables – aim to have at least 5 portions a day of different

fruit and vegetables. One portion is one handful.

• Eat more fish - Try to have fish 2 times a week with one being an oily fish such as

salmon or mackerel.

• Cut down on unhealthy fats – these are called saturated fat. These are found in hard

cheese, cakes, biscuits, cream, butter, lard and pies.

• Cut down on sugar – most people can cut down by having less fizzy drinks, alcoholic

drinks, sugary breakfast cereals, cakes, biscuits and sweets.

• Eat less salt – try to not add salt to your food while cooking or at the table. Many foods

which are ready made already have salt added, try to make your own to avoid hidden

salt.

• Be active – doing a little more exercise such as walking can help maintain your weight

and also boost your mental health -

• Keep hydrated – try to drink 2 litres of fluid throughout the day.

• Don’t skip breakfast – try to have a healthy breakfast within 2 hours of waking up.

For more ideas and healthy recipes visit Eat Better, Feel Better.

www.eatbetterfeelbetter.co.uk

32

http://www.healthyshetland.com/health-topics/exercise/

http://www.healthyshetland.com/health-topics/mental-health/

http://www.nhs.uk/Livewell/loseweight/Pages/Healthybreakfasts.aspx

http://www.eatbetterfeelbetter.co.uk/

http://www.eatbetterfeelbetter.co.uk/


EATWELL PLATE

The Eatwell plate is a well established model, based on scientific evidence, promoted

by UK Government and the NHS to show people how their diet should be made up of

the different food groups. Launched in 2007, the Eatwell Plate shows that to have a

healthy, balanced diet, people should try to eat:

• plenty of fruit and vegetables

• plenty of starchy foods, such as bread, rice, potatoes and pasta

• some meat, fish, eggs, beans and other non-dairy sources of protein

• some milk and dairy foods

• just a small amount of food and drinks that are high in fat and/or sugar.

In addition, it recommends that you should try to choose a variety of different foods

from the four main food groups. Most people in the UK eat and drink too many

calories, too much fat, sugar and salt, and not enough fruit, vegetables, oily fish and

fibre. It's important to have some fat in your diet, but you don't need to eat any foods

from the "foods and drinks high in fat and/or sugar" group as part of a healthy diet.

The Eatwell plate has been criticised as promoting too much refined starch and

carbohydrate; and the inclusion of a section with high fat and sugar foods implies that

it is okay to eat these. (PHE, 2015). However, the Eatwell Plate is probably a far

more realistic goal for most of the population to aim for than the most rigorous,

‘healthy’ diets that would exclude any refined sugar or starch for example. There has

also been criticism that it does not include portion sizes, or take into account the

differences between different meals, but this is being reviewed.

33


GOOD AND BAD FATS

‘Good’ fats: these are called unsaturated fat and can help lower your blood

cholesterol. Examples include vegetable oils (including sunflower, rapeseed and

olive oil), oily fish, avocados, nuts and seeds. All of these are good sources of

protein too and tend to be rich in vitamins and/or minerals, so are doubly good for

you.

‘Bad fats’: these are called saturated fat. These are found in hard cheese, cakes,

biscuits, cream, butter, lard and pies. Cutting down on these can lower your blood

cholesterol and reduce your risk of heart disease.

• The average man should have no more that 30g saturated fat per day.

• The average woman should have no more than 20g saturated fat per day.

One of the easiest ways to cut down on saturated fat is to compare the labels on

similar products and choose the one lower in saturated fat.

34


EAT LESS SUGAR: – HIDDEN SUGARS

Most people in the UK eat too much sugar and could cut down by having fewer fizzy

drinks, alcoholic drinks, sugary breakfast cereals, cakes, biscuits and sweets.

Having sugary foods and drinks too often can cause tooth decay, especially if you

have them between meals, but they are also often high in calories, so cutting down

could help you control your weight.

You can tell if a food is high in sugar by looking at the ‘Carbohydrates (of which

sugars)’ figure on the label.

High is more than 15g sugars per 100g.

Low is 5g sugars or less per 100g.

This figure doesn’t tell you how much of the sugars are added sugars which are the

type we should try to cut down on, rather than sugars which are found naturally in

some foods such as fruit or milk. But you can spot added sugars by looking at the

ingredients list. It always starts with the biggest ingredient first. So if ‘sugar’ is near

the top of the list, you know that the food is likely to be high in added sugars.

And watch out for other words used to describe added sugars such as sucrose,

glucose, fructose, maltose, hydrolysed starch, invert sugar, corn syrup and

honey! They are all designed to confuse us.

You may be surprised by how much sugar different products contain:

35


EAT LESS SALT

Salt is a common seasoning in our diet. It is often included in recipes, and we use it

as seasoning on food after serving. Many people claim that they cannot taste their

dinner without adding some salt but if you cut back you may discover flavours that

you never knew were there!

Eating too much salt can raise your blood pressure. High blood pressure puts added

force against the walls of your arteries, which, over time, can damage them. Anyone

can develop high blood pressure, so even if you think your blood pressure is fine you

should still limit the amount of salt you eat. Try to not add salt to your food while

cooking or at the table. Lots of everyday foods that don’t taste salty, such as cereals,

breads, biscuits and cakes have salt added, let alone the ones that we know are salty

like crisps and bacon. 75% of the salt that we eat comes from readymade foods,

such as bread, cereals and baked beans.

We all need a little bit of salt because it helps our body's cells to absorb nutrients.

However, most of us eat about two-and-a-half times more salt than we need. The

Guideline Daily Amount for adults is 6g per day – that’s about one level teaspoon.

36


EAT MORE FIBRE

Having fibre in your diet helps to keep your intestines healthy and protects against

many common diseases. Increasing your fibre intake protects you against abdominal

problems such as diverticular disease, decreases your cholesterol, and decreases

your risk of diabetes, obesity and being overweight. It decreases the risk of heart

disease and can protect against further health problems even after a heart attack.

Fibre also protects against many cancers including bowel cancer (SACN, 2015).

Our modern diet is often implicated in the increase of these “non-communicable

diseases” which are a major cause of death and disability in modern society. Many of

these conditions are rare or even unheard of in less developed areas where a

“western diet” has not been adopted (Janes, 2006).

This sort of disease prevention is cheap and easy! There are a variety of sources of

dietary fibre, and these natural sources have better evidence as protective factors

than any form of supplementation. Rich sources of dietary fibre such as fruits,

vegetables and whole-grains give you not only the benefits of fibre but the multiple

benefits to both physical and mental health of a healthy balanced diet.

The positive effects of a high fibre diet on improving health and reducing risk of

illness have recently been reviewed, and as a result, the recommendations for fibre

intake have been increased from 18-30g, to 30g for adults. Scotland falls behind this

target and we are still working to achieve our initial goal of 18g per day. (SACN,

2015).

It is best to increase fibre gradually as it can take some time for your body to get

used to. Some people experience bloating and flatulence when they increase dietary

fibre – this should settle with time and gradual introduction of fibre into the diet. It can

take up to 4 weeks to see the effects of a high fibre diet (NICE, 2003).

When increasing fibre make sure to drink plenty of fluids to minimise the chance of

any of these symptoms. Fibre is found in lots of everyday foods – it is best to have a

mixture, with most of your fibre coming from fruit and vegetables. The table below

shows the fibre content of some common foods (table adapted from MeReC, 2004).

