Food & Nutrition Susnet: Mental Health Perspectives on Sustainable Food & Nutrition

Speaker Bio: Jo-Anne Smith RD, Consultant Dietitian (Clinical Academic)

Jo has been working as a Registered Dietitian within the NHS for over 25 years after qualifying in 1997 from Leeds Metropolitan University. She gained a MSc in Evidence Based Practice in 2008 and is currently studying part-time for a PhD in Nutrition at Teesside University. Jo was Head of Dietetics at Tees, Esk and Wear Valleys NHS Foundation Trust for 15 years and previously chaired the Mental Health Specialist Group of the British Dietetic Association (BDA). She currently works as a Consultant Dietitian (Clinical Academic) jointly between the NHS and Teesside University and is Chief Investigator on several NIHR research grants. Jo has a specialist interest in food insecurity, obesity, health inequalities, dietary intakes, and the eating behaviour of people with mental health conditions. Jo also embeds sustainability into her work, in line with current BDA policy.

Website: https://research.tees.ac.uk/en/person…

Twitter: @Jo_AnneSmith

Thank you very much for inviting me along today to speak. It’s an absolute honour to be here, and it’s lovely to be working with Avril again after working together when I was a student. So, yeah, it’s lovely to be here. Avril has already introduced me, but I’m Joe Smith and I’m a consultant dietitian. So I’ve got a joint post now working between Tees, Esk and Wear Valleys NHS Farm Trust, which is a very large mental health trust, which covers pretty much most of the north of England, so from kind of Durham down to the Selby area and right across that coast, so a large trust, and I also work two days a week for university, so. And I’m here today to talk to you about some of the work that I’ve been doing around mental health and sustainability and nutrition, and I’m particularly going to focus on a couple of projects that I have been working on, a couple of research grants. So, first of all, just to tell you a little bit about what you’re going to learn today. So hopefully, by the end of this talk, you will have a better idea about food insecurity for people with severe mental illness in particular. That’s my own specialist area of research, is particularly working with people with severe mental illness. So hopefully you’ll be able to understand the complexity of the issues around food insecurity, but also some of the work that we’re currently doing in Middlesbrough looking at surplus food waste and how we’re hoping to redistribute that. So hopefully, by the end of the talk, you will have achieved all of those learning outcomes. So, first of all, just a little bit about food insecurity. Obviously, it’s really topical at the moment, it’s in the press nearly every day, particularly around the rise in food prices and energy as well. But the official definition isn’t just about access to food, enough food to meet your nutritional requirements, it’s also about having enough food to meet your dietary requirements. So that’s specifically any allergies, any cultural requirements, but also your social needs. So eating out, eating with others. So it’s an all encompassing kind of definition. Sometimes it’s called food poverty, and sometimes it’s even referred to as food security. The latest stats from the Food foundation showed that there were 18% of households in the UK, and that was 9.7 million adults experiencing food insecurity. And that was the last time. I think it was July 2021. And we also know that people who have a disability, whether that’s a physical health condition, or a mental health condition are up to five times more likely to experience food insecurity than those who don’t have a disability. And also, as I’ve mentioned, fuel poverty is another really key issue at the moment in the UK. So in 2022, we know that there were almost 14% of homes in the UK who were experiencing fuel poverty, and that’s down to the rising price of fuel. We know that’s coming down a little bit, but it still remains quite high and is a real issue from the research that we’ve done. So, just to put it into context, there’s the latest stats from the Food Foundation. I’m focusing mostly today on adults, but it is really important to think about the children as well in this. So 4 million children are living in a household with food insecurity. So what impact does food insecurity have on your diet? As you can imagine, it has a huge impact on people’s diet quality. And we know there’s a huge price disparity. This was back in 2014, so it’ll be much higher now, but between healthy foods and unhealthy foods. So, as you can imagine, the unhealthy foods, the high carbohydrate, high fat foods, tend to be cheaper than the healthy products. Your fruit, your vegetables, your high quality proteins, they tend to be much more expensive. And the latest version of the broken plate model, which is issued every year by the Food foundation, found that the deprived fifth of the population would need to spend a large proportion of their disposable income on food in order to meet the government recommendations. So that’s when you look at the eat well place and some of the other government recommendations about healthy diet. They would need to spend a large proportion of their income on that to be able to achieve that. And we’ve found that people who are experiencing food insecurity, they really want to eat healthily, but they