Category: Exercise, Nutrition and Health Sciences

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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