37


Fibre content of common foods

Food Typical portion (weight) Fibre content grams (g) per portion

Breakfast cereals

All-Bran 1 medium sized bowl (40 g) 9.8 g

Bran flakes 1 medium sized bowl (30 g) 3.9 g

Weetabix 2 pieces (37.5 g) 3.6 g

Cornflakes 1 medium sized bowl (30 g) 0.3 g

Bread/rice/pasta /potatoes

Pitta bread (wholemeal) 1 piece (75 g) 3.9 g

Wholemeal bread 2 slices (70 g) 3.5 g

Naan bread 1 piece (160 g) 3.2 g

Brown bread 2 slices (70 g) 2.5 g

Pasta (plain, fresh cooked) 1 medium portion (200 g) 3.8 g

Brown rice (boiled) 1 medium portion (200 g) 1.6 g

Potatoes (old, boiled) 1 medium size (200 g) 2.4 g

Beans

Baked beans (in tomato sauce) Half can (200 g) 7.4 g

Red kidney beans (boiled) 3 tablespoons (80 g) 5.4 g

Vegetables & salad

Peas (boiled) 3 heaped tablespoons (80 g) 3.6 g

Carrots (boiled, sliced) 3 heaped tablespoons (80 g) 2.0 g

Broccoli (boiled) 2 spears (80 g) 1.8 g

Pepper (green/red) Half (80 g) 1.3 g

Tomato (raw) 1 medium/7 cherry (80 g) 0.8 g

Lettuce (sliced) 1 bowl (80 g) 0.7 g

38


Fruit

Avocado pear 1 medium (145 g) 4.9 g

Pear (with skin) 1 medium (170 g) 3.7 g

Orange 1 medium (160 g) 2.7 g

Apple (with skin) 1 medium (112 g) 2.0 g

Banana 1 medium (150 g) 1.7 g

Orange juice 1 small glass (200 mL) 0.2 g

Dried fruit/nuts

Apricots (semi-dried) 3 whole (80 g) 5.0 g

Prunes (semi-dried) 3 whole (80 g) 4.6 g

Mixed nuts 1 tablespoon (25 g) 1.5 g

Raisins/sultanas 1 tablespoon (25 g) 0.5 g

39


How does it all add up?

Only one fifth of adults (19% of men and 21% of women) ate the recommended

number of portions of fruit and vegetables, 5-a-day, in 2012. One in ten adults

consumed no portions of fruit or vegetables (Scottish Government, 2012). Getting

your 5-a-day really helps towards getting enough fibre These are three examples of

how you could get your 30g of fibre in a day:

Breakfast Lunch Dinner Snacks

Example day 1

Bran flakes with

banana, orange juice

Beans on

wholemeal

toast

Meat and peas, carrots,

broccoli and potatoes Pear, Apple

Example day 2

Scrambled egg and

beans on brown toast,

grilled tomato, orange

juice

Pea and ham

soup, pitta

bread

Pasta Bolognese

(including onions, peas,

carrots portion per

person)

Apricots,

tinned

peaches

Example day 3

Wholemeal toast

Rye bread with

avocado, ham

and tomato

Chilli (including carrot,

kidney beans, peppers)

with brown rice

Pear, apple,

carrots +

houmous

Quick Easy Swaps

If going the whole 30g seems too much, why not start small and add some extra fibre

by trying a few of these easy swaps and add-ons:

1. Half’n’half – if the thought of wholewheat is too much, try half wholewheat / half

white bread, rice or pasta. Or bran cereal mixed with your favourite.

2. Give it beans! Add tinned beans (baked beans, kidney beans, broad beans,

black-eyed beans, butter beans) or lentils to salads or have as a side dish for a

quick, easy boost.

3. Eat the fruit not the juice! Or at least have juice with bits in – the fibre is found in

the skins, membranes and solid bits of fruit and vegetables, so...

4. Keep the skins on!

5. Stock up on frozen peas/sweetcorn – 3 heaped tablespoons is a portion and

counts in your 5-a-day –mix in with salad or sandwich fillings. 40


UNDERSTANDING FOOD LABELS

When shopping, always check the nutrition

label to find out exactly what the food

contains and if the nutrition claims are really

as good as they sound. A nutrition guide like

this ‘Food Shopping Card’ can be useful to

use when comparing food labels so you know

what to look for:

Nutrition Claims: What do they really mean?

This table, taken from the Counterweight manual ( Counterweight Ltd, 2011) shows

what nutritional claims mean, and legally what figures manufacturers must abide by

in order to make specific nutritional claims on their products.

Fat free Less than 0.1g fat per 100g

Low fat Less than 3g fat per 100g

Sugar free Less than 0.2g sugar per 100g

Low sugar Less than 5g sugar per 100g

No added sugar No sugar or food mainly made of sugar added to the

product

Salt free Less than 0.05g per 100g

Low sodium Less than 0.4g sodium per 100g

Reduced fat, sugar or sodium 25% less than in regular products

Less fat, sugar or sodium Must state the percentage less than regular food

Source of fibre More than 3g fibre per 100g

High fibre or rich source of fibre More than 6g fibre per 100g

Increased fibre 25% more than in regular food and more than 3g

fibre per 100g

Sometimes the way in which a health claim is worded on the product has the

potential to make it seem a much more healthy option than in fact it is.

41


The real meaning of 85% fat free

• There are 15g of fat per 100g of food (100g food minus 85g ‘fat free’ = 15g fat)

• The food does not fall into the category for either a healthy food or low fat food

• Low fat might be high energy (calories) if there is lots of sugar added

• Foods without a ‘fat free’ claim can have less fat than a food claiming to be ‘fat

free’

(Counterweight Ltd, 2011)

References

Janes, S.E.J., Meagher, A. and Frizelle, F.A. (2006) Management of diverticulitis. British Medical Journal 332 (7536) pp271-275. Counterweight Ltd (2011) Confused about Food labels? Counterweight Programme Adult Weight Management Reference Manual. Counterweight Ltd. pp9-10 NICE (2003) Clinical Knowledge Summary – Diverticular Disease [Online] Available from: http://cks.nice.org.uk [Accessed August 2015]. NHS (2007). The Eatwell Plate. Available at: www.nhs.uk/Livewell/Goodfood/Pages/eatwell-plate.aspx [Accessed: July 2015] NHS Choices (2011) Diverticular Disease and Diverticulitis [Online] Available from: www.nhs.uk [Accessed August 2015]. Public Health England (PHE) (2015) External Reference group – Eatwell Plate. [Online] Available from: www.gov.uk/government/uploads/system/uploads/attachment_data/file/404087/ERG_eatwell_correspondence_summary_paper_final.pdf [Accessed September 2015]. MeReC (2004) Approximate dietary fibre content of selected foods. MeReC Bulletin. Scottish Government (2012) The Scottish Health Survey, 2012, vol. 1, 9. Edinburgh. Scottish Government. Scientific Advisory Committee on Nutrition (SACN) (2015) Carbohydrates and Health, TSO. pp104-143.

42

http://cks.nice.org.uk/

http://www.nhs.uk/Livewell/Goodfood/Pages/eatwell-plate.aspx

http://www.nhs.uk/

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/404087/ERG_eatwell_correspondence_summary_paper_final.pdf

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/404087/ERG_eatwell_correspondence_summary_paper_final.pdf


CHAPTER 3

FOOD AND MENTAL WELLBEING

WHY DIET MATTERS

“Let food be thy medicine, thy medicine shall be thy food” Hippocrates

Most folk recognise a link between what they eat and how it can affect their physical

health. It can be easy to attribute physical ailments to what we have eaten –e.g.

responding to a sore stomach with - “was it something I ate?” - or knowing that a

tight waistband was due to over eating on holiday. However people don’t always

make this same link with mental health. But diet has a major role to play in

maintaining both our physical and mental health: what we eat can have a big impact

on how we feel. The majority of people have, at some point, used food and drink to

alter their mood, perhaps without even realising they are doing so, for example,

seeking mood altering products like chocolate, caffeine and alcohol to provide a

temporary boost.

43


However, food can impact on mental health and wellbeing in many more ways. The

impact of a poor diet can lead to decreased mood, lack of energy, decreased

concentration, decreased memory, tiredness, irritability and weight gain which may

contribute to feelings of low self esteem. It can also have a negative impact on

existing mental health conditions.

The Mental Health Foundation report “Feeding Minds” (2006) details the evidence

linking trends in our eating habits with mental ill health and proposes that nutrition

can play a key role in the treatment and prevention of mental health problems.

“We know that the brain is made up in large part of essential fatty

acids, water and other nutrients. We know that food affects how we

feel, think and behave. In fact, we know that dietary interventions

may hold the key to a number of the mental health challenges our

society is facing”.

