Abstract
Introduction
Addressing health inequalities is high on the public health agenda. In Wales, there is an 18-year gap in healthy life expectancy between the most and least deprived populations, with no signs of improvement. 1 The COVID-19 pandemic has further exposed these health inequalities, with people from lower socioeconomic groups experiencing poorer outcomes. 2
Obesity is a major contributory risk factor in the development of long-term non-communicable health conditions. 3 Childhood obesity has significant effects on physical, social and mental wellbeing and increases risk of obesity in later life. 4 In Wales, 61% of adults and 26% of children aged 4–5 years are classified as overweight or obese,5,6 and the rates of obesity and overweight are significantly higher in the most deprived areas of Wales. 6 Evidence is conclusive that poor diet is a major, modifiable contributory factor in the development of obesity and associated chronic conditions. 7 A system-wide approach is needed to effectively address diet-related health inequalities, at individual, community and societal levels, across the life course.
Implementing The Nutrition Skills For Life® Programme
Delivered in all National Health Service (NHS) health boards in Wales, the programme comprises a series of Level 1 and 2 accredited community food and nutrition courses co-ordinated by registered dietitians. Level 2 courses are provided for the community workforce (e.g. youth practitioners, volunteers, social workers and community nursery nurses), while Level 1 courses are facilitated directly with the community (e.g. parents, adults and school pupils). The programme aims to widen community access to evidence-based nutrition messages and strengthen community food and nutrition action in areas of health inequality.
Through the variety of courses tailored to the needs of the population, Nutrition Skills for Life® seeks to: (1) create supportive environments, (2) develop personal skills and (3) strengthen community action.
Creating supportive environments
Accredited nutrition training has been designed to meet learning needs of community workers from health, social care, education and third sector organisations. It encourages partner organisations to create healthy environments, ensuring the healthy choice is the easy choice within their community. The Community Food and Nutrition Skills Course enables community workers to develop the nutrition knowledge and skills required to promote evidence-based, consistent healthy eating messages. It teaches practical skills such as how to support others with budgeting, shopping for healthy foods, understanding food labels and how to adapt recipes in line with dietary recommendations. This informs implementation of healthy eating initiatives or the community weight management programme (Foodwise), which receive ongoing support from NHS dietitians. The course specifically targets childcare, schools and community settings to develop a ‘whole setting’ approach to food and health. Further to this, the Community Food and Nutrition Skills for the Early Years Course tailors these nutritional messages specifically to early years settings, encouraging early years practitioners to develop knowledge relevant to infants and children.
Developing personal skills
The ‘Get Cooking’ and ‘Come and Cook’ courses were co-produced with community groups to address known barriers to cooking nourishing meals, including lack of cooking skills, time, budget and confidence. These courses focus on practical solutions to barriers by developing personal skills, seeking to improve health literacy, self-efficacy and confidence, empowering people to take control of their own health. Learning can have positive effects on health and wellbeing of course attendees, their families and the wider community, in part by improving employment outcomes, increasing social contact and reducing unhealthy behaviours. 8
Strengthening community action
Nutrition Skills for Life® aims to support local action and development of community food initiatives through co-production. Schemes such as food pantries, community fridges, sustainable food hubs, food co-ops, food growing and gardening projects and cook and eat sessions connect people from all ages and widen access to high-quality, sustainable, affordable food.
Measuring The Impact Of The Programme
The programme contributes towards the following Welsh Government’s Public Health population indicators: 9
Increase life expectancy and healthy life expectancy at birth, and reduce the gap in life expectancy at birth between the most and least deprived.
Increase the number of adults eating five fruit or vegetables portions a day (a proxy measure for a healthy diet).
More children, adolescents and adults are a healthy weight.
The programme has a standard evaluation framework, whereby all health boards submit minimum data sets biannually. Postcourse evaluation questionnaires are completed by all Level 1 and Level 2 course participants, and responses are collated in a national database. As an example of data captured, between 1 April 2018 and 31 March 2019, 86 accredited nutrition skills courses were attended by 799 community workers. Of those who completed postcourse questionnaires (n = 508), 92% gained accreditation and 21% reported intending to deliver food, nutrition and/or cooking courses with community groups. In the same period, 163 community courses (including Foodwise) were delivered to 980 members of the community. Feedback from Level 1 food and nutrition skills course participants who completed postcourse questionnaires (n = 95) found that 96% had made changes to what their family eat, 78% reported eating more fruit and 86% reported eating more vegetables (see Figure 1).
Percent participants (n = 95) reporting making the following positive changes to their diet as a result of attending Level 1 accredited courses
For Foodwise participants who completed postcourse questionnaires (n = 344), 97% reported making changes to their diet and for those with weight measurement recorded pre- and post-programme (n = 472), 84% recorded a reduction, including 12% who lost >5% of their body weight.
Further comments provided by staff and community members include,
The course was life changing not only for work practices but also but also for my own family – I’ve changed shopping, cooking methods and nutritional balance. (Level 2 Community Food and Nutrition Skills attendee) Really enjoyed the programme, learnt lots of tips, reading labels now and walk daily, the group support was great. (Foodwise for Life attendee) Found the course very helpful and have lost half a stone just by choosing healthier options. (Foodwise for Life attendee)
Overall, the programme provides an effective mechanism for engaging with partner organisations and communities to cascade consistent, evidence-based nutrition messages to support healthy eating. It represents an important capacity building strategy for public health nutrition and dietetics. Preliminary data indicate that the programme reaches vulnerable groups including infants and children, older people, the homeless and care experienced children and young people. The programme aims to reach community groups who may not have the knowledge, confidence and skills to prepare and eat a healthy balanced diet. By training those who work closely with, and understand the needs of local people, the programme successfully supports communities across Wales to learn more about healthy eating and put knowledge and skills into practice.
Conclusion
By reorienting dietetic services to focus on prevention and early intervention, and implementing food and health policy in Wales, Nutrition Skills for Life® has had a national impact. Due to COVID-19, the programmes have since been adapted for virtual delivery through the creation of online learning resources developed for community workers to continue to deliver community food and health initiatives and accredited courses. Going forward, the programme requires rigorous external evaluation to establish its full national impact.
Footnotes
Conflict Of Interest
The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship and/or publication of this article.