just can’t afford to do that. They’ve got other priorities, and so it is really difficult to do that. So what about mental health impacts? I’m here today to talk about that. So we’re going to talk a little bit more detail about the impacts on mental health, but also severe mental illness. So what we do know is that food insecurity does lead to more stress and anxiety. So if somebody already has depression or anxiety, or indeed a severe mental illness, then they’re more likely to experience more symptoms of that condition. But also it can lead to a new emergence of a mental illness or somebody who’s never had mental health conditions. Before can suddenly develop, particularly stress and anxiety about not having enough food. And that can really lead to them needing to access support for that. We know that low mood can make it even harder to manage to cook and eat. If people are feeling low or really anxious, they might not want to get out of bed, they might not, certainly might not want to go to the shops or start cooking meals from scratch. So what we tend to find is that people who are accessing our services generally want to have food that’s really easy to cook, or the microwavable meal, which leads to issues in terms of single use, plastic, for example, and other issues around sustainability. So it’s a kind of double edged sword, if you like. You’ve got the issues around people with their mental health, but also it does impact on the environment. We know that one of the key things is around that people who’ve got food insecurity are more likely to struggle to adhere to medications. And we’ll talk a little bit about that when we talk about the research that I’ve been involved with, but it tends to be a lot of medications need to be taken with food. So if you can’t have food and you can’t afford to eat regularly, how do you take your medication? And really worryingly is that across the board in adolescents and adults, is that food insecurity can increase the risk of making a suicide attempt, which is a really sad statistic. What about severe mental illness? For those who are not familiar with severe mental illness, it’s the most significant symptom severity that you have within mental health, alongside things like eating disorders as well. But it tends to be the thing that affects people’s daily life. So we’re talking about conditions such as schizophrenia, bipolar affective disorder, schizoaffective disorder and other types of psychosis. At the moment, in England, we think there are about 574,000 people. And again, when you add the statistics together for Scotland, Wales and Ireland, it’s even higher. So the really concerning thing for us as clinicians working in mental health is that we’re seeing that people with severe mental illness are dying up to 25 years earlier than people without severe mental illness. And a lot of that’s down to preventable health conditions, things like diabetes, coronary heart disease, that kind of thing, and also overweight and obesity. But it’s a really concerning statistic. There are high levels of smoking and alcohol use in this group, but a lot of it is down to diet related conditions. Okay, so I’m now going to talk to you about a study that I’ve been involved with, I was actually leading this study that’s called a mixed method study, even using coal production to explore the issues of food insecurity. And it particularly looks at northern England. This project was done in collaboration between the NHS Trust where I’m employed, Teesside University, and also equally well, UK, which is a part of the Centre for Mental Health down in London. So this project was funded by the NIHS, that’s the National Institute for Health and Care Research, and it was the research for Patient Benefit mental health in the north programme. So it was an 18 month project, ran from September 21, and just finished this March. And I was the joint chief investigator for this project with an academic, Professor Emma Giles from Teesside University. So, just to give you an idea of what we were doing, I’m not going to spend a lot of time on the research methodology, more about the results, but what were the experiences of adults in relation to food insecurity? But also, what approaches do we need to take as clinicians, as academics, as the health mental health practitioners more generally, what do we need to do to try and help people access enough food? So this was just to give you an idea of our inclusion criteria. I won’t spend long on that, but there had to be adults living in northern England with a self reported diagnosis of SMI. There are seven NHS sites, so just a huge thanks to them for their support with recruitment. OK, but you want to know more about the results. So what we found is that this was using the USDA food security measure, which is the gold standard, one that we still use in the UK. We don’t have a UK tool at the moment, so that is a bit of an issue. But we found that over half. So if you look at the bottom table there, we’ve had 50.4% of our sample. We had 135 in the sample, so 50.4 of them, 68 people, met the threshold for food insecurity, which was really concerning. When you look at that in comparison to the general population data, as I say, it was about 9.7 million adults, or 18% of households. And what really concerns us is that’s higher than. I’ve just had a systematic review published on Friday from my PhD, which is looking at this issue