As eating a healthy diet plays an important role in the prevention and recovery from

mental health issues, the reverse is also true – poor diet can make mental health

worse. This could include a lack of essential nutrients required to support our bodies

and brains. A literature review by the Scottish Development Centre (2010) explains

that;

“Essential Fatty Acids (specifically omega-3 and omega-6) help

structure brain cells, which aids communication in the brain, and

amino acids help create neurotransmitters like serotonin, which are

associated with feelings of happiness and contentment.”

Another factor to consider is the physical impact of some of the most common

mental health issues. Both depression and anxiety can have an impact on a person’s

appetite, making them very hungry or for some losing appetite altogether.

Depression in particular also causes a decline in energy levels, making the person

feel very tired and worn out. The impact of both changes in appetite and energy

levels for some people could make healthy eating particularly challenging and make

pre-prepared, potentially less healthy food seem more appealing.

44


It’s not just what we eat, it’s how we eat too

Mental health issues can leave people vulnerable and socially isolated. The health

benefits of preparing, cooking and eating healthy food can be more than just

physical: it can involve learning new skills, building confidence and can give people a

sense of achievement. It can also be a way of spending time with other people. In

this respect healthy eating can be used as a tool to reduce isolation and loneliness –

something else which can form a protective factor for mental health.

A recipe for mackerel

(from our Public Health Annual Report 2012)

Catching your own fish isn’t essential to this recipe; it just adds to the fun. The key to success

is sharing fresh, tasty food with friends and family; all pitching in and having a good time.

You will need:

• A bunch of friends, family, neighbours (preferably of different generations)

• A boat, fishing lines and some bait (alternatively you can use shop bought fish – but it

isn’t quite the same)

• To accompany the fish:

fresh veg

a little wine

laughter – to taste

Step 1: Catch your mackerel. Choose a fine day, take your friends and family off on the boat and catch your fish. Relax,

enjoy yourselves, have fun. Let the older generation teach the younger generation how to fish.

Step 2: Cook Prepare your fish in whatever way you want: add some seasoning, some spice or leave it as it

is. Barbeque on the beach, stick under the grill, fry in the pan - it’s up to you. All join in and

help cook the food.

Step 3: Serve Add some fresh veg, some tatties or brown bread. Serve with a small glass of wine if you like,

iced water for the bairns.

Step 4: Eat As step 1: relax, enjoy yourselves, have fun

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MOOD BOOSTING FOODS

The Mental Health Foundation has produced a Nutrients Table (2006) which details

some of the beneficial nutrients which could be missing in the diet of a person

experiencing various mental health issues. For example if you are experiencing

anxiety your diet may be lacking in Folic Acid, which can be found in foods such as

spinach, broccoli, avocado, cod, tuna, hazelnuts, and oranges. They have also

prepared a selection of nutritious recipes for mental health, available on their

website. A sample recipe is shown below:

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http://www.mentalhealth.org.uk/content/assets/PDF/159555/mhf-recipes.pdf


LOCAL EXAMPLES

There have been a number of local opportunities which have linked nutrition and

mental health.

Clients attending Annsbrae (mental health support service) were invited to participate

in Health & Wellbeing sessions with a focus on health improvement. Participants

chose the session topics based on their own areas of interest – these included

healthy eating and looking at things which promoted recovery and supported good

mental wellbeing. They were encouraged to use the education sessions to help them

set goals for change. For example: someone set a goal to eat more fruit by adding

some as part of their breakfast each day. Similar sessions have also been run with

the Young Mum’s group and Bridges Project.

Although not directly targeted at improving mental wellbeing, one to one

Counterweight sessions focus on lifestyle change through healthy eating and

exercise. Following these behaviour changes many anecdotal reports include “feeling

happier, more confident, more energetic” and “liking myself better”.

Keep Well Health Checks provide an opportunity for a range of topics to be

discussed; they can also provide an ideal opportunity to raise the link between diet

and mental health.

IMPACT OF POVERTY ON HEALTHY EATING AND MENTAL HEALTH

Healthy eating and good mental health complement each other well, and vice versa;

“Nearly two thirds of those who do not report daily mental

health problems eat fresh fruit or fruit juice every day, compared

with less than half of those who do report daily mental health

problems. This pattern is similar for fresh vegetables and

salad.” (Mental Health Foundation website)

Poor mental health is linked with higher rates of unemployment, low income and

poverty; these same factors can also make healthy eating more difficult.

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http://www.mentalhealth.org.uk/help-information/mental-health-a-z/d/diet/


“Even if I buy the food I can’t afford to

cook it, to cook a chicken in the oven it

costs me £4 but to buy a cheap

microwave dinner it’s like 12p. It all

gets to you, I worked all my life until I

got ill before I had to go on disability”

“If you’re no feeding yourself properly, you

start to get restless. It’s about your energy.

Depression is like you’re in a swimming

pool with a beach ball and all your

emotions and all your feelings are the

beach ball and you’re pushing it down and

you’re pushing it down. And that takes a

lot of energy, and people are just

knackered and they don’t know why.”

When it comes to healthy eating on a budget it is often suggested that people buy

items in bulk, batch cook several meals and freeze leftovers to be used later in the

month. Cooking in this method means that your price per portion actually works out

to be quite cost effective. However, if you already have a low income or are reliant

on benefits and/or food banks, the ‘up front’ cost becomes difficult to afford. For

some people getting around this could mean having to plan to gradually make

savings over a few weeks before they are able to afford to bulk buy items.

The Scottish Association for Mental Health published the “Worried Sick” report in

2014 detailing experiences of poverty

and mental health in Scotland. One

female from Glasgow explained why

living in poverty with a pre-paid

electricity meter affects her eating

choices:

.”

While a Glasgow male explained the

impact that poor diet has on his

depression:

In the first six months of 2015, Shetland has seen an increase in the use of food

banks; “the average number of Salvation Army food parcels dished out in Shetland

has been 33 – compared to 23 last year” (Shetland News, 2015). Increased use of

food banks and the rise in poverty was described as “bearing all the signs of a public

health emergency” by six senior public health experts in a letter to the British Medical

Journal in December 2013. (cited in SAMH,2014)

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http://www.shetnews.co.uk/news/11032-budget-will-push-vulnerable-islanders-into-desperation


People with mental health conditions which impact on their ability to work can apply

to claim Employment Support Allowance (ESA) from the Government. However

recent government benefit reforms mean that ESA will be cut by a third for new

claimants, reducing payments to £60 a week.

With the current state of play regarding poverty & food banks and recent benefit

reforms, we have to pay close attention to the potential impact on the mental health

of the public and subsequent needs regarding healthy eating. This may include

supporting people on a one to one basis to make healthier food choices, promoting

an understanding of the impact on diet on mental health, working with others in the

community such as Citizens Advice Bureau to support people to budget for healthy

eating and encouraging the provision of fresh fruit and vegetables to be included in

the packages provided by local food banks. The local Shetland Food Bank is

discussed further in the next chapter.

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References

Mental Health Foundation 2006 “Feeding Minds” [Online] Available from: www.mentalhealth.org.uk/content/assets/PDF/publications/Feeding-Minds.pdf?view=Standard [Accessed August 2015] Mental Health Foundation (2006) Nutrients Table [Online] Available from: www.mentalhealth.org.uk/help-information/mental-health-a-z/D/nutrients-table/ [Accessed August 2015] Mental Health Foundation (no year) Diet and Mental Health [Online] Available from: www.mentalhealth.org.uk/help-information/mental-health-a-z/ [Accessed August 2015] Mental Health Foundation (no year) Recipes for mental health [Online] Available from: http://www.mentalhealth.org.uk/content/assets/PDF/159555/mhf-recipes.pdf [Accessed August 2015] Scottish Association of Mental Health (2014) ‘Worried Sick: Experiences of poverty and mental health across Scotland.’ (cited from The rise of food poverty in the UK British Medical Journal, 3rd Dec 2013, cited in Holyrood Magazine The Cost of Hunger 16th Dec 2013) Glasgow: SAMH. [Online] Available from: www.samh.org.uk/media/417248/deprived_communities_report.pdf [Accessed August 2015] The Scottish Development Centre (2010) Literature review: evidence linking food and positive mental health and wellbeing. Food and Mental Health Bulletin [Online] Available from: www.communityfoodandhealth.org.uk/wp-content/uploads/2012/02/CFHS-SDC-food-and-mental-health-bulletin.pdf [Accessed August 2015] Ridell, N. Budget: vulnerable islanders facing 'desperation'. Shetland News Website [Online] Available from: www.shetnews.co.uk/news/11032-budget-will-push-vulnerable-islanders-into-desperation [Accessed August 2015]

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http://www.mentalhealth.org.uk/content/assets/PDF/publications/Feeding-Minds.pdf?view=Standard

http://www.mentalhealth.org.uk/content/assets/PDF/publications/Feeding-Minds.pdf?view=Standard

http://www.mentalhealth.org.uk/help-information/mental-health-a-z/D/nutrients-table/%20%5bAccessed

http://www.mentalhealth.org.uk/help-information/mental-health-a-z/D/nutrients-table/%20%5bAccessed

http://www.mentalhealth.org.uk/help-information/mental-health-a-z/%20%5bAccessed

http://www.mentalhealth.org.uk/content/assets/PDF/159555/mhf-recipes.pdf

http://www.samh.org.uk/media/417248/deprived_communities_report.pdf

http://www.communityfoodandhealth.org.uk/wp-content/uploads/2012/02/CFHS-SDC-food-and-mental-health-bulletin.pdf

http://www.communityfoodandhealth.org.uk/wp-content/uploads/2012/02/CFHS-SDC-food-and-mental-health-bulletin.pdf




CHAPTER 4

BUT WHY CAN IT BE SO DIFFICULT TO EAT HEALTHILY?

There are lots of reasons why we find it difficult to put all our knowledge about

healthy eating into practice. Even as health professionals, many of us struggle with

this ourselves!

Food choice is complex. Biologically we have to eat to survive but the reasons we

choose the foods that we do are influenced by lots of different factors (EFIC, 2004).

These include:

• Smell, taste, appearance of food

• Our own likes and dislikes; habits and customs

• Our own beliefs about food and diet (eg being vegetarian, organic food,

geneticially modified food; how certain food makes us feel)

• Medical problems (eg food allergies)

• Knowledge and skills( eg cooking skills)

• Cultural and religious beliefs and customs

• Social context (who we are eating with; special occasions)

• Availability and

• Cost.

The environment we live in, and the resources we have, can have a major impact on

what choices we make about what food to eat. Availability is a significant issue: we

can only eat what is available to us. If there are no fruit and vegetables in our local

shop, or if we don’t have transport to somewhere that sells them, or if we can’t afford

them – then how are we supposed to be able to get our ‘five a day’? And on the

other hand, if ‘unhealthy’ food is readily available and easy to access, why wouldn’t

we choose to buy that?

Not being able to prepare and cook food is also a barrier to a healthy diet. In the next

chapter we look at the difference in cost of a ready meal compared to a home cooked

meal. There is a significant difference in cost: but if you don’t know where to start

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with sautéing onions, or browning mince then you have little choice but to take the

expensive ready meal option, or live on snacks and takeaways.

We need to make sure in particular that the most vulnerable people in our

communities do have access to affordable food, and the skills to prepare and cook

that food. Especially as a poor diet may only be one of many factors in their lives that

affect their health.

As noted in the previous chapter, food can affect our emotions and food is often a

significant part of our social lives and relationships. Food plays a big part in many of

our traditions, celebrations and rituals. A romantic meal for two, Christmas dinner,

Easter eggs, and what would a birthday be without cake!

Many of the habits and preferences we have around food start in childhood and they

can be difficult to break or change as we get older. We talk about ‘comfort’ food,

defined by the Oxford English Dictionary as:

Food that provides consolation or a feeling of well-being,

typically having a high sugar or carbohydrate content and

associated with childhood or home cooking.

It is of course fine to have ‘comfort food’ occasionally. But it can become a problem if

we rely on food, especially with a high sugar content, to make ourselves feel better

most of the time.

Not only can it be hard to access healthy food, it can be hard to avoid

unhealthy food. An ‘obesogenic’ environment is one which encourages

people to eat unhealthily and to be inactive. This may be unintentional, and

as a result of trying to improve the environment for certain groups (e.g.

improving disabled access through installing lifts may inadvertently

encourage physically able people to take the lift instead of the stairs).

Walk down the Street, or go into a leisure centre, or community centre,

or Mareel or a youth club. What sort of food and drinks are often

displayed most prominently in shop windows, on the counters,

vending machines and tuck shops?

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VENDING MACHINES

A survey of Shetland Recreational Trust sites found that people tended to buy fizzy

drinks, sport and energy drinks, crisps,

chewy sweets and chocolate, and 60% of

respondents (316 people) were unaware

of any healthy options being available.

There was confusion about what

constituted a healthy snack, and nearly

70% of respondents said they would like

information on how much/what types of

exercise are needed in order to burn

calories.

And most people, especially children, do

not need a ‘Sports’ or ‘Energy’ drink to

rehydrate after exercise. They contain

water, sugar and salts to replace those lost

through sweating. But unless you are an

elite athlete, or doing hours of exercise,

then all you need is water.

A 500ml bottle of Lucozade ‘Sport’

(orange) from a leisure centre vending

machine contains 18g of sugar (over 3

teaspoons). A 380ml bottle of Lucozade

‘Energy’ (orange) contains 48g of sugar

(over 9 teaspoons). These drinks are often

bought as soft drinks rather than to rehydrate after strenuous exercise and sport.

There are far healthier ways of getting an energy boost than drinking ‘sugar water’ -

take a handful of nuts or a piece of fresh fruit.

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FOOD DESERTS

The term Food Desert was first documented in a 1995 report by the ‘Nutrition Task

Force Low Income Project Team’ of the UK Department of Health (Cummins, 1999).

It is defined as “areas of relative exclusion where people experience physical and

economic barriers to accessing healthy foods” (Reising, 2000) Although often used

to describe very deprived inner city areas, we are using it here to talk about places

where there is limited access to fresh ‘healthy’ food, such as in the most rural and

remote parts of Shetland.

The Health Improvement Team has been looking at the issue of food deserts locally

to see if there has been any change in the availability of fresh produce and what local

communities are doing to improve access to healthier foods. Yell is used as an

example to show what is happening locally to improve access to fruit and vegetables

in particular.

Peeling back the layers: Accessing fresh fruit and vegetables in Yell

There has, in general, been an increase in the amount of fruit and vegetables

stocked in the local shops and sold over the last two years. All shops in Yell stock as

wide a range of fruit and vegetables as possible and report that they sell an “awful

lot” with little wastage. They also try to stock Shetland produce, where possible. In

Yell the Kirkhoul strawberries are a prime example of this (customers have been

known to twirl in the shop isles with excitement when they see them!), Shetland

tatties and neeps are also popular. Seasonality is important to the shops; in addition,

they all take various steps to ensure that the produce is as fresh as possible before

even reaching the shelves.

Due to the rurality of the shops, certain fruit and vegetables can sometimes be out of

stock, particularly on days that fall between order and delivery. However, in these

circumstances it is likely to be back in stock the following day. All shops in Yell want

the community to be aware that if they want to place orders for fruit and vegetables

that they do not currently stock that they will happily get things ordered in. Each shop

has different order days so it would be wise for customers to check this with them

directly. Where items are in stock it is also possible for customers to place an order

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by phone and have them set aside. Tinned or frozen fruit and vegetables are always

there as an alternative option when fresh items are unavailable.

Growing Projects in Schools

Growing your own is a key part of education at the Yell schools.

Mid Yell School

Through community fund-raising a poly-tunnel was purchased by Mid Yell JHS a few

years ago and the addition of this to the growing area has led to an increased range

of produce being grown. The produce from the tunnel has been used in both school

snacks and meals and any surplus stock has been sold to the community through the

school. Crops have included; courgettes, peas, cucumbers, beetroot, tomatoes and

sweet corn. Strawberries

were particularly successful

with the original plants being

supplied for free by Kirkhoul

Strawberries. Plans are

already in place for a

second tunnel, thanks to a

successful bid from the

Climate Challenge Fund.