as well. And we found that the prevalence data for people with severe mental illness was 41% living in high and upper middle income countries. So it’s a good almost 10% higher in the UK, which is worrying. That’s just to give you an idea of the participant characteristics. Now, the only thing that was really statistically significant was the region that people lived in. And we found that the Northwest had the highest levels, so 73.3% there at the bottom. And Yorkshire were actually the lowest prevalence of food insecurity, which is in line with some of the national data. When you look at the Trussell Trust and how many food parcels they hang out, what we did find is there was a direct trend between people’s income and food insecurity. So as people’s income rises, the prevalence of food insecurity does decrease. However, there were still people who had incomes between 36,050 2000 a year household income, were still experiencing food insecurity. So there’s a lot around that in work poverty kind of agenda as well, which is quite worrying. And also we found that people who were underweight had the highest prevalence of food insecurity, as well as people who were living with obesity. But those who had a healthier weight range, sort of between 20 and 30, they were less likely to have food insecurity. So it really did seem to affect people’s BMI. Just a word of caution with this. This is the binary logistic regression we undertook. Now, the confidence interval is very wide because we had a small sample, but we found that people who had a child in the house, at least one child, were more likely to have food insecurity. And the ODS ratio was over ten, which was really, really concerning for us as clinicians. We did some interviews as well, interviews for this project, and we looked at experiences of food insecurity and strategies to overcome this and what we found. These are our findings. So, first of all, experiences of food insecurity, it was a long rooted, familiar family issue. Can’t say that word. So that was that people’s parents and grandparents had experienced food insecurity, and it was passing down through the generations. As we’ve already mentioned, people who were experiencing unemployment were more likely to have food insecurity. This was their feelings. And a lot of people talked about that cycle of impact between food insecurity, mental health and physical health, and almost kind of which one comes first? Is it people’s mental health or is it food insecurity and which one causes which? So it was a real cyclical relationship. They talked about fuel poverty, so being given food parcels by the food banks, but not actually having the energy to be able to cook them, or not having the equipment to be able to cook them, either. Cost of living crisis. We had a lot of people talk about difficulty being able to get to food banks, for whatever reason, whether that was down to their mental illness, physical health conditions, or not being able to travel, get the bus, get taxis, that kind of thing. And also in line with what I’ve talked about with the medication, people were saying that they couldn’t take their medication for SMI, so the antipsychotic medication, because it needed to be taken on in a full stomach, and often they didn’t have any food, so therefore they couldn’t take the medication, which clinically is a real concern in terms of managing conditions such as schizophrenia and psychosis. And they also talked about barriers to support, so accessing that emergency support that’s out there, such as food banks, but finding the application forms were just so complicated and difficult to navigate that often people weren’t able to access that support. Just a few quotes there for you to have a look at. I am aware that obviously with time, so I’m just going to leave them on a couple of minutes for you to have a look at. I will say the slides will be made available after this webinar, so I will let you have a look at these in more detail then. So just going on to strategies that people felt would help to tackle food insecurity in people with severe mental illness. One of the key things was around stigma, and that’s not something that’s isolated to this group. That’s something that we hear a lot about around food banks is that fear of kind of going to food banks and being seen by other people at the north, just feeling the shame and embarrassment about having to use a food bank. And what people said is that obviously they’re already experiencing stigma around their mental health condition, potentially other physical health conditions. And then you’re adding in that food insecurity, you’ve got multiple different stigmas that people are having to face. And that was a real challenge. So there was something about us reducing that stigma around experiencing food insecurity. Also, people felt that food banks, and it was mainly centred around food banks, but the support that’s out there doesn’t really cater for different cultures. It tends to be very much whatever’s available at the time. But there wasn’t any kind of awareness of people’s cultural needs. Certainly we need to consider how to transport people to the food banks, but also is there a way to bring food parcels to people’s home when they have mental health conditions? Unsurprisingly, it was about increasing the amount of fresh fruit and vegetables in the food banks and reducing the canned and sugary foods. But also