Once in place folk will have

the chance to rent a space

in the tunnel. The fund has also supported a composting project, where 40 bins were

made available to households across Yell, with the compost being returned for use in

the school poly tunnel. The bins have been popular and are being used right across

the isle. The school also see it as important to hand down traditional growing

techniques before mechanisation, and with help from a local crofter they have

learned hands-on about growing and harvesting grains.

Cullivoe School

As part of their ongoing work to develop their School Grounds, Cullivoe School

created a vegetable patch where they grow neeps, tatties, onions and carrots. The

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children are responsible for the planting, caring for and harvesting. The produce is

used in a number of different ways;

• Pupils make soup which they share with the local community at a coffee

morning.

• They eat the produce as part of their snack and lunch.

• They sell vegetables to parents – sales of fruit and vegetables are good.

They also have a poly-tunnel for growing less traditional things e.g. cucumber,

strawberries, tomatoes. This gives the children an opportunity to experiment with

what grows best indoors or out, and to see fruits and vegetables which they wouldn’t

be able to grow outside. As the growing season goes through the summer holidays

each family is asked to weed and look after the Poly-tunnel which needs watered

daily. In return they are welcome to use any produce which is ready at that point.

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The school is involved with Crofting Connections which is a programme that helps

children to live in a more sustainable way and highlights traditional skills. This has

involved growing traditional crops and Shetland Oats. They have undertaken soil

sampling and worked out what needs to be added to the soil to help things grow.

They are an organic garden so add natural fertilisers to the ground e.g. seaweed.

Cullivoe School gives all children the opportunity to be involved in the garden as part

of their school life. The idea is that over the seven years they become more confident

and knowledgeable in the processes and are more likely to continue with growing

their own food as adults because they are aware of the benefits and they know how

to do it.

Can every school in Shetland ‘grow its own?’

Burravoe School

The pupils of the Burravoe School share their views on the benefits of having a

school garden:

I think having a school garden helps children experience being responsible for caring

for a garden. I like being able to grow and eat our own crops. It helps us realise that

the vegetables we buy have to be grown too and not everything comes easily. It

improves our knowledge of how long it takes vegetables to grow and what they look

like as seeds. We can compare the different varieties and eat food fresh. Kerry P7

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I enjoy having a garden because it keeps me healthy and I get plenty of fresh air. I

also love picking and eating peas and I really like harvesting and eating totties. Honor

P6

The way you can get fruit and vegetables in Yell is you can grow your own. You can

also get other benefits from gardening: you can interact with other people you can

also get fresh air and exercise. Phoebe P6

I really enjoying having a garden because we can pick the peas and gooseberries. It

gives us fresh air. It gives us fresh fruit and veggies that help our inside. It improves

our health and muscles. Bradley P6

Gardening is good for you because when you go outside for gardening you get fresh

air. Also you get fruit and vegetables. At our school we grow things like beans, peas,

carrots beetroot and gooseberries. My favourite part of gardening is delling up the

totties. Abby P5

Gardening is good for you because it’s healthy. Even fresh air is healthy for you. Neil

P4

Gardening is good for you because you get fresh fruit and vegetables. You can have

fun as well picking them. Rosie P4

When you grow vegetables you pick and you eat them. It’s good for your brain and it

gives you enough energy. Emer P3

I like gardening. I will get energy. Sofia P2

Gardening is good for you, it

makes you strong. It is good for

your brain and your bones and

it gives you energy.

Vegetables is good for you.

Hannah P2

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FOOD POVERTY IN SHETLAND

Contributed by the Lerwick Salvation Army

The Salvation Army has been working in Shetland for over 115 years now and has a

long tradition of helping people in need. We run an emergency feeding programme

providing food parcels for folk who find themselves in a crisis and unable to buy food.

The food is donated by the churches and the community and through events like

Tesco FareShare and harvest collections in schools.

The myths and the truth

Myth #1 There is no poverty or food poverty in Shetland – sadly we see two

types of food poverty: people in short term crisis who have no food and people who

can’t afford to eat healthily on a day to day basis.

Myth #2 Anyone can turn up and ask for a food parcel – 95% of parcels are given

to clients who have been referred by a service provider.

Myth #3 Every food parcel client has a substance misuse problem – people of

all ages and backgrounds need food parcels; only a tiny proportion have an addiction

issue.

Myth #4 Every food parcel client is on benefits – many of our clients are in work,

some are pensioners, some are sick or disabled. We feed individuals, couples and

families.

Myth #5 People who get food parcels got themselves into this mess and don’t deserve any help – no one should be hungry and no one chooses to find

themselves in this position.

Myth#6 There are two kinds of poor person, deserving and undeserving –every

person is unique and precious, equally worthy of being treated with dignity and

respect.

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Common questions, and some answers

Who refers clients for parcels?

SIC social work, housing and finance departments; NHS community mental health,

health visitors, practice nurses; CAB, CADSS, Bridges, Through Care and After

Care, MP/MSP’s office, Women’s Aid, Job Centre Plus, British Red Cross, Shetland

College, Bruce Family Centre, Annsbrae, employers and Advocacy. We also feed

people who live in their own homes and don’t have connections with any of the

above.

How many food parcels are distributed in Shetland?

The table below shows how our work in this area has increased since 2011.

Food Parcel Statistics 2011- 2015

Year Total Number per

month

2011 * 38 8

2012 163 13.5

2013 268 22.3

2014 283 23.6

2015 ** 178 29.7

*Partial year: August to end December

**Partial year: January to end June

The table shows a steady increase, in particular for 2015. Although these figures will

not yet include the increase in the number of parcels given out at Christmas, they

would probably add another 4 per month on average.

Why do people need a food parcel?

There are a whole host of reasons: waiting for benefits is the most common – it can

take 5 – 6 weeks for a new benefit claim to be processed. Other reasons include:

homeless and newly arrived in Shetland, benefit sanctions, relationship break-up,

high Hydro bills, paying back a crisis loan, moving into a new property, no income,

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mental health problems, monies lost or stolen, Statutory Sick Pay (SSP) after full

pay, learning difficulties, addiction ( we won’t provide emergency relief on a regular

basis), fines and deductions, needing new clothes for hospital stay, debts or loans,

poor budgeting ( we offer help with this), under-claiming or not claiming benefits or

pension to which entitled, phone and broadband bills (misleading tv adverts about

phone/broadband costs), ferry and bus fares to attend appointments and inability to

pay up front for a cheaper, multi-journey ticket, cost of having to spend a whole day

in town to attend an appointment; needing to eat and drink and somewhere to keep

warm until the bus back at tea time, needing to hire a car or use a taxi to get to the

hospital or doctors’ surgery, TV licence debt, birthday or Christmas gifts for children,

illness, retiring, loss of possessions in house fire, payday loans etc., debt, diabetic /

special dietary needs, access visits to children/family/ court/hospital south, long term

low income (unable to have a financial cushion for emergencies), bank charges and

over draft, partner done a runner with all the money, recently out of hospital or prison

or rehab, started employment but not been paid yet.

What’s in a food parcel and why?

A food parcel is designed to last for a week and usually contains the following: tea,

coffee, dried milk, two tins fruit, tinned rice pudding and custard, cereal, pasta, rice,

sauce, three meals in a tin; tinned carrots, potatoes, sweet corn, peas and tomatoes;

four tins of soup, two of baked beans, some tuna or tinned meat, biscuits, bread,

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butter and cheese, and basic toiletries (soap, shampoo, tooth brush and toothpaste,

deodorant, toilet roll and a couple of laundry tablets). A food parcel like this is worth

approximately £50. Quantities are increased for couples and families as needed.

We give a parcel lasting a week because that’s the least most people need and it

helps them to get back on their feet. Toiletries are important – keeping clean helps

people to feel better about themselves and helps them to look presentable if they are

job hunting.

How does food poverty affect people?

We know that some people are so reluctant to ask for help that when they come to us

they have often not eaten properly for a few days and have nothing left to eat in the

house and no (or very little) money. This is of particular concern when the person

has a medical condition, or when parents have been going without food so their

children can eat. In crisis situations people are definitely going without the food and

nourishment they need. On a more regular basis people on benefits or a low wage

cannot afford to eat healthily – particularly in relation to getting the five to nine

servings a day of fruit and vegetables as recommended by the World Health

Organisation (WHO). Recently a bag of 24 packs of crisps (a well-known brand) was

£3 and a pack of six apples £1.80 – it’s not difficult to see what people on a tight

budget will buy as snacks. We know that poor diet causes many long-term health

problems and doesn’t give children the right start. When people are in a permanent

struggle to make ends meet their quality of life is seriously diminished, they feel

socially excluded and their mental and physical health often suffer.

Three wishes for change:

• milk tokens and multi-vitamins to be issued with any working-age benefits

• fruit and veg schemes for families

• a card-system of paying for school meals to get rid of the stigma of free meal tokens

Information compiled by Lerwick Salvation Army July 2015 ©

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References European Food Information Council (EFIC) ( 2004) Why do we eat what we eat: Food choice - a complex behaviour [Online] Available from: www.eufic.org/article/en/artid/food-choice-complex-behaviour/ [Accessed September 2015] Cummins S, Macintyre S (1999). The location of food stores in urban areas: a case study in Glasgow. British Food Journal 101 (7). pp 545–53. Reising Vmt, Hobbiss A (2000). Food deserts and how to tackle them: a study of one city's approach". Health Education Journal 59 (2). pp 137–49.

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CHAPTER 5

TAKING ACTION!

A TAX ON SUGAR?

There is a lot that individuals can do to manage their weight; cutting down on sugar is

part of that. Professionals such as doctors also have a role, and there are a number

of actions that governments can take:

A prescription for tackling the growing crisis in obesity in the UK:

• Ban advertising of food high in saturated fat, sugar and salt before 9pm

• Traffic light food labelling and visible calorie counts, especially for fast food outlets

• Reduce the number of fast food outlets that are close to schools, colleges, leisure

centres and other places where children gather

• Increase the price of sugary soft drinks by at least 20% by taxing them. Try this for one year to see what the impact is.

The idea of a ‘sugar tax’ has polarised opinion.

Against a sugar tax

The Institute of Economic Affairs is thoroughly

opposed to a sugar tax. In their article ‘Resist

Temptation: a sugar tax won’t make us healthy’,

they argue that the reason campaigners prefer to

‘focus on specific components, rather than the

whole diet, is that it enables them to extend the

anti-tobacco blueprint of sin taxes and hyper-

regulation to the food we eat’.

A 2014 study asked people who sold ‘fast food’

near secondary schools in Scotland what they thought about a sugar tax. They

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tended to be strongly against this approach because they felt that it would be an

unfair burden on small business (Estrade, 2014)

They also felt that any increase in price might drive their young customers to buy the

more expensive foods elsewhere.

In favour of a sugar tax

Public health professionals would argue that

increasing taxes on tobacco was one of a number of

actions that has contributed to the reduction of

tobacco use in this country. NHS Health Scotland

described policies that use regulation and price (for

example, minimum unit price or taxes) to reduce

risky behaviours as being one of the six ‘best

investments’ for preventing poor health, and

reducing health inequalities (Craig, 2014)

In December 2014, the UK Health Forum submitted

a report to the Health Committee. This asked the government to explore the use of

taxes on unhealthy foods (starting with sugar sweetened beverages), to help people

who want to change their behaviour and consume less sugar; and also as a means

of raising funds to spend on prevention and improving health.

“I don’t think that is gonna do

anything [for obesity]. It’s just

gonna affect our business. You

know, because they’ll maybe

not buy it from here, but they’ll

get it cheaper at the

supermarkets”

“Supermarkets can absorb it. We

can’t. We can’t absorb that kind of

tax. It’s crazy. I can’t see how that

would influence obesity”

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What do other countries do? (WHO, 2015)

Country Tax on... Impact

Denmark Tax on saturated fats In the short term consumption of some products

dropped by 10-15%. But there were unconfirmed

reports of cross-border shopping, job losses and

reduction in profits for producers.

Finland Tax on sweets, ice

cream and soft drinks

Reported decrease in consumption of sweets and

soft drinks in 2011 and 2014, but no formal

evaluation.

Hungary Public health product tax

(sugar-sweetened

beverages, energy

drinks, salted snacks,

alcohol with high sugar

content)

There was a reduction in the consumption of these

products. Some products were changed to reduce

the sugar content. However population surveys

and estimates suggest a decrease in consumption

of some nutrients.

France Tax on sugar and

artificially sweetened

beverages

After years of increasing sales, an immediate drop

was recorded

The WHO report Using price policies to promote healthier diets (2015) concluded that

taxes on less healthy foods and drinks can influence how people shop and what they

eat. This can result in a significant impact on important dietary and health-related

behaviour. They also noted that the money raised through taxes has, in some cases,

been successfully ring-fenced for the health budget.

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EARLY NUTRITION: HEALTHY START

The what, why and where

As described in previous chapters, sometimes it can be hard to eat healthily even

when we know we should. And even though you can get lots of vitamins from a

healthy balanced diet, you still might not get everything you need at certain times in

your life – like when you’re pregnant, a new mum or a small child. Healthy eating can

be even more difficult if you don’t have easy access to a healthy diet, or can’t always

afford it. These are some of the key vitamins:

Healthy Start is a UK wide Government scheme which aims to improve health by

supporting pregnant women and families on a low income to access healthy foods.

Healthy Start replaced the Welfare Food scheme in 2006 and has aimed to provide a

nutritional safety net for vulnerable families by giving them the opportunity of the best

start in life. Women who are at least 10 weeks pregnant and families who have

children up to their 4th birthday can receive Healthy Start if they receive:

• Income Support, or

• Income-based Jobseeker’s Allowance, or

• Income-related Employment and Support Allowance, or

• Child Tax Credit (but not Working Tax Credit unless the family is receiving

Working Tax Credit run-on only*) and has an annual income of £16,190 or less

(2014/15)

Vitamin D

• Helps our bodies absorb calcium to keep bones healthy

• Found in oily fish, eggs, fortified cerals and sunlight

Vitamin C

• Keeps you generally healthy

• Body doesn't store it so you need to eat it every day

• Found in fruit & veg - peppers, broccoli, kale, sweet potato, oranges

Vitamin A

• Helps maintain health of skin and mucus linings (like your nose)

• healps immunity against infections

• helps vision in dim light

• found in cheese, eggs, oily fish, milk and yoghurt

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Pregnant women who are under 18 at the time of applying to Healthy Start qualify for

the whole of their pregnancy even if they are not in receipt of any of the above

benefits. (Healthy Start, 2012)

Women can apply for Healthy Start when they are 10 weeks pregnant by completing

an application form which must be signed by a registered health professional

(midwife, health visitor, nurse or doctor) and posted to the Healthy Start Issuing Unit.

The reason for needing a health professional’s signature is to promote early contact

with local maternity and child health services. This provides an opportunity for health

professionals to offer appropriate health, nutrition and lifestyle information. In this

way the scheme links with broader public health priorities.

So what does Healthy Start actually provide?

Healthy Start vouchers every 4 weeks

• Pregnant mum (>10 weeks) - £3.10 per week

• For each baby under one year - £6.20 per week

• For each child aged between one and four years - £3.10 per week

Vitamin Coupons every 8 weeks

• Vitamin tablets - for pregnant mums and those with babies under a year old

• Vitamin drops - for children aged six months to four years

The vouchers can be used to buy milk, plain fresh and frozen fruit and vegetables,

and infant formula milk and coupons can be exchanged for vitamins in participating

shops and pharmacies.

Uptake of Healthy Start in Shetland had been relatively low: between 50 – 60%

compared to the rest of Scotland where most places reach 70% or more. As part of

the Maternal and Infant Nutrition Steering Group the Health Improvement

Department has been working alongside Maternity and Child Health Services to

provide training and awareness to the key health professionals on promoting Healthy

Start. Alongside this the Health Improvement Department have been engaging with

all 33 local shops to increase their registration with the scheme to accept Healthy

Start vouchers.