people thought we really needed to get to the root cause of what is causing food insecurity, which is not about access to food. It’s things like your benefit systems, improving people’s work opportunities, that sort of thing. Right. So now I’m going to just put on some quotes from that, just to let you have a little look at them. They’re more around access and improving things. Okay, I’m going to move on. So just our recommendations from that study were around. We need to be assessing for food insecurity in mental health services. It’s not something we have conversations about at the moment, so we certainly need to be improving staff’s awareness of food insecurity and having those conversations. But really, we need to have some policy reforms to prevent people with severe mental illness from developing food insecurity in the first place, and that they really need to make sure that we consider the needs of vulnerable adults within that, not just people with mental health conditions, but other groups as well. And that we need to work with people who are experiencing mental illness to develop those models. So that’s a core production model, not just coming in and recommending them from a practise or an academic perspective. And we need more research. This was the first UK study looking at this aspect of food insecurity, so we certainly need to generate more evidence. So I’m now going to move on, just finally to talk a little bit about a new project that we’ve got on the go at the moment. So this is another study funded by the NIHR, and this is looking at repurposing some of the surplus food that we have and making it into. So, based on the previous study, trying to improve the situation. So, as you will probably know, if you all work around sustainability, is that at the moment, there’s about 3.6 million tonnes of food that’s wasted every year in the UK, and well over half of that is perfectly edible food, often fruit and vegetables. What we find is people in the food banks are telling us that they don’t know how to cook some of the fruit and vegetables, so they don’t know, for example, what a butternut squash is. So often the fruit and the vegetables are the things that get left behind at the social supermarkets that people access. So often the things are provided, but they don’t purchase them because people don’t know how to cook them or they don’t have the equipment or the fuel to cook them. So we know that that’s enough for about 1.3 billion meals. So obviously that has a huge impact on the environment in terms of the greenhouse gases. So there is a lot of good work going on in the UK at the moment to repurpose surplus food and redistribute it. But as I say, we know that a lot of people are not using the fresh fruit and vegetables in particular, so that’s often going to waste. So that led us on to looking at another project, as I say, in Middlesboro, looking to use up some of this fruit and vegetables, working with people with severe mental illness, and we’re hoping to repurpose some of that. So this is the plan at the moment. We only started in June, but again, it was funded by the NIHR, but this time it was a programme development grant, and we started on June the first, and working very, very closely with a community organisation called Middlesborough Environment City. So working jointly with them to deliver this. That’s the logic model from the project. So basically, what we’re trying to do is work with people with severe mental illness in a group setting for 15 weeks to actually develop some recipes that they find acceptable, they find feasible, to use the fruit and vegetables and make them into a ready meal. This is very much a work in progress, it’s a programme development grant, so we don’t know how this is going to go, but we’re planning to then take their chosen recipe at the end of that and convert that into a ready meal at the Food Science Laboratory at Teesside University. And that will then be redistributed to three different social supermarkets in Middlesbrough Town. And what we plan to do is to try and evaluate how feasible and acceptable that is to the customers from the social supermarkets. And the whole idea is to pilot this project, and if it’s successful, roll this out on a much, much wider scale across the town to try and distribute this surplus food in a ready meal to people from other vulnerable groups, whether that’s people who are homeless, people who are using drugs and alcohol. So it’s really about kind of testing out a solution and seeing how that goes, really. It’s early days, we don’t start the group till October, so we’re still quite early on. We’re just doing a lot of the planning. So we’ve got ethics approval that has come through, and we’re due to start recruiting our participants for the group next. Well, at the end of this week, really, and then we’re going to run the menu development group from October to January, and then look to be piloting the ready meal in the spring. We’re doing the evaluation in May. So the project will end at the end of May. Me, and that’s really all I had to present for you today. Obviously happy to come back and talk to you once we finish that project on how that went with the ready meal and the barriers, the challenges that we had. But thank you for listening today. And there’s my details. If anybody wants to contact me for any more information or drop me a line on Twitter, more than happy to be contacted.