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The main concerns professionals had to raising healthy start were:

It will ruin my

relationship with the family

Not my job to pry about

money

They’ll think I’m judging

them

I don’t know how it works

Don’t know how to ask

about reading/writing

They seem well off – they won’t

be eligible I don’t have time – more important

things to ask about

Someone else will

have asked already

Local shops

won’t take vouchers

With many of the concerns being about welfare issues the training was widened out

to include CAB who were able to provide a comprehensive overview of their service

and give professionals the confidence to both raise the issue of benefits and refer

appropriately.

It is important the Healthy Start is revisited at key stages through pregnancy, after

birth and up to the child going to school, as we understand that circumstances can

and do change from the original plan at prenatal or postnatal to when the child

reaches the age of four.

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Therefore it is paramount that health professionals have the confidence to raise and

promote Healthy Start to ensure those who are eligible have the option to claim their

vouchers and coupons to make a real difference to their shopping bills.

A family who are able to claim Healthy Start from 10 weeks of pregnancy up to that

child’s 4th birthday can receive nearly £900 in total towards healthy eating. We know

that good nutrition during pregnancy, breastfeeding and in early life is vital for the

health of women and children. Adequate nutrition during pregnancy and

breastfeeding optimises health and development outcomes for children. To tackle

health inequalities we need to ensure that those with the greatest need have enough

income to be able to maintain a good level of health and nutrition.

CHALLENGING THE MYTHS

Obesity rates are continuing to increase worldwide, and unfortunately Shetland is no

exception to this. In Shetland, the 10 year Obesity Strategy plan has been set out to

‘inform and provide clear actions in order to both prevent and treat obesity’.

To achieve this we need to take account of a number of factors such as making sure

people have the skills to make informed choices around healthy eating. The many

food myths and conflicting health messages that circulate can make the job of picking

healthy foods quite difficult. As described in chapter 2, the Eatwell plate shows us

the different types of food that make up our diet, and shows the proportions we

should eat them in to have a healthy, balanced diet. However, clever marketing,

branding techniques, ‘diet fads’ and common myths and misconceptions can all add

to the confusion around trying to make these healthy food choices. This section aims

to explore one or two examples of these and address some common food myths.

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Value Line Foods vs. Branded Foods

We can be misled by how a product is branded, its packaging and/or any nutritional

claims it may have. Some shoppers may think that because supermarket value

brands are cheaper than brand name products, they will be of poorer nutritional

quality. However research has shown that as well as providing the same nutritional

goodness as branded products, value line foods also provide excellent value for

money.

Case Study One

S. Cooper and M. Nelson compared the nutritional content and cost of ‘Economy’ line foods

from four supermarkets and brand name equivalents. From this study they concluded that,

Economy line foods had a nutrient composition similar to and often better than the branded

goods. The economy line products frequently had nutrient contents more in line with the

Balance of Good Health (e.g. lower fat and sodium) compared with the branded goods. In

terms of nutrients per pence, the economy line products were far better value for money

compared with the branded lines. (Cooper, 2003)

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Case Study Two Suffolk Trading Standards found that by making changes to buy value apple juice, self-

raising flour and cheddar cheese families could make a potential saving of £1.49 a week or

£77.48 a year. No difference in the food content of these products was found.

(Maden, 2010)

Frozen vs. Fresh

Living on a remote island such as Shetland may sometimes mean that it can be

difficult to always have access to fresh foods, such as fruit and vegetables. When it

comes to food products which are frozen, canned and dried there is evidence to

show that these foods can be just as good for us nutritionally as fresh foods.

Case Study 3

A study carried out by D.J Favell (1998) which compared the vitamin C content in fresh

vegetables at various stages of distribution and storage, with the same vegetable

commercially quick-frozen and stored deep frozen for up to 12 months, found that, The

nutrient status of frozen peas and broccoli was similar to that of the typical market-purchased

vegetable and was superior to peas that have been stored in-home for several days. Fresh

peas and broccoli retained their quality for up to 14 days when stored under chill conditions.

The nutrient status of frozen whole green beans and frozen carrots, with no loss on freezing,

was similar to the fresh vegetable at harvest. Frozen spinach also compared reasonably well

with the harvested fresh vegetable and was clearly superior to all market produce.

Misleading food labels

In chapter 2, we looked at the importance of food labelling and how to make sense of

the labels.

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Case Study Five

This is another example of nutrition claim which could

potentially be misleading. This product states that it

contains 25% less salt than compared to the original

product. However, because the original product is very

high in salt, even 25% less means that the reduced salt

option remains a

high salt product

with 1.3g of salt per

100g.

Ready Meal vs. Home cooked: Which is cheaper?

Many people feel they don’t have time to cook, or don’t have the skills to cook a meal

and so may look to ready meals in order to get food on the table quickly. As well as

a popular choice for single-person households, ready meals may also appeal to

working families and couples as a quick alternative to cooking from scratch. And

Case Study Four

This is an example of a product

which may sound like a good option

to put in your basket, a low fat

yoghurt. However, if you are to look

at the nutrition label on the back you

can see that this low fat yoghurt

contains 17g of sugar per 100g, actually making it a high

sugar product.

73


ready meals may appear to be a cheaper option than buying all the ingredients for a

meal. However, this is not always the case, a cheap and time-saving solution is to

cook in bulk and freeze the leftover portions. This can help in reducing the cost of

each meal and can be a healthier way of making dinners that are quick to prepare.

Case Study 6 Ready meal* costs £2.39 for one serving Supermarket Italian Spaghetti Bolognese 450g Home cooked* costs 87p for one serving 60g spaghetti (Supermarket everyday value @ 60p for 500g): 7.2p

100g beef mince (Supermarket @ £3 for 750g): 40p

200g Tinned tomatoes (Supermarket everyday value @ 34p for 400g): 17p

¼ fresh onion (@16p for one onion): 4p

1 clove fresh garlic (@ 30p per bulb / 10 cloves): 3p

½ tsp / 2.5g dried mixed herbs (Supermarket own brand @70p for 14g): 12.5p

1 tbsp / 15 ml vegetable oil (supermarket brand @ 75p for 500ml): 2.5p

In this case, a home cooked portion of spaghetti bolognaise is £1.43 cheaper than the

readymade version.

Clearly you have to buy larger quantities of ingredients than needed for one portion. If you

bought every ingredient on the list it would cost: £5.22. This would give you enough for two

portions plus lots of ingredients left over. If you bought an extra onion and three more tins of

tomatoes, that would give you eight portions (using slightly less mince - 750g rather than the

recipe’s 800g) and cost £6.06, and still leave some ingredients for another meal. Eight ready

meals would cost £13.80.

*These costs were taken directly from the website of a local supermarket: accessed 09/09/2015.

74


WE ARE EQUAL PROJECT

Healthy eating is important for everyone, and it can be tricky to get it right. There is a

lot of information out there about how much we should eat, what is good for you and

what is not good for you. Trying to take in all this information and make sense of it all

isn’t easy.

For people with learning disabilities, who need support with communication, knowing

how to eat healthy can be really difficult. Quite often, people with communication

difficulties rely on family, carers and health care professionals to explain how to stay

healthy in a way they can understand. This can be a problem if family or carers

themselves are not aware of how to have a healthy diet, or if health care

professionals are not aware that the person needs support in understanding how to

eat healthily. This is one reason why people with learning disabilities are more likely

to become overweight or obese, and as a result are at a higher risk of developing

health conditions such as type 2 diabetes, cardiovascular disease and high blood

pressure.

Supporting people with learning disabilities to become healthier is a key focus of the

Scottish Government, so they released money to help achieve this. We joined forces

with the Shetland Islands Council and were successful in securing some of this

money, using it to set up the We Are Equal Project.

Our aim through We Are Equal was to help the learning disability population in

Shetland become healthier by supporting good communication.

What We Did

Training

One of the biggest barriers to good communication is not knowing or understanding

about why and how we should adapt our communication for people with learning

disabilities. With this in mind, we designed a training programme on how to

communicate well with people with learning disabilities. In the training we covered the

importance of good communication, and gave examples of different ways to

communicate to help understanding, such as using visual aids. We also showcased

resources available to support communication, including easy-read resources on

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healthy eating and an Eatwell plate activity, with food symbols to put in the right

sections of the Eatwell plate. The training was mostly aimed at front-line staff, but

carers, family and members of the public were also welcome to attend. The training

was really well attended, and people told us that it helped their understanding, made

them more confident about communicating with people with learning disabilities and

helped improve their own communication. We hope to continue to deliver the training

through our NHS Shetland Staff Development Department.

Volunteers

Three volunteers from the learning disability community came forward to help with

the project. The volunteers were heavily involved from the start. They chose to have

input to the training by creating a poster presentation which they delivered at training

sessions. As the volunteers were unable to attend all of the sessions, we decided to

video their presentation so that all who attended the training would be able to see the

volunteers’ presentation.

As the delivery of training came to a close, two of the volunteers decided they wanted

to take direct action to help their community become healthier. They designed

“Healthy Workshops” which were peer-led workshops that we arranged to be trialled

through Adult Services Supported Living and Outreach. The volunteers chose three

topics they felt were the most important to cover; Healthy Eating, Keeping Fit and

Staying Happy. The workshops were very interactive, and the volunteers used props

from Health Improvement e.g. common foods with the sugar content displayed in

sugar cubes, for the Healthy Eating workshop. This workshop also included blind-

folded tasting sessions where participants tried to guess what healthy food they

tasted. Overall, the Healthy Workshops were a great success, with around 10 people

attending each session. The workshops are to be continued through the Supported

Living and Outreach department of the Council.

Website

Technology is moving quickly, and online sources of information are often more

accessible for people with communication difficulties. For example, videos, audio files

and interactive sources of information can all support understanding about complex

issues like how to stay healthy. We wanted to include an online hub of accessible

76


health information as part of the project. With the help of NB Communication, we

created a brand new, easy-read website full of local health information. We chose the

name Healthy Shetland to give a local and less corporate feel. The website will allow

us to use more images, videos and sound clips to help provide local health

information in a way that everyone can understand.

Communication Toolkit

Finally, we created the Communication Toolkit – a toolkit of symbolised resources to

help support communication with people with learning disabilities. The toolkit comes

in the form of an attractive orange ring-binder, and all the tools are adapted and

tailored to suit whoever requests a copy. The toolkit includes visual timetables,

symbols, charts, Talking Mats, as well as information about signing, sensory

referencing and other ways to communicate. We have made up toolkits for

professional teams and departments (including Dental Services, Pharmacy,

Audiology, Shetland Befriending and more) as well as for individuals. The feedback

from the toolkits has been excellent, and we hope that they become widely used

throughout Shetland.

Keep Well – Measuring Impact

One way to measure the impact the We Are Equal project has had, is to see how the

health of the learning disability community changes over the years following the end

of the project. In order to do this, we decided to offer Keep Well Health Checks to the

learning disability community. Keep Well is a Scottish programme that aims to

improve the health of individuals who we know have the poorest health in the

country. Through the Keep Well Health checks, we hope to gain a baseline of the

health of the learning disability community with which to compare future measures in

2 years time. In addition, the health checks can highlight any health issues, raise

awareness of good health and support individuals to follow up issues with their GP,

or think about changes they could make to improve their health.

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TACKLING OBESITY: LOOKING TO THE FUTURE

Prevention is the key to tackling the obesity epidemic and to make this happen we

need a focus on healthy eating, physical activity and reduction of sedentary time. And

these are the same priorities we need to take action on to help people who are

overweight overcome their problems and get back into a healthy lifestyle.

Within NHS Shetland we offer the Counterweight programme for people with a BMI

of over 25. This is a lifestyle programme which provides people with the skills and

information they need to make healthy food and lifestyle choices, and to increase

their activity levels gradually in a way which will they will be able to build on and

maintain for life.

Since we changed the way the Health Improvement team works to be based in

localities, we are seeing a very positive uptake of the Counterweight programme by

people living in communities throughout the whole of Shetland. By continuing to

deliver this programme we hope to be able to continue to equip people with the

nutritional knowledge as well as the skills they require to be able to understand what

a healthy diet is and how they can achieve this, to reduce levels of obesity in our

local communities and to prevent people from becoming obese in the future.

The Health Improvement Team is also able to offer an evidence based childhood

obesity treatment programme, SCOTT, to families. This programme focuses on

working with parents and children together in order to make healthy lifestyle changes.

The team are also now better placed to link with schools throughout Shetland and

have been delivering educational sessions to pupils of all ages, from nursery right

through to secondary school, with focus on nutrition and exercise, amongst other

health improvement topics. Giving children and young people the information and

facts around good nutrition at a young age, and the skills to eat healthily, will

encourage and empower them to make positive choices in the future.

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References

Academy of Medical Royal Colleges (2013) Measuring Up: The Medical Profession’s Prescription for the nation’s Obesity Crisis. London: AMRC. Cooper S and Nelson M. (2003) Economy’ line foods from four supermarkets and brand name equivalents: a comparison of their nutrient contents and costs. Journal of Human Nutrition and Dietetics .16 (5) pp 339-347 Craig, N (2014) Best preventative investments for Scotland – what the evidence and experts say. Edinburgh: Health Scotland. Estrade, M. (2014) A qualitative study of independent fast food vendors near secondary schools in disadvantaged Scottish neighbourhoods. BMC Public Health 14:793 Favell,DJ. (1998) A comparison of the vitamin C content of fresh and frozen vegetables. Food Chemistry 62 (1) pp59-64 Healthy Start (2012) Healthy Start Website [Online] Available from: www.healthystart.nhs.uk/ [Accessed July 2015] NHS (2007). The Eatwell Plate. Available at: www.nhs.uk/Livewell/Goodfood/Pages/eatwell-plate.aspx [Accessed: July 2015] NHS Shetland (2012) NHS Shetland Public Health Ten Year Strategy (2012-2022) ‘Changing the World’. [Online] Available from: www.shb.scot.nhs.uk/board/meetings/2012/20120626-2012_34.pdf [Accessed June 2015] Maden,S. (2010). 'Value' supermarket brands as good as standard – study. Moneysavingexpert.com [Online] Available from: www.moneysavingexpert.com/news/shopping/2010/08/value-supermarket-brands-as-good-as-standard [Accessed July 2015] Snowden, C.(2014) Resist Temptation: a sugar tax won’t make us healthy Institute of Economic Affairs [Online] Available at: www.iea.org.uk/blog/resist-temptation-a-sugar-tax-wont-make-us-healthy [Accessed April 2015] WHO (Europe) 2015 Using price policies to promote healthier diets. Copenhagen: WHO. [Online] Available from: www.euro.who.int/__data/assets/pdf_file/0008/273662/Using-price-policies-to-promote-healthier-diets.pdf?ua=1 [Accessed July 2015]

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http://www.healthystart.nhs.uk/

http://www.nhs.uk/Livewell/Goodfood/Pages/eatwell-plate.aspx

http://www.shb.scot.nhs.uk/board/meetings/2012/20120626-2012_34.pdf

http://www.moneysavingexpert.com/news/shopping/2010/08/value-supermarket-brands-as-good-as-standard

http://www.moneysavingexpert.com/news/shopping/2010/08/value-supermarket-brands-as-good-as-standard

http://www.iea.org.uk/blog/resist-temptation-a-sugar-tax-wont-make-us-healthy

http://www.iea.org.uk/blog/resist-temptation-a-sugar-tax-wont-make-us-healthy

http://www.euro.who.int/__data/assets/pdf_file/0008/273662/Using-price-policies-to-promote-healthier-diets.pdf?ua=1

http://www.euro.who.int/__data/assets/pdf_file/0008/273662/Using-price-policies-to-promote-healthier-diets.pdf?ua=1

Documents

Shetland Public Health Annual Report 2015 Food...Mood boosting foods 46 Local examples 47 Impact of poverty on healthy eating and mental health 47 BUT WHY CAN IT BE SO DIFFICULT TO